liver tumor



Overview

Definition

Liver tumors (liver tumors) refer to tumors occurring in the liver and are mainly classified into benign and malignant tumors [1].

Statistics show that 94% of liver tumors are malignant and only 6% are benign [2].

Hepatic malignant tumors have no obvious symptoms in the early stage, and in the late stage, there may be emaciation, epigastric pain and discomfort, and yellowing of the skin.

Benign liver tumors may not have obvious symptoms when the size of the tumor is small, but if the tumor is large, there will be obvious compression symptoms, and once rupture occurs, there will be sudden and severe pain, and there is also the risk of causing hemorrhage and even hemorrhagic shock.

Liver tumors referred to in this article refer to primary liver tumors, excluding liver metastases, i.e. malignant tumors from other parts of the body metastasized to the liver.

Classification

It is mainly classified according to the benign and malignant nature of the tumor. Benign liver tumors are relatively easy to treat and usually have a better prognosis; the prognosis of malignant liver tumors is mainly related to the type of tumor and its stage [3].

Benign liver tumors

Hepatic hemangioma

It is a relatively common benign tumor of the liver and a more common type of visceral hemangioma.

Among them, cavernous hemangiomas are the most common and can occur at any age, often presenting with symptoms in adulthood and are more common in women.

Hepatocellular adenoma

Rarely, the tumor cells are similar to normal hepatocytes.

In recent years, it has been suggested that its occurrence is related to oral contraceptive use.

It occurs in women of childbearing age between 15 and 45 years old who have a history of taking oral contraceptives, and is most common in those between 20 and 39 years old.

Hepatic Dysplasia

It is an extremely rare congenital tumor-like malformation of the liver, which is more common in infants and young children, and is more common in males than females.

Others

Other benign tumors of the liver include hepatic lipoma and inflammatory pseudotumor of the liver, which are relatively rare.

Malignant tumors of the liver

Primary Liver Cancer

Abbreviated as hepatocellular carcinoma, it is a malignant tumor originating from hepatocytes or bile duct cells.

It mainly consists of 3 pathological types [4]:

Hepatocellular carcinoma: It is the most predominant type, accounting for 82.9% of primary liver cancers.

Intrahepatic cholangiocarcinoma: accounts for 11.5%.

Mixed cell carcinoma: rare, accounting for only 5.6%, with both hepatocellular and cholangiocellular components.

Hepatoblastoma

Common in childhood, 90% of children under 5 years old, male to female ratio 2:1.

Primary hepatic sarcoma

Relatively rare, large size, poor prognosis.

Incidence

There are no authoritative statistics on liver tumors as a whole, but hepatocellular carcinoma accounts for the vast majority of liver tumors and can be roughly surmised using the incidence of hepatocellular carcinoma.

Global data

According to the new data released by the International Agency for Research on Cancer (IARC) of the World Health Organization, the number of new cases of liver cancer in 2020 will reach 905,700 globally, ranking 7th among malignant tumors, and 830,100 deaths, ranking 2nd among malignant tumors, only after lung cancer [5].

Data in China

Hepatocellular carcinoma is a common malignant tumor in China, and most of the patients are 31-50 years old, and the incidence of men is significantly higher than that of women.

In 2016, there were 388,800 new cases of hepatocellular carcinoma in China throughout the year, of which 288,800 were men and 100,000 were women.

In the same year, there were 336,400 cases of liver cancer deaths in China throughout the year, of which 249,600 were men and 86,800 were women [6].

[Special reminder] As the data from the National Tumor Registry is generally relatively lagging behind, the data released in the latest report in 2022 is the registration information collected by the National Tumor Registry to summarize the National Tumor Registry in 2016.

Questions you may be concerned about

What color are liver tumors

Liver tumors include benign and malignant tumors, and may appear as dark red, yellow, or white in color.

Liver tumors can be classified into two types: benign tumors and malignant tumors, benign liver tumors such as hemangiomas and malignant tumors such as hepatocellular carcinoma.

Hepatic hemangioma can be dark red, etc., and can be given regular observation and surgical treatment; hepatocellular carcinoma is mostly yellow or white, because of rich blood supply and soft texture, it is very easy to rupture.

Patients with liver tumor should keep a good mindset, actively cooperate with doctors for symptomatic treatment, and at the same time, develop good dietary habits, diet should be digestible, choose high-quality protein, such as lean meat, milk, etc., avoid cold and irritating food, and abstain from smoking and alcohol.

What is liver tumor-associated antigen measurement?

Liver tumor-associated antigen determination includes alpha-fetoprotein, alpha-fetoprotein heterogeneous body and other liver cancer serum markers.

1. Alpha-fetoprotein (AFP): it is a commonly used indicator in clinical diagnosis of liver cancer, and is relatively specific to hepatocellular carcinoma. Elevated AFP is also one of the current diagnostic criteria for liver cancer.

