The document presents an overview of liver cancer, detailing statistics, types, symptoms, risk factors, diagnosis methods, and treatment options. It highlights that primary liver cancer, particularly hepatocellular carcinoma, is rising in incidence, with specific survival rates and staging information provided. The document also discusses benign tumors and metastatic liver cancer, emphasizing the importance of effective management strategies such as surgery, ablation, and embolization.

1. Liver cancer
Presented by
Monika
M.Sc Nursing 2nd year
(oncology)

2. Statistics about liver cancer
The American Cancer Society’s estimates for primary liver cancer
and intrahepatic bile duct cancer in the United States for 2022
are:
• About 41,260 new cases (28,600 in men and 12,660 in women)
will be diagnosed
• About 30,520 people (20,420 men and 10,100 women) will die
of these cancers
• Liver cancer incidence rates have more than tripled since 1980,
while the death rates have more than doubled during this time.
• Liver cancer is also a leading cause of cancer deaths
worldwide, accounting for more than 700,000 deaths each year.

3. Introduction
• Liver cancer is a type of cancer that starts in the liver. Cancer
starts when cells in the body begin to grow out of control.
The liver
• The liver is the largest internal organ. It lies under your right ribs
just beneath your right lung. It has two lobes (sections).

4. Anatomy & physiology of Liver
• The liver is made up mainly of
cells called hepatocytes.
• It also has other types of cells,
including cells that line its blood
vessels and cells that line small
tubes in the liver called bile
ducts.
• The bile ducts carry bile from
the liver to the gallbladder or
directly to the intestines.

5. Cont….
Important functions of liver:
• It breaks down and stores many of the nutrients absorbed from the
intestine that body needs to function.
• Some nutrients must be changed (metabolized) in the liver before
they can be used for energy or to build and repair body tissues.
• It makes most of the clotting factors.
• It delivers bile into the intestines to help absorb nutrients (especially
fats).
• It breaks down alcohol, drugs, and toxic wastes in the blood, which
then pass from the body through urine and stool

6. Types
• The different types of cells in the liver can form several types of
malignant (cancerous) and benign (non-cancerous) tumors.
• These tumors have different causes, are treated differently, and have
a different prognosis
1. Primary liver cancer
 Hepatocellular carcinoma (HCC)
 Intrahepatic cholangiocarcinoma (bile duct cancer)
 Angiosarcoma and hemangiosarcoma
 Hepatoblastoma
2. Secondary liver cancer (metastatic liver cancer)
3. Benign liver tumors
 Hemangioma
 Hepatic adenoma
 Focal nodular hyperplasia

7. Primary liver cancer
A cancer that starts in the liver is called primary liver cancer. There is
more than one kind of primary liver cancer.
a) Hepatocellular carcinoma (HCC)- This is the most common form
of liver cancer in adults.
Hepatocellular cancers can have different growth patterns:
• Some begin as a single tumor that grows larger. Only late in the
disease does it spread to other parts of the liver.
• A second type seems to start as many small cancer nodules
throughout the liver, not just a single tumor. This is seen most often
in people with cirrhosis (chronic liver damage) and is the most
common pattern seen in the United States.

8. Primary liver cancer cont…..
b) Intrahepatic cholangiocarcinoma (bile duct cancer)- About
10% to 20% of cancers that start in the liver are intrahepatic
cholangiocarcinomas.
• These cancers start in the cells that line the small bile ducts
(tubes that carry bile to the gallbladder) within the liver.

9. Primary liver cancer cont…..
c) Angiosarcoma and hemangiosarcoma- These are rare
cancers that begin in cells lining the blood vessels of the liver.
• People who have been exposed to vinyl chloride or to thorium
dioxide (Thorotrast) are more likely to develop these cancers.
• Some other cases are thought to be caused by exposure to
arsenic or radium, or to an inherited condition known
as hereditary hemochromatosis
• These tumors grow quickly and are usually too widespread to
be removed surgically by the time they are found.
• Chemotherapy and radiation therapy may help slow the
disease, but these cancers are usually very hard to treat. These
cancers are treated like other sarcomas.

10. Primary liver cancer cont…..
d) Hepatoblastoma
• This is a very rare kind of cancer that develops in children,
usually in those younger than 4 years old.
• The cells of hepatoblastoma are similar to fetal liver cells.
• About 2 out of 3 children with these tumors are treated
successfully with surgery and chemotherapy, although the
tumors are harder to treat if they have spread outside the liver.

