Liver cancer: symptoms & diagnosis
What are the symptoms of liver cancer?
Often there are no early symptoms of liver cancer, because the liver is a very resilient organ that can continue to work well even when large parts of it are damaged. If you do notice symptoms, they may be similar to those seen in other liver conditions, and are often exactly the same as those in cirrhosis.
- A general feeling of poor health
- Loss of appetite
- Fatigue and weakness
- Nausea and vomiting
- Loss of weight
- Discomfort over the liver area (upper right hand section of the abdomen)
- Itchy skin
- Pale or grey poo
- Dark urine
- Loss of libido (sex drive).
How is liver cancer diagnosed?
Your GP will take your medical history and ask about your symptoms. They will also perform a detailed clinical examination. Your GP will then take some blood samples and may arrange for you to have an abdominal ultrasound scan.
If this first round of blood tests and the ultrasound indicate a tumour may be present, you will be sent to see a specialist doctor (surgeon or gastroenterologist/hepatologist) who may take more blood tests and arrange for special imaging tests of your liver to examine it more closely. You may be required to have a biopsy. if doctors are still unable to make a diagnosis after these tests.
If you have been diagnosed with cirrhosis, particularly if it’s related to hepatitis B or C, alcohol or haemochromatosis, you should receive regular ultrasound scans and blood tests every six months to monitor your liver.
Early detection of any tumours will give the best opportunities for successful treatment.
Surveillance may not be offered if you have alcohol-related cirrhosis and continue to drink, as the continued damage from alcohol would reduce the chances of any successful treatment.
A blood test provides information on the general health of your liver. If HCC is suspected, a protein found in the blood called alpha-fetoprotein (AFP) will also be measured.
In around five to seven out of 10 people with HCC, AFP levels will rise as the disease progresses. However, a negative AFP blood test does not guarantee that someone does not have HCC. Likewise, AFP levels can be elevated for reasons other than HCC. AFP levels usually come down if a treatment is working, so it is a useful tool to measure how effective treatment is.
Ultrasound is a painless test that sends sound waves into the body. The echoes are picked up and used to build a picture of the condition of the liver, bile ducts and gallbladder. If the ultrasound highlights any areas of tissue that are concerning, you should be referred to a specialist liver unit for a CT or MRI scan. You should be seen by a specialist within two weeks.
A CT scanner gives detailed images of the inside of the body, including soft tissues such as muscles, organs and nerves, which an ordinary X-ray cannot.
Images of the body from different angles are fed into a computer, which processes them as a series of cross sections (or ‘slices’). This provides a 3D image of the inside of your body and can show the size of the tumour, and if it has spread and is present in other organs.
An MRI scan uses strong magnetic fields and radio waves to create detailed images of the inside of the body. MRIs are commonly used where more detailed examination is required.
Hepatic angiography is an X-ray study of the blood vessels that supply the liver and may be needed if the diagnosis is still doubtful after a CT and MRI scan. It may also be used as part of some treatment techniques, such as chemoembolization. The procedure uses a catheter (a thin, flexible tube) that is placed into a blood vessel through a small cut in the groin. A dye is then injected through the catheter, which highlights the blood vessels in the tumour as well as those feeding the tumour. A hepatic angiogram is usually done under local anaesthetic and you are also likely to be given sedation. Because of this, you may be asked to stay in hospital overnight.
A laparoscopy may be performed to assess damage to your liver and bile ducts and also to look for tumours in the abdominal cavity. In this procedure a tiny camera (endoscope) with a light on the end of a flexible fibre optic tube is inserted into your side through a small cut in your skin (‘keyhole’) to take pictures of your liver. If needed, a biopsy of your liver can be taken at the same time. A laparoscopy is performed under a general anaesthetic so you might need to stay in hospital overnight.
Usually, a diagnosis can be made using imaging techniques but occasionally a biopsy may be required. During a liver biopsy, a tiny piece of the liver is carefully removed via a long needle and taken for study. Liver biopsies are often needed in patients who are to be considered for sorafenib, a drug used to treat primary liver cancer .
For more information on these and other tests, see our Liver disease tests explained publication.
Treatment for liver cancer
A number of treatment options are available for primary liver cancer. The aim of some (surgery or liver transplant) is to remove the cancer completely. If this is not possible then treatment will aim to shrink the size of the cancer to relieve symptoms, delay progression or to make surgery possible. Treatments may be used on their own or in combination. Unfortunately, liver cancer can be hard to treat because there are often very few early symptoms, which means that by the time a diagnosis is made, the disease is quite advanced.
Generally, surgery is the most effective treatment, but may not always be possible. Whether you will be suitable for surgery will depend on a number of different factors, including:
- the size and position of the cancer, whether it’s contained in one part of the liver and whether major blood vessels are involved
- whether the cancer has spread beyond the liver
- whether the rest of your liver would be able to cope after an operation
- other health conditions that could affect how successful the operation is, or your recovery.
