Liver cancer: Full guide

What is liver cancer?

The liver is a large organ on the right side of your belly. It cleans your blood, makes proteins, and helps digest food.

The most common liver cancer in adults is hepatocellular carcinoma, or HCC. It starts in the main liver cells. This guide is about HCC.

Most HCC grows in a liver that is already damaged. Long-term scarring of the liver is called cirrhosis. Hepatitis B, hepatitis C, heavy alcohol use, and fatty liver disease are the most common causes. Hepatitis B can cause HCC even without cirrhosis.

Cancer that spreads to the liver from another place, like the colon, is not liver cancer. It is treated like the cancer where it started.

With liver cancer, your care team must treat two things: the cancer and the liver itself. How well your liver works guides which treatments are safe for you.

Types

Hepatocellular carcinoma (HCC)

The most common primary liver cancer. It starts in liver cells called hepatocytes. It is most often linked to cirrhosis or hepatitis B.

Fibrolamellar carcinoma

A rare type that usually affects teens and young adults. It is not linked to cirrhosis or hepatitis. Surgery is often possible.

Combined HCC and cholangiocarcinoma

A rare tumor with features of both liver cell cancer and bile duct cancer. It is treated differently from HCC.

Cholangiocarcinoma (bile duct cancer)

Cancer that starts in the bile ducts inside or outside the liver. It is a different disease with its own treatment.

Cancer that spread to the liver

Also called liver metastases. It comes from another cancer, such as colon or breast cancer. It is treated based on where it started.

Tests you may have

Ultrasound

Uses sound waves to make pictures of the liver. People at high risk often have one every 6 months to look for cancer early.

Multiphase CT or MRI

Special scans taken at several times after a contrast dye is given. In people with cirrhosis, the way a tumor lights up can confirm HCC without a biopsy.

LI-RADS score

A scoring system radiologists use to describe liver spots. A LI-RADS 5 result means the spot is HCC.

Biopsy

A thin needle takes a small piece of tissue. It is not always needed. It may be done if scans are not clear or the liver is healthy.

AFP blood test

Alpha-fetoprotein is a protein that some liver cancers make. It can help with diagnosis and follow-up, but it is not high in everyone.

Liver function tests

Blood tests such as bilirubin, albumin, and INR (a clotting test) show how well your liver is working.

Hepatitis tests

Blood tests for hepatitis B and C. If you have either, treating it is an important part of your care.

Upper endoscopy (EGD)

A camera looks for swollen veins (varices) in the food pipe and stomach. These can bleed in people with cirrhosis. It is often needed before some medicines.

Chest CT

Checks if the cancer has spread to the lungs.

What the stage means

Liver cancer staging looks at three things: the size and number of tumors, how well your liver works, and how well you can do daily activities.

Many US centers use the BCLC (Barcelona Clinic Liver Cancer) system. Your team may also tell you your Child-Pugh class. This is a score of liver health: A is best, B is in the middle, and C is most damaged.

Very early and early stage (BCLC 0 and A)

One tumor, or a few small tumors, and a liver that works well. Surgery, ablation, or a liver transplant may be options. The aim is to remove or destroy all the cancer.

Intermediate stage (BCLC B)

Several tumors in the liver, but no spread outside it and no blood vessel invasion. Treatments that go through the liver's blood supply, like TACE, are common.

Advanced stage (BCLC C)

The cancer has grown into large blood vessels or spread outside the liver. Treatment uses medicines that travel through the whole body, like immunotherapy.

End stage (BCLC D)

The liver is badly damaged, or the person is very weak. Care focuses on comfort and quality of life.

Child-Pugh class

A liver health score based on blood tests, fluid in the belly, and confusion. Most cancer medicines are safest with Child-Pugh A.

Tumor markers and liver tests

Liver cancer has fewer gene targets than some other cancers. Treatment is chosen mostly by stage and liver health.

A few blood tests still matter a lot. Ask your team what your numbers mean.

AFP

A protein made by some liver cancers. It can help track how the cancer responds. A very high level may point to one specific medicine.

AFP of 400 or higher

If AFP stays very high after first treatment, a medicine called ramucirumab may be an option.