11. Secondary liver cancer (metastatic
liver cancer)
• Most of the time when cancer is found in the liver it did not start
there but has spread (metastasized) from somewhere else in
the body, such as the pancreas, colon, stomach, breast, or lung.
• Because this cancer has spread from its original (primary) site,
it is called a secondary liver cancer.
• These tumors are named and treated based on their primary
site (where they started). For example, cancer that started in
the lung and spread to the liver is called lung cancer with
spread to the liver, not liver cancer. It is also treated as lung
cancer.
• In the United States and Europe, secondary (metastatic) liver
tumors are more common than primary liver cancer. The
opposite is true for many areas of Asia and Africa.

12. Benign liver tumors
• Benign tumors sometimes grow large enough to cause
problems, but they do not grow into nearby tissues or spread to
distant parts of the body.
• If they need to be treated, the patient can usually be cured with
surgery.
a) Hemangioma- The most common type of benign liver tumor,
hemangiomas, start in blood vessels.
• Most hemangiomas of the liver cause no symptoms and do not
need treatment. But some may bleed and need to be removed
with surgery.

13. Benign liver tumors cont….
b) Hepatic adenoma- Hepatic adenoma is a benign tumor that starts
from hepatocytes (the main type of liver cell).
• Most cause no symptoms and do not need treatment.
• But some eventually cause symptoms, such as pain or a lump in the
abdomen (stomach area) or blood loss.
• Because there is a risk that the tumor could rupture (leading to
severe blood loss) and a small risk that it could eventually develop
into liver cancer, most experts will usually advise surgery to remove
the tumor if possible.
• Using certain drugs may increase the risk of getting these tumors.
• Women have a higher chance of having one of these tumors if they
take birth control pills, although this is rare.
• Men who use anabolic steroids may also develop these tumors.
Adenomas may shrink when these drugs are stopped.

14. Benign liver tumors cont….
c) Focal nodular hyperplasia
• Focal nodular hyperplasia (FNH) is a tumor-like growth made
up of several cell types (hepatocytes, bile duct cells, and
connective tissue cells).
• Although FNH tumors are benign, they might cause symptoms.
• It can be hard to tell them apart from true liver cancers and
doctors sometimes remove them when the diagnosis is unclear.
• Both hepatic adenomas and FNH tumors are more common in
women than in men.

15. Risk factors of liver cancer
• Gender- Hepatocellular carcinoma is much more common in men
than in women. The fibrolamellar subtype of HCC is more common in
women.
• Race/ethnicity
• Chronic viral hepatitis
• Cirrhosis
• Non-alcoholic fatty liver disease
• Primary biliary cirrhosis
• Inherited metabolic diseases- hereditary
hemochromatosis absorb too much iron from their food. The iron
settles in tissues throughout the body, including the liver. If enough
iron builds up in the liver, it can lead to cirrhosis and liver cancer.

16. Risk factors of liver cancer
• Heavy alcohol use
• Tobacco use
Diseases that increase the risk of liver cancer include:
• Tyrosinemia
• Alpha1-antitrypsin deficiency
• Porphyria cutanea tarda
• Glycogen storage diseases
• Wilson disease
Factors that may lower your risk of liver cancer
• Hepatitis B vaccine
• Treatment of viral hepatitis

17. Causes
• Certain chemicals that cause liver cancer, such as aflatoxins,
are known to damage the DNA in liver cells.
• For example, studies have shown that aflatoxins can damage
the TP53 tumor suppressor gene, which normally works to
prevent cells from growing too much. Damage to the TP53 gene
can lead to increased growth of abnormal cells and formation of
cancers.
• Hepatitis viruses can also change DNA when they infect liver
cells. In some patients, the virus's DNA can insert itself into a
liver cell's DNA, where it may turn on the cell's oncogenes.

19. Signs and Symptoms of Liver Cancer
• Weight loss (without trying)
• Loss of appetite
• Feeling very full after a small meal
• Nausea or vomiting
• An enlarged liver, felt as fullness under the ribs on the right side
• An enlarged spleen, felt as fullness under the ribs on the left side
• Pain in the abdomen (belly) or near the right shoulder blade
• Swelling or fluid build-up in the abdomen (belly)
• Itching
• Yellowing of the skin and eyes (jaundice)
• Other symptoms can include fever, enlarged veins on the belly that
can be seen through the skin, and abnormal bruising or bleeding.