The most common form of liver surgery is known as resection, where the part of the liver affected by the cancer is cut away and removed. The liver will then regrow to the volume required by the body. However, resection surgery is only suitable for those who have very good liver function (Child Pugh class A). If you have HCC caused by damage to the liver through cirrhosis, then resection may not be possible, especially in those with more advanced cirrhosis. This is because your liver may be too damaged to recover after the operation. A liver transplant may be considered, but only a few people are suitable for this. Alternatively, surgery may not be possible if the tumour is in a position that makes it difficult for the surgeon to access it.
Liver surgery is a major operation and there are some risks such as infection, bleeding or bile leakage. There is also a risk that a number of undetected cancer cells will have escaped. This means there is a risk the cancer may recur despite excellent treatment and advanced medical techniques.
It is also important to be aware that if liver cancer has developed because of cirrhosis, there is a risk that the cancer may come back.
A liver transplant may be considered if you have:
- a single tumour less than 5cm in diameter or
- up to five tumours, but all less than 3cm in diameter or
- a single tumour greater than 5cm but less than 7cm if there has been no tumour progression for six months
- AFP less than <1000iu/mL.
You will be assessed by the transplant team and if considered suitable, your consultant may recommend that you are put on the transplant waiting list. However, it may be some time before a suitable liver becomes available and you may need other treatments to slow the growth of the tumour in the meantime.
For more information see our publication on Liver transplantation.
There are a number of treatments aimed at reducing the growth of the cancer if surgery is not an option. In some circumstances these may be effective at halting the cancer for several years and the various approaches may be used at different times in the same patient.
These therapies work by targeting the cancer with micro or radio waves placed directly into the tumour by needle-like electrodes. These destroy the cancerous cells. A similar procedure involves freezing the tumour (cryogenics). There are three common techniques used: where the needle is passed through the skin (percutaneously), via keyhole surgery (laparoscopy) or a large single incision made in the abdomen (‘open’ surgery).
An ultrasound or CT scan is used to guide the needle into the correct position. This type of treatment works best with small tumours and can be carried out under general anaesthetic or sedation. Most people will need to stay in hospital overnight, and many patients feel tired and sick after treatment. This is normal, as is a raised temperature and flu-like symptoms.
Chemotherapy is a treatment which uses drugs to kill cancer cells, or to stop them from multiplying. It aims to shrink tumours down and slow the development of the disease. As well as the type of chemotherapy outlined below (TACE), it can also be given by injection or tablet form. Chemotherapy will not cure your cancer, but it may control the cancer or even reduce its size. This can help to reduce symptoms and may also extend your lifespan.
Embolisation is a technique used to cut off the blood supply to the tumour, killing the cancerous cells.
TAE involves injecting the hepatic artery (one of two arteries that supply the liver with blood, the other being the portal vein) with a substance containing tiny gel-coated beads or pieces of a gelatine sponge. This creates a seal that blocks the supply of blood to the tumour to stop it growing. The injection is via an artery in the groin.
TACE is a procedure that delivers chemotherapy drugs directly to the liver to target the cancer, after which the embolising substance (tiny gel-coated beads) is also injected to create a ‘seal’ around the chemotherapy drug and block off the blood supply to the tumour to help slow down its growth. This ensures it’s as effective as possible over a long period of time. This therapy is given under local anaesthetic and sedation, and requires an overnight stay in hospital. Giving chemotherapy in this way means side effects such as hair loss may be avoided, although abdominal pain, feeling or being sick and a high temperature for days or even weeks afterwards are common.
New methods aimed at improving delivery of these drugs are being developed and your medical advisor can provide more information about these treatments.
Selective internal radiation therapy (SIRT) is a way of giving radiotherapy treatment for cancer in the liver that can’t be removed with surgery. It’s a type of internal radiotherapy, and is sometimes called radioembolisation. It involves using tiny spheres or beads, made from either glass (TheraSphere) or resin (Sir-Spheres), which contain a radioactive substance called yttrrium-90. The tiny beads called are put down a thin tube into the main blood vessel that supplies blood to your liver (the hepatic artery). Each bead is smaller than the width of a human hair. They enable the drugs to be delivered directly to the liver tumours. These spheres ‘cluster’ around the small blood vessels surrounding the tumour, where they then release radiation and destroy the cancer cells.
In England and Wales NICE has recommended selective internal radiation therapy (SIRT) as an option for some people with advanced liver cancer (also called hepatocellular carcinoma or HCC).
For more on SIRT click here
The methods below have been developed to deliver extremely targeted radiotherapy to cancer tumours with minimal damage to the surrounding healthy cells.
This is most suitable for those with smaller cancers and involves several thin beams of radiation being focussed on the tumour. The treatment is painless, although you may feel tired, and have red, sore skin afterwards.
