Primary liver cancer begins in the cells of the liver itself.
Although many cancers are declining in the United States, new
cases of primary liver cancer are increasing and are likely to
continue to increase for the next two decades.
Liver cancer also occurs as metastatic cancer,
which happens when tumors from other parts of the body spread
(metastasize) to the liver. In the United States, most cancer
found in the liver spread there after originating elsewhere.
Rather than being called liver cancer, this type of cancer in
the liver is named after the organ in which it began such as
metastatic colon cancer in cancer that starts in the colon and
spreads to the liver.
liver cancer is rarely discovered early and is difficult to
control with current treatments, the prognosis is often poor.
Even when treatments fail to provide much improvement, however,
they often can help control pain and improve quality of life.
But the most important news about primary liver cancer is that
you can greatly reduce your risk by protecting yourself from
hepatitis infection and cirrhosis, the leading causes of the
Signs and Symptoms
Most people don't have signs and symptoms in the
early stages of liver cancer, which means the disease may not be
detected until it's quite advanced. When symptoms do appear,
they may include some or all of the following:
Loss of appetite and weight
Abdominal pain, especially in the upper right
part of your abdomen, that may extend into your back and
Nausea and vomiting
General weakness and fatigue
An enlarged liver
Abdominal swelling (ascites)
A yellow discoloration of your skin and the
whites of your eyes (jaundice)
Weighing between 3 and 4 pounds and about the
size of a football, your liver is the largest internal organ in
your body. It's located in the upper right portion of your
abdomen, beneath your diaphragm and above your stomach. Your
liver is divided into two main sections (lobes). Each lobe is
made up of thousands of smaller lobes (lobules), which are
connected to a network of ducts. The lobules are the functioning
parts of your liver and perform hundreds of tasks essential for
your health and well-being.
Your liver processes most of the nutrients
absorbed from your small intestine and determines how much sugar
(glucose), protein and fat enter your bloodstream. It also
manufactures blood-clotting substances and certain proteins and
every day produces nearly a quart of bile a fluid that helps
your body digest fats.
Your liver also performs a vital detoxifying
function by removing drugs, alcohol and other harmful substances
from your bloodstream. At any one time your liver holds about 13
percent of your body's total blood, which enters the liver
through two vascular systems: the hepatic artery and portal
Because of the complexity of the liver and its
exposure to so many potentially toxic substances, it would seem
especially vulnerable to disease. But the liver has an amazing
capacity for regeneration it can heal itself by replacing or
repairing injured tissue. In addition, healthy cells will take
over the function of damaged cells, either indefinitely or until
the damage has been repaired. Yet in spite of this, your liver
is prone to a number of diseases that can cause serious or
irreversible damage. One of these diseases is primary liver
What happens in liver cancer?
In liver cancer some cells begin to grow
abnormally. It's not completely understood why this happens, but
researchers believe that cancer starts with damage to DNA — the
material that contains the instructions for every chemical
process in your body, including the rate of cellular growth. DNA
damage causes changes in these instructions. One result is that
cells may begin to grow out of control and eventually form a
tumor — a mass of malignant cells.
Factors known to damage DNA in liver cells
Hepatitis B and C.
Worldwide, chronic infection with
the hepatitis B virus (HBV) or hepatitis C virus (HCV) is
the most common cause of liver cancer. In the United States,
hepatitis C infection is responsible for half the new cases
of hepatocellular carcinoma (HCC), the most common type of
primary liver cancer. Hepatitis C is transmitted primarily
through transfusions with blood that hasn't been screened
for the virus, through contaminated needles used to inject
drugs or, less commonly, through needles used in tattooing
or body piercing. In some cases, hepatitis C may be
transmitted sexually. Just how it damages DNA isn't well
understood. The virus doesn't insert its genetic material
into healthy liver cells the way HBV does, but some experts
think that the virus may interfere with the action of a gene
that prevents cells from reproducing at an accelerated rate.
HBV is spread through unprotected sexual
contact and through contaminated needles. In addition, women
infected with HBV can pass the virus to their unborn
children. The virus appears to affect the liver by inserting
some of its genetic material into healthy liver cells. This
disrupts the normal functioning of the cells and eventually
may lead to cancer.
In the United States, alcohol abuse is the most common cause
of cirrhosis, a disease that leads to irreversible scarring
in the liver. Hereditary hemochromatosis, which causes
excess iron to accumulate in your liver and other tissues,
also can lead to cirrhosis.
Long-term exposure to aflatoxins.
These highly toxic carcinogens are formed when certain crops
or foods are contaminated with the fungus Aspergillus flavus.
