Liver cancer

What is liver cancer?

In primary liver cancer, a malignant tumor forms from cells within the liver. This is usually liver cell cancer. Doctors refer to this as hepatocellular carcinoma (HCC ). Liver cancer (hepatocellular carcinoma) often develops as a result of liver cirrhosis. Possible signs of liver cancer are upper abdominal pain, tiredness and loss of appetite. However, it often only causes symptoms at an advanced stage.

More rarely, cancer develops from the cells of the bile ducts(bile duct carcinoma; cholangiocarcinoma) within the liver. This type of cancer usually requires a different therapy than liver cancer.

What are liver metastases?

Not every malignant tumor discovered in the liver originates from the liver’s own cells. Cancer cells in the liver that have not originated from liver cells are referred to as liver metastases or secondary liver cancer.

Secondary liver cancer occurs when tumors that have arisen elsewhere in the body spread to the liver and form metastases there. In particular, cancers of the gastrointestinal tract (e.g. bowel cancer), breast or lung can lead to such liver metastases. As a rule, those affected suffer from another cancer that has progressed to such an extent that the liver is ultimately also affected.

How common is liver cancer?

The most common form of primary liver cancer, liver cancer (HCC), occurs mainly in South East Asia and Africa. However, the number of new cases has also risen significantly in western countries in recent years. Liver cancer is relatively rare compared to many other cancers. Every year, for example, 4300 people in Switzerland are diagnosed with colon cancer – around 820 people are diagnosed with liver cancer. Men develop liver cancer more than twice as often as women. Liver cancer rarely occurs before the age of 50 and is most common after the age of 70.

Symptoms of liver cancer

Liver cancer (liver carcinoma) often initially causes rather general, non-specific symptoms. In the early stages of the disease, there are usually no symptoms, which is why liver cancer is often diagnosed late. This worsens the prognosis.

Possible symptoms of liver cancer are

• Pressure pain in the right or middle upper abdomen
• Nausea
• Loss of appetite
• Feeling of weakness, reduced performance
• Elevated temperature without a recognizable cause
• Unexplained weight loss
• Palpable swelling under the right costal arch (occasionally)
• Jaundice

The liver produces bile, which flows into the digestive tract via the bile ducts. Tumors of the liver or bile ducts can obstruct this outflow. This causes the bile to build up. The typical symptoms of jaundice (icterus) then appear: The whites of the eyes and later also the skin and mucous membranes turn increasingly yellow. In addition, the urine is darker than usual, while the stool is lighter than usual. The skin may also itch.

Complaints such as nausea, abdominal pain or loss of appetite can have many causes and are not necessarily a sign of liver cancer. Nevertheless, if you notice such symptoms over a longer period of time, you should consult a doctor. He can rule out or confirm whether it is actually liver cancer.

Causes of liver cancer

The exact causes of liver cancer are unknown. Cirrhosis of the liver is an important risk factor. Liver cirrhosis (“shrunken liver”) is severe liver damage that is often caused by years of alcohol abuse or liver inflammation (hepatitis). The most common form of primary liver cancer, liver cancer (hepatocellular carcinoma), almost always develops as a result of liver cirrhosis. Around nine out of ten people with liver cancer have liver cirrhosis.

Infection with hepatitis viruses

Even without liver cirrhosis, the risk of liver cancer is significantly increased if a person suffers from chronic, i.e. permanent liver inflammation(hepatitis) caused by viruses. Infection with the hepatitis B virus in particular can promote liver cancer. Anyone infected with hepatitis B at birth has a higher risk of developing liver cancer in the course of their life than someone who is infected later. Chronic hepatitis C infection is also a risk factor.

Chronic liver inflammation due to fatty liver

Another risk factor for liver cancer is fatty liver, which can lead to chronic liver inflammation. A fatty liver can have various causes. Alcohol, diabetes mellitus and obesity play a major role in its development.

