Liver CancerTreatment | RCG Martin MD

Treatment Options for Liver Cancer

Surgery

The best option to cure liver cancer is with either surgical resection (removal of the tumor with surgery) or a liver transplant. If all cancer in the liver is completely removed, you will have the best outlook.

Partial Hepatectomy: This surgery removes the tumor along with part of the liver. It’s generally used when the tumor is small and confined to one area, and the rest of the liver is healthy.

Liver Transplantation: For select patients whose cancer hasn’t spread beyond the liver, a transplant may be possible. This procedure involves replacing the diseased liver with a healthy liver from a donor and is often used for patients with small tumors who also have underlying liver disease, like cirrhosis.

Partial Hepatectomy

Partial hepatectomy is surgery to remove part of the liver. Only people with good liver function who are healthy enough for surgery and who have a single tumor that has not grown into blood vessels can have this operation.

Imagining tests, such as CT or MRI with angiography are done first to see if the cancer can be removed completely. Still, sometimes during surgery the cancer is found to be too large or has spread too far to be removed, and the surgery that has been planned cannot be done.

Most patients with liver cancer in the United States also have cirrhosis. In someone with severe cirrhosis, removing even a small amount of liver tissue at the edges of a cancer might not leave enough liver behind to perform important functions.

People with cirrhosis are typically eligible for surgery if there is only one tumor (that has not grown into blood vessels) and they will still have a reasonable amount (at least 30%) of liver function left once the tumor is removed. Doctors often assess this function by assigning a Child-Pugh score, which is a measure of cirrhosis based on certain lab tests and symptoms.

The different liver segments and types of partial hepatectomy procedures are shown below.

Liver Transplant

When it is available, a liver transplant may be the best option for some people with liver cancer. Liver transplants can be an option for those with tumors that cannot be removed with surgery, either because of the location of the tumors or because the liver has too much disease for the patient to tolerate removing part of it. In general, a transplant is used to treat patients with small tumors (either 1 tumor smaller than 5 cm across or 2 to 3 tumors no larger than 3 cm) that have not grown into nearby blood vessels. It can also rarely be an option for patients with resectable cancers (cancers that can be removed completely). With a transplant, not only is the risk of a second new liver cancer greatly reduced, but the new liver will function normally.

According to the Organ Procurement and Transplantation Network, about 1,000 liver transplants were done in people with liver cancer in the United States in 2016, the last year for which numbers are available. Unfortunately, the opportunities for liver transplants are limited. Only about 8,400 livers are available for transplant each year, and most of these are used for patients with diseases other than liver cancer. Increasing awareness about the importance of organ donation is an essential public health goal that could make this treatment available to more patients with liver cancer and other serious liver diseases.

Most livers used for transplants come from people who have just died. But some patients receive part of a liver from a living donor (usually a close relative) for transplant. The liver can regenerate some of its lost function over time if part of it is removed. Still, the surgery does carry some risks for the donor. About 370 living donor liver transplants are done in the United States each year. Only a small number of them are for patients with liver cancer.

People needing a transplant must wait until a liver is available, which can take too long for some people with liver cancer. In many cases a person may get other treatments, such as embolization or ablation, while waiting for a liver transplant. Or doctors may suggest surgery or other treatments first and then a transplant if the cancer comes back.

Complications of Liver Surgery

Liver surgery, is a major operation with serious risks and should only be done by skilled and experienced surgeons. Possible risks include:

Bleeding
Infection: People who get a liver transplant are given drugs to help suppress their immune systems to prevent their bodies from rejecting the new organ. These drugs have their own risks and side effects, especially the risk of getting serious infections. By suppressing the immune system, these drugs might also allow any liver cancer that had spread outside of the liver to grow even faster than before. Some of the drugs used to prevent rejection can also cause high blood pressure, high cholesterol, and diabetes; can weaken the bones and kidneys; and can even lead to a new cancer.
Blood clots
Complications from anesthesia
Rejection of new liver: After a liver transplant, regular blood tests are done to check for signs of the body rejecting the new liver. Sometimes liver biopsies are also taken to see if rejection is happening and if changes are needed in the drugs that prevent rejection.

Unresectable Liver Cancer

Unresectable cancers include cancers that haven’t yet spread to lymph nodes or distant parts of the body, but that can’t be removed safely by partial hepatectomy. This might be because:

The tumor is too large to be removed safely.
The tumor is in a part of the liver that makes it hard to remove (such as very close to a large blood vessel).
There are several tumors or the cancer has spread throughout the liver.
The person isn't healthy enough for liver surgery.

Treatment options might include ablation, embolization, or both for the liver tumor(s). Other options may include targeted therapy, immunotherapy, chemotherapy (either systemic or by hepatic artery infusion), and/or radiation therapy. For some of these cancers, treatment may shrink the tumor(s) enough so that surgery (partial hepatectomy or transplant) may become possible.

Minimally Invasive Surgery

Minimally invasive techniques, including laparoscopic, robotic-assisted surgeries, ablation and embolization have increasingly been used for liver cancer treatments in recent years. These approaches can lead to shorter hospital stays, reduced postoperative pain, and quicker recoveries for patients. The choice of surgical technique depends on factors like the tumor's location within the liver, its size, the stage of the disease, and the patient's overall health condition.

Additionally, effective postoperative care and recovery management are crucial to achieving optimal outcomes. Patients are encouraged to work closely with their healthcare team to address any concerns, monitor recovery progress, and support liver function during the healing process.

Microwave Ablation

What is Microwave Ablation (MWA)?