Aflatoxins can damage the p53 gene, which normally works to
prevent excessive cell growth. Although the risk from
aflatoxins in the United States is small, the toxins have
been found in corn and corn products, peanuts and peanut
products, cottonseed, milk, Brazil nuts, pecans, pistachios
and walnuts. As a result, the Food and Drug Administration
has instituted a number of procedures to identify and
measure aflatoxins in the food supply.
Vinyl chloride and thorium dioxide (Thorotrast).
Vinyl chloride is a chemical used to manufacture plastics.
Thorotrast was at one time given to people undergoing X-ray
tests. Both chemicals are known to play a role in the
development of rare cancers that begin in the liver's blood
vessels (angiosarcomas or hemangiosarcomas).
Arsenic. Drinking water contaminated
with arsenic, a known carcinogen, has been implicated in the
development of liver cancer.
Primary biliary cirrhosis. People with
primary biliary cirrhosis, an inflammation of the bile ducts
in the liver, have a significantly increased risk of
cholangiocarcinoma, a type of primary liver cancer. For that
reason, doctors usually recommend routine cancer-screening
tests for people with this condition.
Ulcerative colitis. This inflammatory
condition of the colon and digestive tract leads to changes
within the bile ducts and increases the risk of
Types of primary liver cancer
Several types of liver cancer exist, each with
its own set of causes:
Hepatocellular carcinoma (HCC).
This is the most common form of primary liver cancer in both
children and adults. It starts in the hepatocytes, the main
type of liver cell, but can spread in different ways — as a
single tumor that slowly invades the rest of the liver or as
cancer that immediately spreads throughout the entire organ.
The most common causes of HCC include cirrhosis, hepatitis B
or C infection, and ingestion of aflatoxin-contaminated
Cholangiocarcinoma. This type of
cancer begins in the small bile ducts within the liver.
You're at increased risk of developing cholangiocarcinoma if
you have gallstones or ulcerative colitis. Certain liver
parasites commonly found in parts of Southeast Asia also may
contribute to this type of cancer.
Hepatoblastoma. This rare type of
liver cancer affects children younger than 4 years of age
and may be caused by an abnormal gene. Most children with
hepatoblastoma can be successfully treated.
Angiosarcoma or hemangiosarcoma.
These rare cancers begin in the blood vessels of the
liver and are associated with exposure to industrial
chemicals such as vinyl chloride or the drug thorium dioxide
(Thorotrast). They're much less likely to occur today.
Medical use of Thorotrast was discontinued nearly 50 years
ago, and workers are better protected from exposure to
United States, most cancer found in the liver has spread there
from another part of the body. Rather than being referred to as
liver cancer, this type of cancer is usually named after the
organ where it originated and is described as "metastatic." For
instance, cancer that has spread to the liver from the colon is
referred to as metastatic colon cancer.
cancers form when malignant cells detach from the primary cancer
and travel through the body in the circulatory or lymphatic
system. Because the liver is close to a number of significant
organs including the pancreas, gallbladder, stomach, colon,
breasts and lungs and because the liver is richly supplied with
blood, it's especially vulnerable to metastatic tumors.
Types of Benign Tumors
Noncancerous (benign) tumors also can develop in the liver. They
Hemangioma. This is the most common type of benign
liver tumor. It affects the liver's blood vessels and
usually results from a malformation of tissue during fetal
development. Most hemangiomas of the liver don't cause signs
or symptoms and don't need treatment.
Hepatic adenoma. This benign tumor originates in the
hepatocytes the main type of liver cell. In most cases,
hepatic adenomas don't cause signs or symptoms, but
occasionally you may experience abdominal pain, a mass in
the abdomen or blood loss. You're more likely to develop
this type of benign tumor if you use birth control pills,
but simply stopping the pill often causes the tumor to
Focal nodular hyperplasia. This tumor is a combination
of several types of cells, including hepatocytes, bile duct
cells and connective tissue. Like other benign tumors, it's
more common in women than in men and usually doesn't cause
signs or symptoms.
Liver cancer can affect people of all ages and
races, but certain factors may increase your risk, including:
Sex. Men are twice
as likely to develop liver cancer as women are.
Asian-Americans have the highest rate of liver cancer in the
United States due to high rates of chronic hepatitis B
infection. American blacks and Hispanics are more likely to
develop liver cancer than whites are, but their risk is more
moderate than it is for immigrants from Asian countries
where hepatitis B infection is endemic.
Age. In the United
States, liver cancer occurs most often in people age 60 and
Chronic infection with
HBV or HCV. Chronic infection with hepatitis B or C is
by far the most important risk factor for liver cancer.
