What Is a Liver Neoplasm and How Is It Treated?

A liver neoplasm is any abnormal growth of cells in the liver, ranging from harmless lumps that never cause symptoms to aggressive cancers that require urgent treatment. Some liver neoplasms start in the liver itself, while others are cancers that spread there from somewhere else in the body. The word “neoplasm” on a radiology report can understandably cause alarm, but many liver neoplasms turn out to be benign, and even malignant ones now have a wider range of treatment options than they did a decade ago.

Benign Liver Neoplasms

The most common liver neoplasm of any kind is a hemangioma, a tangle of blood vessels that forms a soft mass inside the liver. Hemangiomas are found in anywhere from less than 1% to 20% of the general population, depending on how carefully you look, and the vast majority never cause trouble. They are typically discovered by accident during an abdominal scan ordered for something else entirely. On contrast-enhanced imaging, hemangiomas have a distinctive filling pattern that makes them easy to identify without a biopsy.¹

Focal nodular hyperplasia (FNH) is the second most common benign liver tumor. It is not truly a tumor in the way most people think of the word; it is more of a localized overgrowth response, often centered around a fibrous scar. FNH carries no risk of turning into cancer, and treatment is only considered if it causes significant symptoms like pain or pressure.²

Hepatocellular adenoma (HCA) is less common but more clinically important. It is strongly linked to long-term oral contraceptive use, obesity, and metabolic syndrome. Unlike hemangiomas and FNH, adenomas can occasionally rupture and bleed, and a small fraction can transform into liver cancer. For that reason, doctors typically recommend stopping oral contraceptives in anyone diagnosed with an adenoma, and surgery may be warranted based on the tumor’s size and molecular subtype.¹ Adenomas have been classified into six distinct subtypes based on their molecular and pathological features, each carrying different levels of risk for bleeding or malignant change.²

Primary Liver Cancers

When a malignant neoplasm originates in the liver rather than arriving from elsewhere, it is called a primary liver cancer. The two most common types are hepatocellular carcinoma (HCC), which arises from the liver’s main cells, and cholangiocarcinoma, which develops from the cells lining the bile ducts within or around the liver.³

HCC accounts for the large majority of primary liver cancers and almost always develops against a background of chronic liver disease. Cirrhosis is present in roughly nine out of ten HCC patients. The path from healthy liver to cancer typically runs through years of ongoing damage: viral hepatitis, chronic alcohol use, metabolic liver disease, or toxic exposures cause inflammation and scarring, and over time, the scarred liver tissue promotes conditions where cancerous cells can emerge.⁴ The liver’s scar tissue itself plays an active role, changing the surrounding environment in ways that dampen the immune system’s ability to detect early cancerous changes and creating a reservoir of growth-promoting signals.⁵

Intrahepatic cholangiocarcinoma (iCCA) is less common and behaves differently from HCC. It tends to affect a somewhat different demographic: patients with iCCA are more often female, and a smaller proportion have underlying cirrhosis compared to HCC patients. In one large U.S. study, cirrhosis was present in about a third of iCCA patients compared to nearly nine in ten with HCC.⁶ Cholangiocarcinoma also tends to be caught at a more advanced stage and carries a worse prognosis overall, with a median survival of about 9 months in one national analysis compared to 13 months for HCC.⁷

Metastatic Tumors in the Liver

The liver is a common landing site for cancers that start somewhere else, particularly colorectal cancer. At least a quarter of people with colorectal cancer develop liver metastases at some point during their illness.⁸ The liver’s rich blood supply and its role as a filter for blood returning from the gut make it especially vulnerable to catching circulating cancer cells. Breast cancer, lung cancer, pancreatic cancer, and melanoma are among other cancers that frequently spread to the liver.

Metastatic liver tumors are not “liver cancer” in the technical sense. A colorectal metastasis in the liver is still colorectal cancer; it behaves and responds to treatment like colorectal cancer, not like HCC. This distinction matters because treatment decisions, drug choices, and prognosis all depend on the cancer’s origin rather than its current location. When a scan reveals a liver mass, one of the first diagnostic priorities is figuring out whether it is a primary liver tumor or a metastasis from somewhere else.

What Drives Liver Cancer Risk

Chronic hepatitis B and C infections have historically been the dominant drivers of liver cancer worldwide, and they remain enormously powerful risk factors. A large systematic review and meta-analysis found that hepatitis B carried an odds ratio of roughly 15 for liver cancer, and hepatitis C about 13, both substantially higher than the risk that smoking confers for lung cancer.⁹ Co-infection with hepatitis D pushed the risk even higher. These numbers put viral hepatitis in a league of its own among established cancer risk factors.

