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In a highly supportive and collaborative environment, physicians who are nationally recognized leaders in the care of patients with all stages of liver cancer provide patients with the most advanced, coordinated, and comprehensive medical care available—treatment that is effective and innovative in curing and controlling cancer and managing its impact on quality of life.
At BMC, diagnosis and treatment of patients with liver cancer combine the resources of a multidisciplinary clinical center dedicated to personal, patient-focused care with the state-of-the-art expertise and technological advances of a major teaching hospital. As the primary teaching affiliate of the Boston University Chobanian & Avedisian School of Medicine, BMC is at the forefront of clinical practice, surgical expertise, and research in oncology.
Boston Medical Center’s Hepatobiliary and Pancreatic Tumor Program was established in 2008 to effectively treat the growing number of patients being diagnosed with cancers of the liver, biliary tree, gallbladder, and pancreas.
"My sister has cancer and Dr. Sachs performed her surgery. We are so happy with him. He takes the time to speak with you and answer all questions. He returns phone calls promptly. He is a caring and wonderful Doctor. Would recommend him without hesitation. Although I have not been his patient, I write this for my sister. All we can say is what he is a wonderful, caring Doctor that will take all the time you need."
What Is Liver Cancer?
Liver cancer is a type of cancer that is caused by the abnormal growth of cells in the liver.
The liver is the largest organ in the abdomen. It is located on the right side of the body, behind the right ribs and below the right lung. It is divided into left and right lobes.
The liver gets its blood supply from two sources: the hepatic artery, which supplies the liver with oxygen-rich blood, and the portal vein, which supplies the liver with nutrient-rich blood from the intestines. The portal vein is the liver’s primary source of blood.
The liver performs several functions. It breaks down toxic substances in the blood and gets rid of them. It produces enzymes and bile that help digest food and turn it into substances the body needs to sustain itself and grow. It also produces proteins and clotting factors important in healing.
Growths in the liver can be benign (noncancerous) or malignant (cancerous). Benign growths are generally not life threatening, can often be removed, and do not spread to distant sites in the body. Malignant growths can spread to distant sites in the body and may be life threatening.
The two types of liver cancers are primary liver cancers and secondary liver cancers.
Primary Liver Cancers
Primary liver cancers are cancers that begin in the liver. There are several types of primary liver cancers, but the two most common are:
- Hepatocellular carcinoma (HCC): Hepatocellular carcinoma, also called malignant hepatoma, develops in the hepatocytes (the main type of liver cell). It is the most common form of liver cancer in adults. Approximately 4 out of 5 primary liver cancers are HCCs (American Cancer Society 2015).
- Intrahepatic cholangiocarcinoma (bile duct cancer): Intrahepatic cholangiocarcinoma develops from cholangiocytes (bile duct cells) located inside the liver. These cholangiocytes line the bile ducts, which facilitate excretion of bile produced by the liver. Intrahepatic cholangiocarcinoma accounts for 1 or 2 out of every 10 cases of liver cancer (American Cancer Society 2015).
Secondary Liver Cancers
Secondary liver cancers are cancers that develop in other parts of the body and metastasize (spread) to the liver. The most common of these is cancer of the gastrointestinal tract, like colon cancer. These cancers often require multiple specialists in order to achieve the best survival. Even though these are metastatic cancers, many times the potential of cure is still possible.
Primary liver cancers are the focus of the rest of these pages.
Symptoms of Liver Cancer
Many early-stage liver cancers do not cause symptoms, with symptoms only developing with progression. Common symptoms include:
- Abdominal pain
- A bulge on the right side
- Unintentional weight loss
- Lack of appetite
- Feeling full without eating a lot
- Nausea and vomiting
- Yellowing of the eyes (icterus)
- Yellowing of the skin (jaundice), pale stools, and dark urine
Many of these symptoms can be caused by health problems other than liver cancer. Patients experiencing any of these symptoms should see their physician.
Causes of Liver Cancer
Although the exact causes of liver cancer remain unknown, certain risk factors connected to the disease have been identified. A risk factor is anything that affects one’s chance of getting a disease. While risk factors may be useful in identifying high-risk individuals, they do not determine whether a person develops a disease. Some risk factors, such as alcohol consumption, are within the individual’s control, while others, such as gender, are not.
Possible risk factors for liver cancer include:
- Gender: Men develop liver cancer more often than women.
- Ethnicity: Asian Americans and Pacific Islanders have the highest risk of developing liver cancer.
- Location: The disease is less prevalent in the United States than in other places in the world, such as countries in sub-Saharan Africa and Southeast Asia.
- Hepatitis B virus (HBV) or Hepatitis C virus (HCV): Long-term infection with either of these viruses may increase a person’s risk of developing liver cancer.
