Liver metastases

Cancer that starts in one part of the body and spreads to the liver is called liver metastases. It's sometimes called metastatic liver disease. Cancer that starts in the liver is called primary liver cancer. Liver metastases are much more common than primary liver cancer.

Metastatic cancer is also called:

• metastatic tumour, tumours or disease
• metastasis (one cancerous tumour)
• metastases (more than one cancerous tumour)
• advanced 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
• esophagus
• melanoma
• neuroendocrine

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

Liver metastases may not cause any symptoms at first because the liver is large and can work normally even if there is cancer in it. Symptoms vary depending on the number of metastases 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 jaundice)
• itchy skin
• discomfort or pain in the abdomen
• swelling of the abdomen caused by a buildup of fluid (called ascites)
• swelling of the ankles

Diagnosis is the process of finding out the cause of a health problem. The following tests may be used to diagnose liver metastases. Many of the same tests can help your healthcare team plan treatment and watch for changes to the cancer.

Your health history is a record of your symptoms, risks and all the medical events and problems you have had in the past. 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. Your doctor may feel the abdomen to see if the liver is enlarged or sore when touched.

Find out more about a physical exam.

Blood chemistry tests measure amounts of certain chemicals in a sample of blood. They show how well certain organs are working and can help find abnormalities.

Liver function tests look at how well the liver is working. This is the most common blood chemistry test used to help diagnose liver problems, including liver metastases.

Blood glucose (sugar) and blood clotting tests may also be done. These tests may find liver damage caused by liver metastases.

A complete blood count (CBC) is done to check your general health and how well the bone marrow is working.

Tumour marker tests measure the amount of a specific protein in the body. They may be done if you have had cancer before. For example, if you had colorectal cancer in the past, your doctor may measure the levels of carcinoembryonic antigen (CEA) in your blood. An increase in CEA levels over time could mean the cancer has come back and spread to the liver.

Sometimes tissues removed during a biopsy will be tested for tumour markers, to help identify what type of cancer has spread to the liver.

Find out more about blood chemistry tests, a complete blood count (CBC) and tumour markers.

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.

A 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 a dye ( contrast medium) to show areas more clearly.

An ultrasound is used to check for an enlarged liver or changes in its shape or texture, or to look for fluid in the abdomen. It is also used to guide a biopsy needle or laparoscope to a specific area of the liver.

An 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 a CT scan or an ultrasound.

A 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 CT scans, ultrasounds, MRIs and PET scans.

A biopsy is a test that removes cells or tissues to be examined under a microscope. In most cases, imaging tests can diagnose tumours in the liver. But if the doctor can't tell if there are liver metastases based on imaging tests, or if there is no history of cancer, a biopsy may be done.

A core needle biopsy uses a large, hollow, cutting needle to remove a cylinder-shaped sample (core) from a tumour or abnormal mass. It is the most commonly used biopsy to test the liver because it provides enough tissue for doctors to make a diagnosis.

A laparoscopic biopsy may also be done while examining the abdomen and pelvis.

Find out more about biopsies and a laparoscopy.

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 include:

• CT scan of the chest to check for lung cancer
• colonoscopy to check for colorectal cancer

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 treatments are 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 had
• how well the liver is working
• what you prefer or want

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

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 (flow) 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) 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 complex. 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.

Transarterial chemoembolization (TACE) delivers chemotherapy directly to liver tumours. A catheter (tube) 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. TACE 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 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.

Targeted therapy uses drugs that find and attach to specific substances (such as proteins) on the surface of cancer cells 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.

The type of targeted therapy drug used will depend on where the cancer started. 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 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.

Immunotherapy boosts the immune system or helps the immune system to find cancer and attack it. Immunotherapy may be given as a treatment on its own, but it is most often used with other types of therapy such as chemotherapy and radiation therapy.

The type of immunotherapy drug used will depend on where the cancer started.

Side effects of immunotherapy depend mainly on the type and dose of the drug. Common side effects 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 immunotherapy.

Find out more about immunotherapy.

Surgery may be used to treat liver metastases 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 (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 a 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. Side effects include pain, bleeding, wound infection and pleural effusion.

Find out more about surgery.

Ablation therapy is a procedure that removes or destroys cells or tissues with heat, chemicals or other methods. 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. Side effects include pain, nausea and fever.

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 an ultrasound or a 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.

Percutaneous ethanol injection uses a needle to inject ethyl alcohol directly into a liver tumour. The doctor uses an ultrasound or a 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 is not usually used to treat liver metastases. This is because radiation can damage the liver (called radiation-induced liver disease). In rare cases, external 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, delivers radiation directly to liver tumours. It uses tiny radioactive beads called microspheres. The radioactive substance used in the microspheres is yttrium 90. 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 to 3 small liver metastases. This is a type of external radiation therapy that delivers a high dose of radiation directly to a tumour. It avoids healthy liver tissue around the tumour. How many sessions of stereotactic radiation therapy are used depend on things like the size, location and number of metastases being treated.

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 include nausea and vomiting, abdominal pain and fatigue.

Find out more about radiation therapy.

Hormonal therapy adds, blocks or removes certain hormones to slow or stop the growth of some types of cancer cells that need hormones to grow. Drugs, surgery or radiation therapy can be used as hormonal therapy to change hormone levels or block their effects.

Hormonal therapy may be used to help slow the growth of tumours in the liver and relieve symptoms. It is used 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 include hot flashes, weight gain and less interest in sex.

Find out more about hormonal therapy.

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 as a pill by mouth or through a needle into a vein. 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 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.

Clinical trials look at new ways to prevent, find or treat cancer. Talk to your doctor about clinical trials open to people with metastatic cancer in Canada. Find out more about clinical trials.

You may want to consider a type of care to make you feel better without treating the cancer itself. This may be because the cancer treatments don't work anymore, they're not likely to improve your condition or they may cause side effects that are hard to cope with. There may also be other reasons why you can't have or don't want cancer treatment.

Talk to your healthcare team. They can help you choose care and treatment for advanced cancer.

Adjusting to life with liver metastases often takes time. In many cases, it is a chronic condition. A person with liver metastases may have concerns about the following.

Loss of appetite 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 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 healthcare team about medicines you could take to help improve appetite.

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

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 things, 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.

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 things, including where the cancer started, the number of metastases 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 your doctor. The doctor may be able to estimate survival based on what they know about you and the type of cancer, but everyone responds differently to cancer and cancer treatments.