Other risk factors

Other factors that increase the risk of liver cancer include:

• Liver-damaging substances such as aflatoxin B1 in food (poison from the fungus Aspergillus flavus, which grows on cereals, peanuts and other foods in humid climates)
• Hereditary metabolic diseases, e.g. iron storage disease (hemochromatosis), Wilson’s disease
• Taking certain sex hormones (e.g. anabolic steroids)
• Occupational exposure to chemical substances such as solvents or pesticides

Causes of bile duct cancer

The causes of the less common bile duct carcinoma (cholangiocarcinoma) are not fully understood. However, certain diseases increase the risk. These include

• Cysts of the bile duct (choledochal cysts),
• initially benign tumors of the bile ducts (adenomas),
• Bile duct stones,
• a rare chronic inflammation of the bile ducts (so-called primary sclerosing cholangitis, PSC) and
• Liver diseases caused by chronic infections with parasites such as liver flukes (especially in countries such as China and Japan).

Smoking and older age also appear to increase the risk of liver cancer and bile duct cancer.

Bile duct carcinoma is divided into three localizations:

• In the liver (intrahepatic)
• At the junction of the left and right bile ducts (Klatskin tumor)
• In the bile duct outside the liver (distal bile duct carcinoma)
• The treatment of cholangiocarcinoma varies depending on the location.

Diagnosis of liver cancer

If liver cancer (liver carcinoma) is suspected, a number of examinations are necessary. If cancer has indeed been found, it is important to find out,

• whether the tumor originally originated in the liver (so-called primary liver cancer) or
• whether there are liver metastases (so-called secondary liver cancer).

It all starts with a detailed discussion between you and us. For example, we ask about

• Nature and duration of the complaints,
• Pre-existing and concomitant diseases and
• possible risk factors for liver cirrhosis such as chronic hepatitis or alcohol abuse.

This is followed by a thorough physical examination: among other things, the doctor will palpate the liver and other abdominal organs through the abdominal wall. Other initial investigations include:

• Ultrasound (sonography): Ultrasound allows us to view the liver, bile ducts and gallbladder, the kidneys and the spleen. We can also examine the lymph nodes. The ultrasound examination is risk-free and painless.
• Blood sampling and laboratory tests: Based on the blood count, we can identify possible indications of cancer. Secondly, we can use the blood values to determine how well the liver is working. In addition, hepatitis viruses can be detected or ruled out in the blood. A certain tumor marker in the blood is often elevated in various cancers: Alpha-fetoprotein(AFP). However, the AFP value alone does not allow a reliable statement as to whether liver cancer is present or not. AFP is also often naturally elevated during pregnancy.

Treatment of liver cancer

The treatment of liver cancer depends on the location, size and spread of the tumor on the one hand and on the patient’s liver function and state of health on the other. It is also important to determine whether the tumor has developed as a result of liver cirrhosis. There are numerous options for the treatment of liver cancer, which can be combined under certain circumstances.

If liver cancer is suspected, further examinations are useful to confirm the diagnosis and determine how far the tumor has spread. These include:

• Computed tomography (CT) with administration of a contrast agent
• Contrast medium ultrasound examination (KMUS)
• Magnetic resonance imaging (MRI) with administration of a contrast agent
• PET-CT, especially if there is a suspicion of secondary liver cancer (metastases)

If it is unclear whether the cancer is primary liver cancer or liver metastases, we may perform a gastroscopy and/or a colonoscopy. This enables us to find out whether a cancer in the stomach or intestine has spread to the liver.

Ultimately, only a histological examination of the abnormal liver areas under the microscope can confirm with 100% certainty that it is liver cancer. In the vast majority of cases, the radiologist can diagnose liver cancer on the basis of an MRI scan.

If bile duct cancer is suspected, an endoscopy of the bile ducts with an endoscope (endoscopic retrograde cholangiography, ERCP) can provide clarity, and fine needle puncture can often also be performed from the inside. In cancer of the bile ducts, a certain tumor marker is elevated in the blood: Ca 19-9 (cancer antigen 19-9, cancer = cancer). We therefore take blood samples and test them for this protein. However, the determination of the tumor marker alone is not suitable for diagnosis.

Self-help groups

The exchange with people who are affected by the same disease can be a great support in coping with the disease. Advice on finding a suitable self-help group is available from Selbsthilfe Zürich. Self-Help Zurich and the University Hospital Zurich are cooperation partners in the national project “Health literacy thanks to self-help-friendly hospitals”.