Introduction

Primary liver cancer is an uncommon but serious type of cancer that begins in the liver.

This is a separate condition from secondary liver cancer, which occurs when cancer that first develops in another part of the body spreads to the liver.

The rest of this article refers to primary liver cancer only. The Macmillan Cancer Support website has more information about secondary liver cancer.

Signs and symptoms

Symptoms of liver cancer are often vague and don't appear until the cancer is at an advanced stage. They can include:

  • unexplained weight loss
  • loss of appetite
  • feeling very full after eating, even if the meal was small
  • feeling sick and vomiting
  • pain or swelling in your abdomen (tummy)
  • jaundice (yellowing of your skin and the whites of your eyes)
  • itchy skin
  • feeling very tired and weak

Visit your GP if you notice any of the symptoms listed above. Although they are more likely to be the result of a more common condition, such as an infection, it's best to have them checked.

You should also contact your GP if you have previously been diagnosed with a condition known to affect the liver, such as cirrhosis or a hepatitis C infection, and your health suddenly deteriorates.

What causes liver cancer?

The exact cause of liver cancer is unknown, but most cases are associated with damage and scarring of the liver known as cirrhosis.

Cirrhosis can have a number of different causes, including drinking excessive amounts of alcohol over many years and having a long-term hepatitis B or hepatitis C viral infection.

It is also believed obesity and an unhealthy diet can increase the risk of liver cancer because this can lead to non-alcoholic fatty liver disease.

By avoiding or cutting down on alcohol, eating healthily and exercising regularly, and taking steps to reduce your risk of becoming infected with hepatitis B and C, you may be able to significantly reduce your chances of developing liver cancer.

Read more about the causes of liver cancer.

Who is affected?

Despite being a common type of cancer worldwide, liver cancer is relatively uncommon in the UK, with just over 4,000 new cases diagnosed each year. However, the chances of developing the condition are high for people with risk factors for the condition.

The number of people affected by liver cancer rises sharply with age, with around 8 in every 10 cases diagnosed in people aged 60 or older, although it also affects many people younger than this. Around two in every three cases affect men.

Over the past few decades, rates of liver cancer in the UK have risen considerably, possibly as a result of increased levels of alcohol intake and obesity. 

Diagnosis and screening

Liver cancer is usually diagnosed after a consultation with a GP and a referral to a hospital specialist for further tests, such as scans of your liver.

However, regular check-ups for liver cancer (known as surveillance) are often recommended for people known to have a high risk of developing the condition, such as those with cirrhosis.

Having regular check-ups helps ensure the condition is diagnosed early. The earlier liver cancer is diagnosed, the more effective treatment is likely to be.

Read more about diagnosing liver cancer.

How liver cancer is treated

Treatment for liver cancer depends on the stage the condition is at. If diagnosed early, it may be possible to remove the cancer completely.

Treatment options in the early stages of liver cancer include:

  • surgical resection – surgery to remove a section of liver
  • liver transplant – where the liver is replaced with a donor liver
  • microwave or radiofrequency ablation – where microwaves or radio waves are used to destroy the cancerous cells

However, only a small proportion of liver cancers are diagnosed at a stage where these treatments are suitable. Most people are diagnosed when the cancer has spread too far to be removed or completely destroyed.

In these cases, treatments such as chemotherapy will be used to slow down the spread of the cancer and relieve symptoms such as pain and discomfort.

Liver cancer prognosis

Because liver cancer is most often detected at an advanced stage, only around one in every five people live for at least a year after being diagnosed, and just 1 in every 20 people live at least a further five years.

Read more about treating liver cancer.

Causes

The exact cause of liver cancer is unknown, but many cases are linked to a problem with the liver called cirrhosis. This is where the tissue of the liver has become scarred and cannot perform many of its usual functions.

Cancer is a condition where cells in a specific part of the body grow and reproduce uncontrollably, producing a lump of tissue known as a tumour.

In cases of liver cancer, it is uncertain why and how the cells of the liver are affected, but it appears that cirrhosis can increase a person's chances of developing the condition.

However, most cases of cirrhosis do not lead to liver cancer, and people without cirrhosis can also develop liver cancer.

Common causes of cirrhosis

The main causes of cirrhosis in the UK are outlined below.

Heavy and harmful drinking

The liver is a tough and resilient organ. It can endure a high level of damage that would destroy other organs and is capable of regenerating itself. But despite the liver's resilience, excessive alcohol intake over many years can damage it.

