The liver
The liver is the largest organ inside the body. It is found on the right hand side of the abdomen under the ribs, just beneath the right lung and diaphragm.
The liver is shaped like a pyramid and is made up of two sections called the right and left lobes. Blood from both the artery and the portal vein flows to the liver. The portal vein carries nutrients from the intestine back to the liver where they can be made into energy.
The liver performs several important functions including:
- storing some nutrients
- converting food with sugars and fats to energy
- producing bile to dissolve fat so it can be digested
- making blood proteins
- helping the blood to clot
- making other chemicals the body needs
- breaking down harmful substances such as alcohol and getting rid of waste products.
Unlike other internal body organs, the liver can usually repair itself. It can function normally even if only a small part of it is working and it can grow back to normal size in a couple of weeks or months.
Types of liver cancer
There are two different types of liver cancer.
Primary liver cancer:
- cancer that starts in the liver
- two main types: hepatocellular carcinoma (HCC) and cholangiocarcinoma
- HCC starts from the main cells in the liver (hepatocytes), and is the most common type of primary liver cancer
- HCC occurs frequently in people with liver disease called cirrhosis
- cholangiocarcinoma starts in the cells lining the bile duct
Secondary liver cancer:
- starts in another part of the body and spreads (metastasises) to the liver
- most common types start in the bowel, breast, pancreas, stomach, oesophagus, ovary or lung
- named after the primary cancer - for example, bowel cancer that has spread to the liver is called metastatic bowel cancer
- can be diagnosed before or after the primary cancer
How common is it?
Primary liver cancer:
- about 360 people are diagnosed each year
- over twice as common in men as women, and in people over 65.
Secondary liver cancer:
- the most common type of liver cancer
- about 20 times more common than primary liver cancer.
Diagnosis
Blood test
- Sometimes called a liver function test (LFT).
- Tests can show how liver is working before, during and after treatment.
- checks the level of a chemical called alpha-fetoprotein (AFP).
Ultrasound
- Scan that uses soundwaves to build up pictures of the body.
- A paddle-shaped device is moved over the abdomen for a few minutes.
- Painless and non-invasive.
- Only takes a few minutes.
CT (computerised tomography) scan
- Uses x-ray beams to compile many pictures of the body.
- You may have an injection of a special dye into your veins before the scan.
- You will be asked to lie still on a table while the CT scanner, which is large and round like a doughnut, slowly moves around you.
- Painless.
- Takes 10-30 minutes.
MRI (magnetic resonance imaging) scan
- Uses a combination of magnetism and radio waves to build up detailed cross-section pictures of the body.
- A special dye may be injected into your veins before the scan.
- You will lie on a couch in a metal cylinder – a large magnet – that is open at both ends.
- Painless.
- Takes about one hour.
Biopsy
- Tissue is removed by fine needle aspiration or surgically.
- Fine needle aspiration – a needle is inserted and a small tissue sample is removed. An ultrasound machine may be used to guide the needle.
- Surgery – usually done by laparoscopy (keyhole surgery). A small cut is made in your lower abdomen and a thin tube is inserted. Tissue is removed through this opening.
- A biopsy isn’t required if the tumour can be removed surgically or you are having a liver transplant.
PET (positron emission tomography) scan
- A specialised imaging test, available at some hospitals.
- You are given a radioactive glucose solution that circulates your body for 30 to 90 minutes.
- Your body is scanned for high levels of radioactive glucose.
- Takes several hours to prepare for and undergo the scan.
Staging
Staging tells the doctor how far the cancer has spread. This helps your health care team decide what treatment is best.
Staging a tumour is related to:
- its size
- whether it has invaded blood vessels
- if it has spread to organs around the liver, within the abdominal cavity, or to organs further away.
Staging for primary liver cancer (hepatocellular cancer) may also involve assessing the underlying liver function.
If you have any questions about staging, ask your doctors.
Prognosis
Prognosis means the expected outcome of a disease.
You will need to discuss your prognosis with your doctor, but it is not possible for any doctor to give you a 100% accurate prediction on the course of the illness. The type of cancer, test results, the rate and depth of tumour growth, how well you respond to treatment, and other factors such as age, fitness and your medical history are all important factors in assessing your prognosis.
Treatment
Surgery
Surgery for liver cancer is called liver resection. It is the main treatment for primary liver cancer.