- Hemochromatosis: Hemochromatosis is a disease that causes the body to take up and store too much iron. The body stores the excess iron in the heart, liver, and pancreas. The disease may be hereditary (passed on from one’s parents), or it may result from blood transfusions. Having hemochromatosis may increase a person’s risk of developing liver cancer.
- Cirrhosis: Cirrhosis is a disease that develops when liver cells become damaged and are replaced by scar tissue. Infection with HBV and HCV, heavy alcohol consumption, hemochromatosis, and certain drugs and parasites can all cause liver damage. People with cirrhosis are prone to developing liver cancer.
- Environmental factors and toxins: Several environmental factors, such as aflatoxin (a toxic substance produced by certain types of mold that grows on some foods), and toxins, such as tobacco, alcohol, and solvent vinyl chloride (a substance used in the production of plastics), can increase a person’s risk of developing liver cancer.
- Anabolic steroids: Using anabolic steroids (substances that act like the male hormone testosterone) may put a person at greater risk of developing liver cancer.
- Obesity and diabetes: Being obese (very overweight) or having type 2 diabetes may increase a person’s risk of developing the disease.
Liver Cancer Staging
Staging is used to determine the extent of the cancer and treatment options. There are several different staging systems in place for liver cancer. Some staging systems, such as the American Joint Committee on Cancer’s TNM system, look only at how widespread the cancer is. Other systems also take liver function into account.
Physicians frequently categorize liver cancers by whether they can be resected (surgically removed) or not. Surgery is a potential treatment for many patients diagnosed with a tumor or tumors within the liver. These include primary tumors, which originate in the liver, and secondary tumors that develop in other parts of the body and spread to the liver. Staging helps physicians determine the best treatment options for patients.
A liver cancer can potentially be placed into one of five categories:
- A liver cancer is potentially resectable if surgery can be used to remove the cancer, and the health of the patient permits it.
- It is potentially transplantable if the surgeon is able to perform a liver transplant.
- It is unresectable if the surgeon cannot remove the cancer, but it has not spread beyond the liver.
- The cancer is inoperable with only local disease if surgery could be used to remove the cancer, but the health of the patient does not permit it.
- It is metastatic if the cancer has metastasized (spread) beyond the liver. (American Cancer Society 2015)
Liver function is key to determining the best treatment options for patients. A system called the Child-Pugh score helps physicians determine how well the liver is functioning based on the measures of different substances in the blood, fluid in the belly, and brain function.
Patients are encouraged to discuss cancer staging and treatment options with their physicians.
American Cancer Society. 2015. Liver Cancer Overview. PDF. http://www.cancer.org/acs/groups/cid/documents/webcontent/003058-pdf.pdf
National Cancer Institute. 2009. What You Need To Know About™ Liver Cancer. PDF. Bethesda: National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human Services. https://ccr.cancer.gov/liver-cancer-program
Treatments & Services
Tumor ablation is an image-guided, minimally invasive treatment used to destroy cancer cells. In tumor ablation, a physician inserts a specially equipped needle (probe) into the tumor or tumors guided by computed tomography (CT). Once the probe is in place, energy is transmitted through it and into the tumor.
Tumor Ablation: Microwave
In which radio waves heat the probe to kill the cancer cells.
Percutaneous Ethanol Injection
Percutaneous ethanol injection uses ethanol, a type of alcohol, to destroy cancer cells. The physician guides the ethanol directly into the tumor using ultrasound. Generally, this procedure only requires local anesthesia. If the patient has multiple tumors, it may require general anesthesia.
Transarterial Chemoembolization (TACE)
TACE injects chemotherapy coated beads directly into a tumor while also blocking off its blood supply. This allows a high dose of chemotherapy drugs to concentrate at the tumor site for a longer period of time while having little effect on the rest of the body.
Radioembolization inserts radioactive beads into the artery to deliver a small dose of radiation directly to the tumor(s).
Targeted therapy is a type of cancer treatment that uses drugs or other substances to precisely identify and attack cancer cells. Usually, targeted therapy does less damage to normal cells than other cancer treatments.
Chemotherapy is a medication or combination of medications used to treat cancer. Chemotherapy can be given orally (as a pill) or injected intravenously (IV).
Radiation uses special equipment to deliver high-energy particles, such as x-rays, gamma rays, electron beams or protons, to kill or damage cancer cells. Radiation (also called radiotherapy, irradiation, or x-ray therapy) can be delivered internally through seed implantation or externally using linear accelerators (called external beam radiotherapy, or EBRT).
CyberKnife delivers highly targeted beams of radiation directly into tumors, in a pain-free, non-surgical way. Guided by specialized imaging software, we can track and continually adjust treatment at any point in the body, and without the need for the head frames and other equipment that are needed for some other forms of radiosurgery.
