Although primary liver cancer is not common in the UK (approximately 2,500 people in the UK are diagnosed with this type of cancer each year), the instances of it are increasing.

We asked Dr Stephen Pereira, senior lecturer in hepatology and gastroenterology at University College Hospital, what he'd want to know about liver cancer.  

What's the difference between primary and secondary liver cancer?

• Primary liver cancer starts in the liver and there are two different types. Hepatoma or hepatocellular carcinoma (HCC) derives from the main cells (hepatocytes) of the liver. It's the most common type of primary liver cancer and is more common among men. Biliary tract cancer (cholangiocarcinoma or gallbladder cancer) is less common and starts in the cells that line the bile ducts or gallbladder.
• Secondary liver cancer is cancer that starts elsewhere in the body, such as the breast, colon or lung, and travels to other parts of the body via the blood stream or lymphatic system.

What are the causes of primary liver cancer?

Hepatoma is almost always a result of cirrhosis of the liver. Cirrhosis (or scarring of the liver) can be caused by alcohol misuse, certain inherited diseases and infections, such as hepatitis B or hepatitis C. If you have cirrhosis, it doesn't mean you'll develop primary liver cancer. 

Biliary tract cancer can be caused by any condition that inflames the bile ducts or gallbladder, but in most people there's no apparent underlying risk factor for developing bile duct or gallbladder cancer.   

What tests will I have?

You may have a blood test to detect the levels of a chemical called alpha-fetoprotein (AFP) in your blood. Very often, people with hepatomas have higher than normal levels of AFP. You'll also have an ultrasound that will show an image of the liver. 

If there's evidence of cancer, you'll then have a CT or MRI scan that can show where the tumour began and whether it has spread. You may also have a liver biopsy or a laparoscopic (keyhole) examination to confirm the diagnosis and to find out if the cancer has spread.

Will I need surgery?

Surgery is the most effective treatment for primary liver cancer. However, it can only be performed if the cancer is contained in the liver and hasn't spread, and if the liver isn't seriously damaged by cirrhosis.

• A liver resection (taking the cancer and surrounding tissues out) may be done if the cancer is small. 
• A lobectomy involves removing a lobe of the liver. The liver is divided into two main lobes that are further divided into thousands of smaller lobes.
• A liver transplant may be considered for some people with hepatoma, although this depends on how big the tumour is. If biliary tract cancer has begun to spread into the liver, a partial liver resection will be considered. 

What are the risks of surgery?

Operating on the liver involves major surgery and there may be serious complications, such as bleeding, leakage and infection. In addition, there's a high mortality rate after both liver transplant or liver resection procedures: one in 10 patients may die in the first year after surgery. For this reason, patients are carefully assessed before being recommended for surgery.

What are the alternative treatments?

For hepatoma, there are three main alternatives:

• Chemoembolisation (TACE) is a technique used to reduce the size of the tumour. The blood supply to the tumour is blocked, often with a gel or minuscule plastic beads, and anti-cancer drugs are administered directly to the tumour. It helps kill cancer cells because it cuts off the tumour's food and oxygen supply. This technique is effective for people who don't have cancer outside the liver and also have reasonably good liver function. Some hospitals offer this as standard treatment but it's not known if this is better than embolisation alone (TAE). In certain patients, TACE and TAE have been shown to improve survival over those who don't receive this treatment. Trials of this treatment are currently underway. 
• Radiofrequency ablation is a treatment that uses radio waves to heat and kill the cancer cells.
• Percutaneous ethanol injection is when, to kill the cancer cells, alcohol is injected into the cancer using ultrasound.

The treatment offered will depend on the size of the tumour.

A tablet called sorafenib (a multi-target drug that interferes with the growth of certain cancer cells) has recently been shown in two studies to improve survival, but not cure, patients for who the above treatments are unsuitable. This includes patients with cancer that has spread beyond the liver. In these studies, sorafenib was well tolerated, with patients remaining on treatment for an average of six to nine months. Sorafenib is under review by the National Institute of Health and Clinical Excellence (NICE).

For biliary tract cancer, if the bile duct is blocked by a tumour, you'll almost always have a stent inserted. 

Are there any new developments in the treatment of primary liver cancer?

Sorafenib, a new drug that interferes with the growth of certain cancer cells, is under review by NICE. It's hoped that suitable patients with liver cancer will be offered potentially beneficial treatment. 

• For biliary tract cancer, if the bile duct is blocked by a tumour, you'll almost always have a stent inserted. In addition, there are two experimental treatments:
  The effects of photodynamic light therapy (PDT) in biliary tract cancer (bile duct or gallbladder cancer) is at present part of a large, ongoing international trial called Photostent-02. PDT is used, in combination with a biliary stent, to treat small tumours that haven't spread throughout the body. Patients are injected with a photosensitising agent that makes the body's cells sensitive to light. When the area to be treated is exposed to laser light, the cells are killed. Patients who receive PDT will need to avoid exposing their skin to direct sunlight for some weeks afterwards to avoid sunburn. They'll have to wear long-sleeve tops, trousers, gloves and a hat if outdoors in daylight hours during this time. Patients will be given a booklet that fully explains what they should do. Currently this trial is only available at a few sites in the UK but more sites will be participating in the near future. Stenting alone improves survival; any extra benefit of PDT will not be known until the study finishes.
   
• The use of chemotherapy as an alternative treatment is part of an ongoing trial called ABC-02. The aim of this trial is to compare whether the chemotherapy drug gemitiabine is more effective on its own or in combination with another drug called cisplatin. This chemotherapy is generally very well tolerated. The trial is running in approximately 40 UK sites. Outside of the trial patients may be offered other types of chemotherapy.

To find out more about how experimental trials are conducted and how you can take part, visit the NHS Choices' Health research page or read the UK Clinical Research Collaboration's Understanding Clinical Trials document.