Liver cancer

• Liver cancer is categorised as either primary or secondary.
• Primary liver cancer is rare in the UK.
• The most common route to diagnosing liver cancer is emergency presentation.
• There are a number of staging systems that can help to determine the size and position of the liver cancer so as to make decisions about treatment.

There is a variety of types of cancer. Cancer is not just one disease; it can start in the lungs, the breast, the colon, the liver and even in the blood. Cancers are similar in a number of ways, but they differ in the way that they grow and metastasise (spread).

Metastatic (secondary) liver cancer is much more prevalent than primary liver cancer (deWit et al, 2018); liver cancer can be benign or malignant. Any cancer can spread to the liver. The most common cancers to do so are: breast cancer, bowel cancer and lung cancer.

There are several kinds of liver cancer. Table 1 discusses two types of primary liver cancer.

An individual's risk of developing liver cancer depends on a number of factors. These include the person's age (old age is the main risk factor), genetics and exposure to risk factors (including some potentially avoidable lifestyle factors). Those people with cirrhosis have the highest risk of developing hepatocellular carcinoma (Forner et al, 2018).

Cirrhosis may be due to:

• hepatitis B virus (HBV) or hepatitis C virus (HCV) infection
• alcoholism
• genetic haemochromatosis
• primary biliary cirrhosis
• a metabolic syndrome, diabetes and/or smoking.

Old age is the main risk factor; other factors include obesity, with 23% of liver cancer caused by overweight and obesity. In the UK, 20% of liver cancers are caused by smoking (Brown et al, 2018).

In people with HIV/AIDS, liver cancer risk is 5–6 times higher compared with the general population.

Most people do not have signs and symptoms in the early stages of primary liver cancer. The symptoms associated with liver cancer can be vague. People with liver cancer often present with symptoms of advancing cirrhosis and liver failure (Table 2). 

Some other symptoms can include: pyrexia (raised body temperature/fever), enlarged veins on the abdomen that can be seen through the skin (periumbilical collateral veins), and abnormal bruising or bleeding.

Emergency presentation is the most common route to diagnosing liver cancer. A medical history is taken and the patient is asked about symptoms. Diagnostic tests are used to determine the presence of a tumour and the stage, to make a definitive diagnosis.

Tests include blood samples and imaging, for example, abdominal ultrasound scan, MRI or CT scan. Special imaging tests of the liver to provide a closer examination may be required. There may be a need to have a percutaneous fine needle biopsy if a diagnosis needs to be confirmed.

A specialist X-ray study, an hepatic angiography of the blood vessels that supply the liver, may be needed if the diagnosis is still uncertain after CT and MRI scans have been performed. The hepatic angiogram is typically performed under local anaesthetic. A laparoscopy (keyhole surgery, performed under general anaesthetic) may be undertaken to assess damage to the liver and bile

In order to make decisions about treatment, it is important to know the size and position of the liver cancer and how well the liver is functioning (cirrhosis of the liver may interfere with effective hepatic function). A multidisciplinary team working with the patient and ensuring that the patient is at the centre of all that is done will formulate a plan of care. As no two people are the same, individual treatment options are offered and discussed with the patient.

The Barcelona Clinic Liver Cancer (BCLC) staging system is often used to help determine size and position of the liver cancer. The BCLC staging system considers the number and size of tumours in the liver and as to how well the patient is overall and how the liver is functioning. A score (Child-Pugh score) is allocated to this, after assessment has been made (European Association for the Study of

I would like to thank Mrs Frances Cohen for her help and support.