External Beam Radiation Therapy
External beam radiation therapy is one of the most common types of radiation for cancer treatment. Radiation comes from a machine outside the body and delivers radiation to a specific location inside the body.
Stereotactic Body Radiation Therapy
Stereotactic body radiation therapy directs multiple beams of energy at the tumor from different angles. The radiation oncologist is able to deliver higher doses of radiation to the tumor and minimize damage to surrounding healthy tissue.
Diagnostics and Tests
Liver cancer can be difficult to diagnose early, as symptoms frequently do not develop until the later stages of the disease. Patients experiencing any of the symptoms of liver cancer, or those who have cirrhosis and notice it getting unexpectedly worse, should see their physician.
Gastroenterology/Hepatobiliary Tumor Board
The results of the diagnostic tests are discussed at the Gastroenterology/Hepatobiliary Tumor Board. During this weekly meeting, the entire multidisciplinary team comes together to discuss new cases and develop individualized treatment plans for each patient.
Physical Exam for Liver Cancer
The physician feels the abdomen for any unusual lumps or changes in the sizes and shapes of the liver, spleen, and surrounding organs. The physician also checks the abdomen for an abnormal buildup of fluid called ascites. He or she may also examine the skin and eyes for jaundice (a condition which may cause them to take on a yellowish appearance).
Diagnostic ultrasound, also called sonography or diagnostic medical sonography, is an imaging method that uses high-frequency sound waves to produce images of structures within the body. The images can provide valuable information for diagnosing and treating a variety of diseases and conditions. Most ultrasound examinations are done using a sonar device outside the body, though some ultrasound examinations involve placing a device inside the body.
Computed Tomography (CT) Scan
CT scans use x-ray equipment and computer processing to produce 2-dimensional images of the body. The patient lies on a table and passes through a machine that looks like a large, squared-off donut.
Magnetic Resonance Imaging (MRI)
This test uses a magnetic field, radiofrequency pulses, and a computer to produce detailed images of body structures in multiple places. You may be asked to drink a contrast solution for better imaging, and you will most likely lie on a moving table as pictures are taken.
You will receive an intravenous sedative and pain medication. Once comfortable, the physician will then examine the area using an endoscope—a lighted tube with a small camera at the end. The physician will be able to view any abnormalities and take a tissue samples (biopsies) if necessary.
An angiography is an imaging test that uses x-rays to view the body’s blood vessels.
Bone scans involve a low dose of radioactive material that is injected into a vein. Bone attracts this material. Concentrated areas show up on the scan and are referred to as "hot spots." Hot spots may be indicative of a variety of diseases and conditions.
A common tool for disease screening, blood tests provide information about many substances in the body, such as blood cells, hormones, minerals, and proteins.
BMC’s comprehensive hepatobiliary cancer team includes surgeons, medical oncologists, radiation oncologists, gastroenterologists, hepatologists, and interventional radiologists. The team’s patient-centered, multidisciplinary approach assures each patient benefits from the collaborative expertise of physicians uniquely focused on their individual needs.
Nana O Addo-Tabiri, MD, PhD
Gastrointestinal malignancies, health disparities
Hussein Assi, MD
Gastrointestinal malignancies, neuroendocrine tumors (NETs)
Medical Oncology Nurse Practitioners
Christine A Engle, NP
Lisa M Keller, APRN
Kimberley S Mak, MD, MPH
Thoracic, gastrointestinal, breast, and musculoskeletal malignancies, Cyberknife® radiosurgery, radiotherapy
Jennifer F Tseng, MD, MPH
Gastric cancer; Pancreatic cancer; Pancreatitis; Hereditary cancer syndromes; Cancer prevention; Surgical risk reduction
David McAneny, MD
Endocrine surgery, surgical oncology
Teviah E Sachs, MD, MPH
Surgical oncology; Liver, pancreas, and biliary cancers; Stomach cancer; Sarcoma; Melanoma
Surgical Oncology Physician Assistants
Suvranu Ganguli, MD
Interventional neuroradiology, vascular and interventional radiology
Kevin P Daly, MD
Mohammad M Bader, MD
Diagnostic radiology, surgery, vascular and interventional radiology
David Guez, MD
Interventional Radiology Physician Assistants
Stephen Benjamin Perez, PA
David P Nunes, MD
Liver disease, viral hepatitis, liver lesions
Arpan Mohanty, MD
Christopher S Huang, MD
David R Lichtenstein, MD
Endoscopic diagnosis, gastrointestinal disorders
Gastroenterology Nurse Practitioners
Liver Cancer Clinical Trials
BMC offers a number of clinical trials specifically for pancreatic cancer patients. Promising new techniques in the diagnosis, treatment, and care of patients with cancer are tested in these studies. The number and types of clinical trials available are constantly changing. View an up-to-date list of ongoing trials here. Those interested in participating in any clinical trials at BMC should speak with their physician.
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