Every time you drink alcohol, your liver filters out the poisonous alcohol from your blood and some of the liver cells die. The liver can regenerate new cells, but if you drink heavily for many years, your liver will lose the ability to do this and it can become damaged and scarred over time.

Non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease occurs when small deposits of fat build up inside the tissue of the liver. It's a common condition and causes no noticeable symptoms in most people.

However, in some people high levels of fat can make the liver inflamed. Over time, the inflammation can scar the liver.

The exact cause of non-alcoholic fatty liver disease is unclear, but it is associated with obesity and type 2 diabetes.

Hepatitis C

A long-term infection of hepatitis C can cause inflammation and scarring of the liver. 

Hepatitis C is spread by blood contact. The most common ways this happens worldwide include poor medical practice with the use of contaminated needles, or injected drug use, where any item of injecting equipment (not just needles) is shared.

If you smoke or regularly drink alcohol and have hepatitis C, your risk of developing liver cancer further increases.

Early treatment of long-term hepatitis C with antiviral medication can prevent the liver becoming scarred.

Other causes of cirrhosis

Less common causes of cirrhosis in the UK are described below.

Hepatitis B

Hepatitis B is a virus that can be spread through contaminated blood and other types of bodily fluids, such as saliva, semen and vaginal fluids.

Like hepatitis C, hepatitis B is spread through blood contact. It is most commonly spread from mother to child at birth or from child to child in early life (usually in areas outside the UK where the infection is very common), and very rarely sexually or through injecting drugs.

It affects about 1 in every 200 people in the UK. Most of those infected were born in parts of the world where the hepatitis B virus is very common.

As with hepatitis C, hepatitis B can also cause inflammation and scarring of the liver over time.

If you smoke or drink and have hepatitis B, your risk of developing liver cancer further increases.

Early treatment of long-term hepatitis B with antiviral medication is not always needed, but can substantially reduce the risk of the liver becoming scarred.

Haemochromatosis

Haemochromatosis is a genetic condition where the body stores too much iron from food.

The excess levels of iron have a poisonous effect on the liver and cause scarring over time, although treatment can reduce the risk of the condition leading to liver cancer.

Primary biliary cirrhosis

Primary biliary cirrhosis is a rare and poorly understood liver condition.

One of the main functions of the liver is to create a fluid called bile, used by the body to help break down fat. The bile is transported to the digestive system via a series of tubes called bile ducts.

For reasons that are unclear, in cases of primary biliary cirrhosis the bile ducts gradually become damaged. This eventually leads to a build-up of bile inside the liver, which damages the liver and causes cirrhosis.

Diagnosis

For many people, the first stage of diagnosing liver cancer is a consultation with a GP, although people at risk are usually tested regularly for the condition.

If you visit your GP, they will ask about your symptoms, when they started, and when they are noticeable. They will also examine you.

If they feel you need further tests, they will refer you to a hospital specialist. Some of the tests you may have are described below.

Surveillance for liver cancer

If you are in a high-risk group for developing liver cancer, regular screening – known as surveillance – is often recommended. This is because the earlier the cancer is diagnosed, the greater the chance there is of curing it.

Surveillance is usually carried out every six months and often involves:

  • ultrasound scans – high-frequency sound waves are used to create an image of your liver, which can highlight any abnormalities
  • blood tests – your blood is tested for a protein called alphafetoprotein (AFP), which is found in some people with liver cancer

Surveillance is usually recommended if you have cirrhosis (scarring of the liver), although there are other factors that can also affect your risk of liver cancer.

The potential benefits of surveillance should be discussed with you before you enter any screening programme.

Further testing

The tests above can also be used to look for liver cancer in people who are not being routinely screened.

If these initial tests suggest there is a chance you could have liver cancer, one or more further tests will usually be recommended to confirm the diagnosis.

The further tests include:

  • computerised tomography (CT) scans – a series of X-rays of your liver are taken to give a more detailed three-dimensional image
  • magnetic resonance imaging (MRI) scans – uses a strong magnetic field and radio waves to build up a picture of the inside of your liver
  • biopsy – a needle is inserted into your abdomen (tummy) to remove a small sample of liver tissue, which is then tested in a laboratory for cancerous cells
  • laparoscopy – a small incision is made in your abdomen under general anaesthetic (where you are asleep) and a flexible camera called an endoscope is used to examine your liver

After these tests have been carried out, it will usually be possible to confirm a diagnosis of liver cancer and determine the condition's "stage".

Staging liver cancer

Staging is a term used to describe how far a particular cancer has spread. There are a number of different systems used to stage liver cancer.

Many liver cancer specialists use combination staging systems that include features of both the cancer and the underlying liver function to stage a person's condition.