2. Alpha-fetoprotein heterogeneous body: suitable for differential diagnosis of patients with elevated alpha-fetoprotein. It can be used in differential diagnosis with hepatitis, cirrhosis and gastrointestinal tumors.

3. Other hepatocellular carcinoma serum markers: suitable for the diagnosis of alpha-fetoprotein negative hepatocellular carcinoma. Including glutamyl transpeptidase isoenzyme and abnormal prothrombinogen, which can be used as auxiliary diagnostic indexes.

The specific problems of patients’ liver tumor diagnosis still need professional doctor’s guidance.

What does it mean to see hyperechoic nodule after liver tumor resection?

Hypoechoic nodules after resection of liver tumor may be caused by tumor metastasis, intrahepatic bile duct stones, hemangioma, intrahepatic calcification.

1. Tumor metastasis: when liver tumor is not completely resected, the residual cancer cells will be transferred to the liver without lesions through blood vessels to form hypoechoic nodules.

2. Intrahepatic bile duct stones: Intrahepatic bile duct stones can also form echogenic nodules. When the stones are small, it will not affect the bile excretion, and the patients usually have no symptom, but if there are more stones, the bile will be stagnant, which will easily lead to the formation of stones.

3. Hemangioma: it is a common benign liver lesion, ultrasonography often suggests intrahepatic hypoechoic signals, and patients often have no obvious symptoms when the hemangioma is small.

4. Intrahepatic calcification: Calcified foci are often secondary to localized inflammation or tissue necrosis in the liver, and may also show high echo signal, which has less effect on human body and can be reviewed regularly.

After resection of liver tumor, it is recommended to go to the hospital for diagnosis of the cause and active treatment.

Etiology

The etiology of liver tumor is unknown, but studies have found that developmental abnormalities, oral contraceptives, hepatitis B virus infection, aflatoxin and other factors may be related to the development of the disease, which are also known as the high-risk factors for liver tumor [1-4].

Causes

The etiology of liver tumors is complex and not yet fully understood.

High-risk factors

They are described below by tumor type.

Benign liver tumors

Hepatic hemangioma

Developmental anomalies: usually thought to be related to abnormal development of hepatic blood vessels during embryonic period.

Oral contraceptive use: Since the size of hepatic hemangiomas increases significantly when female patients become pregnant or take oral contraceptives, it is now believed that estrogen may also be associated with the growth of hemangiomas.

Hepatocellular adenoma

Oral contraceptives: Hepatocellular adenomas were extremely rare before the introduction of oral contraceptives; however, the incidence of this disease increased significantly after steroidal hormonal contraceptives became widely used in the 1970s.

Hepatic Dysplasia

Developmental abnormality: Hepatic malformation is not a tumor in the true sense of the word, but is caused by the abnormal development of hepatic blood vessels during the embryonic development of the liver, resulting in the abnormal proliferation of vascular endothelial cells.

Oral contraceptive pills: In recent years, it is believed that the development of hepatic malformation tumor is also related to oral contraceptive pills.

Liver malignant tumor

Primary hepatocellular carcinoma

Viral infection: hepatocellular carcinoma is associated with hepatitis B/hepatitis C virus (HBV/HCV) infection, and intrahepatic cholangiocarcinoma is associated with HCV infection and HIV infection.

Cirrhosis: a common risk factor for hepatocellular carcinoma and intrahepatic cholangiocarcinoma.

Toxic substances: e.g. aflatoxin and certain chemical carcinogens.

Liver diseases: metabolism-associated fatty liver disease (MAFLD), alcoholic liver disease, etc.

Hepatoblastoma

Infant anomalies: e.g. low birth weight, preterm labor, etc.

Accompanying certain hereditary tumors or congenital disorders: e.g. Beckwith-Wiedemann syndrome, Sotos syndrome, familial adenomatous polyposis, etc.

Abnormalities in the mother’s pregnancy: long-term exposure to certain chemical products, mother’s pregnancy combined with hypertension and other diseases.

Primary hepatic sarcoma

Partially related to exposure to carcinogens such as thorium dioxide, vinyl chloride, arsenic compounds, and so on.

For more about the causes, please refer to read the section on causes of liver cancer.

Questions you may be concerned about

How often do liver tumors cause liver pain

Symptoms of liver pain in patients with liver tumors usually do not depend on the size of the tumor, but are generally related to the location of the tumor growth and inflammation in the liver.

When suffering from a liver tumor, as the tumor grows it can cause the hepatic envelope to be stretched, resulting in symptoms of liver pain. Excessive tumor growth can cause necrosis and liquefaction within the tumor and secondary infection. When infection occurs in the liver, it can lead to liver cell damage, thus creating the symptom of pain in the liver area. Some patients can also cause liver pain in the late stage of the tumor.

When a liver tumor is diagnosed, it should be treated in time. In the early stage, it can be treated by surgery. If the disease is in the middle or late stages, chemotherapy should be administered using drugs such as cisplatin carboplatin. When the pain in the liver is severe, it can be treated by using drugs such as tramadol for pain relief.

