Liver cancer

"Liver cancer" is really two different diagnoses under one name, and the difference between them decides everything that follows: where the illness came from, what it is treated with, and whether it could have been prevented. The complaints of the two are so alike that telling them apart without investigation is impossible.

The tumour that starts here and the one that arrives

Primary cancer begins in the liver itself and, in the vast majority of cases, grows not on healthy tissue but on scarred tissue: eight out of ten such tumours are found in people with cirrhosis or long-standing viral hepatitis. Hence the most important practical rule on this page — once the liver is already damaged, a tumour stops being a matter of chance and becomes an expected event, one to be looked for in advance rather than waited for.

Secondary, or metastatic, cancer is made of cells from someone else's tumour carried here by the blood from the bowel, stomach, lung, pancreas or breast: the liver collects blood from the whole abdomen, so deposits settle in it more often than anywhere else. It says nothing about the liver, and it is treated according to its source — bowel cancer deposits are treated as bowel cancer. There is a piece of news here that is rarely said out loud: single deposits from the bowel are often removed surgically with the intention of cure, and that has long since stopped being an exception.

There is also a rare type, fibrolamellar carcinoma, which arises in young people with a completely healthy liver; because nobody expects it, it is found late. If a tumour turns up in someone under forty without a single risk factor, it is worth asking about this variant outright: it is treatable, but by different rules.

How the illness gives itself away

An early liver tumour neither hurts nor interferes: liver tissue itself has no pain endings, and the organ keeps working after losing a large share of its volume. Relying on symptoms is therefore a poor plan, because they give far too little head start.

• Jaundice: the whites of the eyes and the skin turn yellow, urine darkens, stools go pale, and the skin itches without any rash. On brown and black skin the yellow tinge shows best in the whites of the eyes and under the tongue.
• Loss of appetite and weight loss nobody was aiming for.
• Tiredness and exhaustion that rest does not fix.
• A dull ache or heaviness under the right ribs, sometimes felt in the shoulder and shoulder blade.
• A lump that can be felt below the right costal margin.
• Feeling full quickly, nausea, a new dislike of food.
• An abdomen that swells regardless of meals — that is how fluid build-up shows itself.
• A low-grade fever and night sweats with no obvious infection.

There is a separate and very common situation: someone with known cirrhosis suddenly stops holding steady on their usual treatment — fluid returns to the abdomen, jaundice deepens, confusion appears. That kind of deterioration without a visible cause is by itself a reason to look for a tumour.

See a doctor within the next few days if you have jaundice, a lump in the abdomen, unexplained weight loss, or abdominal complaints that have not settled in two or three weeks. Call an ambulance (in European countries, the single number 112) for vomiting blood or black tarry stools, sudden severe abdominal pain with marked weakness and pallor, confusion and drowsiness, or a high fever in someone with fluid in the abdomen. Sudden pain with a falling blood pressure can mean the tumour has ruptured — rare, but counted in hours.

What raises the risk

The list of causes of primary liver cancer is unusual in that almost all of it is removable: nearly every item is a specific disease that can be treated or prevented.

• Chronic hepatitis B is the one cause capable of producing a tumour even without cirrhosis, so surveillance is needed even when the blood tests look quiet.
• Chronic hepatitis C: now cured with tablets within months in almost everyone, though where cirrhosis has already formed the risk remains after the cure.
• Cirrhosis of any origin, including alcoholic and autoimmune.
• Fatty liver disease linked to metabolism: excess weight, type 2 diabetes, high triglycerides. It is the fastest-growing cause, and it produces tumours even without obvious cirrhosis.
• Regular alcohol over years, especially alongside hepatitis or excess weight: the causes do not add up, they multiply.
• Inherited iron overload and, less often, alpha-1-antitrypsin deficiency.
• Aflatoxins, the poison of moulds growing on badly stored nuts, maize, grains and spices. Mouldy food is not trimmed, it is thrown out.
• Smoking and long industrial exposure to vinyl chloride.
• Liver flukes, parasites picked up from raw freshwater fish in some regions.
• Age over sixty and male sex: men are affected roughly three times as often.

What is not on this list, although source texts sometimes slip it in, is gallstones: they have no connection with liver cancer.

What can be done in advance

The hepatitis B vaccine was the first vaccine in history shown to reduce the incidence of a cancer: where children are vaccinated, liver tumours in young adults have become a rarity. It is on the schedule in all six countries, and unvaccinated adults can have it at any age.

Hepatitis C needs to be found and cured. It runs for decades without symptoms, and testing once in a lifetime is enough — plus again if there were blood transfusions, old operations, tattoos in doubtful conditions or drug use.