For secondary liver cancer, surgery is only performed if the cancer is not widespread throughout the liver, or if the secondary cancer has not spread to other parts of the body.
Partial hepatectomy:
- surgery to remove a part of the liver
- the gall bladder is also removed, and sometimes part of the diaphragm
- the liver may repair itself and grow back to its normal size within weeks.
- If a small segment of your liver is removed it is called a segmentectomy.
Liver transplant:
- surgery to remove the liver and replace it with a liver from another person
- a suitable donor will have to be available.
Radiofrequency ablation (RFA)
- A type of treatment that uses radio waves to heat and destroy cancer cells.
- A needle is inserted into the tumour under anaesthesia.
- An electrical current passes into the tumour, destroying the cells and creating scar tissue.
- Takes about 15 minutes.
- Side effects, like pain and fever, can be managed with medication.
- If tumours are close to the surface of the liver, you may also have surgery.
Alcohol injection
- In this procedure pure alcohol is injected through the skin directly into the tumour to destroy the cancer cells. This technique is useful for treating tumours less than 4 cm.
- The treatment is given under local anaesthetic and an ultrasound is used to guide the needle into the tumour. You may have more than one injection over several treatment sessions.
- You may have some pain or a fever after this treatment but these side effects can be managed with medication.
Cryotherapy (cryosurgery)
- A probe is inserted into the tumour (usually through a cut in the abdomen) and liquid nitrogen is injected.
- The area is frozen and cancer cells are destroyed.
- Takes about 30 to 60 minutes.
- You may have to stay in hospital overnight, and your doctors will help you manage any pain with medications.
- Cryotherapy treatment is a treatment used for liver tumours that are less than 4 cm. Sometimes chemotherapy is given after the cryotherapy.
Chemotherapy and chemoembolisation
Chemotherapy is the treatment of cancer with anti-cancer (cytotoxic) drugs.
The aim of chemotherapy is to kill cancer cells while doing the least possible damage to healthy cells. Chemotherapy is the main treatment for secondary liver cancer, and is sometimes used to treat primary liver cancer.
One type of chemotherapy treatment is called chemoembolisation:
- A way of delivering the chemotherapy directly to the part of the liver with cancer
- Done in the x-ray department of a hospital
- Chemotherapy drugs are injected into the liver through the hepatic artery.
- The hepatic artery is blocked by tiny plastic beads or pieces of soft gelatin sponge.
- Stronger drugs can be used without creating many side effects.
- Hospital stay of a few days.
Radiotherapy
Radiotherapy is the use of high-energy x-rays or electron beams to kill or damage cancer cells. It is usually used as palliative treatment for liver cancer.
One type of radiotherapy is called selective internal radiation therapy (SIRT):
- Works by targeting a liver tumour with a dose of internal radiation 40 times higher than conventional radiotherapy.
- Radioactive pellets, or sir-spheres, are directly inserted into the liver tumour.
- Best used in people with who have secondary tumours that can’t be removed, or people who have multiple small tumours throughout the liver.
- Side effects include flu-like symptoms.
Endoscopic palliation
In some patients with liver cancer, obstructions of the bile ducts can cause jaundice, feelings of itchiness, pale stools and dark urine. Sometimes endoscopic palliation – inserting a stent to open the ducts – can ease these symptoms.
This is done as a day procedure by a gastroenterologist who inserts a tube through the mouth and stomach and then into the bile duct.
Palliative treatment
Palliative treatment helps improve people’s quality of life by alleviating symptoms of cancer, without trying to cure the disease.
Often treatment is concerned with pain relief and stopping the spread of cancer, but it can also involve the management of other physical and emotional symptoms. Treatment may include radiotherapy, chemotherapy or other medication.
Health professionals you may see
Your GP will arrange the first tests to assess your symptoms.
If these tests do not rule out cancer, you will usually be referred to a specialist who will arrange further tests and advise you about treatment options.
Health professionals who may care for you include:
- hepatobiliary surgeon – a surgeon who specialises in surgery of the liver and surrounding organs
- gastroenterologist – a specialist in diseases of the digestive system
- medical oncologist – plans and administers chemotherapy
- radiation oncologist – plans and administers radiotherapy
- hepatologist – a specialist in liver disease
- cancer nurse coordinators and nurses – give you the course of treatment and support and assist you through all stages of your treatment
- social worker, physiotherapists, occupational therapist and dietician – link you to support services and help you to resume normal activities.