Patients should seek medical treatment when they experience discomfort to avoid aggravation of the disease.

How big is the liver tumor to cause pain in liver area?

Liver pain caused by liver tumor has some correlation with the size of the tumor, but it is not directly related to it, and the pain is mainly caused by the compression and stimulation of the liver peritoneum.

With the growth of liver tumor, it may compress and invade the hepatic peritoneum, which will further lead to the symptoms of pain and discomfort in the liver area.

There is no direct correlation between liver pain and the size of the lesion. Some tumors, even if small in size, are located at the edge of the liver, which may cause pericardial irritation and pain; however, the larger the size of the tumor, the greater the probability of causing pain overall.

If liver tumor is found to cause obvious pain in the liver area, accompanied by localized mass and decreased liver function, it is necessary to consult a doctor in time for examination, and carry out standardized treatment under the guidance of clinicians after diagnosis of the disease.

Symptoms

There are no special clinical symptoms in the early stage of liver tumors, and the symptoms of different types of liver tumors are not the same. Common symptoms include epigastric pain and discomfort, abdominal distension and loss of appetite.

Main Symptoms

Benign liver tumor

Liver hemangioma

Early symptoms are not obvious.

When the tumor is large in size, there may be epigastric discomfort or mass, abdominal distension, pain, loss of appetite and other symptoms.

When the hemangioma ruptures, it manifests as intra-abdominal hemorrhage, and in severe cases, shock may even occur.

Hepatocellular adenoma and hepatic malformation tumor

They grow slowly and have no obvious symptoms in the early stage.

With the gradual increase of tumor size, abdominal distension, vague pain in the abdomen or nausea and other pressure symptoms may appear.

Malignant tumor of liver

Primary liver cancer

Right upper abdomen pain: it is the most common symptom of liver cancer, mostly presenting persistent distension or dull pain in the right upper abdomen.

Yellowing of skin: i.e. jaundice, yellowing of skin and whites of eyes will occur in the advanced stage of liver malignant tumor.

Cirrhosis manifestation: it often occurs in the late stage of liver cancer, but there are also many patients who have cirrhosis before the occurrence of liver cancer. Abdominal fluid accumulation, esophageal-fundus vein varices and so on may appear.

Systemic manifestations: such as persistent weight loss, fever, lack of appetite, malaise and malnutrition in advanced stage of hepatocellular carcinoma.

Hepatoblastoma and primary hepatic sarcoma

Symptoms are similar to those of hepatocellular carcinoma, including epigastric discomfort and abdominal distension. Hepatoblastoma abdominal pain may not be obvious, but when the tumor is large, a painful mass can be felt in the patient’s (mostly children) right upper abdomen with pressure.

Other symptoms

Metastatic symptoms

Metastatic symptoms refer to the symptoms caused by malignant tumor metastasis to distant parts and other organs, and the most common distant metastasis of liver cancer are lungs, bones, brain, lymph nodes and so on.

Lung metastasis

Symptoms such as irritating cough, coughing up sputum and hemoptysis may appear.

When invading pleura, chest pain and pleural effusion can occur, leading to respiratory difficulty.

Bone metastasis

Commonly found in ribs, spine, pelvis and long bones.

They may be asymptomatic in the early stage, with local pain and pressure in the later stage, and even pathological fracture.

If spinal metastasis compresses or invades the spinal cord, it may lead to urinary and fecal incontinence or paraplegia.

Brain metastasis

Early stage may be asymptomatic.

In the middle and late stages, central nervous system symptoms often appear.

Complications

Hepatic encephalopathy

Hepatic encephalopathy is the most serious complication of end-stage liver cancer. The presence of hepatic encephalopathy suggests a poor prognosis and requires close communication with clinicians.

Upper gastrointestinal bleeding

Upper gastrointestinal bleeding accounts for 15% of the causes of death of liver malignant tumors. Bleeding is often associated with rupture of esophageal-fundus varices and portal hypertension gastropathy combined with coagulation disorder.

Tumor rupture bleeding

Both benign and malignant tumors of liver have the possibility of rupture and bleeding, which can cause acute abdominal pain, and massive bleeding can lead to shock and death.

Consultation

For symptoms such as right upper abdominal pain, abdominal distension, yellowing of the skin, loss of appetite, etc., it is recommended to go to Gastroenterology, General Surgery and other departments.

Department of Medicine

Gastroenterology

Gastroenterology or Hepatology is recommended for symptoms such as right upper abdominal pain, bloating, yellowing of the skin and loss of appetite.

General Surgery

If you have a preliminary diagnosis of a liver tumor, especially if diagnostic operations or surgical treatment is required, it is recommended that you consult the Department of General Surgery or the Department of Hepatobiliary Surgery for medical treatment.

Oncology

Patients diagnosed with liver malignant tumors may also seek medical treatment from the Department of Oncology or the Department of Radiotherapy for surgery, anti-tumor drug treatment and radiotherapy.

