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Metastatic cancer

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Liver metastases

Liver metastasis is cancer that started in another part of the body and spread to the liver. It’s sometimes called secondary liver cancer or metastatic liver disease. Liver metastasis is not the same as cancer that starts in the liver (called primary liver cancer). Liver metastasis is much more common than primary liver cancer.

Some kinds of cancer are more likely to spread to the liver than others. The most common types of cancer that spread to the liver are:

  • colorectal
  • lung
  • breast
  • pancreatic
  • stomach
  • melanoma
  • neuroendocrine

Cancer can spread to any part of the liver. Sometimes there is only one liver metastasis. Most people develop many liver metastases in both lobes of the liver.

Symptoms

Liver metastases may not cause any symptoms at first because the liver is large and can work normally even if it contains cancer. Symptoms of liver metastases vary depending on the number of tumours and where they are in the liver. Other health conditions can cause the same symptoms as liver metastases.

See your doctor if you have these symptoms, especially if they are getting worse:

  • loss of appetite
  • nausea
  • fatigue
  • weight loss
  • fever
  • yellow skin and eyes and dark coloured urine (called jaundicejaundiceA condition in which the skin and whites of the eyes become yellow and urine is dark yellow.)
  • itchy skin
  • discomfort or pain in the abdomen
  • swelling of the abdomen caused by a buildup of fluid (called ascites)
  • swelling of the ankles

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Diagnosis

The following tests may be used to diagnose liver metastases. Many of the same tests can help your healthcare team plan treatment and monitor liver metastases.

Health history and physical exam

Your health history is a record of your symptoms, risk factors and all the medical events and problems you have had in the past. In taking a health history, your doctor will ask questions about a personal history of symptoms that suggest liver metastases.

A physical exam allows your doctor to look for any signs of liver metastases. During a physical exam, your doctor may feel the abdomen to see if the liver is enlarged or sore when touched.

Find out more about physical exam.

Blood tests

Blood tests are usually done to check your general health and find out how well the liver is working. The most common blood tests used to help diagnose liver metastases are liver function tests. Other blood tests that may be abnormal include a complete blood count (CBC), blood glucose (sugar) and blood clotting tests.

Sometimes tumour marker tests are done if you have had cancer before. These tests measure the amount of a specific protein in the body. For example, carcinoembryonic antigen (CEA) is a tumour marker measured in the blood. It is usually checked during follow-up after treatment for colorectal cancer. An increase in CEA levels over time could mean the cancer has come back and it may have spread to the liver.

Find out more about blood tests.

Imaging tests

Imaging tests are an important part of diagnosing liver metastases. It is common for people to have one or more imaging tests when the doctor thinks the cancer may have spread to the liver. The imaging tests used to diagnose liver metastases include the following.

Computed tomography (CT) scan is a common imaging test to check for liver metastases. It can also check for metastases in organs and tissues around the liver. The CT scan is usually done with contrast mediumcontrast mediumA substance used in some diagnostic procedures to help parts of the body show up better on x-rays or other imaging tests. to show areas more clearly.

Ultrasound is used to check for an enlarged liver or changes in its shape or texture. It is also used to guide a biopsy needle or laparoscopelaparoscopeA procedure that uses an endoscope (a thin, tube-like instrument with a light and lens) to examine or treat organs inside the abdomen and pelvis. to a specific area of the liver.

Magnetic resonance imaging (MRI) may be used to find small metastatic tumours in the liver. It is usually used when doctors are not certain about the results of other imaging tests such as CT scan or ultrasound.

Positron emission tomography (PET) scan may be used to check for metastases in organs and tissues around the liver. It is often used when there is a history of colorectal or stomach cancer.

Find out more about imaging.

Biopsy

A biopsy is the removal of cells or tissues so they can be examined under a microscope. It may be needed to diagnose liver metastases. It is done when the doctor can’t tell if there is liver metastasis based on imaging tests or if there is no history of cancer. A biopsy may also be done to check tumour markers that help guide treatment. A percutaneouspercutaneousThrough the skin. needle biopsy or endoscopic biopsy during laparoscopy may be used.

