Liver cancer

• About 80 to 90 out of 100 primary liver cancers.
• This map is about this type.

Intrahepatic cholangiocarcinoma starts in the bile ducts inside the liver and is treated like bile duct cancer. Choose Gallbladder and bile duct above. Fibrolamellar carcinoma is a rare type in young people.

A triple-phase CT or MRI of the liver. HCC has a typical appearance, so in a patient with cirrhosis it can often be diagnosed without a biopsy. A biopsy is done if the scan is not typical.

A tumour marker. Raised in many patients; used to follow treatment.

Blood tests (bilirubin, albumin, clotting) and examination for fluid or confusion give a Child-Pugh score (A, B or C). It shows how much reserve the liver has, and decides which treatments are safe.

HBsAg, HBV DNA, anti-HCV and HCV RNA. If positive, antiviral treatment is started; it protects the liver and makes cancer treatment safer.

Checks for swollen veins in the food pipe (varices), which can bleed. They are treated before medicines like bevacizumab are started.

Before starting chemotherapy, immunotherapy or targeted therapy, these tests check that you are fit for treatment, and give a starting point to compare with later.

Before immunotherapy, also:

Sometimes needed, depending on your treatment:

• Pregnancy test for women who could be pregnant.
• Calcium and magnesium: for example before cisplatin or bone-strengthening injections.
• Dental check-up before bone-strengthening injections (zoledronic acid or denosumab), as they can rarely affect the jaw bone.
• Hearing test before cisplatin, in some patients.
• Clotting tests (PT/INR) before a biopsy or chemoport.

Your doctor will choose the tests that apply to you. Some of them are repeated during treatment.

• The scans and liver function decide between surgery, ablation, transplant, TACE or medicines.
• Varices must be checked and treated before some medicines, to prevent bleeding.
• Hepatitis B must be controlled before treatment, to prevent a flare.

A single tumour, or up to 3 small tumours, with good liver function. The aim is cure.

Several tumours in the liver, not spread outside it, with good liver function.

Spread into the main blood vessel of the liver (portal vein) or outside the liver, or the cancer is affecting your fitness.

Liver function is very poor. Treatment focuses on comfort and symptoms; a transplant is considered for a few patients.

1. Surgery to remove the tumour, if the liver is healthy enough.
2. Ablation (radiofrequency or microwave): the tumour is destroyed with a needle, without open surgery.
3. Liver transplant: for selected patients with cirrhosis and small tumours. It treats both the cancer and the liver disease.

Side effects: surgery and procedures

1. TACE (chemoembolisation): chemotherapy is injected into the artery feeding the tumour, which is then blocked. Can be repeated.
2. TARE / SIRT: tiny radioactive beads are injected into the artery instead.
3. TACE combined with medicines, for patients with larger or more tumours:
   • TACE with durvalumab and bevacizumab.
   • TACE with lenvatinib and pembrolizumab.
   • TACE with lenvatinib.
4. If there are too many tumours for TACE: medicines as in the advanced stage.

Side effects: TACE · immunotherapy · bevacizumab and lenvatinib

1. First treatment, options:
   • Atezolizumab with bevacizumab (after varices are treated).
   • Durvalumab with tremelimumab.
   • Nivolumab with ipilimumab.
   • Lenvatinib or sorafenib tablets, if immunotherapy is not suitable.
2. Other combinations approved in some Asian countries (such as China): camrelizumab with rivoceranib (apatinib), toripalimab with bevacizumab, and sintilimab with a bevacizumab biosimilar. Availability in India may be limited; your doctor will advise.
3. Later options: regorafenib, cabozantinib, or ramucirumab (if AFP is 400 or more).
4. Radiotherapy can help with spread to bones or blood vessels.

Side effects: immunotherapy · targeted medicines

Focus on comfort: relief of pain, fluid and other symptoms. Supportive and palliative care. A liver transplant is considered for a few patients.

• After TACE: fever, tummy pain and nausea for a few days (post-embolisation syndrome). It settles with medicines.
• After surgery: the liver regrows over weeks; tell us about yellowness or tummy swelling.

• The immune system can affect normal organs: thyroid, skin (rash, itching), bowel (loose stools), lungs (cough, breathlessness) and liver.
• These can happen months after starting, or even after stopping. Report any new symptom, even if it seems small.
• Thyroid, cortisol and liver blood tests are checked regularly.

More about immunotherapy · Side effects of your regimen

• Bevacizumab: high blood pressure, protein in urine, bleeding (especially from varices).
• Lenvatinib / sorafenib: high blood pressure, sore red palms and soles (hand-foot syndrome), loose stools, tiredness, poor appetite.

• Stop alcohol completely.
• Keep taking hepatitis B or C medicines as prescribed.
• Avoid herbal and home remedies; some can damage the liver.
• Control diabetes and weight if you have fatty liver.

Family members of patients with hepatitis B should be tested, and vaccinated if not immune.

Scans and AFP every 3 months at first, then less often.

Vomiting blood, black stools, increasing yellowness, tummy swelling, confusion or drowsiness, fever, or severe tummy pain need urgent care.

When to seek help urgently