Emergency Department

Patients with previous symptoms such as abdominal distension, epigastric pain, loss of appetite, or those who have been diagnosed with hepatic hemangiomas or hepatic adenomas, if they suddenly experience severe abdominal pain, it may be due to rupture and bleeding of hepatic hemangiomas, and they need to seek emergency medical treatment or call 120 immediately.

Preparation for medical treatment

Consultation Notes: Registration, Preparation of Documents, Frequently Asked Questions

Tips for Consultation

When you visit the doctor, you may need to have an X-ray or CT scan of the abdomen. Avoid wearing clothing that contains metal, such as jumpsuits and dresses with zippers and buttons.

Record the symptoms, duration and other relevant information for your doctor’s reference.

It is recommended to have a family member accompanying you to the doctor’s office.

Preparation Checklist

Symptom list

Pay particular attention to the time of onset of symptoms, special manifestations, etc.

Is there any pain and bloating in the upper right abdomen and how long has it been present?

Is there any loss of appetite and how long has it been present?

Is there unexplained weight loss?

Is there fever and what is the highest temperature?

Medical History Checklist

The patient may have a history of the following, but not all people with the following histories have liver tumors:

Has he or she smoked cigarettes, abused alcohol, or consumed moldy foods?

What occupation is practiced?

Is there a family history of a malignant tumor such as liver cancer?

Is it associated with other diseases such as viral hepatitis and cirrhosis?

Any history of drug or food allergy?

Checklist

Examination results in the past six months, which can be brought to the doctor’s office

Imaging tests: Ultrasound of upper abdomen, CT, MRI (Magnetic Resonance Imaging), Positron Emission Computed Tomography (PET-CT), Bone Nuclide Scan.

Laboratory tests: blood routine, blood type, liver and kidney biochemical tests, four infections, coagulation function, tumor markers.

Other tests: pathologic examination, biopsy report.

Diagnosis

Diagnosis of liver tumor should be combined with medical history, clinical manifestations and laboratory and imaging findings.

Benign tumors can be diagnosed by imaging examination, while malignant tumors require pathology examination for final diagnosis.

Diagnosis is based on

Medical History

Patients may have a history of the following.

History of viral hepatitis B/C.

History of cirrhosis.

A personal history of smoking, alcohol abuse, and chronic consumption of moldy foods.

Clinical manifestations

Symptoms

There are no obvious symptoms in the early stage, while patients in the middle to late stage may have symptoms such as right upper abdominal pain, loss of appetite, weight loss, and fever.

Physical signs

There are usually no abnormal physical signs in the early stage, but patients in the middle and late stages may have hepatomegaly, ascites, yellowing of the skin and whites of the eyes.

Laboratory Tests

General examination

Before treatment, patients need to undergo blood routine, liver and kidney function, electrolytes, coagulation analysis and other necessary general examinations, which can determine the general condition of patients.

Patients may have infections, anemia, thrombocytopenia, abnormal liver and kidney functions, electrolyte disorders, and abnormal coagulation function.

Tumor Markers

Commonly used tumor markers include alpha-fetoprotein (AFP), serum fucosidase (AFu), γ-glutamyl transpeptidase isoenzyme II (γ-GT2), and abnormal prothrombin (PIVKA-II).

Positive results of combined testing of the above indicators can provide additional evidence to confirm the diagnosis of hepatic malignancy, and can also be used to monitor postoperative recurrence or metastasis.

Imaging

Most benign liver tumors can be diagnosed by imaging, but in a few cases, further pathological examination is required.

Ultrasound

Ultrasonography is mainly used to check the size of tumors in the liver area, and can also be used to observe the metastasis in the hilar lymph nodes, kidneys and other parts and organs, providing information for tumor staging.

Ultrasonography can provide a more accurate basis for identifying the benign and malignant nature of the tumor.

Ultrasound-guided puncture can be used for puncture biopsy of liver tumors, hepatoportal lymph nodes, and metastases in parenchymal organs, and the specimen can be obtained for histological examination.

X-ray

X-ray can be used to initially screen liver tumors for lung and bone metastases.

Enhanced CT

For liver tumors, plain CT is of little diagnostic significance and enhancement CT is usually required.

Enhanced CT of the upper abdomen is a commonly used imaging method for diagnosis, staging, efficacy evaluation and post-treatment follow-up of liver tumors.

Enhanced CT of the upper abdomen can effectively detect early liver tumors and further evaluate the location of the tumor, the extent of involvement and lymph node metastasis, which can help clinical staging.

CT examination of other parts including brain, liver and kidney can help doctors clarify whether there are distant metastases.

MRI

MRI can help determine the extent and location of tumor invasion, etc. It can also be used to assess the efficacy and review after treatment.

It can also show the relationship between the tumor and the surrounding tissues and organs, lymph node metastasis, etc., which can provide a more reliable basis for the follow-up treatment.

MRI of other parts of the body can determine whether metastasis has occurred or not.

Angiography

It can clarify the size, number, scope and dissemination of liver tumor lesions.

