What are the treatment options?
There are a number of therapeutic procedures for the treatment of liver cancer. The therapeutic procedure with the best prognosis is surgical removal of the cancer. This usually requires the removal of part of the liver.
However, in many cases this is not possible. In these cases, a liver transplantation may be considered. However, liver transplantation involves a long waiting period, so that various procedures have been developed to prevent tumor growth until the transplantation is complete.
The last therapeutic option for patients with hepatocellular carcinoma without metastases is liver transplantation. Due to the lack of organ donors, however, it is not a very frequent procedure, because time constraints usually prevent transplantation. A liver transplant can only be performed if the so-called Milano criteria are met (1 tumor must be less than 5 cm in size or a maximum of 3 tumors of 3 cm in diameter each).
If the tumor is already connected to the blood vessel system or if findings occur outside the liver, this rules out a liver transplant. In addition, the patient must meet certain guidelines: is there an alcohol problem in addition to the liver disease? For example, the patient must have lived abstinently for the last time in order to be shortlisted for a donor organ.
If the patient fulfills the criteria for a liver transplant and is placed on the waiting list, bridging therapy measures should be considered. Another therapeutic option is radiofrequency ablation. Here, heat is generated in the tumor tissue by means of electricity to destroy it.
This procedure can be used as a bridging measure until liver transplantation or as a curative therapy. However, the risk of recurrence, i.e. the risk of cancer developing in the liver again, is very high at 70%. If the patient has fluid in the abdomen (ascites), or if the tumors are located near large bile ducts, this type of therapy should be avoided.
Laser induced thermotherapy (LITT) can also be used in the treatment of metastases. Here, the tumor site is first punctured in a computer tomograph (CT) and then the laser is introduced. Using magnetic resonance imaging, i.e. an MRI of the liver, the success rate of the treatment can be monitored with the help of temperature-dependent images.
However, liver metastases whose origin is in the stomach, pancreas or lungs are not likely to be treated with LITT, as a systemic event must be assumed. Transarterial chemoembolization is another possibility. Here, chemotherapeutic agents are applied locally to the cancer via the vessels to reduce its growth and cut off its blood supply.
This method takes advantage of the fact that hepatocellular carcinoma is mainly supplied arterially. During treatment, the patient’s femoral artery is first punctured and a catheter is placed through the aorta into the liver-supplying coeliac artery. The vessels are better visualized by the administration of a contrast medium.
Another catheter is now advanced through the first one directly to the liver tumor. The closer the catheter is to the tumor, the lower the risk of embolizing healthy areas. If the catheter is correctly positioned, a number of drugs are now delivered directly to the tumor via the catheter.
Lipidol Emulsion – Vessels supplying the liver are sealed and increase the duration of action of the chemotherapeutic agent. Plastic particles are injected into the tumor area, slowing down the blood flow velocity and causing the vessels supplying the tumor to close. Doxorubicin, carboplatin and mitomycin, among others, can be used as chemotherapeutic agents.
This embolization is then repeated. This treatment must not be performed in patients with heart or liver failure, an allergy to contrast media or blood clotting disorders. In very advanced stages, where the cancer has already infiltrated surrounding vessels or spread to other organs, only palliative treatment of liver cancer with the drug sorafenib is given.
The aim is no longer to cure the patient, but to improve the quality of life. The therapy for hepatocellular carcinoma (liver cancer) is distributed among the patients as follows: 73% of patients do not receive therapy because the time of diagnosis is too late and the disease is too advanced. 12% receive surgical therapy with removal of liver parts or metastases.
6% receive chemotherapy. 9% of the patients receive another, unclassified therapy.The surgical removal of liver cancer is the therapy with the best chances of cure. The liver can be divided into four lobes.
During surgery, one, two or even three lobes are usually removed. However, there are many cases in which this therapy is not possible. Factors that speak against surgery are, on the one hand, infiltration of the entire liver or too poor liver function of the tissue not affected by cancer, e.g. due to cirrhosis of the liver.
Liver cirrhosis is a connective tissue-like transformation of the liver, which is accompanied by a deterioration in its function. In these cases, liver transplantation is a possible therapy. In cases where it is not certain whether the remaining tissue is sufficiently functional, a special operation can be performed.
In this surgical procedure, the blood vessels supplying the part of the liver that is to be removed are clamped in a first step. Then it is checked whether the functionality of the remaining liver tissue is sufficient. In the second step, the liver part can then be removed or reconnected to the blood supply.
Furthermore, patients can no longer be operated on if the cancer has metastasized or infiltrated blood vessels. For many, liver transplantation is the only option if liver function is too poor. The problem with liver transplantation is the long waiting time, as there are far too few organs.
Currently, the waiting time is between 6-18 months. Since the cancer cannot be left untreated during this time, various procedures are used to prevent cancer growth during this period. Two common procedures for the so-called bridging are the radioablation procedure and chemoebolisation, which are explained in the chapter “What treatment procedures are there?
In order to be considered for a liver transplant, however, a number of conditions must be met. For example, the tumor must not infiltrate any vessels and there must be no metastases. The tumor is between 2 and 5 cm in size or there are 1 to 3 tumors between 1 and 3 cm.
If all criteria are met, patients are placed on the waiting list. Urgency is assigned according to the severity of the disease. For this purpose, the liver value Bilirubin, the kidney value Creatinin and the blood clotting are taken into account.
A score is calculated from these values. Patients with a tumor can receive additional points. In principle, there is also the possibility of a living donation.
For this, the same conditions must be fulfilled. In the western world, chemotherapy for the treatment of liver cancer plays hardly any role, since here liver cancer is often accompanied by cirrhosis of the liver. In other countries, chemotherapy is used to treat liver cancer.
In the western world, local chemotherapy procedures are used. However, these usually have no intention of healing, but are used for so-called bridging – i.e. to combat tumor growth while waiting for a new liver. The procedure is called transarterial chemoembolization (TACE).
A catheter is inserted through the groin into the hepatic arteries. Through this catheter, chemotherapeutic agents can then be administered locally. In addition, small plastic particles are injected into the vessel that supplies the tumor.
As a result, this vessel is blocked and the cancer cells are no longer supplied with sufficient nutrients and oxygen and die. Chemo-embolization is also frequently combined with drug therapy in patients undergoing palliative treatment, as studies have shown an extension of life. However, TACE should only be used in patients who still have good liver function.
There are two different possibilities of radiation. Firstly, there is the classic radiation therapy, in which radiation is applied to the liver cancer from outside. This procedure is used when the tumor cannot be removed by surgery.
Another radiation procedure is selective internal radiotherapy (SIRT), also known as Transarterial Radioembolisation (TARE). In SIRT, the cancer cells are irradiated from within. Small beads that emit radiation are positioned in the tumor’s vessels. This exposes the cancer cells to a higher radiation dose and the vessels supplying the tumor are sealed.
