Understanding Liver Cancer
Introduction +

In the United States approximately 10,000 new patients are diagnosed with primary liver cancer (hepatocellular carcinoma) each year. This is the most common type of cancer to arise in the liver.

The number of liver cancers diagnosed in the US and throughout the world is increasing at an alarming rate. The number of liver cancers will continue to increase over the next few decades. Most of the increase in liver cancer is attributable to patients who became infected with hepatitis B and C viruses. Hepatitis B and hepatitis C viral infections peaked in the 1950's to 1980's. Approximately 4 million (that is about 2% of the US population!) Americans are infected with Hepatitis C virus. People become infected with hepatitis viruses by coming in contact with infected person's blood. After 2 to 3 decades patients infected with these viruses can develop complications of long-standing (chronic) viral infection.

The complications of long-standing (chronic) viral infection include liver scarring (cirrhosis) and liver cancer. Liver cancer is a lethal cancer with untreated patients rarely surviving more than one year.

The Johns Hopkins Medical Institution is a leader in the treatment and investigative study of liver cancer. We have created this Web site as a resource for patients and physicians to access the latest clinical and research developments as well as to the multidisciplinary team assembled here to treat liver cancer.

We have also included a chat room so that users of the web page can directly support each other.

Diagnosis +

Masses that occur in the liver can be determined to be harmless (benign) or malignant (cancerous) in various ways. The first, involves the use of imaging techniques such as Computed Axial Tomography (CT) scan / Magnetic Resonance Imaging (MRI) or the injection of a dye into the blood vessels (angiography). The larger the liver cancer the more likely these imaging techniques will be able to diagnose it. Liver cancer has special features, such as a rich blood supply or tendency to increase in size, which these imaging techniques can detect.

If imaging can not determine if a tumor is benign or malignant, a fine needle biopsy may be performed. In this procedure, a fine (very thin) needle is passed through the skin, into the liver and directed toward the tumor using an exterior ultrasound to guide the needle.

If a needle biopsy is performed, Johns Hopkins' pathologists, Drs. Robert Anders, Michael Torbenson, John Boitnott all have focused interest on interpreting these biopsies. The normal liver cells grow in columns that are one or two cells thick. In liver cancer, the columns of liver cells become wider than one or two cells. The wide columns of liver cells can be seen on microscopic examination and are one helpful feature of liver cancer.

Screening +

Screening tests are used to detect liver cancer at the earliest possible stage. There are no good screening tools for liver cancer. Current screening methods include a blood test, Computed Axial Tomography (CT) scan / Magnetic Resonance Imaging (MRI) or angiography (the injection of a dye into the blood vessels). There are currently no reliable blood test to diagnose liver cancer. A test for alpha fetal protein (AFP) may be slightly elevated in 2/3 of patients with liver cancer, but may also be slightly elevated in patients with chronic liver disease. Very high levels of serum AFP is a good indication of liver cancer, but is only seen in a few patients. At risk individuals can also be screened using imaging techniques such as Computed Axial Tomography (CT) scan / Magnetic Resonance Imaging (MRI) or angiography (the injection of a dye into the blood vessels).

At Johns Hopkins, the Department of Gastroenterology and Hepatology are actively involved in day to day screening of patients at high risk for developing liver cancer.

Prevention +

Since most liver cancer develops in patients with long standing (chronic) hepatitis viral infection, prevention of infection is vital. Avoiding contact with an infected person's blood can prevent the transmission of hepatitis viruses. In addition, there is an effective vaccine for hepatitis B. To learn more about this vaccine click here. However, there is no vaccine for hepatitis C virus.

Once patients develop chronic infection with hepatitis viruses, the goal is to preserve liver tissue and prevent scarring (cirrhosis). This requires a multi-disciplinary approach involving the patient, a hepatologist and pathologist. Once it is established that a patient is chronically infected with a hepatitis virus, the patient will need to enter into a treatment program to minimize liver damage. This program involves regular visits to a hepatologist who will monitor the relative health of the liver. This monitoring may involve simple blood tests or occasionally a liver needle biopsy. A pathologist experienced in interpreting liver biopsies will determine the amount of liver damage and scarring. Patients need to learn to avoid activities with can further damage the liver, such as consuming alcohol or taking certain medications. In addition, patients can engage in liver healthy activities such as maintaining an ideal body weight and a liver healthy diet.

Treatment +

Treatment of liver injury
Most liver cancers develop in patients with chronic liver disease. Chronic liver injury and liver scarring (cirrhosis) are fertile environments for the development of liver cancer. Current treatments are aimed at reducing chronic injury and attempt to prevent cirrhosis. These treatments include interferons, ribavirin and lamivudine. These medications are given as an injection or a pill and require supervision of a doctor.

Treatment of liver cancer
Once liver cancer develops there are 3 main treatment options. First, surgery that involves the removal of the tumor or even liver transplant in which the entire liver is surgically removed and replaced with a new liver from a donor, offers the best hope of a cure. The size and location of the tumor, the health of the remaining liver, if the tumor has spread and the overall health of the patient determines if this is an option. Second, tumor ablation in which the cancer cells in the tumor are directly killed by radiofrequency, freezing or chemical injection are relatively new treatment options. Tumor ablation techniques involve placing a fine probe into the center of the tumor and injecting cold or toxic chemical that destroy the tumor cells. Third, radiation and chemotherapy have been used. Radiation can shrink a tumor but is not a curative procedure. Similarly, chemotherapy has been shown to shrink liver cancers, but it is unclear if this increases patient survival.

Although most cancers develop in patients with liver scarring (cirrhosis), some patients develop liver cancer without first developing cirrhosis. Johns Hopkins researchers have a particular interest in this type of liver cancer.

Cancer Types +

As the largest internal organ, the liver performs a variety of vital functions. Different cell types are responsible for these diverse functions. The basic liver cells (known as hepatocytes) produce blood clotting factors, synthesize bile, metabolize proteins and remove toxins from the blood. The liver has a rich network of blood vessels carrying nutrients and toxins from the intestine to the liver and back to the circulation. The liver also has a system of bile ducts which carry bile (a green fluid that helps digestion of food) from the liver and gall bladder into the intestine. Tumors may arise from any of these types of cells and thus there is a wide variety in types of liver cancer.

pie chart

Tumors can be generally thought of as benign or malignant. Benign tumors are unlikely to metastasize (spread throughout the body) while malignant tumors are cancerous and are likely to spread to other organs.

Liver Cancer types listed by cell of origin
List of benign tumors and cell of origin List of malignant (cancerous) tumors and cell of origin
  • - Hepatocytes
    • Adenoma
    • Focal nodular hyperplasia
  • - Vessels
    • Hemangioma
  • - Bile duct
    • Adenoma
    • Hamartoma (Von Myenberg Complex)
  • - Hepatocytes
    • Hepatocellular carcinoma
    • Hepatoblastoma
    • Fibrolamellar carcinoma
  • - Vessels
    • Angiosarcoma
  • - Bile duct
    • Cholangiocarcinoma