It can also be used for tumor embolization.

Venous angiography is necessary to confirm the diagnosis and determine the treatment plan in difficult cases [18].

Bone nuclear scan

Abbreviated as bone scan, it is a routine test to determine the presence or absence of bone metastases.

When bone scanning examination suggests suspected metastasis in bone, MRI, CT or PET-CT is required to verify the suspected site.

Positron Emission Tomography (PET-CT)

PET-CT is a whole-body scan, which is the best method for diagnosis of benign and malignant liver tumors, staging (malignant tumors with or without metastasis), efficacy evaluation and prognosis assessment.

It can also be used for radiotherapy localization and outlining of the treatment target area.

Liver Puncture Biopsy

It is a reliable method to confirm the diagnosis of liver tumor.

It is an invasive test with occasional risk of bleeding. Cancer cells may also spread to other parts of the body through the puncture needle tract, i.e. needle tract metastasis.

Pathologic examination

Pathological diagnosis of liver biopsy specimen is mainly to clarify the presence or absence of tumor and the histological type of tumor, which is the “gold standard” for final diagnosis of liver tumor.

For advanced inoperable patients, pathological diagnosis should be subtyped as far as possible, and for cases with atypical morphology, immunohistochemical staining should be combined to further clarify the diagnosis.

Staging

There is no staging for benign liver tumors, and staging mainly applies to hepatocellular carcinoma among malignant liver tumors, which is commonly used in Chinese hepatocellular carcinoma staging.

The staging of hepatocellular carcinoma is mainly based on 6 factors: number of liver tumors, size, vascular invasion, extrahepatic metastasis, Child-Pugh classification and Physical Status (PS) score.

The staging needs to be determined comprehensively, including stage Ia, stage Ib, stage IIa, stage IIb, stage IIIa, stage IIIb and stage IV.

[Tips] For more about liver cancer staging, please refer to the section on reading liver cancer.

Differential Diagnosis

Liver tumors are mainly differentiated from benign and malignant, in addition to cirrhotic nodules and hepatic cysticercosis.

Cirrhotic nodules

Similarities: Cirrhotic nodules can also be characterized by liver masses, and occasionally yellowing of the skin when the nodules press on the bile ducts.

Differences: Cirrhotic nodules are commonly seen in people with a history of cirrhosis. Enhanced CT shows that cirrhotic nodules have the same enhancement characteristics as the surrounding liver tissue, whereas hepatocellular carcinoma can be seen as early enhancement in the arterial phase. This result depends on the interpretation of medical professionals.

Hepatic cysticercosis

Similarity: The same liver mass is present, as well as pain in the right upper abdomen and yellowing of the skin.

Differences:

Patients with liver worm disease often have a history of living in pastoral areas and exposure to diseased animals.

Hepatic encapsulosis has no enhancement on enhanced CT, while hepatocellular carcinoma shows arterial phase enhancement. This result depends on the interpretation of medical professionals.

Treatment

Aim of treatment: benign and early malignant tumors should be eradicated by surgery, and middle and late malignant tumors should be treated as far as possible to control the symptoms, delay the progression of the disease, prolong the survival period and improve the quality of life.

Treatment principle: benign tumors can be observed or treated by surgery, malignant tumors need to be actively treated once discovered, and individualized comprehensive treatment through surgery, radiotherapy, targeted therapy, immunotherapy and other means.

Surgical treatment

Surgical treatment of hepatocellular carcinoma is an important means of long-term survival for hepatocellular carcinoma patients, including surgical resection and liver transplantation [7].

Benign liver tumors

Small and asymptomatic hepatic cavernous hemangiomas do not require treatment and can be dynamically observed by reviewing ultrasound every 6-12 months. If the symptoms are obvious and affect normal life and work, or if the tumor diameter is more than 10 cm and there is a risk of rupture, it can be surgically resected.

Since hepatic adenoma has the risk of rupture and bleeding and malignant transformation, and it is not easy to identify with hepatocellular carcinoma, most scholars advocate that once found, it should be treated by surgery as soon as possible, and at the same time, stop using oral contraceptive pills. For those who have difficulty in surgical operation, biopsy should be done to confirm the diagnosis and long-term follow-up [17].

Hepatic malignant tumors generally do not have the risk of rupture and bleeding, and can be observed when they are small and asymptomatic in the early stage, and should be surgically resected if the tumor is large enough to produce compression symptoms on adjacent organs.

Hepatic malignant tumors

Surgical resection

Surgical treatment should be preferred according to the patient’s specific situation, and complete resection of the tumor should be strived for during surgery to reduce recurrence and metastasis of the tumor.

Preoperative Child-Pugh score and indocyanine green 15-minute retention test are required to evaluate liver reserve function, which depends on the clinician’s assessment [8].

According to the size of incision and trauma, it can be further categorized into conventional open surgery and minimally invasive laparoscopic surgery [9].