The landscape is shifting, however. Between 2010 and 2019, the fastest-growing causes of liver cancer globally were non-alcoholic steatohepatitis (now often called metabolic-associated steatohepatitis) and alcohol, while rates tied to hepatitis B and C declined, thanks largely to vaccination and antiviral treatments.¹⁰ This trend means the typical liver cancer patient in many Western countries increasingly looks different from the historical profile: less likely to have viral hepatitis, more likely to be overweight with metabolic syndrome. The same meta-analysis found metabolic-associated steatotic liver disease carried an odds ratio of about 2.6 and alcohol about 2.4 for liver cancer, lower than the viral hepatitis figures but affecting far larger populations.⁹

How Liver Neoplasms Are Diagnosed

Most liver neoplasms are first spotted on imaging, often during an ultrasound or CT scan performed for another reason. When a suspicious mass is found in someone at risk for liver cancer, the workup typically involves multiphase contrast-enhanced CT or MRI. These scans capture the liver at different moments as contrast dye flows through, and each type of tumor has a characteristic enhancement pattern. HCC, for example, tends to light up brightly during the arterial phase and then “wash out” relative to the surrounding liver in later phases.

To standardize how radiologists interpret these scans, the Liver Imaging Reporting and Data System (LI-RADS) assigns each observation a category from LR-1 (definitely benign) through LR-5 (definitely HCC). This system was designed specifically for patients already at risk for liver cancer, such as those with cirrhosis or chronic hepatitis B. An LR-5 reading can establish an HCC diagnosis without a biopsy, which is important because biopsy of a cirrhotic liver carries its own risks.¹¹

When comparing gadoxetic acid-enhanced MRI to multiphase CT using LI-RADS categories, one study found that both had similar sensitivity for definitively categorizing HCC, at roughly 60 to 64%. CT detected the classic “washout” and capsule features somewhat more often, while MRI offered additional ancillary features that led to category upgrades in about 18% of tumors.¹² In practice, MRI and CT are often used as complementary tools rather than competitors, each filling in gaps the other misses.

Distinguishing HCC from intrahepatic cholangiocarcinoma on imaging can be tricky. Cholangiocarcinoma tumors tend to show less blood vessel richness and are more often associated with bile duct dilation, while HCC patients more commonly have signs of portal hypertension like an enlarged spleen. Differences in tumor marker levels, particularly alpha-fetoprotein (elevated in HCC) and CA 19-9 (elevated in cholangiocarcinoma), help narrow the diagnosis further.¹³

Surgical Treatment and Transplantation

For primary liver cancers caught early, surgery offers the best chance at long-term survival. The two main surgical options are resection (removing the tumor along with a margin of healthy liver tissue) and liver transplantation. Resection works well when the tumor is confined and the remaining liver is healthy enough to regenerate and sustain the patient. In patients with significant cirrhosis, however, removing a chunk of liver can cause liver failure, making transplantation the preferred route when feasible.

Liver transplantation has the unique advantage of removing both the cancer and the diseased liver in one stroke, eliminating the scarred tissue where new cancers could emerge. The trade-off is a limited supply of donor organs and the lifelong need for immunosuppressive medication. Transplant eligibility depends on tumor size and number, and patients who fall outside standard criteria may receive locoregional treatments to keep their tumors in check while they wait for a donor organ.

For colorectal liver metastases, surgical resection remains the gold standard when the tumors can be completely removed. Even patients with multiple metastases may be candidates if the number, size, and location allow for safe removal while leaving enough functioning liver behind.⁸

Ablation Therapies

When surgery is not an option because of tumor location, the patient’s overall health, or insufficient liver reserve, ablation offers a way to destroy tumors without removing them. The two main techniques are radiofrequency ablation (RFA), which uses electrical current to generate heat, and microwave ablation (MWA), which uses electromagnetic waves to do the same. Both are typically performed by inserting a needle-like probe through the skin and into the tumor under imaging guidance.

MWA tends to create larger ablation zones than RFA, meaning more tissue is destroyed around the target. In a randomized trial, the average ablation zone was about 37 cubic centimeters with MWA versus 28 with RFA.¹⁴ Whether this translates into meaningfully better long-term outcomes depends on the tumor type. A systematic review and meta-analysis of randomized trials in HCC patients found that MWA was associated with lower rates of local tumor progression compared to RFA.¹⁵ For colorectal liver metastases specifically, another meta-analysis found that MWA showed better disease-free survival at one and two years.¹⁶ Despite these findings, both techniques remain in wide use, and the choice often comes down to tumor size, location, and institutional expertise.

Arterial Therapies for Unresectable Tumors

HCC has an unusual feature that makes it vulnerable to a particular treatment strategy: it gets most of its blood supply from the hepatic artery, while the surrounding normal liver is fed predominantly by the portal vein. This allows doctors to deliver therapy directly to the tumor through the artery while relatively sparing healthy tissue.

