Liver and bile duct cancer

• Abdominal pain or swelling.
• Jaundice (yellowing of the skin and eyes).
• Unexplained weight loss.
• Loss of appetite.
• Fatigue.
• Itching, pale stools, or dark urine (more common with bile duct cancers).

• Ultrasound, CT and MRI scans to assess the liver and bile ducts in detail.
• PET scans in some cases, to look for spread outside the liver.
• Biopsy when necessary and safe, although for HCC diagnosis can often be made by imaging alone.
• Blood tests, including liver function and tumour markers (AFP for HCC, CA 19-9 for cholangiocarcinoma)
• Molecular profiling, which is particularly important for cholangiocarcinoma. This can identify mutations such as FGFR2 fusions, IDH1 and BRAF mutations, HER2 amplification, microsatellite instability or MSI-high, and NTRK fusions, which may open the door to new treatments such as targeted therapy and/or a clinical trial.

Rapid investigation and early MDT discussion are crucial, both to confirm the diagnosis and to decide the best treatment plan without delay.

Liver cancer treatment depends on tumour type, stage, liver function, overall health, and goals of care. Our liver cancer team makes the full spectrum of treatments available, and we often recommend them in combination or as a sequenced approach.

For patients with good liver function and no significant cirrhosis, liver resection (also called partial hepatectomy) can be curative. In carefully selected patients with HCC, liver transplant may be an option provided the tumour fits within strict criteria. The Birmingham team has vast experience in this particular area.

Cholangiocarcinoma treatment can be more complex. Surgery depends on tumour location. Operations can involve removal of part of the liver and bile duct, often with reconstruction. These surgeries are often high-risk, and outcomes are best when surgery is integrated with adjuvant therapy such as chemotherapy and radiotherapy.

These procedures are usually offered when surgery is not suitable, such as in the presence of liver cirrhosis. They usually mean having a general anaesthetic and overnight stay in hospital:

• Ablation (radiofrequency or microwave) uses heat to destroy small tumours. A probe is pushed through the skin into the tumour, and heat is applied directly.
• TACE (transarterial chemoembolisation) delivers chemotherapy directly into the liver’s blood supply via an artery in the groin or arm, and blocks the blood vessels feeding the tumour.
• SIRT (selective internal radiation therapy) uses tiny radioactive yttrium-90 beads injected into the liver arteries to deliver localised radiation.

These treatments can provide tumour control and buy time, but responses are often incomplete, meaning that residual tumour remains active. This is where SABR offers an additional and often more effective option.

SABR is one of the most flexible and effective options for HCC and cholangiocarcinoma. It delivers very high doses of radiation to liver cancer cells with millimetre precision, whilst sparing nearby healthy tissue. SABR is completed in just 3–5 outpatient sessions. The most advanced technology, MRI-guided SABR, allows us to see the tumour and surrounding organs in real time as we treat, adjusting every radiation beam for maximum accuracy.

Benefits of SABR include:

• Totally non-invasive, and painless – no anaesthetic, needle or overnight stay.
• Very high rates of tumour control, often comparable to ablation or surgery.
• Known to be safe in people without very late-stage liver cirrhosis.
• Useful as a bridge to liver transplant, controlling tumours while you wait for a donated liver.
• Can treat larger or more complex tumours, or those close to blood vessels where ablation is difficult.
• Can eradicate secondary tumours in lung, bones or lymph nodes where spread outside the body is limited.
• For cholangiocarcinoma, SABR can provide durable control when surgery is not possible, and is increasingly used worldwide.
• Palliative radiotherapy can relieve pain, bleeding, or bile duct obstruction caused by advanced liver cancer, improving quality of life.

My own work in pioneering SABR in the UK over the last decade, including MRI-guided SABR, means that I probably have more experience in this technique than any other UK oncologist.

This is the use of drugs to treat liver cancer.

• For HCC: First-line treatment involves immunotherapy combined with targeted drugs (e.g. atezolizumab + bevacizumab, or durvalumab + tremelimumab). Tyrosine kinase inhibitors (sorafenib, lenvatinib) are another option, with later-line therapies including regorafenib, cabozantinib, and ramucirumab.
• For cholangiocarcinoma (bile duct cancer): Chemotherapy (gemcitabine + cisplatin) is the standard first-line, often now combined with immunotherapy such as durvalumab. Targeted therapies are also available for selected patients — FGFR inhibitors (pemigatinib, futibatinib), IDH1 inhibitors (ivosidenib), HER2 therapies, and NTRK inhibitors. Second-line regimens or a clinical trial provide further options. Systemic therapy is often combined with tumour-directed treatments such as SABR to maximise benefit. Many patients now move through several lines of therapy, with each step offering more time and control.

The best results often come not from a single liver cancer treatment, but from combining them in the right sequence. Our MDT brings together liver surgeons, oncologists, radiologists, pathologists, transplant specialists, and the holistic care team. Together, we recommend:

• Who is suitable for surgery or transplant.
• When to use SABR versus ablation or embolisation treatment.
• Who might benefit from systemic therapy.
• Whether clinical trials or targeted therapies are appropriate.

This level of integration is what gives patients the best chance of living longer and living well.

Thriving while you have liver cancer treatment is about more than treating the tumour. We also focus on:

• Liver and general health: controlling cirrhosis, hepatitis, and portal hypertension.
• Nutrition: dietitian support to maintain strength and manage cachexia.
• Symptom control: pain, itching, digestive problems, jaundice due to blocked bile duct.
• Psychological support: clinical nurse specialists and psychologists are available.
• Lifestyle advice: exercise, sleep, supplements, and immune system health.

These elements are woven into every patient’s care plan, ensuring treatment is as tolerable as possible.