Liver transplantation

Liver transplantation is a surgical procedure in which a failing liver that can no longer function properly is removed and the resected liver is replaced with a healthy liver from a deceased donor or a partially healthy liver from a living donor.

Liver transplantation is a treatment option for certain patients with liver cancer and for patients with liver failure whose condition cannot be controlled by other treatments.

Ablation Therapy

Patients with hepatocellular carcinoma who are not suitable for surgical resection can choose ablation therapy, which is characterized by less impact on liver function, less trauma, and precise efficacy [10].

Ablation modalities

It mainly includes radiofrequency ablation (RFA), microwave ablation (MWA), anhydrous ethanol injection therapy (PEI), cryotherapy, high-intensity ultrasound focused ablation (HIFU), and irreversible electroporation (IRE).

Applicable conditions

It is applicable to the following cases, and can obtain radical therapeutic effect:

CNLC stage Ia and part of stage Ib hepatocellular carcinoma: single tumor, diameter ≤5 cm, or 2-3 tumors, maximum diameter ≤3 cm.

No invasion of blood vessels, bile ducts and neighboring organs as well as distant metastasis.

The location is easy to locate and puncture.

Those with liver function grade Child-Pugh A/B.

TACE

Transcatheter arterial chemoembolization (TACE) is a commonly used nonsurgical treatment for hepatocellular carcinoma [11].

Currently, TACE combined with local ablation, surgery, molecularly targeted drugs and other comprehensive treatments are advocated to further improve the efficacy of TACE.

TACE is suitable for patients with stage: CNLC stage IIb, IIIa and some stage IIIb hepatocellular carcinoma, which requires Child-Pugh assessment as well as PS scoring, and the specifics of which should follow the clinician’s professional decision.

Radiation therapy

Tumor radiotherapy is a local treatment that can be used to destroy and eradicate local primary tumors or metastatic lesions, and can be divided into external irradiation radiotherapy and internal irradiation radiotherapy.

External irradiation

Patients with small hepatocellular carcinoma who do not wish to receive invasive treatment may consider stereotactic radiotherapy (SBRT). It has been reported to achieve similar results as surgical resection or local ablative therapy [12].

The objectives of radiotherapy for intermediate and advanced hepatocellular carcinoma are to alleviate or reduce symptoms, improve quality of life, as well as prolong survival with tumor.

The cutoff between large and small hepatocellular carcinomas is 5 cm in diameter. in patients with large hepatocellular carcinomas confined to the liver, a subset of them can be converted to surgical resectable by local radiotherapy, thus potentially achieving a radical cure [13].

Internal irradiation

It is a method of treating liver cancer with radioactive particles implanted in the body, including 90Y microsphere therapy, 131I monoclonal antibodies, radioiodinated oil, and 125I particle implantation.

Radioactive particles are able to produce radiation continuously, and implanting radioactive particles in tumor tissues can kill tumor cells by continuous low-dose radiation.

For example, strontium chloride (89Sr) emits beta rays, which can be used for targeted treatment of liver cancer bone metastasis lesions.

Drug therapy

Drug treatment of liver cancer mainly includes chemotherapy, targeted therapy and immunotherapy, etc. These treatments can be used singly or in combination.

For patients with advanced liver cancer, effective drug therapy can reduce tumor load, improve tumor-related symptoms, improve quality of life and prolong survival time.

Chemotherapy

Chemotherapy is mainly for liver malignant tumors, through oral or intravenous injection of chemical drugs, to achieve the purpose of killing tumor cells or blocking the continued growth of tumor cells.

FOLFOX4 regimen (oxaliplatin+calcium folinate+fluorouracil) is approved in China for: first-line treatment of locally advanced and metastatic hepatocellular carcinoma that is unsuitable for surgical resection or local treatment.

The need to combine with other treatment modalities such as chemotherapy, radiotherapy, targeted therapy and immunotherapy can be considered according to the specific conditions of patients.

Targeted therapy

Targeted therapy is to take tumor cells as the target point, and the drugs are similar to precision-guided missiles. The drugs enter the body and specifically select the cancer-causing sites to bind and take effect to inhibit the growth of tumor cells or even remove the tumor cells without or less affecting the normal tissue cells around the tumor.

At present, the commonly used targeted drugs in liver cancer treatment include lenvatinib, regorafenib, donafenib, sorafenib, apatinib and so on.

Immunotherapy

Immunotherapy is to activate the body’s immune system through drugs and rely on autoimmune function to kill cancer cells and tumor tissues.

As of January 2023, the immunotherapy drugs recommended by domestic guidelines mainly include atilizumab, sindilizumab, karelizumab and tirilizumab, etc [10].

Questions you may be concerned about

How are liver tumors caused?

Liver tumors are mainly divided into benign and malignant tumors, including hepatic hemangiomas, hepatocellular adenomas, hepatocellular carcinomas, etc. They are usually related to congenital factors, hormonal changes, dietary habits and liver diseases.

