What are the treatments for Liver Cancer?
Once the patient is diagnosed to have liver cancer, doctor will generally suggest the following treatments depending on the cancer stage:
(1) Removal by surgery
- Rationale of treatment: To remove the tumor and the surrounding affected tissues.
- Suitable for: Removal by radical surgery is suitable for 20% of liver cancer patients whose tumors affect only one of the liver lobes and their liver functions are normal. 62% of them can survive 3 years while 50% of them can survive 5 years.
(2) Trans-arterial Chemoembolization (TACE)
- Rationale of treatment: This is to block the blood vessels, thus stopping them from providing the tumor with nutrition. This can stop the cancer tumor from growing, which can reduce its size. This can be achieved by injecting drugs into selected blood vessels which are for providing the tumor with nutrition through aorta. This is to block the artery, which monitors the liver cancer, to achieve treatment results and not to affect the normal liver tissues.
- Suitable for: This is suitable for a patient whose tumor has spread to both sides of the liver but has not yet metastasized to other organs, or a patient whose tumor is limited to one side of the liver but whose liver function, tumor location, tumor size, or tumor number is not suitable for surgery or local ablative treatment.
(3) Injection of alcohol
- Rationale of treatment: With the help of ultrasound or computer scan, the location of the tumor is confirmed. Then alcohol with 95% concentration is injected directly into the tumor with a thin needle through the skin. The highly concentrated alcohol will dry up the cells and thus kill them.
- Suitable for: It is suitable for a patient whose tumor is smaller than 3cm or whose number of tumors is less than 3. As the injection can only make the central part of the tumor to wither, which means the neighboring tissues still survive and keep growing, so the patient has to get many injections to ensure the liver cancer cells are killed.
(4) Radiofrequency ablation
- Rationale of treatment: This is to use localized thermal treatment technique, when temperature reaching 60∘C to destroy the tumor tissues. Depending on the location and size of the tumor, the surgery can be performed through percutaneous or laparotomy. Simultaneously ultrasonography is used to guide the electrode and to monitor the ablation level of the tumor.
- Suitable for: This is for those who are infected with primary liver cancer and metastatic liver cancer.
(5) Liver transplant
- Rationale of treatment: This is for those who cannot undergo an operation for the removal of liver. They are patients whose livers function badly, and patients having undergone Transarterial Chemoembolization and injection of alcohol, provided that their tumors are no larger than 5cm. If the tumor has grown to a certain size, it is highly likely that the cancer cells have spread to other parts of the body. If then liver transplant is carried out, the cancer cell will reproduce themselves rapidly in the new liver, which will result in the recurrence of liver cancer.
(6) Selective Internal Irradiation (SIRT)
- Rationale of treatment: SIRT is a radio-embolization technique in which radioactive microspheres are injected via intravascular catheters into the hepatic artery that supplies the tumor. These microspheres are tagged with Yttrium-90 which is capable of emitting short-distance radiation. Hence, SIRT allows preferential irradiation of the tumor to a high radiation dose without causing excessive damage to the normal liver function. Various studies of SIRT in patients with advanced liver cancers reported response rates (RR) of 20-89%, and a median time-to-progression of 7-12 months.
- Suitable for: liver cancers that are not eligible for surgery or local ablative therapy. In contrast to TACE, some patients with Portal vein thrombosis, a contraindication for TACE, appeared to tolerate SIRT favorably. Retrospective comparison between SIRT and TACE suggested similar efficacy, but there is no reported randomized controlled trials to compare SIRT and TACE face-to-face.
- SIRT is contraindicated in patients who have poor liver function or uncontrolled ascites. Pre-treatment assessment with hepatic angiogram and Technetium MAA scan is necessary to evaluate the amount of microspheres uptake in lung, liver, and gastrointestinal tract. Inadvertent delivery of SIR- microspheres to the gastrointestinal tract or pancreas will cause acute abdominal pain, acute pancreatitis, cholecystitis, or peptic ulceration. Excessive shunting to the lung may lead to radiation pneumonitis. Excessive radiation to the normal liver parenchyma may result in radiation hepatitis.
(7) Stereotactic ablative body radiotherapy (SABR)
- Rationale of treatment: External beam irradiation for HCC was rarely used in the past because of the low radiation tolerance of liver. The risk of radiation induced liver disease (RILD) increases with poor baseline liver function. With growing experience, it is now known that disease control can be possible if high radiation dose can be delivered to the tumor while sparing a sufficient amount of normal liver reserve. Technological advances in Stereotactic ablative body radiotherapy (SABR) through the use of multi-modality image registration, radiation treatment planning, breathing motion management and image guided radiation therapy have significantly increased treatment delivery accuracy and made it possible for ablative doses of radiation to be delivered safely to focally unresectable HCC.
- Suitable for: patients who are not amenable to undergo surgery or local ablative therapies. It is also indicated in patients who have developed recurrence despite multiple courses of TACE. Patients with Portal vein thrombosis who are not suitable for TACE can also be treated with SABR. Objective response rates are 80-90% in HCCs less than 5 cm in diameter, and in the range of 50-70% in larger cancers. Improved local control and survival have been seen in patients treated with higher doses.
(8) Sytemic therapy & Targeted therapy
- Before the development of sorafenib, first-line systemic therapies for the treatment of unresectable HCC were lacking. Many randomized-controlled trials had demonstrated that the use of systemic chemotherapy, hormonal compounds, octreotide and interferon in patients with unresectable HCC did not improve survival compared with no treatment.
- Sorafenib is currently the only targeted therapy approved by the US Food and Drug Administration to be used in patients with unresectable HCC, based on the survival advantage over best supportive care demonstrated in two randomized controlled trials. Sorafenib inhibits the following receptor tyrosine kinases: VEGFR-2, VEGFR-3, PDGFR-b, c-KIT, and Flt-3. Since Sorafenib has the potential to decrease blood flow in the tumor, studies have been initiated to investigate sorafenib as an adjuvant to potentially curative treatments such as resection or local ablation in resectable HCC, or the combination of sorafenib and TACE or SBRT in patients with unresectable HCC.
- Although sorafenib represents a palliative treatment option for patients with advanced HCC, it also produces toxicities that may significantly affect patients’ quality of life. High rates of dermatologic side effects (Hand foot syndrome), hypertension, fatigue and gastrointestinal discomfort have been reported. Other complications include cardiac ischemia, thyroid dysfunction, bowel perforation, bleeding and hepatitis.