Treatment options for liver cancer
Your liver cancer treatment will depend upon the size, location, and stage of the tumour, as well as your general health and fitness. You should be fully informed and involved in decisions about your treatment options.
The choice of treatments should be discussed with you, and your preferences should be considered. Your treatment should be discussed by a multidisciplinary team (MDT), which means that experts in different areas of cancer treatment (e.g. surgeons, gastroenterologists, radiologists, oncologists and nurses) come together to share their expertise in order to provide the best patient care.
Currently, the best chance for potentially curing liver cancer is through surgery or complete destruction of the tumor using heat methods, such as microwave or radiofrequency. Surgery can be performed in an attempt to remove the tumour, or a liver transplant may be performed in cases of some primary liver tumours, such as hepatocellular cancer, in suitable patients.
Surgery is the removal of the tumour and some surrounding healthy tissue during an operation. It is likely to be the most successful way of removing the cancer. Surgery may not be an option if the tumour is too big, the liver is too damaged, the tumour has spread outside the liver, or you are too unwell. Typically, this surgery is performed by a hepatobiliary surgeon, who has specialised training in surgery on the liver, but liver transplant surgeons may also be involved in these operations.
The success of a liver tumour removal depends on the following factors:
- The location of the tumour.
- The number of tumours.
- The distribution of the tumours.
- The amount of liver left after tumour removal.
Two types of surgery are used to treat primary liver cancer are a hepatectomy or liver transplant.
A hepatectomy is when a portion of the liver is removed. A hepatectomy can be done only if the cancer is in one part of the liver and the liver is working well. The remaining section of liver takes over the functions of the entire liver. The liver may grow back to its normal size within a few weeks.
The liver resection may be called:
- Right or Left hepatectomy – the right or left part of the liver is removed.
- Extended Right or Left hepatectomy – most of the liver is removed.
- Segmentectomy – small section of the liver is removed.
A hepatectomy may not be possible if you have advanced cirrhosis, even if the tumour is small.
The side effects of a hepatectomy may include pain, weakness, fatigue and temporary liver failure. The health care team will watch for signs of bleeding, infection, liver failure, or other problems that need immediate treatment.
Sometimes, a liver transplantation can be done. This procedure is possible only when specific criteria are met, including tumour size and number and whether a suitable donor is found. These criteria usually include are a single tumour that is 5 cm or smaller or three or fewer tumours, all of which are smaller than 3 cm. It is important to understand that the number of available donor livers is very limited, so transplantation is not always an option.
Liver transplantation is a particularly effective treatment for people with a small tumour because transplantation removes the tumour and the damaged liver. However, to be considered for a liver transplant, you need to be reasonably fit, not smoke or take illegal drugs, and have stopped drinking alcohol for at least six months. Donor livers are scarce, and waiting for a suitable liver may take many months. During this time, the cancer may continue to grow. As a result, most people have tumour ablation to control the cancer while they wait for a donor.
The liver transplant team can advise you on how long the wait is likely to be and what rules are used to prioritize people on the waiting list.
Unfortunately, the cancer may progress in some people despite treatment to the point at which a liver transplant will no longer be possible. In this situation, you will be removed from the liver transplant waiting list, and your doctor will discuss alternative treatment options.
If you undergo a liver transplant, you will be watched closely for signs that your body might be rejecting the new liver or that the tumour has returned. You will need to take medications called immunosuppressants idefinitely to prevent rejection of the new liver, which can cause side effects, such as puffiness in the face, high blood pressure or increased body hair. Liver transplant has significant risks of serious complications, including death from infection or the body’s rejection of the donor liver.
For tumours smaller than 3 cm, you may be offered tumour ablation. This destroys the tumour without removing it and may be the best option if you cannot have surgery or are awaiting transplantation. Ablation can be done in different ways, depending on the size, location and shape of the tumour. The most common is thermal ablation and less common alcohol injection.
Other treatment options
RFA uses heat to destroy a tumour. The heat may come from radio waves or microwaves. Using an ultrasound or CT scan as a guide, your doctor will insert a needle through the abdomen into the liver tumour. This needle then emits radio waves that produce heat and destroy the cancer cells. Side effects may include pain, nausea or fever, but these can be managed with medicines.
