Liver Cancer

Treatment

Many things must be considered when treating HCC, which is a complex cancer in a complex organ. HCC treatment is highly personalized so the many health-related variables can be addressed. The underlying condition causing the cancer and the cancer must be treated. This requires a multidisciplinary team of specialists to plan and oversee all phases of treatment. This means doctors, nurses and other health care professionals from different medical fields will work together to provide you with the best possible care (see who's who below).

The therapies chosen for you will depend heavily on your liver function and your general health, so a thorough health assessment will be performed and more tests may be ordered before any recommendations are offered.

Your doctors will consider the following factors, among others:

  • How much of the liver is affected, including tumor size, location and number
  • Whether cancer has spread (metastasized) outside the liver
  • How well the liver is working; whether noncancerous areas remain healthy
  • Other serious health conditions you may have and your overall physical condition
  • Your personal preferences about under-going certain treatments and/or their potential effects on your quality of life

Treatment doesn’t always mean “cure.” As you and your medical team discuss treatment options, it is very important that you agree with the goal of treatment and recognize that over time, that goal may change.

Common treatment goals follow.

  • Eliminate the cancer to cure HCC. This is called curative treatment.
  • Shrink the tumor(s) to make liver resection or transplantation possible. This may be referred to as downstaging the tumor.
  • Slow the cancer’s growth or progression to extend life.
  • Improve quality of life, either by minimizing or managing side effects during treatment, treating post-operative pain and symptoms or helping relieve pain and discomfort without active treatment. This is called supportive (or palliative) care (see Supportive Care).

Recent breakthroughs in liver cancer research have led to more options for extending life and improving quality of life for people diagnosed at any stage. However, for individuals living with advanced or late-stage HCC, no curative treatments are currently approved by the U.S. Food and Drug Administration (FDA). Also, for many reasons, even people diagnosed with early stage HCC may not be good candidates for receiving a curative treatment. Therefore, fully understanding what undergoing treatment potentially can – and cannot – achieve for you is essential when making decisions about your care.

Common Treatments For HCC

Your medical team will likely recommend one or more of the following treatments. Particularly for people diagnosed with advanced HCC, clinical trials are an important treatment option that deserve serious consideration. These medical research studies may provide access to new investigational therapies that are not yet available to the public (see Clinical Trials).

Surveillance

This option may be recommended for tumors that appear to be growing very slowly. Postponing treatment while doctors closely monitor you (every three months is common) allows you to avoid potential side effects for as long as possible. It is very important to make and keep follow-up appointments because treatment should begin if the pace of cancer progression speeds up (see Ongoing Monitoring & Care).

Surgery

This is the primary curative method for treating HCC, through a partial hepatectomy (HEH-puh-TEK-toh-mee) or liver transplantation. Liver surgery is often complex and requires a high degree of training and skill. Seek treatment at a cancer facility known for performing a high volume of surgical procedures for liver cancer. Do not hesitate to get a second or third opinion before deciding on a surgeon.

  • Partial hepatectomy, or liver resection, removes a wedge, an entire lobe or more of the liver that contains the tumor(s), along with a margin of healthy tissue. The remaining healthy organ will continue to function as it regenerates (regrows), often to near normal size. Surgical resection may be an option when your liver is functioning well, the tumors are small, the disease is early stage and blood vessels are not involved. You must also be healthy enough to have surgery.

More complex hepatectomies may be performed through traditional open resection with a large incision into the abdomen. This is major surgery and requires significant recovery time. For minor resections involving easily accessible tumors, minimally invasive laparoscopic surgery may be performed. A few small incisions are made in the abdomen to insert a long, tube-like medical instrument (laparoscope) with a tiny video camera on the end. Magnified images from inside the body are transmitted to a video screen in the operating room to guide the surgeon. This method usually results in shorter recovery time, less blood loss and fewer post-surgery complications compared to open surgery.

  • Liver transplantation removes the entire liver (hepatectomy) and replaces it with a healthy liver, most often from a deceased donor. It is a highly effective treatment for HCC, but only a very small percentage of people qualify for transplantation. Candidates must meet strict criteria concerning the size, stage, location and number of tumors present and must have a qualifying “liver score” based on blood levels of creatinine, bilirubin and sodium, along with how well the liver makes factors for clotting blood. If your doctors believe you may be a potential candidate, you can be referred to a transplantation center for assessment. In rare cases, transplant centers may suggest a living donor – typically a relative – though the criteria used to assess candidacy are not different than for using deceased donor livers.

Percutaneous Ablation Therapy

When surgery is not an option, percutaneous (passing through the skin) ablation therapy is often used to treat HCC and may be curative. This minimally invasive, image-guided procedure kills cancer cells by inserting a needle directly into the tumor and running electrical current through it to subject the tumor to extreme temperatures.

  • Microwave ablation (MWA) uses microwave energy for the same purpose.
  • Cryoablation, also called cryosurgery or cryotherapy, delivers extremely cold gas through a hollow needle. This technique may be referred to as thermal ablation.
  • Percutaneous ethanol injection (PEI), also called alcohol ablation, delivers alcohol directly into the tumor.