Find out more about biopsy and tumour markers.

Other tests

If liver metastases are found before the primary cancer is diagnosed, the doctor may order tests to find out where the cancer started. These tests may include:

  • CT scan of the chest to check for lung cancer
  • colonoscopy to check for colorectal cancer
  • laparoscopy to examine organs in the abdomen and pelvis

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Treatments and supportive therapies

If you have liver metastases, your healthcare team will create a treatment plan just for you. It will be based on your needs and usually includes a combination of different treatments. Treatments can control and slow the growth of liver metastases, but most metastases don’t go away completely unless they can be removed by surgery. Treatments can also manage or prevent problems caused by liver metastases. These are sometimes called supportive therapies.

When deciding which treatments and supportive therapies to offer for liver metastases, your healthcare team will consider:

  • where the cancer started
  • where cancer is in the liver
  • how many metastases there are
  • the size of the metastatic tumours
  • if there is metastatic cancer in other parts of the body
  • cancer treatments you’ve already received
  • how well the liver is working
  • your personal preferences

You may be offered the following treatments and supportive therapies for liver metastases.

Chemotherapy

Chemotherapy is the most common treatment for liver metastases. It is used to help stop or slow the growth of cancer and relieve symptoms. Chemotherapy may also be used to shrink the cancer so surgery can be done, or it may be given after surgery to lower the risk of the cancer coming back. Chemotherapy is sometimes used along with other treatments such as targeted therapy.

Systemic chemotherapy means that the drugs circulate throughout the body to destroy cancer cells. It is usually given intravenously (through a needle into a vein) or orally (as a pill by mouth). The drugs, dose and schedule will vary for each person. The type of chemotherapy drug or combination of drugs used depends on where the cancer started.

Hepatic arterial infusion (HAI) is a procedure that delivers chemotherapy directly to liver tumours. The chemotherapy is supplied through a pump to the main artery of the liver (called the hepatic artery). Floxuridine (FUDR) is the most common chemotherapy drug used in HAI. HAI is not used as often as systemic chemotherapy because it is a complex and labour-intensive technique. It requires many medical experts, including surgeons, oncologists and radiologists, who all have experience in giving HAI. It may be used to treat liver metastases when cancer has only spread to the liver and the tumours can’t be removed by surgery.

Chemoembolization, or transarterial chemoembolization (TACE), is a procedure that delivers chemotherapy directly to liver tumours. A catheter is placed in the hepatic artery, which is the main blood vessel that goes to the liver. The chemotherapy and a special substance that blocks the blood supply to the tumour (called an embolic agent) are given through the catheter. Once the blood supply is blocked, the cancer does not receive the oxygen and nutrients it needs to grow. Also, the tumour is exposed to the chemotherapy longer. Chemoembolization may be used to stop or slow the growth of liver metastases when the cancer has only spread to the liver.

Side effects of chemotherapy will depend mainly on the type of drug, the dose and how it’s given. Common side effects of many chemotherapy drugs are bone marrow suppression (low blood cell counts), nausea and vomiting, mouth problems and bowel problems. HAI and TACE tend to have fewer side effects than systemic chemotherapy.

Find out more about chemotherapy and side effects of chemotherapy.

Targeted therapy

Targeted therapy uses drugs that find and attach to specific substances (such as proteins) on the surface of or inside cancer cells. These substances help send signals that tell cells to grow or divide. The targeted therapy drugs block the substances to stop or slow the growth and spread of cancer cells.

Targeted therapy may be used to control the growth of liver metastases from some types of cancer, such as:

  • bevacizumab (Avastin) or cetuximab (Erbitux) is used for colorectal cancer
  • erlotinib (Tarceva) is used for pancreatic cancer

Targeted therapy is given intravenously (through a needle into a vein) or orally (as a pill by mouth). It is most often used along with chemotherapy.