CyberKnife radiotherapy is the latest in radiotherapy technology. It involves treating tumours with radiotherapy administered by a robotic system that uses cameras to pinpoint the cancer exactly. This means fewer sessions and visits to hospital for the patient.
This is a non-invasive technique that uses a strong electric current passed through fine needles to destroy cancerous cells.
The needles pass through the skin and are guided into place around the tumour, using ultrasound or a CT scan. An electric current is then passed between them, killing the cancer cells. There is minimal damage to the surrounding healthy tissues. This can be used when traditional surgery isn’t an option. It is done under general anaesthetic and requires an overnight stay in hospital.
Targeted liver cancer drugs/biological therapies
Sorafenib (also known by its brand name, Nexavar®) is a type of targeted cancer drug called a protein tyrosine kinase inhibitor (TKI). It stops signals that tell cancer cells to grow and slows down the formation of new blood vessels so the supply of blood to the cancer cells is reduced. This type of drug is sometimes referred to as a biological therapy because it uses substances found naturally in the body, or artificial versions of these, to help fight the cancer. Sorafenib is given in tablet form and is suitable for those with advanced liver cancer but is only available on the NHS to adults classified as ‘A’ on the Child-Pugh liver function scale (those with good liver function). You can read the NICE guidance at www.nice.org.uk/guidance/ta474
Regorafenib is taken orally and works by slowing down the growth and spread of cancer cells by cutting off the blood supply that keeps cancer cells growing.
Stivarga® (regorafenib) has been approved for use as a monotherapy for the treatment of adult patients with hepatocellular carcinoma (HCC) who have been previously treated with Nexavar® (sorafenib).
Lenvatinib is part of the kinase inhibitor class of medicines. It blocks the signals between cancer cells to help stop them from spreading and can also shrink tumours.
Lenvatinib can be prescribed for advanced liver cancer in people:
- who have good liver function (Child-Pugh grade A or ECOG score of 0 or 1)
- whose liver cancer can’t be treated surgically
- who haven’t already had their cancer treated with medicine
You take it as two or three capsules once a day. You should swallow the capsules whole, do not crush or break them.
Atezolizumab with bevacizumab work to kill liver cancer cells in different ways. Atezolizumab is an immunotherapy drug that helps your immune system recognise and fight cancer. Bevacizumab stops the tumour from growing blood vessels so it is starved of fuel.
Atezolizumab with bevacizumab can be prescribed for advanced liver cancer in people:
- who have good liver function (Child-Pugh grade A or ECOG score of 0 or 1)
- whose liver cancer can’t be treated surgically
- who haven’t already had their cancer treated with medicine.
You have atezolizumab with bevacizumab through a drip directly into your bloodstream (intravenously).
This treatment is currently approved by NICE for patients in England and Wales. The Scottish Medicines Consortium are currently considering it for approval.
When all the tests have been completed, your consultant will review your results with a medical team that includes specialists in surgery, liver disease (hepatologist), digestive diseases (gastroenterologist) and cancer (oncologist), as well as other professionals who may be involved in your care. That team may be at another hospital in the region.
As well as confirming a cancer diagnosis, the tests will provide information on how advanced the cancer is (how big it is, where it is and the number of tumours present). This is referred to as ‘staging’ the cancer and is often measured using the TNM classification:
Tumour (T) – the size of the primary tumour
Node (N) – whether the tumour has spread to your lymph glands
Metastases (M) – whether the tumour has spread to other organs.
Another type of staging that is often used is the Barcelona Clinic Liver Cancer (BCLC) staging system, which looks at other aspects, including liver function and the size and number of tumours.
The health of your liver will also be classified, most commonly using a scoring system called Child-Pugh (class A, B or C). This takes into consideration blood test results, the presence of fluid in the abdomen (ascites) and brain function (encephalopathy). A Child-Pugh class A indicates the liver is working well, whereas class C indicates more severe liver damage.
No two patients are the same and this information will help your medical team to decide on the most appropriate treatment options to discuss with you.
If you are finding it difficult to eat, there are plenty of dietary supplements available on prescription. Some are powders you sprinkle on your food and some are drinks that are complete meals in themselves. Ask your doctor or dietician for help, and see our publication on Diet and liver disease.
Alcohol and smoking
Alcohol is processed by your liver and as a result, it can be dangerous for anyone with liver problems. Check with your doctor whether it is safe for you to drink any alcohol and if so, how much. Smoking is dangerous to everyone’s health. People with liver disease are more vulnerable to infection and to poor health overall, so smoking or exposure to passive smoking is not advised.
Your team may suggest that you are referred to your local community palliative care team. They are experts in pain relief and can be very helpful in supporting you and your family while you are having treatment or when treatment is no longer possible. They can advise and help you with symptom control and also provide emotional support to you and your family. For more on planning your future or palliative care, download our publication here.
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