20. Signs and Symptoms of Liver Cancer
Some liver tumors make hormones that act on organs other than
the liver. These hormones may cause:
• High blood calcium levels (hypercalcemia), which can cause
nausea, confusion, constipation, weakness, or muscle problems
• Low blood sugar levels (hypoglycemia), which can cause
fatigue or fainting
• Breast enlargement (gynecomastia) and/or shrinkage of the
testicles in men
• High counts of red blood cells (erythrocytosis) which can cause
someone to look red and flushed
• High cholesterol levels

21. AJCC TNM STAGING SYSTEM
21
TX Main tumor cannot be assessed due to lack of information.
T0 No evidence of a primary tumor
T1a A single tumor 2 cm (4/5 inch) or smaller that hasn't grown into blood
vessels (T1a).
T1b A single tumor larger than 2cm (4/5 inch) that hasn't grown into blood
vessels (T1b).
T2 Either a single tumor larger than 2 cm (4/5 inch) that has grown into blood
vessels, OR more than one tumor but none larger than 5 cm (about 2
inches) across (T2).
T3 More than one tumor, with at least one tumor larger than 5 cm across (T3).
T4 At least one tumor (any size) that has grown into a major branch of a large
vein of the liver (the portal or hepatic vein)

22. NX Regional lymph nodes cannot be assessed due to lack of
information
N0 The cancer has not spread to nearby lymph nodes
N1 The cancer has spread to nearby lymph nodes (N1)
M0 The cancer has not spread to distant parts of the body
M1 It has spread to distant organs such as the bones or lungs
22

23. Stomach Cancer Stages According to
AJCC TNM staging system
AJCC STAGE STAGE GROUPING
IA T1a N0 M0
I B T1b N0 M0
II T2 N0 M0
III A T3 N0 M0
III B T4 N0 M0
IV A ANY T N1 M0
IV B ANY T, ANY N, M1 23

24. Liver cancer survival rate
SEER
STAGE
5-YEAR
RELATIVE
SURVIVAL RATE
Localized 35%
Regional 12%
Distant 3%
All SEER
stages
combined
20%
• Localized: There is no sign that the cancer
has spread outside of the liver.
• Regional: The cancer has spread outside
the liver to nearby structures or lymph
nodes.
• Distant: The cancer has spread to distant
parts of the body, such as the lungs or
bones.
*SEER = Surveillance, Epidemiology, and
End Results

25. Diagnosis
• Medical history and physical exam
• Imaging tests- use x-rays, magnetic fields, or sound waves
• To help find suspicious areas that might be cancer
• To help a doctor guide a biopsy needle into a suspicious
area to take a sample
• To learn how far cancer might have spread
• To help guide certain treatments in the liver
• To help determine if treatment is working
• To look for possible signs of cancer coming back after
treatment

26. Diagnosis cont…..
• Ultrasound- This test can show tumors growing in the liver.
• Computed tomography (CT)- CT scan of the abdomen can
help find many types of liver tumors.
• It can give specific information about the size, shape, and
location of any tumors in the liver or elsewhere in the abdomen,
as well as nearby blood vessels.
• CT scans can also be used to guide a biopsy needle precisely
into a suspected tumo
• Magnetic resonance imaging (MRI)
• Angiography

27. Diagnosis cont…..
• Bone scan
• Biopsy- it can be done in several ways.
• Needle biopsy
• Laparoscopic biopsy
• Surgical biopsy
• Lab tests
• Alpha-fetoprotein blood (AFP) test- If AFP levels are very high in
someone with a liver tumor
• Liver function tests
• Tests for viral hepatitis
• Blood clotting tests
• Kidney function tests
• Complete blood count (CBC)

28. Management
Surgery- The best option to cure liver cancer is with either surgical
resection (removal of the tumor with surgery) or a liver transplant.
Partial hepatectomy- Partial hepatectomy is surgery to remove part
of the liver. Only people with good liver function who are healthy
enough for surgery and who have a single tumor that has not grown
into blood vessels can have this operation.
Possible risks and side effects
• Bleeding
• Infection
• Complications from anesthesia
• Blood clots
• Pneumonia

29. Surgery
Liver transplant
• liver transplant may be the best option for some people with
liver cancer.
• Liver transplants can be an option for those with tumors that
cannot be removed with surgery, either because of the location
of the tumors or because the liver has too much disease for the
patient to tolerate removing part of it.

30. Ablation for Liver Cancer
• Ablation is treatment that destroys liver tumors without removing
them. These techniques can be used in patients with a few small
tumors and when surgery is not a good option (often because of poor
health or reduced liver function).
• Ablation is best used for tumors no larger than 3 cm across
• For slightly larger tumors (1 to 2 inches, or 3 to 5 cm across), it may
be used along with embolization
• Because ablation often destroys some of the normal tissue around
the tumor, it might not be a good choice for treating tumors near
major blood vessels, the diaphragm, or major bile ducts.