Bilirubin and albumin

Bilirubin shows how well the liver clears waste. Albumin is a protein the liver makes. Both help decide which treatments are safe.

Hepatitis B and C viral load

Measures how much virus is in your blood. Antiviral medicines keep the liver healthier and can make treatment safer.

Platelet count

Platelets help blood clot. They are often low with cirrhosis. This matters for procedures and bleeding risk.

Main treatments

Surgery (liver resection)

Removing the part of the liver with the tumor. It works best for one tumor in a liver that works well. The liver can regrow some of what is removed.

Liver transplant

Replacing the whole liver with a donor liver. It treats both the cancer and the cirrhosis. It is for people who meet set limits on tumor size and number, such as the Milan criteria.

Ablation

Destroying small tumors with heat, cold, or alcohol, using a needle through the skin. It can work as well as surgery for very small tumors.

TACE (chemoembolization)

A doctor threads a thin tube through a blood vessel to the liver. Chemotherapy goes straight into the tumor, then the blood supply is blocked. It is often used for intermediate stage.

Y-90 radioembolization

Tiny beads with radiation are sent through the liver's blood vessels to the tumor. The radiation works from inside, close to the cancer.

SBRT (focused radiation)

High-dose radiation aimed precisely at the tumor in a few visits. It may be used when ablation or TACE is not a good choice.

Immunotherapy combinations

For advanced cancer, common first treatments are atezolizumab with bevacizumab, durvalumab with tremelimumab, or nivolumab with ipilimumab. These help your immune system attack the cancer.

Targeted pills

Medicines such as lenvatinib, sorafenib, cabozantinib, and regorafenib block signals that tumors use to grow and make blood vessels. They are used first or after immunotherapy.

Bridging to transplant

While waiting for a donor liver, treatments like ablation or TACE keep the cancer in check. Sometimes they shrink it enough to become a transplant candidate.

Supportive (palliative) care

Care focused on symptoms like pain, belly fluid, itching, and tiredness. It can be given at any stage, along with cancer treatment.

Common side effects and what helps

Post-embolization syndrome

After TACE or Y-90, many people have fever, belly pain, nausea, and tiredness for a few days. Medicines can help. Call if the fever is high or pain is severe.

Fatigue

Very common with cirrhosis and with treatment. Short walks and rest breaks help. Ask others for help with chores.

Hand-foot skin reaction

Some targeted pills cause red, sore, or blistered skin on the palms and soles. Use thick moisturizers, wear soft shoes, and avoid hot water. Tell your team early.

High blood pressure

Common with bevacizumab and many targeted pills. Check your blood pressure at home if asked. Medicines can control it.

Diarrhea and low appetite

Common with targeted pills. Drink fluids, eat small meals, and ask about medicines. Call if diarrhea is severe.

Bleeding risk

Bevacizumab and cirrhosis can both raise bleeding risk. Your team may check and treat swollen veins first. Report black stools or vomiting blood right away.

Immune side effects

Immunotherapy can cause swelling in the liver, bowels, lungs, skin, or hormone glands. It can be hard to tell from liver disease. Report new diarrhea, rash, cough, yellow skin, or feeling very unwell.

Protein in the urine

Some medicines can affect the kidneys. Your team will check your urine regularly.

Belly swelling (ascites)

Fluid can build up in the belly with cirrhosis. A low-salt diet, water pills, or draining the fluid can help.

Confusion

A sign the liver is not clearing toxins (hepatic encephalopathy). Medicines can treat it. Caregivers should watch for sleepiness or confusion and call.

Living with and after liver cancer

Taking care of your liver is part of treating the cancer. Do not drink alcohol. Ask before taking any new medicine, supplement, or herbal product, including over-the-counter pain relievers.

If you have hepatitis B or C, take your antiviral medicine as prescribed. Treating the virus protects your liver.

After treatment, you will have scans and AFP tests often, usually every few months at first. New tumors can grow in a damaged liver, so follow-up is important.

Eat a balanced diet with enough protein. A dietitian can help, especially if you have belly fluid and need less salt.

Family members may want to be tested for hepatitis B and C. Ask about the hepatitis B vaccine for those who are not protected.

It is normal to feel scared or tired. Support groups, counselors, and social workers can help you and your caregivers.