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- Stage of the disease: size of the tumour, how much of the liver has been affected, whether there is spread to other parts of the body.
- Liver function: how well the liver is working, including whether or not there is underlying cirrhosis.
- The patient’s general health.
- Effects of the treatment.
Staging
When liver cancer is diagnosed, it is important to know the extent of the disease as this will help with planning the treatment. Staging determines the size of the tumour, whether it affects part of or the whole liver, and whether it has spread to other parts of the body. Staging will show if the tumour can be surgically removed.
The tests mentioned above provide much of the information needed to stage the disease. Additional tests may include a chest X-ray or CT scan of the chest to look for spread to the lungs, and a bone scan if there is suspected spread to the bone. A laparoscopy may also be used to look directly at the liver and adjacent organs.
Depending on the size of the tumour and evidence of spread to the lymph nodes and other parts of the body, liver cancer can be classified into stages. A number of staging systems for HCC exist, but most have limitations and none are universally accepted. International guidelines recommend particular roles for certain staging systems.
In terms of deciding on treatment, liver cancer can be staged as:
- Early-stage HCC: the cancer is localised to the liver, has not spread and can be completely removed by surgery. Potentially curable.
- Intermediate-stage HCC: the cancer is localised to the liver, has not spread, but cannot be completely removed by surgery. Treatment is still aimed at increasing life expectancy.
- Late-stage HCC: the cancer has spread throughout the liver or to other parts of the body. Incurable.
Treatment
Treatment options are available for the management of hepatocellular carcinoma. These include:
Surgery
- Resection
- Liver transplantation
Local ablative procedures
- Cryoablation
- Radiofrequency thermal ablation (RFA)
- Percutaneous ethanol injection (PEI)
- Transarterial chemoembolization (TACE)
- Laser and microwave therapy
- Regional radiotherapy
Systemic therapy
- Chemotherapy
- Targeted molecular therapy
- Symptomatic treatment
Supportive care
The choice of treatment depends on the stage of the cancer, the condition of the liver, and the age and general health of the patient. The patient’s personal values and the possible side effects of treatment are also taken into account.
Surgery
Resection (partial hepatectomy): this involves removal of the part of the liver containing the cancer, a rim of normal tissue and maybe a wedge or a whole lobe or more than a lobe of liver tissue. A normal liver can tolerate up to 80 percent of resection of functional tissue. Partial hepatectomy is the choice of treatment for non-cirrhotic patients with HCC.
Liver transplantation: the entire liver is removed and replaced with a healthy donated liver. This can only occur if the cancer is confined to the liver and a donor liver becomes available. Transplantation manages both the cancer and the underlying liver disease.
Surgical treatment options offer the only possibility of cure. Unfortunately, most liver cancers present late and are not amenable to surgical resection.
Locoregional therapy
These techniques are used in patients with early- and intermediate-stage HCC who are not suitable for surgical treatment. They are usually performed by using imaging-guided ultrasound or computed tomography (CT).
Cryoablation: a probe is inserted into the tumour via laparoscopy or open surgery. Liquid nitrogen is passed through the probe to freeze and kill the cancer cells.
Radiofrequency thermal ablation (RFA): alternating current is passed through a probe inserted into the tumour. This results in ionic agitation, which produces heat and kills the cancer cells. It is limited by the size (smaller than 5cm), number and location of tumours within the liver. The procedure can be done percutaneously using local anaesthetic or during laparoscopy or open surgery.
Percutaneous ethanol injection (PEI): alcohol is injected directly into the tumour to kill cancer cells. It is carried out under local anaesthetic using ultrasound to guide the needle to the correct position. It is used when the tumour is smaller than 3 cm and there are three or fewer.
Transarterial chemoembolization (TACE): Tiny beads called microspheres, are delivered to the hepatic artery, where they lodge and obstruct the blood flow. These beads are combined with chemotherapeutic agents, which can stay in the liver for longer because of the decreased blood flow, allowing them to kill off large HCC tumours. (Doctors call this necrosis of the tumours.) Although the hepatic artery is blocked, healthy liver tissue survives because it can still receive blood from the portal vein.
Transarterial radioembolization: this involves the administration of radiolabeled microspheres (tiny radioactive beads) via the hepatic artery to deliver radiation therapy to the tumour.
Other therapies that use heat to destroy cancer cells are laser and microwave therapy, but not much information is available on the success of these techniques.
Regional radiotherapy (radiation therapy) uses high-energy rays to kill cancer cells. It is used in advanced cancers to alleviate symptoms and slow progress of the cancer. In selected cases the tumour can be somewhat shrinked, but results are generally not very good.
Systemic therapy
Chemotherapy
Chemotherapy uses drugs to kill the cancer cells or to stop them from dividing. Normal cells like blood, hair and cells of the gastrointestinal tract are also affected, resulting in various side effects. The drugs can be injected into a vein, taken orally or be given directly into the liver (regional chemotherapy).
Liver cancer is relatively resistant to chemotherapy delivered via injection or orally. It has a low response rate of 15-20%, which is usually incomplete and lasts for only a short while. This therapy is used in advanced cancer to slow the progress of the disease.
When drugs are delivered directly to the liver via a catheter placed into the hepatic artery, it is called hepatic artery infusion. With this treatment, higher concentrations of the drugs go directly to the cancer cells in the liver with less effect on the normal cells of the body, but results have also been disappointing.
Targeted molecular therapy
Thanks to modern advances in the understanding of cancer, new systemic therapies have been developed that target the molecular pathways involved in the development and growth of the tumour. These drugs seek out and kill only the cancer cells, leaving surrounding healthy tissue unscathed. Sorafenib has been the first of these to show a prolonged survival and has been approved for the management of advanced HCC. Several other targeted therapies are in early stages of evaluation.
Supportive (palliative) care
Supportive treatment is an important aspect of management of patients with HCC. The aim is to enhance the patient’s quality of life as much as possible in his or her remaining short lifespan. The goals of palliative care are:
- Relief of pain and other symptoms.
- Psychological and spiritual care for patients to allow them to come to terms with dying.
- A support system to maintain personal integrity and self-esteem.
- A system to support the family to cope with the patient’s final days and their bereavement.
