Source: Cancer Resource Room

What is Liver Cancer?
Cancer is a disease caused by a group of abnormal cells that grow and multiply without stopping. As these cells grow and multiply, they form a tumor. The tumor cells crowd out the normal cells of an organ. When normal cells get crowded out, there are fewer healthy cells left to do the job of that organ. Tumor cells can travel through the blood and lymph to other parts of the body and form more tumors called metastases.

Liver cancer comes from abnormal liver cells that grow and multiply, crowding out normal liver tissue. As a tumor in the liver grows and damages the normal tissue, the rest of the liver keeps working. Liver cancer is common throughout the world, with more than 1 million new cases occurring each year. In the United States, there are about 15,000 new cases a year.

What is the liver? What does the liver do?
The liver is a large, solid organ (not hollow like the stomach). It is located in the right upper part of the abdomen, under the ribs and below the diaphragm. It has two main sections, called the right and left lobes of the liver. Cancer of the liver can start in one or both of the lobes. Between the lobes of the liver, tucked up under the right lobe is the gallbladder. The gallbladder stores bile made by the liver. Bile is used by the body to digest fats. The bile drains from the liver to the gallbladder through a series of tubes called ducts. When bile is needed by the digestive system, the gallbladder squeezes bile into a duct connected to the duodenum (first part of the small intestine). Cancer of the liver can block the ducts to the gallbladder, causing a back up of bile. Cancer can also start in the bile ducts or gallbladder and spread into the liver.

The liver has several important jobs:

• filters all the blood coming from the digestive system
• balances blood sugar by releasing or storing glucose (sugar)
• breaks down drugs and alcohol
• stores some vitamins and minerals
• controls fat metabolism (levels of “good fats” and “bad fats” in the body)
• clears nitrogen waste away from the blood stream
• makes bile for digesting fats
• gets rid of old blood cells and some bacteria
• makes some proteins carried by the blood
• makes clotting factors that control bleeding

The liver has so many important jobs that there is a lot more liver tissue than is absolutely necessary. This is an advantage when part of the liver is injured or diseased. We do not get sick if just part of the liver is not working. But it also means that the damage can go unnoticed for a long time. The normal liver tissue can continue working for a long time even though a disease is damaging another part of the liver.

How is liver cancer diagnosed?
Liver cancer is diagnosed by the patient’s symptoms, medical history, physical exam, blood tests, and xrays. Sometimes liver cancer is discovered by chance. The patient may be examined for some other problem and a tumor (or mass) is found on an xray, an ultrasound, or a CT scan of the liver or abdomen. Some blood tests may be abnormal when the liver is irritated or injured.

What are the symptoms of liver cancer? What the patient feels or notices.
When liver cancer causes symptoms, they include:

• dull pain in the right upper part of the abdomen
• poor appetite
• weight loss (without dieting)
• a lump in the right upper part of the abdomen
• swelling of the abdomen
• yellow color of the skin and eyes from jaundice

Many patients with liver cancer do not have any of these symptoms. These symptoms can occur in many non-cancerous illnesses, too. They should be evaluated by a doctor.

Learning about the patient - Medical history and physical exam
A patient’s medical history and physical exam are the first steps in making a diagnosis of any disease. In the case of liver cancer, the patient’s history may include information about hepatitis B or C virus infections, exposure to certain chemicals, some rare inherited diseases (for example, hemochromatosis, porphyria, Wilson’s disease), alcohol use, a history of cirrhosis, and cancers of other organs.

The physical exam focuses on the abdomen. The liver is located in the upper right quarter of the abdomen; under the ribs and below the diaphragm. An enlarged or tender liver can be felt along the bottom of the right ribs. A large tumor, or one near the edge of the liver, may be felt along the bottom of the ribs. Swelling of the abdomen can occur when a liver tumor causes fluid to collect in the abdomen (the fluid is called ascites). It can be detected by pushing back and forth on the sides of the belly. Tapping gently on the abdomen helps to tell whether swelling is caused by gas or fluid.

Blood tests and a chest xray check a patient’s general health. There are no blood tests that diagnose liver cancer, but blood tests can show how well the liver is working. If the liver is damaged, several tests may be abnormal.