Two forms of this approach are commonly used. Transarterial chemoembolization (TACE) delivers chemotherapy drugs directly into the tumor’s blood supply and then blocks the feeding vessels with tiny particles, cutting off both blood flow and trapping the drugs in place. Transarterial radioembolization (TARE), also called selective internal radiation therapy, uses tiny radioactive beads that lodge in the tumor’s blood vessels and irradiate it from the inside. Both are standard treatments for HCC that cannot be surgically removed, but they differ in their mechanisms and side-effect profiles.¹⁷

Candidates for these arterial therapies need adequate baseline liver function. Patients with severely compromised livers, such as those classified as Child-Pugh C, are generally not eligible for TACE because the procedure can worsen liver function to a dangerous degree.¹⁸

Systemic Therapies and Immunotherapy

For advanced HCC that has spread beyond the reach of surgery or locoregional treatments, systemic therapy is the mainstay. For years, sorafenib, a tyrosine kinase inhibitor, was the only first-line option. While it represented a genuine advance when it was approved, its survival benefit was modest, and resistance frequently developed.¹⁹

The field changed substantially with the arrival of immunotherapy combinations. The landmark IMbrave150 trial showed that atezolizumab (an immune checkpoint inhibitor) combined with bevacizumab (which blocks blood vessel growth) reduced the risk of death by about 42% compared to sorafenib in patients with unresectable HCC. Twelve-month survival was roughly 67% in the combination group versus about 55% with sorafenib.²⁰ This combination became the new standard of care for first-line treatment of advanced HCC.

Real-world data from observational studies have largely confirmed the trial results. A meta-analysis pooling over 2,000 patients treated with this combination outside of clinical trials found six-month and twelve-month overall survival rates of about 82% and 65%, respectively.²¹ The twelve-month figure closely mirrors the trial results, which is reassuring because clinical trial participants are often younger and healthier than typical cancer patients. Other immunotherapy combinations have since entered the landscape, further expanding options.

Why Liver Function Shapes Every Treatment Decision

A feature unique to liver cancer treatment is that doctors must weigh two prognoses simultaneously: the cancer itself and the underlying liver disease. A small tumor in a severely cirrhotic liver can be more dangerous than a larger tumor in an otherwise healthy liver, because the patient may not tolerate treatment. The Child-Pugh scoring system has long been used to grade liver function, while a newer measure called the albumin-bilirubin (ALBI) score focuses purely on two blood test results and avoids some of the subjective elements of the older system.

Research has shown that the ALBI score provides meaningful prognostic information even after accounting for tumor-related factors like blood vessel invasion and tumor stage.²² In practical terms, this means two patients with identical-looking tumors on a scan can face very different treatment paths depending on how well their liver is working. Someone with well-preserved function might be offered resection or aggressive locoregional therapy, while someone with poor function may only be eligible for systemic treatment or supportive care.

Emerging Tools in Precision Oncology

Comprehensive genomic profiling is increasingly used in advanced HCC to look for mutations that might open the door to targeted therapies. While no single genetic target has yet transformed HCC treatment the way certain mutations have in lung or breast cancer, genomic analysis helps researchers understand why some patients respond to immunotherapy while others do not, and it supports efforts to identify predictive biomarkers for current and emerging therapies.²³

Liquid biopsy, which analyzes circulating tumor DNA and circulating tumor cells from a simple blood draw, is another area of active development. Rather than requiring a needle biopsy of the liver, a liquid biopsy can detect genetic alterations that may influence whether a patient responds to specific drugs, including tyrosine kinase inhibitors and immune checkpoint inhibitors.²⁴ This technology is not yet routine in clinical practice for HCC, but it is moving closer.

Surveillance After Treatment

Liver cancer, particularly HCC, has a high rate of recurrence even after successful treatment. This makes ongoing surveillance critically important. After liver transplantation, for instance, research suggests that getting at least three surveillance scans within the first two years provides the highest probability of catching a recurrence early enough for aggressive retreatment.²⁵ For patients who were treated with resection or ablation, most guidelines recommend imaging every three to six months in the first couple of years and then at longer intervals if no recurrence appears.

Risk stratification models help clinicians decide how intensively to monitor each patient. Someone with a small, well-differentiated tumor that was completely removed is at lower risk of recurrence than someone who had a large tumor with vascular invasion. In settings where imaging resources are stretched, these risk models can help prioritize surveillance for the patients most likely to benefit.²⁶

Liver Tumors in Children

Liver neoplasms in children are rare but deserve mention because they behave very differently from adult liver cancers. The most common malignant liver tumor in young children is hepatoblastoma, which typically appears before age three. Unlike adult HCC, hepatoblastoma is not associated with cirrhosis or chronic liver disease and is treated with a combination of chemotherapy and surgery.

Outcomes depend heavily on how far the disease has spread at diagnosis. In one single-center review, all children with early-stage disease survived, while survival among those with advanced-stage disease was around 50%. The overall survival rate across all stages was 75% over a median follow-up of nine years.²⁷ Alpha-fetoprotein, the same blood marker used in adult liver cancer, serves as a useful tracking tool in hepatoblastoma: levels normalized after treatment in all surviving patients in that study, making it a reliable indicator that the cancer has been controlled.

Palliative Care for Advanced Disease

When liver cancer reaches a terminal stage where no tumor-directed treatment is feasible, the focus shifts to palliative care aimed at maintaining quality of life. Pain management, nutritional support, and psychological care become the pillars of treatment. Patients with end-stage HCC often experience abdominal pain, loss of appetite, fatigue, and fluid buildup in the abdomen (ascites), all of which can be managed to varying degrees with medication and supportive measures.²⁸ Early referral to palliative care specialists, rather than waiting until the very end, tends to improve symptom control and patient satisfaction, and this is an area where many oncology teams are working to do better.