31. Ablation for Liver Cancer cont…
• Ablation can be done without surgery by inserting a needle or probe
into the tumor through the skin.
• The needle or probe is guided into place with ultrasound or CT scan.
• Sometimes, though, to be sure the treatment is aimed at the right
place, the ablation may be done in the operating room under general
anesthesia and may need an incision (cut) like the one for a partial
hepatectomy .
• Radiofrequency ablation (RFA)- Radiofrequency ablation is one of
the most common ablation methods for small tumors. It uses high-
energy radio waves. The doctor inserts a thin, needle-like probe into
the tumor through the skin. A high-frequency current is then passed
through the tip of the probe, which heats the tumor and destroys the
cancer cells.

32. Ablation for Liver Cancer cont…
• Microwave ablation (MWA)- Microwave ablation uses the energy
from electromagnetic waves to heat and destroy the tumor using a
probe.
• Cryoablation (cryotherapy)- Cryoablation destroys a tumor by
freezing it using a thin metal probe. The probe is guided into the
tumor and then very cold gasses are passed through the probe to
freeze the tumor which causes the cancer cells to die.
• Ethanol (alcohol) ablation- This is also known as percutaneous
ethanol injection (PEI). In this procedure, concentrated alcohol is
injected directly into the tumor to damage cancer cells. Sometimes
multiple treatments of alcohol ablation may be needed.
Possible side effects after ablation therapy include abdominal pain,
infection in the liver, fever and abnormal liver tests.

33. Embolization for Liver Cancer
• Embolization is a procedure that injects
substances directly into an artery in the liver to
block or reduce the blood flow to a tumor in
the liver.
• The liver is special in that it has 2 blood
supplies. Most normal liver cells are fed by
the portal vein, where as a cancer in the liver
is mainly fed by the hepatic artery.
• Blocking the part of the hepatic artery that
feeds the tumor helps kill off the cancer cells,
but it leaves most of the healthy liver cells
unharmed because they get their blood supply
from the portal vein.

34. Embolization for Liver Cancer Cont…
• Embolization is an option for some patients with tumors that cannot
be removed by surgery. It can be used for people with tumors that
are too large to be treated with ablation (usually larger than 5 cm
across) and who also have adequate liver function.
• Embolization can reduce some of the blood supply to the normal
liver tissue, so it may not be a good option for some patients whose
liver has been damaged by diseases such as hepatitis or cirrhosis.
• Trans-arterial embolization (TAE)
• Trans-arterial chemoembolization (TACE)
• Drug-eluting bead chemoembolization (DEB-TACE)
• Radioembolization (RE)

35. Embolization for Liver Cancer Cont…
Possible side effects of embolization
• Possible complications after embolization include:
• Abdominal pain
• Fever
• Nausea
• Infection in the liver
• Blood clots in the main blood vessels of the liver

36. Radiation Therapy for Liver Cancer
• Radiation therapy uses high-energy rays (or particles) to kill cancer
cells.
• It may not be a good option for some patients whose liver has been
greatly damaged by diseases such as hepatitis or cirrhosis.
• Radiation can be helpful in treating:
• Liver cancer that cannot be removed by surgery
• Liver cancer that cannot be treated with ablation or embolization or
did not respond well to those treatments
• Liver cancer that has spread to other areas such as the brain or
bones
• People with pain because of large liver cancers
• People with a tumor thrombus (a collection of liver cancer cells)
blocking the portal vein.

39. Targeted Drug Therapy
Kinase inhibitors
• Kinases are proteins on or near the surface of a cell that carry
important signals to the cell’s control center. Many of the targeted
drugs used to treat liver cancer are kinase inhibitors. These drugs
block several kinase proteins, which normally help tumor cells grow
in one of two ways:
• Some kinases help tumor cells grow directly.
• Some kinases help tumors form the new blood vessels they need in
order to get bigger (a process called angiogenesis).
Blocking these proteins can often help stop the growth of the cancer.

40. Targeted Drug Therapy Cont….
• Sorafenib (Nexavar) and lenvatinib (Lenvima)- Sorafenib is a
pill taken twice daily. Lenvatinib is a pill that is taken once a
day.
• Sorafenib may work better in people with liver cancer caused by
hepatitis C.
• Regorafenib (Stivarga) and cabozantinib (Cabometyx)-
These drugs can be used to treat advanced liver cancer.
• Regorafenib is a pill, typically taken once a day for 3 weeks,
followed by a week off. Cabozantinib is a pill taken once a day.