Side effects of targeted therapy depend mainly on the type and dose of the drug. Common side effects of many targeted therapy drugs include flu-like symptoms and fatigue. Most side effects go away on their own or can be treated. Tell your healthcare team if you have these side effects or others you think might be from targeted therapy.

Find out more about targeted therapy.

Surgery

Surgery may be used to treat liver metastasis when only one area or a few areas of cancer are found. The surgery, called liver resection, removes the part of the liver that contains cancer. It is most often used for colorectal cancer that has spread to the liver.

A surgeon who specializes in liver surgery (called a hepatobiliary surgeon) will do the liver resection. This surgery is usually done by making a cut, or incision, in the abdomen (called open liver resection). The surgeon can also do a liver resection by making several small cuts in the abdomen and then inserting a laparoscope (a thin, tube-like instrument with a light and lens) and tools to do the surgery (called laparoscopic liver resection). A laparoscopic liver resection may not be available at all treatment centres. Liver resection takes several hours to complete.

Side effects of surgery will depend mainly on the amount of liver removed and your overall health. Some side effects include pain, bleeding, wound infection and pleural effusionpleural effusionAn abnormal buildup of fluid in the pleural cavity (space between the lungs and the walls of the chest)..

Find out more about surgery and side effects of surgery.

Ablation therapy

Ablation therapy is a procedure that removes or destroys cells or tissues with heat, chemicals or other techniques. Different types of ablation therapy may be used to treat liver metastases. They are mainly used to treat small liver tumours when surgery can’t be done because it’s not safe or possible.

Ablation therapies for liver metastases are done by surgeons with specialized experience. They may not be available at all treatment centres.

The following ablation therapies may be used to treat liver metastases. Side effects will depend mainly on the procedure done and how much of the liver is treated.

Radiofrequency ablation (RFA) uses electrical currents to create heat that destroys cancer cells. A needle is placed directly into a liver tumour. The surgeon will use an imaging test, such as ultrasound or CT scan, to guide the needle into the tumour. Electrical currents are passed through the needle. These currents heat and destroy the tumour. Find out more about radiofrequency ablation.

Cryotherapy uses extreme cold to freeze and destroy abnormal and cancerous cells or tissue. It is also called cryosurgery or cryoablation. The doctor uses an imaging test (such as ultrasound) to find the liver tumour that will be treated. Then the doctor places a probe directly into a liver tumour through a small cut, or incision, made in the skin. An extremely cold gas, such as liquid nitrogen, is passed through the probe to the tumour. The gas freezes and destroys the cancer. Sometimes the freezing process is repeated. Find out more about cryotherapy.

Percutaneous ethanol injection uses a needle to inject ethyl alcohol directly into a liver tumour. The doctor uses ultrasound or CT scan to guide the needle through the skin and into the tumour. The ethyl alcohol kills cancer cells and shrinks the tumour.

Radiation therapy

Radiation therapy is not used that often to treat liver metastases. This is because radiation can damage the liver (called radiation-induced liver disease). In rare cases, external beam radiation may be given to the whole liver to relieve symptoms (called palliative treatment). Newer radiation therapy techniques can deliver more targeted doses of radiation to the liver tumours and lower the risk of liver damage.

Radioembolization, or selective internal radiation therapy, is a procedure that delivers radiation directly to liver tumours. It uses tiny radioactive beads called microspheres. A catheter carries the radioactive beads through the hepatic artery to the liver. The beads deliver radiation only to the tumour and not to healthy liver tissue. They also block the blood supply to the tumour so the cancer can’t get the oxygen and nutrients it needs to grow. Radioembolization may be used to slow the growth of liver metastases and relieve symptoms when other treatments can’t be used.

Stereotactic body radiation therapy may be used when there are 1–3 small liver metastases. This is a type of external beam radiation therapy that delivers a high dose of radiation directly to a tumour. It avoids treating healthy liver tissue around the tumour with radiation. How many sessions of stereotactic radiation therapy are used depend on the size, location and number of metastases being treated, as well as other factors.