This is because the length of time a person lives and how well they tolerate potential treatments will be determined not only by how advanced their cancer is, but also by their level of health and how good their underlying liver function is.

One combination system for staging liver cancer is known as the Barcelona Clinic Liver Cancer (BCLC) staging system. The BCLC staging system consists of five stages. These are:

  • stage 0 – the tumour is less than 2cm (20mm) in diameter and the person is very well and has normal liver function
  • stage A – a single tumour has grown but is less than 5cm (50mm) in diameter, or there are three or fewer smaller tumours less than 3cm (30mm) in diameter and the person is very well with normal liver function
  • stage B – there are multiple tumours in the liver, but the person is well and their liver function is unaffected
  • stage C – any of the above circumstances, but the person is not so well and their liver function is not so good, or where the cancer has started to spread into the main blood vessel of the liver, nearby lymph nodes or other parts of the body
  • stage D – where the liver has lost most of its functioning abilities and the person begins to have symptoms of end-stage liver disease, such as a build-up of fluid inside their abdomen

Treatment

The treatment for liver cancer depends on the stage of the condition. Treatment can include surgery and medication.

Cancer treatment teams

Most hospitals use multidisciplinary teams (MDTs) to treat liver cancer. These are teams of specialists that work together to make decisions about the best way to proceed with your treatment.

Deciding which treatment is best for you can often be confusing. Your cancer team will recommend what they think is the best treatment option, but the final decision will be yours.

Your treatment plan

Your recommended treatment plan will depend on the stage your liver cancer is at (see diagnosing liver cancer for more information about staging).

If your cancer is at stage A when diagnosed, a complete cure may be possible. The three main ways this can be achieved are:

  • removing the affected section of liver – known as a resection
  • having a liver transplant – an operation to remove the liver and replace it with a healthy one
  • using heat to kill cancerous cells – known as microwave or radiofrequency ablation (RFA)

If your cancer is at stage B or C, a cure is not usually possible. However, chemotherapy can slow the progression of the cancer, relieve symptoms, and prolong life for months or, in some cases, years. There is also a medication called sorafenib that can help prolong life.

If your cancer is at stage D when diagnosed, it is usually too late to slow down the spread of the cancer. Instead, treatment focuses on relieving any symptoms of pain and discomfort you may have.

The main treatment options for liver cancer are discussed in more detail below.

Surgical resection

If damage to your liver is minimal and the cancer is contained in a small part of your liver, it may be possible to remove the cancerous cells during surgery. This procedure is known as surgical resection.

As the liver can regenerate itself, it may be possible to remove a large section of it without seriously affecting your health. However, in the majority of people with liver cancer, their liver's regenerative ability may be significantly impaired and resection may be unsafe.

Whether or not a resection can be performed is often determined by assessing the severity of your cirrhosis (scarring of the liver).

If a liver resection is recommended, it will be carried out under a general anaesthetic, which means you will be asleep during the procedure and won't feel any pain as it is carried out.

Most people are well enough to leave hospital within a week or two of having surgery. However, depending on how much of your liver was removed, it may take several months for you to fully recover.

Risks

Liver resection is a complicated surgery and can have a considerable impact on your body. There is a significant risk of complications occurring during and after surgery.

Possible complications of liver resection include:

  • infection at the site of the surgery
  • bleeding after the surgery
  • blood clots that develop in your legs – the medical term for this is deep vein thrombosis (DVT)
  • bile leaking from the liver – further surgery may be required to stop the leak
  • jaundice (yellowing of the skin and whites of the eyes)
  • liver failure (where your liver is no longer able to function properly)

Liver resection can also sometimes cause fatal complications, such as a heart attack. It is estimated that around 1 in every 30 people who have liver resection surgery will die during or shortly after the operation.

Liver transplant

A liver transplant involves removing a cancerous liver and replacing it with a healthy one from a donor.

This is a major operation and there is a risk of potentially life-threatening complications. It's estimated around 1 in every 30 people will die during the procedure and up to 1 in 10 people will die at some point in the year after surgery.

A liver transplant may be suitable for you if:

  • you only have a single tumour less than 5cm (50mm) in diameter
  • you have three or fewer small tumours, each less than 3cm (30mm)
  • you have responded exceptionally well to other treatments, with no evidence of tumour growth for six months

If you have multiple tumours or a tumour larger than 5cm, the risk of the cancer returning is usually so high that a liver transplant will be of no benefit.

If you are suitable for a liver transplant, you will normally need to be placed on a waiting list until a donor liver becomes available. The average waiting time for a liver transplant is 142 days for adults.