Percutaneous ethanol injection is a procedure in which alcohol is injected directly into the liver tumour to destroy it. This procedure may not be available at all hospitals and is rarely used. Using an ultrasound as a guide, your doctor will insert a needle through the abdomen into the liver tumour. The needle then injects alcohol to destroy the cancer cells. You might need more than one injection. Side effects may include pain or fever, but these can be managed with medicines.
Traditional chemotherapy is rarely used for primary liver cancer. Instead, trans-arterial chemoembolization (TACE) is used to deliver high doses of chemotherapy directly into the tumour. Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing, dividing, and making more cells. During this procedure, drugs are injected into the hepatic artery, and the flow of blood through the artery is blocked for a short time so the chemotherapy stays in the tumour. It is usually given to people who cannot have surgery or ablation or are awaiting transplantation. You may feel some pain, which can be controlled with medicines. Some people feel tired or report flu-like symptoms for up to a week after the procedure. Radiation therapy is performed by an oncology radiologist after discussion with your surgeon.
Radiation therapy is the use of high-energy X-rays to destroy cancer cells. Radiation therapy is a common treatment option for primary liver cancer. Two techniques may be offered, either stereotactic body radiation therapy (SBRT) or selective internal radiation therapy (SIRT).
Radiation therapy is performed by an interventional radiologist after discussion with your surgeon.
SBRT is a treatment where a machine will deliver tightly focused beams of high-dose radiation precisely onto the tumour from many different angles. SBRT may be offered to people with HCC tumours that cannot be removed with surgery or treated with tumour ablation or TACE. SBRT may also be offered to people to shrink tumours while they are waiting for a liver transplant.
Also called radioembolisation, SIRT is a treatment that precisely targets cancers in the liver with high doses of radiation while causing little damage to normal liver tissue. SIRT may be offered for primary liver cancer when the tumours cannot be removed with surgery or to shrink tumours before surgery or a liver transplant. It involves tiny radioactive beads being inserted into the liver. SIRT can be given as a single treatment to the whole liver or separate treatments to the right and left lobes. The procedure is done by an interventional radiologist.
Immunotherapy is designed to boost the body’s natural defences to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function. One common type of immunotherapy is called an immune checkpoint inhibitor. Immune checkpoint inhibitors work by blocking the pathways that would otherwise allow the cancer to hide from the immune system.
Talk with your health care team about whether immunotherapy is recommended for you.
Targeted therapy is a type of drug treatment that attacks specific features of cancer cells to stop the cancer growing and spreading. It targets the cancer’s specific genes, proteins or tissue environment which contribute to cancer growth and survival. It acts to block the growth and spread of cancer cells while limiting damage to healthy cells.
People who have advanced HCC and meet certain criteria may be offered targeted therapy. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors within your tumour. This helps doctors to better match each patient with the most effective treatment whenever possible. Your treatment team will monitor you while you are taking targeted therapy drugs. Generally, targeted therapy is continued for as long as there is benefit. If liver cancer progresses despite treatment with targeted therapy, your doctor may suggest you join a clinical trial to access new types of therapy.
You may be eligible to take part in a clinical trial, which is a type of research study that investigates new or specialised therapies or treatments. While you are discussing therapy options with your care team, it is a good idea to ask about clinical trials that may be suitable for your condition and discuss whether participating may be right for you.
Being involved in a clinical trial may be beneficial in that you may access the latest treatments before they become generally available. Additionally, clinical trial participation is often associated with closer monitoring of your care and condition and potentially improved outcomes.
For further information on the latest upper GI cancer trials visit the Australian Gastro-Intestinal Cancer Trials Group (AGITG) website or the Australian Cancer Clinical trials website:
Being referred to a specialist centre
Anyone diagnosed with liver cancer should have their case reviewed at a centre where there is a specialist multidisciplinary team of doctors and allied health professionals, who are able to assess and treat the disease.
Depending on your treatment, your multidisciplinary team may consist of a number of different health professionals, such as:
- General Practitioner – your GP looks after your general health and works with your specialists to coordinate treatment
- Gastroenterologist – specialises in diseases of the digestive system, can also perform endoscopy procedures
- Upper gastrointestinal (UGI) surgeon – specialises in surgery to treat diseases of the upper gastrointestinal system.
- Medical oncologist – prescribes and coordinates chemotherapy treatment
- Radiation oncologist – prescribes and coordinates radiation therapy treatment
- Cancer nurses – assist with treatment and provide information and support throughout your treatment
- Other allied health professionals – such as dietitians, exercise physiologists, social workers, pharmacists, speech pathologists and counsellors