Side effects of radiation therapy will depend mainly on the type of radiation therapy and how much of the liver is treated. Common side effects of radiation therapy include fatigue and skin problems.

Find out more about radiation therapy and side effects of radiation therapy.

Hormonal therapy

Hormonal therapy is a treatment that adds, blocks or removes certain hormones to slow or stop the growth of cancer cells that need hormones to grow. Drugs, surgery or radiation therapy can be used as hormonal therapy.

Hormonal therapy may be used to help slow the growth of tumours in the liver and relieve symptoms. It is given for some types of cancer that have spread to the liver, especially breast cancer.

Side effects of hormone therapy will depend mainly on the type of hormonal therapy. Common side effects of many types of hormonal therapy are hot flashes, weight gain and less interest in sex.

Find out more about hormonal therapy and side effects of hormonal therapy.

Pain medicines

Not everyone with liver metastases will have pain. Pain can happen when the capsule around the liver is stretched. Pain medicines may be used. They are often given because other treatments may take a while to relieve pain or may not stop pain completely.

Pain medicines can be given different ways. They are usually given orally or intravenously. The most common pain medicines used for liver metastases are:

  • opioids such as morphine (MS Contin, Statex, MOS) and codeine
  • corticosteroids such as dexamethasone (Decadron, Dexasone)
  • nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin, Advil, Nuprin)

Side effects of pain medicines will depend mainly on the type of drug, the dose and the length of treatment. Common side effects of pain medicines like opioids are upset stomach, drowsiness and constipation. Corticosteroids can cause sleep problems, increased appetite, fluid buildup in the legs, arms or face, weight gain, high blood sugar levels, infection, mood changes and skin problems (such as a rash or acne). NSAIDs can upset the stomach.

Find out more about pain and how to manage it.

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Living with liver metastases

In many cases, liver metastasis is a chronicchronicOccurring slowly, lasting a long time or progressing very gradually. condition. Adjusting to life with liver metastases often takes time. A person with liver metastases may have concerns about the following.

Loss of appetite

Loss of appetite, or anorexia, is a common symptom of liver metastases. It can be caused by the cancer, the liver not working properly, treatments or other symptoms such as pain and ascites. Not eating enough because of loss of appetite can lead to problems like weight loss, a weakened immune system and fatigue.

There are several ways to manage loss of appetite and make sure you are getting enough nutrition. You can try to eat small meals and snacks at regular times throughout the day. Serve food cold or at room temperature to reduce strong tastes and smells. Eat foods high in calories and protein such as ice cream, nuts and eggs. Try commercial nutrition products when your appetite is poor. Ask your doctor about medicines that you could take to help improve appetite.

Find out more about loss of appetite and tips for managing it.

Fatigue

Many people with liver metastases have fatigue. Fatigue is when you feel tired and don’t have energy to do normal activities. It can greatly affect your quality of life.

Fatigue can be caused by many factors, including cancer treatments, loss of appetite, poor nutrition, pain and pain medicines. It can become a chronic problem. Talk to your healthcare team about ways to treat the causes and learn how to cope with fatigue.

Find out more about fatigue.

Survival

A diagnosis of advanced cancer can lead to questions about survival. There is no way of knowing exactly how long someone will live with liver metastases. It depends on many factors, including where the cancer started, the number of tumours in the liver and the treatments used.

Survival with liver metastases depends on the type of cancer that has spread to the liver and whether or not surgery is possible. For example, survival with liver metastases from prostate or breast cancer is often measured in years. Survival with lung cancer that has spread to the liver is often measured in months. Some people may live much longer than expected, while others may die sooner than expected.

The best person to talk to about survival is the doctor. The doctor may be able to estimate survival based on what they know about a person and the type of cancer, but it’s not an exact science.

Find out more about living with advanced cancer.

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