Worldwide, HBV infection is involved in the majority of
cases of HCC. In the United States, hepatitis C infection is
a greater risk factor.
This progressive and irreversible condition causes scar
tissue to form in your liver and increases your chances of
developing liver cancer.
People with this blood sugar disorder have a greater risk of
liver cancer than do people who don't have diabetes. Having
both diabetes and hepatitis C infection increases the risk
Having certain gene
mutations. Doctors have long known that women with
mutations in the BRCA1 and BRCA2 genes are more likely to
develop breast and ovarian cancer than are women who don't
have these genetic defects. Now BRCA1 and BRCA2 mutations
have been tied to a moderately increased risk of other
cancers, including primary liver cancer.
Exposure to aflatoxins.
Consuming foods contaminated with aflatoxins greatly
increases the risk of liver cancer.
consumption. Consuming more than a moderate amount of
alcohol can lead to irreversible liver damage and increase
your risk of liver cancer. Moderate consumption is defined
as no more than two drinks a day for men and one for women.
A drink is one 4- to 5-ounce glass of wine, 12 ounces of
beer or a 1.5-ounce shot of 80-proof distilled spirits.
tobacco of any kind makes it more likely that you'll develop
Screening and Diagnosis
No completely accurate screening test for liver
cancer exists. Doctors sometimes use a blood test that checks
for the presence of alpha-fetoprotein (AFP) a type of protein
not normally found in adults to screen people at high risk of
the disease. But the test isn't perfect. Not all malignant liver
tumors produce AFP, and those that do may be advanced by the
time protein levels become elevated. In addition, other types of
cancer and even some noncancerous liver diseases can raise AFP
Although AFP screening can detect small tumors in
some people, most liver cancer isn't diagnosed early. That's
because symptoms usually don't appear until late in the disease
and because liver cancers grow quickly. The most common type of
liver cancer, HCC, doubles in size every four months. Diagnosis
is also difficult because the effects of some liver tumors may
resemble those of other medical conditions, and because liver
cancer can't be diagnosed using a standard panel of liver tests.
If you experience any of the symptoms of liver
cancer, such as unexplained weight loss, persistent abdominal
pain or swelling, or jaundice, see your doctor as soon as
possible. He or she will interview you about your medical
history, perform a physical exam, and will likely recommend one
or more of the following tests, each of which has certain
advantages and disadvantages:
Ultrasound (ultrasonography). This noninvasive test,
which doesn't expose you to radiation or dyes, uses sound
waves to produce a picture of internal organs, including the
liver. Ultrasound is painless and usually takes less than 30
minutes. While you lie on a bed or examining table, a
wand-shaped device (transducer) is placed on your body. It
emits sound waves that are reflected from your liver and
transformed into a computer image. Ultrasound is especially
good at providing information about the shape, texture and
makeup of tumors.
Computerized tomography (CT) scan. This test uses X-rays
to produce cross-sectional images of your body. You may also
have a variation of the test known as a CT angiogram in
which contrast dye is injected into an artery in your liver.
X-rays then track the dye as it flows through the blood
vessels in your liver. A CT angiogram, which may take up to
an hour to perform, can provide detailed information on the
number and location of liver tumors, but a CT scan exposes
you to more radiation than conventional X-rays do, and some
people may experience an allergic reaction to the contrast
resonance imaging (MRI). Instead of X-rays, MRI creates
images using a magnetic field and radio waves. Sometimes a
contrast dye also may be used. The test can take from 15
minutes to an hour. You may find an MRI more uncomfortable
than a CT scan because you're enclosed in a tube that is
quite confining and because the machine generates a thumping
noise that many people find disturbing. Headphones or
earphones can help with the noise, and if you're very
claustrophobic, your doctor may recommend medication to help
you relax. Newer MRIs can show images of the ducts that
transport bile from the liver to the upper part of the small
intestine (duodenum) as well as of the arteries and veins
within the liver.
In this procedure, a sample of tissue is removed from your
liver and examined under a microscope. Liver biopsy is
considered the only definitive way to diagnose liver cancer.
Your doctor may use a thin needle or a lighted instrument
(laparoscope) to obtain the sample. If the tumor is small,
an ultrasound or CT scan is often used to help pinpoint the
area to be biopsied. A needle biopsy is the simpler
procedure, with less risk of bleeding, but it doesn't always
provide enough cells for an accurate evaluation. Because the
liver is so well supplied with blood vessels, bleeding is
the most common risk of a biopsy, but bruising and infection
also can occur.
tests. If tests reveal that you have liver cancer, your
doctor may perform additional blood tests to check the
condition of the liver tissue not affected by cancer. This
information may play a role in determining the best
treatment for you.
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