There are two broad categories of liver cancer: primary liver cancer, which starts in the liver itself, and secondary (metastatic) liver cancer, which spreads to the liver from somewhere else in the body. Within primary liver cancer, hepatocellular carcinoma is by far the most common type, accounting for roughly 75% of all cases. But several other types exist, each with distinct risk factors, age groups, and behavior.
Hepatocellular Carcinoma (HCC)
HCC develops in the main cells of the liver and is the dominant form of primary liver cancer worldwide. It almost always arises in a liver that’s already damaged. Chronic hepatitis B or C infection, long-term heavy alcohol use, and fatty liver disease are the leading drivers. Cirrhosis, the severe scarring that results from years of liver damage, is present in the majority of people diagnosed with HCC.
Because HCC grows in a predictable pattern tied to liver health, doctors use a specific staging system called the Barcelona Clinic Liver Cancer (BCLC) system to guide treatment decisions. It has five stages based on tumor size and number, how well the liver still functions, and whether cancer has spread beyond the liver:
- Very early (Stage 0): A single tumor 2 cm or smaller, confined to the liver, with preserved liver function and no symptoms.
- Early (Stage A): A single tumor of any size, or up to three tumors none larger than 3 cm, still without spread or symptoms.
- Intermediate (Stage B): Multiple tumors beyond early-stage criteria, but liver function is still intact and the cancer hasn’t invaded blood vessels or spread elsewhere.
- Advanced (Stage C): Cancer has grown into blood vessels or spread outside the liver, though the person is still relatively functional.
- End stage (Stage D): Severe cancer-related symptoms or significantly impaired liver function, with limited treatment options.
Caught at the localized stage, when it’s still confined to the liver, HCC has a five-year survival rate of about 38%. That drops to around 13% once it reaches nearby lymph nodes and to roughly 4% when it has spread to distant organs. These numbers reflect a mix of treatments and include some patients who received no treatment, so individual outcomes can vary considerably depending on how early the cancer is found and how healthy the liver remains.
Fibrolamellar Carcinoma
Fibrolamellar carcinoma is a rare subtype of hepatocellular carcinoma that behaves very differently from conventional HCC. It typically strikes younger adults, with a median age at diagnosis around 26, and shows a slight female predominance. Unlike standard HCC, it has no association with cirrhosis, hepatitis, or other chronic liver diseases. A person with fibrolamellar carcinoma usually has an otherwise healthy liver.
This subtype is driven by a specific genetic change: a fusion of two genes (DNAJB1 and PRKACA) that serves as a definitive marker for the disease. On imaging, fibrolamellar tumors can sometimes be mistaken for a benign liver growth called focal nodular hyperplasia because both can have a characteristic central scar. By the time of diagnosis, the cancer has often invaded blood vessels, and up to 40% of patients already have spread to nearby lymph nodes. Surgery is the primary treatment when the tumor can be removed.
Intrahepatic Cholangiocarcinoma
Cholangiocarcinoma, or bile duct cancer, forms in the tubes that carry bile from the liver to the small intestine. When it starts inside the liver, it’s called intrahepatic cholangiocarcinoma (ICC). This type makes up roughly 10 to 20% of all primary liver tumors and about 3% of gastrointestinal cancers worldwide.
ICC has been rising sharply. Over a 30-year period, its incidence in the United States increased by 165%. The reasons aren’t entirely clear, partly because nearly 40% of patients diagnosed with ICC have no identifiable risk factor. Known risk factors include chronic hepatitis B or C infection, cirrhosis, a condition called primary sclerosing cholangitis (an inflammatory disease of the bile ducts), and bile duct stones. People with primary sclerosing cholangitis carry a 5 to 10% lifetime risk of developing cholangiocarcinoma, with half of those cases appearing within two years of diagnosis.
Geography plays a striking role. In Thailand, where parasitic liver flukes are common, ICC rates reach as high as 100 per 100,000 people. In the United States, by comparison, the rate is under 1 per 100,000. These parasites, acquired by eating raw or undercooked freshwater fish, cause chronic inflammation in the bile ducts. An estimated 8 to 10% of people chronically infected with liver flukes eventually develop ICC. Hispanic Americans in the U.S. have the highest incidence among ethnic groups (1.22 per 100,000), while African Americans have the lowest (0.3 per 100,000).
Angiosarcoma
Angiosarcoma of the liver is rare, representing just 0.1 to 2% of all primary liver cancers. Despite those small numbers, it is the third most common primary liver malignancy overall and the most common type that arises from the liver’s connective tissue rather than its main cells or bile ducts. It is aggressive and often diagnosed at an advanced stage.
About 75% of cases have no known cause. Among the remaining cases, the strongest links are to occupational or environmental exposures: vinyl chloride (used in plastics manufacturing), a now-discontinued radiologic contrast agent called Thorotrast, chronic arsenic ingestion, and long-term use of anabolic steroids. Because of the long lag between exposure and cancer development, sometimes spanning decades, pinpointing a cause in any individual case is difficult.
Hepatoblastoma in Children
Hepatoblastoma is the most common primary liver tumor in children, typically diagnosed before age 3. It is biologically distinct from adult liver cancers and has its own treatment protocols. The most common first sign is a swollen abdomen or a mass that a parent or doctor can feel. Some children also develop fatigue, loss of appetite, or discomfort from the growing tumor. In rare cases, the tumor secretes hormones that trigger early puberty.
Hepatoblastoma generally responds well to a combination of chemotherapy and surgery, and survival rates in children are considerably higher than those for adult liver cancers, particularly when the tumor is caught early and can be fully removed.
Secondary (Metastatic) Liver Cancer
Secondary liver cancer is far more common than primary liver cancer. After the lymph nodes, the liver is the most frequent destination for cancer that has spread from another organ. The most common sources are cancers of the colon, rectum, pancreas, stomach, esophagus, breast, and lung, along with melanoma.
Liver metastases sometimes appear at the same time the original cancer is found, or they may show up months to years after the primary tumor was treated. These tumors are still classified and treated as the original cancer type. For example, colon cancer that spreads to the liver is treated as metastatic colon cancer, not liver cancer. This distinction matters because treatment strategies, drug choices, and expected outcomes all depend on where the cancer originated, not where it landed.
Screening for High-Risk Groups
If you have cirrhosis, chronic hepatitis B, or other known risk factors for HCC, screening can catch tumors early enough to make a significant difference in outcome. Current guidelines recommend a liver ultrasound and a blood test measuring alpha-fetoprotein (AFP, a protein that liver tumors often produce) every six months for adults between 21 and 75 who are at increased risk. Regular screening is one of the few tools that consistently shifts diagnoses toward earlier, more treatable stages.