Liver cancer can often be silent, with no noticeable symptoms. It occurs when abnormal cells form and multiply within the liver, an organ situated behind the rib cage in the upper right section of the abdomen. The liver performs many critical functions: it filters and detoxifies the blood, produces bile and enzymes that aid digestion, manufactures essential proteins and regulates cholesterol and hormone levels. At Yale Medicine, we offer specialized treatment for all types and stages of liver cancer.
What are the types of liver cancer?
There are two main types of liver cancer: primary and secondary.
Primary liver cancer starts in the liver. A majority of primary liver cancers begin in liver cells called hepatocytes and are called hepatocellular carcinomas or malignant hepatomas. A rarer form of primary liver cancer is bile duct cancer, which starts in tubes inside the liver that carry bile to the gallbladder.
Secondary liver cancer, which in the United States is the more common of the two, is cancer that has spread to the liver from elsewhere in the body. For example, this cancer could have originated in the esophagus, colon, pancreas, breasts or lungs.
What are risk factors for liver cancer?
The following factors may increase the risk of developing primary liver cancer:
Long-term, chronic infection with hepatitis B or C: Hepatitis B and C are viruses that can inflame the liver. People living with one of these viruses may develop scarring of the liver (cirrhosis), which, in turn, raises the risk of developing liver cancer. Many people who have hepatitis may be unaware that they are infected, which can complicate matters.
Cirrhosis: Cirrhosis of the liver is a condition in which excessive scar tissue accumulates in the liver as a result of damage to healthy cells. Most commonly it is caused by alcohol abuse or certain viral infections within the liver, such as hepatitis B or C.
Inherited metabolic conditions: Some hereditary disorders raise the risk of liver disease and of developing a primary liver tumor. The most common is hereditary hemochromatosis, which causes the body to absorb excess iron from food, leading to liver damage. Rarer inherited disorders that may increase the risk include:
- Tyrosinemia (an inability to effectively break down the amino acid tyrosine)
- Alpha-1 antitrypsin deficiency (alpha-1 antitrypsin is a protein made in the liver)
- Porphyria cutanea tarda (an enzyme deficiency)
- Glycogen storage disease (an enzyme deficiency that disrupts the liver’s ability to properly store glycogen, an important energy source)
- Wilson disease (which leads to excess copper in the liver)
What are the symptoms of liver cancer?
Early stages of primary liver cancer typically have no symptoms. But as the cancer progresses, patients may experience:
- Jaundice (yellowing of the skin and the whites of the eyes)
- Unintended weight loss
- Appetite loss
- Fullness and/or bloating after consuming a small amount of food
- Nausea and vomiting
- Abdominal pain and/or pain in the area of the right shoulder blade
It’s important to note that many of these symptoms are also commonly associated with other liver problems, such as a benign liver tumor and Gilbert’s disease, an inherited condition that causes jaundice.
How is liver cancer diagnosed?
If you have a known pre-existing condition that puts you at higher risk for developing a liver tumor (such as hepatitis B or C, or cirrhosis), periodic cancer screening (using blood tests) are likely part of your medical care. Blood tests can help assess how well the liver is functioning and screen for blood markers that could indicate an early-stage liver tumor.
If you don't have a known pre-existing condition but are experiencing any of the above symptoms, you should see a doctor. In many such cases, it may be that you actually have a previous condition that went undiagnosed.
A doctor may order imaging tests to see tumors in the liver and, where there is cancer, determine whether it has spread. Those scans are noninvasive and painless, but do require you to lie still for an extended period of time. Scans doctors may recommend include:
CT Scan: A computerized tomography (CT) scan uses special X-ray equipment connected to a computer to provide a a more detailed set of images than those from a typical set of screening X-rays. The CT scan machine travels in an arc over the area of the body being scanned, taking pictures as it moves. The pictures depict a cross-section of the scanned area, which enables doctors to see the precise size and shape of a tumor. You may be injected with a dye to make structures inside the body appear more clearly on the scans. A CT scan is usually faster than an MRI.
MRI: Magnetic resonance imaging (MRI) uses magnetic fields from a powerful magnet and radio waves (not radiation) to produce detailed pictures of organs, bones and tissues.
Ultrasound: An ultrasound uses sound waves to create a picture of structures inside the body and may be used to detect whether there is a tumor in the liver.
