Liver Cancer

Treatment Planning

Treating hepatocellular carcinoma (HCC), a type of liver cancer, is a coordinated effort among many skilled and caring professionals. Though research continues to produce more options for treating HCC, it is important to realize that treatment does not always mean “cure.” However, progress is still being made that is leading to longer, better lives for people who have HCC. Learn, ask questions and be informed so you can contribute to making the important decisions ahead.

You will work closely with a multidisciplinary team of specialists who will treat your HCC as well as any underlying conditions that caused it. As a result, many things must be taken into consideration, including the following:

How much of the liver is affected, including the number of tumors, tumor size and location
Whether the cancer has spread (metastasized) outside the liver
How well the liver is working and whether noncancerous areas remain healthy
Comorbidities (other serious health conditions) you have
Your overall physical condition
Your preferences about quality of life

A thorough health assessment will be performed and more tests may be ordered before any recommendations are offered. As you and your medical team discuss how to move forward, it is very important that you agree about the goal of treatment. Ask about the treatments that may be helpful to you and about the side effects that you can generally expect with each. Be honest about your feelings toward those treatments and about your expectations for managing them on a daily basis.

Also, keep in mind that over time your treatment goals may change. Some goals to think about include the following:

Opting for curative treatment, which means eliminating the cancer
Downstaging the tumor, which includes shrinking the tumor(s) to make liver resection or transplantation possible
Slowing the cancer’s growth or progression to extend life
Using supportive (or palliative) care to improve your 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

Common Treatments for HCC

Your medical team will likely talk with you about one or more of the following options after diagnosis and at various times throughout treatment.

Surveillance , also called watchful waiting, may be recommended for tumors that appear to be growing very slowly. Postponing treatment while doctors closely monitor you (every 3 months is common) allows you to avoid potential side effects for as long as possible and for your doctors to watch for signs the cancer has returned. Regularly scheduled follow-up appointments that include imaging tests and blood tests will be necessary. It is very important to make and keep these appointments because treatment should begin if the pace of cancer progression increases.

Clinical trials are a valuable treatment option that deserve serious consideration, especially if you are diagnosed with advanced HCC. These medical research studies may provide access to new therapies or combination therapies that are not yet available outside of a clinical trial. Ask your doctor if you should consider a clinical trial immediately after diagnosis or at any other time during your treatment.

Surgery is the primary curative method for treating HCC. Liver surgery is often complex and requires a high degree of training and skill. It is recommended that you 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.

Liver resection, also called a partial hepatectomy (HEH-puh-TEK-toh-mee), 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.

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.

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.

Liver transplantation is another highly effective potentially curative treatment for HCC. During the transplant, the entire liver is removed (hepatectomy) and replaced with a healthy liver, most often from a deceased donor. 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.

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 for assessment to a transplant center with extensive experience performing the procedure.

If you are deemed a candidate for a transplant, you will likely undergo bridging treatment while you wait for a liver to become available. Bridging therapy is designed to prevent the cancer from growing or spreading and may include ablation, embolization, radiation therapy or systemic drug therapy.

Radiofrequency ablation (RFA) therapy may be curative. It may be used to treat HCC when a tumor is unresectable or surgery is not an option for another reason. In this type of locoregional therapy, which focuses on the cancer’s location, this minimally invasive, image-guided procedure kills cancer cells by inserting a needle through the skin directly into the tumor and running electrical current through it to subject the tumor to extreme temperatures. Other types of ablation therapy include the following:

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 procedures, though not curative, 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 tumors and reduce symptoms, although radioembolization has also been used to reduce the size of tumors to permit subsequent surgical treatment.

Drug therapy may be used at different times throughout treatment to manage HCC. It is systemic therapy, which means the drugs travel throughout the body. Different forms of drug therapy may be used.

Molecularly targeted therapy is designed to slow the cancer’s progression. For this type of treatment, targeted therapy drugs travel through 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. 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. Other targeted therapies treat mutations in the neurotrophic tyrosine receptor kinase ( NTRK ) (pronounced EN-track) gene, which cause cancer cells to grow. Many targeted therapies are taken orally at home. Targeted therapy may be used alone or in combination with 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 travel throughout the body targeting 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). Immunotherapy may be used alone or combined with another immunotherapy. It may also be used with targeted therapy.

Radiation therapy is another type of loco-regional therapy. It uses 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 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.

Drug Therapies for HCC
As of 10/22/21

cabozantinib (Cabometyx)

entrectinib (Rozlytrek)

larotrectinib (Vitrakvi)

lenvatinib (Lenvima)

pembrolizumab (Keytruda)

ramucirumab (Cyramza)

regorafenib (Stivarga)

sorafenib (Nexavar)

Possible Combination Therapies

atezolizumab (Tecentriq) with bevacizumab (Avastin)

ipilimumab (Yervoy) and nivolumab (Opdivo)

As of 10/22/21