Microwave ablation (MWA) is a treatment used to destroy cancer cells in the liver by using high-energy microwaves. It’s a minimally invasive procedure, which means it doesn’t involve major surgery and has a faster recovery time. MWA is often used for small liver tumors that cannot be removed by surgery or in patients who are not good candidates for surgery.

How Does It Work?

MWA uses heat from microwave energy to target and destroy liver cancer cells. Here’s what happens during the procedure:

A needle-like probe is inserted through the skin and guided to the liver tumor.
Once the probe reaches the tumor, it emits microwave energy.
The microwave energy heats the tumor tissue to very high temperatures, causing the cancer cells to die.

The procedure can be guided by imaging tools such as ultrasound or CT scans to make sure the probe is placed in the right spot.

Who Can Benefit from MWA?

MWA may be recommended for:

Patients with small liver tumors (usually under 5 cm).
Patients who cannot undergo surgery due to health conditions.
Patients whose tumors are in difficult locations within the liver.
People who have liver tumors that have not spread to other parts of the body.

Benefits of Microwave Ablation

Minimally invasive: No large incisions are made.
Quick recovery time: Most patients return to normal activities within a few days.
Targeted treatment: The procedure targets only the tumor, leaving healthy liver tissue unharmed.
Can be repeated: If new tumors develop, MWA can be performed again.

Irreversible Electroporation(IRE)

IRE (Irreversible Electroporation) is a relatively new and innovative technique used for the treatment of liver cancer particularly in cases where surgery is not an option due to the tumor's location or the patient's overall health. IRE is a non-thermal, minimally invasive procedure that uses electrical pulses to destroy cancerous cells. IRE does not injure surrounding non-cancerous cells, blood vessels and other vital structures. It has been in patients since 2008 in the treatment of some types of cancers. One of the largest unmet needs in cancer that IRE has been used is in Cholangiocarcinoma when resection is not an option.

Learn More about IRE

Embolization

Embolization is a procedure that injects substances directly into an artery in the liver to block or reduce the blood flow to a tumor in the liver.

The liver is special in that it has 2 blood supplies. Most normal liver cells are fed by the portal vein, whereas a cancer in the liver is mainly fed by the hepatic artery. Blocking the part of the hepatic artery that feeds the tumor helps kill off the cancer cells, but it leaves most of the healthy liver cells unharmed because they get their blood supply from the portal vein.

Embolization is an option for some patients with tumors that cannot be removed by surgery. It can be used for people with tumors that are too large to be treated with ablation (usually larger than 5 cm across) and who also have adequate liver function. It can also be used with ablation. Embolization can reduce some of the blood supply to the normal liver tissue, so it may not be a good option for some patients whose liver has been damaged by diseases such as hepatitis or cirrhosis. It isn’t yet clear which type of embolization has a better long-term outcome.

Trans-arterial embolization (TAE)

During trans-arterial embolization a catheter (a thin, flexible tube) is put into an artery in the inner thigh through a small cut and eased up into the hepatic artery in the liver. A dye is usually injected into the bloodstream to help the doctor watch the path of the catheter. Once the catheter is in place, small particles are injected into the artery to plug it up, blocking oxygen and key nutrients from the tumor.

Trans-arterial chemoembolization (TACE)

Trans-arterial chemoembolization is usually the first type of embolization used for large liver cancers that cannot be treated with surgery or ablation. It combines embolization with chemotherapy (chemo). Most often, this is done by giving chemotherapy through the catheter directly into the artery, then plugging up the artery, so the chemo can stay close to the tumor.

Drug-eluting bead chemoembolization (DEB-TACE)

Drug-eluting bead chemoembolization combines TACE embolization with drug-eluting beads (tiny beads that contain a chemotherapy drug). The procedure is essentially the same as TACE except that the artery is blocked after drug-eluting beads are injected. Because the chemo is physically close to the cancer and because the drug-eluting beads slowly release the chemo, the cancer cells are more likely to be damaged and die. The most common chemo drugs used for TACE or DEB-TACE are mitomycin C, cisplatin, and doxorubicin.

Radioembolization (RE)

Radioembolization combines embolization with radiation therapy. This is done by injecting small beads (called microspheres) that have a radioactive isotope (yttrium-90 or Y-90) attached to them into the hepatic artery. Once infused, the beads lodge in the blood vessels near the tumor, where they give off small amounts of radiation to the tumor site for several days. The radiation travels a very short distance, so its effects are limited mainly to the tumor.

Chemotherapy

Targeted Therapy

Drugs like Sorafenib and Lenvatinib are designed to target specific cancer cell proteins, slowing their growth and spread.
Immunotherapy (e.g., Nivolumab, Pembrolizumab): Boosts the body’s immune response against cancer cells, especially useful in advanced cases.

Systemic Chemotherapy

Though often less effective for liver cancer, chemotherapy may still be used, typically in combination with other treatments for advanced cases.

Immunotherapy

Immunotherapy drugs, such as checkpoint inhibitors, are being studied in clinical trials for liver cancer. These drugs aim to stimulate the immune system to recognize and attack cancer cells.

Radiation Therapy

External Beam Radiation Therapy: Using targeted radiation beams, sometimes with advanced methods like stereotactic body radiation therapy (SBRT).

Selective Internal Radiation Therapy (SIRT): Similar to radioembolization, but focuses on delivering radiation therapy internally via the bloodstream.

Clinical Trials

Many patients also explore clinical trials to access newer treatments like gene therapies or novel immunotherapies that are still under investigation.