1. Hepatic hemangioma: it belongs to congenital abnormality of blood vessel development, or it is caused by hormonal influence after birth, such as increased level of estrogen and progesterone, etc., which may promote the growth of tumor.

2. Hepatocellular adenoma: the cause of this disease is not clear, and it may be related to long-term use of oral contraceptives, so the incidence rate of women is higher than men.

3. Hepatocellular carcinoma: it usually develops from hepatitis, cirrhosis and liver fibrosis. Some patients are caused by long-term consumption of aflatoxin-contaminated food.

If liver tumor is detected at present, it is necessary to consult the doctor in time to clarify the nature of the tumor, and then according to the diagnostic results of targeted treatment to prevent the tumor from continuing to grow or cause lesions.

Surgical Procedure of Liver Tumor Resection

The procedure of hepatic tumor resection is roughly divided into 6 steps, and the specific steps may be different due to various factors affecting the operation.

1. Surgical anesthesia: general anesthesia is usually used.

2. Selection of position and incision: lying position can be selected, and the incision will be chosen by the surgeon according to the patient’s condition.

3. Exposure of the field of view: After entering the abdominal cavity layer by layer, the liver and the surrounding vascular and neural structures are revealed.

4. Resection: Surgical methods include segmental resection, lobectomy, hemihepatectomy and hepatic trilobectomy, etc. The specific method of resection should be decided according to the size and location of the tumor, the degree of cirrhosis and the patient’s general condition.

5. Treatment of liver section: larger bleeding point or bile leakage should be ligated with fine silk suture.

6. Closure of abdominal cavity: after finishing, close the abdominal cavity layer by layer.

The steps of tumor resection may be different due to the different conditions of patients. Therefore, the guidance of specialized doctors should be followed.

Can liver tumor be eliminated by taking traditional Chinese medicine?

Liver tumor can not be eliminated by taking traditional Chinese medicine in general, but it should be judged comprehensively and treated differently according to the volume, nature and quantity of the tumor.

1. Liver cancer: Simply using Chinese herbs can not eliminate the tumor, Chinese herbs can be used as auxiliary treatment means to cooperate with surgery, radiotherapy and chemotherapy in order to reduce its adverse reactions. Herbal medicine is suitable for patients in advanced stage of liver cancer and liver decompensation stage who cannot tolerate other treatments. It can improve the general condition of patients, prolong their lives and alleviate their pains through herbal medicine treatment.

2. Hepatic hemangioma: For small solitary hepatic hemangioma, the tumor may disappear by taking Chinese medicine. According to Chinese medicine, hepatic hemangioma is caused by qi stagnation and blood stasis, resulting in spleen deficiency, water-dampness and phlegm stagnation in the veins and channels, and accumulation of blood and qi, which can be treated by the prescription of promoting qi and dredging the liver, activating blood circulation and removing blood stasis, and softening and dispersing the knots.

If liver tumor is diagnosed, early and standardized treatment is recommended to reduce the adverse effects of the disease. All the above medications should be used under the guidance of a doctor, avoid self-medication.

Prognosis

Cure

Benign liver tumors and early stage liver malignant tumors can be cured by surgical resection.

Advanced liver malignant tumors usually do not have the chance of surgery, and the progression of the disease can be slowed down by chemotherapy, radiotherapy and targeted therapy, but most of them have a poor prognosis.

Primary liver cancer cannot be cured on its own, and if left untreated, peripheral lymph node metastasis and metastasis to neighboring organs can occur, leading to death.

Hepatocellular carcinoma

The 1-, 3- and 5-year survival rates of patients with hepatocellular carcinoma are 73.2%, 53.7% and 42.4%, respectively [14].

Intrahepatic bile duct cancer

The 5-year survival rate after surgery for intrahepatic cholangiocarcinoma is 24% to 44%.

Hepatoblastoma

Clinical staging and staging of patients with hepatoblastoma is a key factor in assessing and determining the quality of the patient’s prognosis, and the overall 5-year survival rate is about 80% [15-16].

[Special reminder].

The overall survival time of cancer patients can be roughly predicted by the 5-year survival rate, which refers to the proportion of patients whose tumors survive for more than 5 years after various comprehensive treatments. the probability of recurrence after 5 years is very low, and it is generally regarded as clinical cure.

Statistical data such as the 5-year survival rate are for clinical studies only and do not represent an individual’s specific survival period.

Survival should be analyzed in the light of the stage of the disease, physical condition, and whether the patient has received standardized treatment and regular follow-up, etc. Consultation with the physician is recommended.

Prognostic factors

Prognostic factors are factors that affect the overall survival and quality of life of patients.

Benign liver tumors

Benign tumors of the liver depend on the presence or absence of complications, such as tumor rupture, hemorrhage and other complications have a poorer prognosis.

Benign liver tumors without complications generally have a better prognosis after surgical resection and should be reviewed regularly.

Malignant liver tumors

The later the stage of liver tumor, the worse the prognosis.

The smaller the liver tumor, the less the number of tumors and the less the blood vessels are involved, the better the prognosis.