To confirm whether a tumor is cancerous, doctors take a small tissue sample from the tumor that a pathologist analyzes under a microscope. A biopsy may be taken via a long, thin needle that’s guided by CT, MRI, or ultrasound and inserted into the tumor, or by using a laparoscope, a thin, fiber-optic camera inserted through a small incision in the abdomen. A biopsy may be performed during exploratory surgery of the abdomen.
How is liver cancer treated?
At Yale Medicine, a team of specialists treat liver cancer. A treatment plan is likely to include a surgeon (if surgery to remove the tumor is viable), a medical oncologist (who treats cancer with chemotherapy and other drugs), a radiation oncologist (who specializes in treating cancer with radiation) and a gastroenterologist (whose expertise is in treating conditions of the GI system). Several factors influence the type of treatment chosen and its success, including the stage of the cancer, your overall health and how you respond to treatment.
“In general, the first treatment decision is whether a tumor can be removed surgically,” says Kimberly Lauren Johung, MD, PhD, director of Yale Medicine's Gastrointestinal Radiotherapy Section. Surgery offers the best chance of successfully treating liver cancer and can consist of removing the diseased portion of the liver (through a partial hepatectomy) or a liver transplant, if a transplant is available and the cancer meets strict criteria related to tumor size and the number of tumors.
Generally, surgery is only performed if you have early-stage liver cancer that is localized and has not spread beyond the liver. In addition, surgery is reserved for patients whose livers aren’t significantly damaged by such other conditions, as cirrhosis. That's because the remaining part of the liver will take over the functions of the parts that have been removed, and an already damaged liver probably cannot handle the added workload.
Performed by interventional radiologists, ablative therapies are nonsurgical methods that destroy a liver tumor. They’re typically performed if you have a few small tumors, but cannot have surgery due to the tumors’ locations.
One method is called radiofrequency ablation and uses high-energy heat to kill tumor cells. The heat comes from electrodes at the end of a probe that the interventional radiologist inserts directly into the tumor.
Other ablative techniques include cryosurgery (which kills cancer cells by freezing them) and percutaneous ethanol injection (whereby alcohol is injected into the tumor to kill cancer cells). While ablative therapies aren’t as successful as surgery in curing liver cancer, they can be effective in many patients.
Chemotherapy uses drugs, often given intravenously, to kill cancer cells, thus slowing tumor growth and shrinking the tumor. Chemotherapy attacks cancer cells throughout the body and is used in cases of primary liver cancer that has spread outside the liver.
Radiation therapy techniques are often a key part of treating liver cancer. Radioembolization is one method doctors could use, whereby radioactive beads are injected into the hepatic artery (a blood vessel leading to the liver) via an X-ray guided catheter run from the groin. This is often used in cases where surgery isn’t possible, when tumors are too large to be treated with ablation and when the tumors don’t respond to chemotherapy. This procedure is performed by an interventional radiologist and typically doesn’t lead to serious complications.
Another form of radiation used to treat liver cancer is external beam radiation, which is delivered by a radiation oncologist. This form of radiation is noninvasive, so it does not require breaking the skin with a needle or running a catheter through the body.
One relatively newer form of external beam radiation offered at Yale Medicine is stereotactic body radiotherapy (SBRT), which is used to treat primary and secondary liver cancers. SBRT is a special form of external beam radiation that uses higher doses of radiation than conventional radiation therapy and typically requires fewer treatments.
“SBRT is a promising new treatment option for liver tumors that are noninvasive, Dr. Johung says. “Higher but very focused doses of radiation are delivered to ablate the tumor, and treatment is generally well tolerated with minimal side effects and can be given in three to five treatments.”
Generally, SBRT is used to treat smaller groups of liver tumors or metastases, and can be used in place of surgery in cases in which surgery isn’t an option, perhaps due to the location of the tumors or the overall health of the patient.
What makes Yale Medicine’s approach to treating liver cancer unique?
At Yale Medicine, liver cancer is treated by a team of specialists. Care is patient-centered, with each patient’s case being discussed in a tumor board comprising surgeons, gastroenterologists, medical oncologists, interventional radiologists and radiation oncologists—every physician involved in the patient’s treatment. The group makes treatment decisions only after careful discussion, with each doctor providing invaluable insight based on his or her expertise.
In addition, Yale Medicine’s Therapeutic Radiology Department has been using SBRT to treat liver cancer for several years, and thus has significant experience using this relatively newer form of treatment.