41. Targeted Drug Therapy Cont….
Monoclonal antibodies-
• Bevacizumab (Avastin)- Bevacizumab is a monoclonal
antibody that targets vascular endothelial growth factor (VEGF),
a protein that helps new blood vessels to form. This drug can be
used along with the immunotherapy. This drug is given as an
infusion into a vein (IV), typically once every 3 weeks.
• Ramucirumab (Cyramza)-This drug can be used to treat
advanced liver cancer, typically after another treatment stops
working. This drug is given as an infusion into a vein (IV),
usually once every 2 weeks.

42. Immunotherapy
Immune checkpoint inhibitors
PD-1 and PD-L1 inhibitors- PD-1 is a checkpoint protein on immune
cells called T cells. When PD-1 attaches to PD-L1, a protein on other
cells in the body, it acts as a type of “off switch” that basically tells the
T cell to leave the other cell alone. Some cancer cells have large
amounts of PD-L1, which helps them hide from an immune attack.
Drugs that target either PD-1 or PD-L1 can block this binding and
boost the immune response against cancer cells
• Atezolizumab (Tecentriq) and durvalumab (Imfinzi) target the PD-
L1 protein.
• Pembrolizumab (Keytruda) and nivolumab (Opdivo) are drugs
that target PD-1

43. Immunotherapy cont…
CTLA-4 inhibitor
• Ipilimumab (Yervoy) and tremelimumab (Imjudo) are other
types of drugs that boost the immune response, but they have a
different target. They block CTLA-4, another protein on T cells
that normally helps keep them in check.
• Tremelimumab (Imjudo) can be used with another
immunotherapy drug durvalumab as the first treatment for liver
cancer that cannot be removed with surgery. It is given as an
intravenous (IV) infusion once every 4 weeks.

44. Immunotherapy cont…
Side effects of these drugs can include:
• Feeling tired or weak
• Fever
• Cough
• Nausea
• Itching
• Skin rash
• Loss of appetite
• Muscle or joint pain
• Constipation or diarrhea
• Infusion reactions
• Autoimmune reactions

45. Chemotherapy
The most common chemotherapy drugs for treating liver cancer
include:
• Gemcitabine (Gemzar)
• Oxaliplatin (Eloxatin)
• Cisplatin
• Doxorubicin (pegylated liposomal doxorubicin)
• 5-fluorouracil (5-FU)
• Capecitabine (Xeloda)
• Mitoxantrone (Novantrone)
• Sometimes, combinations of 2 or 3 of these drugs are used. GEMOX
(gemcitabine plus oxaliplatin) is one option for people who are fairly
healthy and may tolerate more than one drug. 5-FU based
chemotherapy, for example with FOLFOX (5-FU, oxaliplatin and
leucovorin), is another option for people with bad liver disease.

46. Nursing Interventions: Liver Cancer
• Give analgesics as ordered and encourage the patient to
identify care measures that promote comfort.
• Provide patient with a special diet that restricts sodium, fluids,
and protein and that prohibits alcohol.
• To increase venous return and prevent edema, elevate the
patient’s legs whenever possible.
• Keep the patient’s fever down.
• Provide meticulous skin care.

47. Cont….
• Turn the patient frequently and keep his skin clean to prevent
pressure ulcers.
• Prepare the patient for surgery, if indicated.
• Provide comprehensive care and emotional assistance.
• Monitor the patient for fluid retention and ascites.
• Monitor respiratory function.
• Explain the treatments to the patient and his family, including
adverse reactions the patient may experience.

48. Prevention of liver cancer
• Avoid and treat hepatitis B and C infections
• Limit alcohol and tobacco use
• Get to and stay at a healthy weight
• Limit exposure to cancer-causing chemicals

49. References
• https://www.cancer.org/cancer/liver-cancer/about/what-is-liver-cancer.html
• https://www.cancer.org/cancer/liver-cancer/causes-risks-prevention.html
• Nursing Interventions for Liver CancerNursing File | Nursing File
• https://nursestudy.net/liver-cancer-nursing-diagnosis/
• https://www.cancer.org/cancer/liver-cancer/treating.html
• https://www.cancer.org/cancer/liver-cancer/detection-diagnosis-
staging.html
• https://www.slideserve.com/naasir/radiation-therapy-for-liver-malignancies
• https://www.slideserve.com/cara/primary-liver-cancer-hepatocellular-
carcinoma-and-cholangiocarinoma