Special blood tests that are useful in diagnosing liver cancer are:

• CBC — complete blood count
• LFT’s — liver function tests
• Clotting factors — platelets, PT, PTT, bleeding time
• Glucose — amount of sugar in the blood
• Hepatitis B and C virus —chronic infections linked to liver cancer
• CEA— a tumor marker associated with several cancers
• AFP— alpha fetoprotein, another tumor marker linked to several cancers

Xrays and other imaging tests:

• Chest xray — may show cancer spread to the lungs, fluid in the lungs, an abnormal shape of the diaphragm (thin muscle separating the chest from the abdomen)
• CT scan—a series of xrays are taken in thin cross-sections across the abdomen. The xrays create pictures of the liver and other organs in layers. This is an excellent way to find a tumor, to see what size it is, and to see whether or not it has spread to nearby lymph nodes or other tissues. An abdominal CT scan shows the stomach, lymph nodes, liver, gallbladder and bile ducts, pancreas, small and large intestines, kidneys, major blood vessels, and part of the spine. The patient may need to drink a contrast solution to help outline the digestive organs. An IV is used to give the patient contrast “dye” that travels through the blood. Contrast dye in the blood makes a person feel very warm for a brief time, and causes the sensation of needing to pee urgently. Both feelings pass quickly. CT scans are not painful but do require lying on a table for about 30 minutes.
• MRI—Magnetic Resonance Imaging is similar to CT scans, but it uses strong magnets rather than xrays to make the pictures of the organs. The process is nearly the same as a CT scan.

What about a biopsy?
A biopsy uses a small piece of tissue or group of cells to diagnose a disease. The tissue is taken from a spot suspected of being abnormal. A pathologist examines the biopsy tissue under a microscope. The diagnosis is based on the appearance of the tissue and cells. A biopsy is usually not needed for liver cancer. Usually, the patient’s history, physical exam, imaging tests and blood tests can diagnose liver cancer without a biopsy. If a patient can be treated by surgery, a biopsy will not add anything to the planning. However, if the patient is not going to be treated with surgery, sometimes a biopsy is done to be certain of the diagnosis before starting treatments. A biopsy of the liver can cause problems like bleeding, tumor rupture, and leaving tumor cells along the path of the biopsy needle. New little tumors can form wherever tumor cells are left.

Are all liver cancers the same?
Liver cancer is usually a type called hepatocellular carcinoma. Worldwide, there are as many as one million new cases of this type each year. The greatest number occur in areas of the world where hepatitis is common. There are other cancers of the liver, but they are all rare. Some of these are:

• Hepatoblastoma — type of liver cancer in children
• Angiosarcoma — cancer of the blood vessels of the liver
• Epithelioid hemangioendothelioma — cancer of lining cells in the liver
• Cholangiocarcinoma — cancer of the bile ducts
• Liver metastases (secondary liver cancer) – tumors in the liver that started in another part of the body, such as the colon or breast

Some liver tumors are benign (not cancer) and include:

• Hemangioma
• Hepatocellular adenoma
• Focal nodular hyperplasia
• Biliary adenomas

What is the “stage” of liver cancer?
The stage of a cancer describes how much disease the person has. It tells how big the tumor is and whether or not the disease has spread to lymph nodes or to other parts of the body. The stage is used to help plan the right treatments for each patient.

Stage describes:

• how large the tumor is
• whether it is in more than one lobe of the liver
• if it has spread to tissues, blood vessels, and/or lymph nodes around the area of the liver
• if it has spread to lymph nodes and to other parts of the body, such as the lungs, bones, or brain

The most common staging system used in liver cancer is called the TNM system. T is for the size and spread of the original tumor. N is for spread of the cancer to lymph nodes. M is for metastasis (spread) of the disease to other parts of the body.

T- Tumor: how large the tumor is and where it has spread

• T0 – the primary or original tumor cannot be found
• T1 – One single tumor with no spread into blood vessels
• T2 – One single tumor that has spread to blood vessels or many tumors no bigger than 5 cm, without spread to blood vessels
• T3 – Many tumors more than 5 cm, or one tumor involving a major branch of the portal or hepatic veins (large veins coming into or leaving the liver).
• T4 – Tumor has spread to nearby organs other than the gallbladder or the tumor has spread to the covering tissue over the liver (visceral peritoneum).

N-Lymph nodes: tumor spread to the lymph nodes

• N0– No nearby lymph node metastasis (spread)
• N1 – Regional lymph node metastasis

M – Metastasis: tumor spread to other organs

• M0 – No distant metastasis
• M1 – Distant metastasis

The T, N, and M letters and numbers are put together to find the stage of the liver cancer:

• Stage 1—one tumor with no spread to any blood vessels, lymph nodes, or other tissues. T1, N0, M0
• Stage 2—one tumor that has spread into blood vessels, or several tumors no bigger than 5 cm, without spread into blood vessels. No spread to lymph nodes, and no metastasis. T2, N0, M0
• Stage 3A—several tumors bigger than 5 cm, or one tumor that has spread into the portal or hepatic vein (large veins going into or out of the liver). No spread to lymph nodes, and no metastasis. T3, N0, M0
• Stage 3B—tumor that has spread to other organs near the liver (other than the gallbladder), or spread into the tissue that covers the liver. No spread to lymph nodes, and no metastasis. T4, N0, M0
• Stage 3C—tumor of any size and spread in or near the liver, with spread to lymph nodes, but no metastasis. Any T, N1, M0
• Stage 4—tumor of any size and spread in or near the liver, with spread to lymph nodes, and metastasis to other parts of the body. Any T, any N, M1

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