Surveillance in cirrhosis is the thing that genuinely saves lives. Everyone with cirrhosis, and some people with chronic hepatitis B, has a liver ultrasound every six months for life regardless of how well they feel, sometimes together with a blood test for alpha-fetoprotein. The point is precisely the regularity: a tumour of a couple of centimetres gives no sign at all yet can be treated with the intention of cure, while the same tumour a year later cannot. If you have cirrhosis and this surveillance has never been arranged, ask about it yourself.

The rest is well known but no less effective: keep your weight in check and treat diabetes, give up alcohol with any liver disease, do not smoke, and do not eat anything mouldy.

How it is investigated

The conversation usually starts with a primary care doctor: questions, examination of the abdomen, and blood tests covering liver enzymes, bilirubin and clotting. If a tumour is suspected, you are referred to a specialist.

• Ultrasound is the first and main tool, and the one used for surveillance in cirrhosis.
• Contrast scanning, CT or MRI, is the key investigation. The liver has a feature that is rare in cancer medicine: the characteristic behaviour of contrast within a lesion in a cirrhotic liver allows the diagnosis to be made without a biopsy.
• A biopsy is needed when the picture is ambiguous, when it matters what tissue the lesion is made of, and when looking for the source of a secondary tumour.
• Alpha-fetoprotein makes no diagnosis on its own: it can be normal with a tumour and raised without one.
• Assessing the liver's reserve matters as much as the size of the tumour: what can be offered depends on how much healthy tissue is left.

Waiting for results stretches into weeks and by itself means nothing bad. It is worth bringing someone with you to the appointment where they are discussed: what is heard is poorly retained, and two people remember more.

How it is treated

The plan is put together by a team: hepatologist, surgeon, oncologist, radiologist and radiotherapy specialist. Three things are weighed at once — the tumour, the state of the rest of the liver, and the person's overall reserves. That sets liver cancer apart from most others: even a small tumour sometimes cannot be operated on, because the remaining tissue would not withstand it.

• Resection, removing part of the liver, is possible when the organ is well preserved; it later regains some of its volume.
• Liver transplant is the only method that removes the tumour and the cirrhosis at once. It is considered for small nodules in people whose liver works poorly, and it should be raised early.
• Ablation destroys the nodule with heat through a needle guided by ultrasound or a scanner. For small lesions it matches surgery in outcome and is far easier to tolerate.
• Chemoembolisation: a catheter is threaded along the vessel to the tumour, the drug is injected, and the feeding artery is blocked. It is used when there are several nodules and surgery is not possible.
• Radioembolisation takes the same route but delivers microscopic particles carrying a radioactive substance, which irradiate the tumour from inside.
• Drug treatment of advanced disease is now more often a combination of immunotherapy with targeted drugs than classical chemotherapy, which works poorly here.
• Precision radiotherapy is used less often: for awkwardly placed nodules and to relieve pain.

With secondary cancer everything is decided by the source: some deposits are removed or burned out with the intention of cure, others are treated with drugs aimed at the original tumour. Asking whether your case was discussed by a multidisciplinary team is an entirely reasonable question.

What helps during treatment

• The itch of jaundice wears people down more than pain does. Besides restoring bile drainage with a stent, certain medicines help, along with cool showers, loose clothing and short fingernails.
• Pain relief. Anti-inflammatory drugs are dangerous for the kidneys and stomach when the liver is diseased, so the ordinary antipyretic is usually preferred — but in cirrhosis its daily dose is reduced, so check it with your doctor.
• Eating. Protein is not restricted, quite the opposite: liver disease calls for more of it than usual, or muscle is lost. Salt is limited only when there is swelling or fluid in the abdomen. Supplements "for the liver" and herbal mixtures are best avoided: no benefit has been shown and cases of liver damage have been described.
• Palliative care teams deal with quality of life, not only with its final weeks; bringing them in early makes the whole of treatment easier to bear.

Online consultation

A remote appointment neither makes nor excludes this diagnosis — that needs imaging and blood tests. It is useful at several points, though, and earliest of all at the most important one: if you have cirrhosis or chronic hepatitis, a doctor online will check whether surveillance is actually being done as it should be, and help you build a scan calendar so that six-month intervals do not quietly turn into two-year ones. If blood tests or a scan have shown changes in the liver, they will explain what those mean and which investigations settle the question. With the work-up already done, they will help you make sense of unfamiliar words in a report and prepare questions for the oncologist; during treatment, they will help you manage side effects, itching, nausea, eating and the safety of the medicines you take. Questions about the hepatitis B vaccine for you and your family belong here too. The situations in the emergency section are not dealt with online: for those, call an ambulance.

This material is for information only and does not replace medical advice.