In some cases, a small part of the liver of a living relative can be used. This is known as a living donor liver transplant.

The advantage of using a living donor liver transplant is that the person receiving the transplant can plan the procedure with their medical team and relative, and will not usually have to wait very long.

Read more about liver transplants.

Microwave or radiofrequency ablation

Microwave or radiofrequency ablation (RFA) may be recommended as an alternative to surgery to treat liver cancer at an early stage, ideally when the tumour or tumours are smaller than 5cm (50mm) in diameter.

They can also be used to treat tumours larger than this, but the treatment may need to be repeated in such cases.

These treatments involve heating the tumours with microwaves or radio waves produced by small, needle-like electrodes. This heat kills the cancer cells and causes the tumours to shrink.

Similar procedures using lasers or freezing can also achieve the same result.

There are three main ways microwave ablation or RFA can be carried out:

  • where the needles are passed through the skin (percutaneously)
  • where the needles are inserted through small incisions in your abdomen – "keyhole" surgery (laparoscopy)
  • where the needles are inserted through a single large incision made in your abdomen – "open" surgery

Continuous ultrasound or computerised tomography (CT) scans are used to make sure the needles are guided into the correct position.

Microwave ablation or RFA can be carried out under general anaesthetic or local anaesthetic (where you are awake but the area being treated is numbed), depending on the technique used and the size of the area being treated.

How long it takes to carry out the treatment depends on the size and number of tumours being treated, but it usually takes between one and three hours in total. Most people need to stay overnight in hospital.

You may experience some minor discomfort and flu-like symptoms, such as chills and muscle pains, for a few days after the procedure.

The risk of complications occurring with microwave ablation or RFA is low, but possible problems can include bleeding, infection, minor burns and damage to nearby organs.

Chemotherapy

Chemotherapy uses powerful cancer-killing medications to slow the spread of liver cancer.

A type of chemotherapy called transcatheter arterial chemoembolisation (TACE) is usually recommended to treat cases of stage B and C liver cancer. In these cases, the treatment can prolong life, but cannot cure the cancer.

TACE may also be used to help prevent cancer spreading out of the liver in people waiting for a liver transplant.

It is not recommended for stage D liver cancer because it can make the symptoms of liver disease worse.

TACE procedure

During TACE a fine tube called a catheter is inserted into the main blood vessel in your groin (femoral artery) and passed along the artery to the main blood vessel that carries blood to the liver (hepatic artery).

Chemotherapy medication is injected directly into the liver through the catheter and either a gel or small plastic beads are injected into the blood vessels supplying the tumours to help slow down the speed they grow at.

TACE usually takes one to two hours to complete. After the procedure, you will stay in hospital overnight before returning home.

This procedure can be completed several times if necessary.

Side effects

Injecting chemotherapy medications directly into the liver, rather than into the blood, has the advantage of avoiding the wide range of side effects associated with conventional chemotherapy, such as hair loss and tiredness.

However, the procedure is not free of side effects and complications. The most common side effect is post-chemoembolisation syndrome, which can cause abdominal (tummy) pain and a high temperature (fever), as well as making you vomit or feel sick.

These symptoms may last for a few weeks after a TACE session.

Read more about chemotherapy.

Alcohol injections

If you only have a few small tumours, alcohol (ethanol) injections may be used as a treatment. A needle passes through the skin to inject alcohol into the cancerous cells. This dehydrates the cells and stops their blood supply.

In most cases, this is carried out under a local anaesthetic, meaning you will be awake, but the affected area is numbed so you won't feel any pain.

Sorafenib

Sorafenib is a medication given in tablet form that can disrupt the blood supply to liver tumours and slow down their growth.

It is sometimes used as a treatment for advanced cases of liver cancer, although it is not routinely available on the NHS because the National Institute for Health and Care Excellence (NICE) has said the cost of the medication is high for the limited benefit it offers.

Whether or not you are eligible for sorafenib will be decided by your medical team, and will depend on the likelihood of whether you will significantly benefit from the medication.

For more information, see the NICE guidelines on sorafenib for the treatment of advanced hepatocellular carcinoma.

Advanced liver cancer

Treatment for advanced liver cancer focuses on relieving symptoms such as pain and discomfort, rather than attempting to slow down the progression of the cancer.

Some people with advanced liver cancer require strong painkillers, such as codeine or possibly morphine. Nausea and constipation are common side effects of these types of painkillers, so you may also be given an anti-sickness tablet and a laxative.

Read more about end of life care.