Embolization

When curative treatment is not possible, embolization procedures can extend life and improve quality of life.

  • A minimally invasive, image-guided procedure, chemoembolization treats HCC by administering chemotherapy into small hepatic arteries that are the main source of blood for most tumors developing in the liver, and then blocking them off to allow the chemotherapy to remain present in the area of the tumor for longer periods of time.
  • Transarterial embolization (TAE) involves making a small incision in the groin and inserting a catheter, which is a thin, flexible tube that is guided through the body to the hepatic artery. When the catheter is in place, tiny particles made of gelatin beads or sponges are injected to block small arteries, cutting off the flow of blood feeding the tumor. Healthy liver tissue continues to receive blood from other blood vessels.
  • Transarterial chemoembolization (TACE) is a similar procedure, but with the blood supply temporarily blocked, chemotherapy drugs can be delivered through the hepatic artery to the tumor and remain trapped there for a longer period of time.
  • Radioembolization, also called Y90 or Yttrium 90, combines radiation therapy with embolization. Microscopic glass beads containing high-dose radiation are injected into the hepatic artery to be delivered directly to the tumor. The goal is to slow the growth of the disease and reduce symptoms, though radioembolization has also been used to reduce the size of tumors to permit subsequent surgical treatment.

Molecularly Targeted Therapy

This treatment option is designed to slow the cancer’s progression. Targeted therapy drugs travel throughout the body in the bloodstream looking for specific proteins and tissue environments to block cancer cell signals and thereby restrict the growth and spread of cancer. The most common type of targeted therapy approved for use with HCC is called an angiogenesis inhibitor, which means it works by blocking the growth of new blood vessels that feed the cancer cells. Blood vessels deliver nutrients the tumors need to grow and spread, so by shutting down the formation of new blood vessels, angiogenesis inhibitors in effect “starve” the tumor. Most of these targeted therapies are taken orally at home.

Immunotherapy

Immunotherapy fights cancer by stimulating the body’s immune system to recognize and destroy cancer cells. Training the immune system to respond to cancer has the potential for a more lasting response that can extend beyond the end of treatment. Immune checkpoint inhibitors are the type of immunotherapy currently approved to be used for advanced HCC in certain instances. They target proteins (PD-1 and PD-L1) on the surface of specific immune system cells. By blocking these proteins, immune checkpoint inhibitors prevent tumors from slowing down the immune response and thereby allow the immune cells to continue fighting the cancer. This type of immunotherapy is given intravenously (IV).

Radiation Therapy

By using high-energy X-rays or other types of radiation to destroy cancer cells, the goal of radiation therapy is to shrink tumors or slow their growth. Different forms of external-beam radiation therapy (EBRT) may sometimes be used as adjuvant treatment following surgery. EBRT may also be used in palliative care to relieve pain and other cancer symptoms by shrinking tumors. Using radiation therapy as a curative treatment for HCC is an intense research focus in clinical trials.

Drug Therapies for HCC

  • cabozantinib (Cabometyx)
  • lenvatinib (Lenvima)
  • nivolumab (Opdivo)
  • pembrolizumab (Keytruda)
  • ramucirumab (Cyramza)
  • regorafenib (Stivarga)
  • sorafenib (Nexavar)

Some Possible Combination Therapies

  • atezolizumab (Tecentriq) in combination with bevacizumab (Avastin)
  • ipilimumab (Yervoy) and nivolumab (Opdivo)

As of 6/1/20

 

Who’s Who on the Health Care Team

Your multidisciplinary team may include many of the following specialists, as well as other health care professionals.

Gastroenterologist:Diagnoses and treats disorders of the gastrointestinal (GI) tract (digestive system), which includes the liver

Hepatobiliary surgeon: Specializes in surgical procedures for the liver, bile ducts, gallbladder and pancreas

Hepatologist (subspecialty of Gastroenterology): Diagnoses and treats disorders of the liver, gallbladder and pancreas. May also participate in evaluation of liver transplant candidacy

Interventional radiologist: Specializes in minimally invasive imagery-guided procedures, such as ablation and embolization

Medical oncologist: Treats cancer using medicines such as chemotherapy, targeted therapy or immunotherapy

Oncology nurse practitioner (ONP): Specializes in managing the physical and psychological needs of cancer patients and their loved ones

Oncology nurses: Provide cancer care in inpatient and outpatient settings

Palliative care specialists: Offer physical and emotional relief for cancer symptoms, treatment-related side effects, pain management and more

Patient navigator/nurse navigator: Guides people with cancer and their loved ones through diagnosis, treatment and followup; may also serve as a patient advocate

Pharmacist: A health professional who has special training in preparing and dispensing (giving out) prescription drugs

Radiation oncologist: Uses radiation therapy to treat cancer

Surgical oncologist: Specialist that treats cancer using surgical procedures

 

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