Liver tumors that are combined with cirrhosis, increased alpha-fetoprotein (AFP), and c-myc amplification by genetic testing suggest a poor prognosis.

Patients treated with hepatic resection as radical therapy have longer survival than patients treated with hepatic artery chemoembolization.

Hepatitis B virus infection is associated with alcoholism and a poorer prognosis in hepatocellular carcinoma.

Patients with hepatocellular carcinoma <5 cm in diameter who are able to undergo early surgery have a better prognosis, as well as patients with an intact cancer envelope, a high degree of differentiation, no thrombus formation yet, and a good immune status [13].

For more on the prognosis of liver cancer, please refer to the section on reading liver cancer.

Daily routine

The following various daily recommendations and preventive screening recommendations for patients with liver tumors are also available for the healthy population.

Daily management

Dietary management

Diet should be light, easy to digest and nutritious.

It is recommended to consume more protein-rich foods such as beef and mutton, fish, eggs and milk to replenish sufficient energy for the body.

Consume more foods rich in vitamins and dietary fiber, such as fresh vegetables and fruits.

Avoid cold, greasy, spicy and irritating foods such as fried chicken, cream and animal offal.

Refrain from drinking alcohol, including all kinds of alcoholic beverages.

For people with impaired liver function, it is recommended to consult a medical professional or dietitian for targeted dietary advice.

Life Management

Quit smoking and drinking, avoid strenuous work, have a regular routine, avoid staying up late and get enough sleep.

Maintain a healthy body weight, take appropriate activities such as slow walking, tai chi, qigong, breathing exercises, etc., and avoid going to crowded places.

During radiotherapy, avoid rubbing and scratching the skin, keep it clean and dry, and ban the use of soap and towel for bathing.

Psychological support

A good mood and mindset cannot be replaced by drugs.

After diagnosis the patient may develop a sense of fear and may be afraid of pain, abandonment and death. With the encouragement and help of doctors, family and friends, patients need to get rid of their fears as soon as possible, face up to the disease, actively follow the doctor’s instructions, and have an optimistic attitude towards the prognosis.

Family members should pay attention to listening to the patient’s heart, improve the patient’s psychological tolerance, and relieve anxiety symptoms.

It is recommended that the patient’s family give support so that the patient can face the surgery and other treatments positively with a good mindset.

During and after treatment, family members are advised to encourage the patient to do work and household chores that are within his/her ability, so as to reintegrate into social roles.

Disease monitoring

Monitor the patient’s clinical symptoms, such as epigastric pain, abdominal distension, loss of appetite, emaciation, yellowing of the skin, etc., and pay attention to whether the symptoms reappear or worsen.

Follow-up review

Importance of follow-up

Regular follow-up helps to detect recurrence and metastasis of liver tumor in time. The specific time and items for follow-up should be based on the clinician’s instructions.

Follow-up time

Within 2 years after treatment of hepatic malignant tumors, review every 3 months; within 2 to 5 years, review every 6 months; after 5 years, review every year.

Small and asymptomatic hepatic cavernous hemangiomas that are judged by your doctor not to require treatment for the time being may be reviewed by ultrasound every 6 to 12 months.

If there is any discomfort, consult the doctor at any time.

Rechecking items

Tumor markers, enhanced CT of the upper abdomen, ultrasound of the liver, and MRI of the abdomen and PET-CT are necessary.

Prevention

Tumor prevention mainly focuses on its possible high-risk factors, although it cannot completely prevent the disease from occurring, it can minimize the probability of its occurrence. It can be broadly divided into daily prevention and regular screening.

Daily prevention: to reduce or avoid the risk factors of liver tumors and increase their protective factors.

Regular screening: It means that the general population should do regular medical checkups, and high-risk groups are recommended to consult professional doctors and follow the doctor’s instructions for tumor screening.

Daily prevention

Correct use of drugs. If a woman chooses to use short-acting oral contraceptives, she must first ask her doctor for an evaluation, and regular checkups of liver ultrasound and blood clotting function are recommended during the period of taking the medication.

Stop smoking and drinking. Quit smoking, including cigarettes and e-cigarettes, and stay away from passive smoking. Refrain from drinking alcohol and alcoholic beverages.

Take good occupational protection. People at risk of occupational exposure should take good protective measures to avoid exposure to carcinogens such as asbestos, chromium and nickel.

Pay attention to dietary hygiene. Do not eat moldy food, eat more fresh fruits and vegetables, and supplement dietary fiber.

Timely and standardized treatment. Patients with viral hepatitis and fatty liver, alcoholic cirrhosis should receive timely and standardized treatment.

Healthy lifestyle. Try to have a regular routine, moderate exercise, weight control and balanced nutrition.

Regular screening

For patients with viral hepatitis, fatty liver, alcoholic cirrhosis disease and other primary diseases, as well as people with a history of primary tumors or a history of tumors in the family, regular review and physical examination should be conducted.