How to treat Primary Liver Cancer?

Treatment for hepatocellular carcinoma (HCC) depends on how advanced the cancer is at the time of diagnosis. Your doctors evaluate this by observing how far the liver tumour(s) have developed, how seriously the liver is damaged and affects your overall health status. Depending on this, different treatment options exist:

Surgery

Wherever possible, the standard of care for HCC is an operation. Surgery or transplantation achieve the best outcomes and are the first option in patients with early tumour(s).

The most frequent form of liver surgery is known as resection, where the part of the liver affected by the cancer is cut out and removed. In some cases the liver will re-grow this section or parts of it. Resection is only suitable for those who have very good liver function (class A according to the Child Pugh score - a classification system used to assess the prognosis of chronic liver disease and cirrhosis). If you have HCC caused by damage to the liver through cirrhosis, then resection is often not possible. This is because your liver may be too damaged to recover after the operation.

The only way to cure patients with early liver cancer and underlying liver disease who cannot undergo resection will be transplantation.

However donor organs are in short supply and there is a long waitlist.

Local ablation

Local ablation to destroy tumours with radiofrequency, microwaves or ethanol injection is considered the standard of care for patients with small tumours in very early and early stages, who are not suitable for surgery.

  • Radiofrequency ablation is a way of destroying a tumour using heat. A needle electrode is being passed into the liver tumour where high-frequency current which creates heat destroys the tumour cells.
  • Microwave ablation is similar to radiofrequency ablation, but uses heat from microwave energy to destroy cancer cells.
  • Ethanol is a type of pure alcohol that can be injected into liver tumour(s) to kill the cancer cells by dehydrating them. The ethanol is injected through the skin into the tumour using a very thin needle.

Transarterial embolisation (TAE), transarterial chemoembolisation (TACE) and hepatic intra-arterial chemotherapy (HIAC)

Transarterial embolisation (TAE) involves an injection of tiny gel-like beads or pieces of a gelatin sponge into an artery of the liver. This creates a seal that blocks the supply of blood to the tumour to stop it growing.

Transarterial Chemoembolisation (TACE) is the most widely used treatment for HCC that is inoperable or cannot be ablated. There are two types of TACE – conventional TACE (cTACE) and Drug Eluting Bead TACE (DEB-TACE).

In cTACE a chemotherapy agent is directly injected into an artery that supplies the tumour with blood. The agent is kept at its place by an embolic/occlusive material following the chemotherapy. The systemic side effects (effect on the rest of the body) from the anti-cancer drugs (chemotherapy) are reduced due to the injection directly into the blood supply of the tumour.

In DEB-TACE, small particles loaded with chemotherapeutic agents are injected into an artery supplying a tumour and hereby interrupting the tumours supply with nutricians and oxygen.

Both forms of TACE normally require multiple treatments and in many cases several days of hospitalisation.

Hepatic intra-arterial chemotherapy (HIAC) also known as Hepatic arterial infusion (HAI) is a medical procedure to deliver chemotherapy directly to the liver. Catheters are put into an artery in the groin that leads to the liver, and drugs are given through the catheters.

Targeted therapies

Targeted therapies are using drugs or other substances to identify and attack specific cancer cells only.

Sorafenib is the standard systemic therapy since 2007 for advanced HCC that cannot be treated surgically or locally. It is prescribed for patients with advanced disease and good liver function.

Regorafenib received approval in 2017 for patients with HCC who have been previously treated with and well tolerated sorafenib.

Selective Internal Radiation Therapy (SIRT)

SIRT is a special type of radiation therapy that targets liver tumours and delivers radiation from millions of tiny radioactive beads, called SIR-Spheres Y-90 resin microspheres, directly to the tumours.

The microspheres are injected through a catheter in the groin and travel through the arteries of the liver to lodge in the very small blood vessels in and around the liver tumour(s) where they emit high doses of radiation. As the microspheres only give off radiation to a small area, they target the liver tumour while doing little damage to the surrounding healthy liver tissue.

For patients with inoperable HCC, one or two treatments with SIRT using SIR-Spheres Y-90 resin microspheres have been shown to be at least as effective as multiple TACE procedures and are well tolerated.1,2 SIRT also appeared to have similar efficacy as systemic therapy of HCC with daily doses of sorafenib, but with fewer side effects and less impact on patient’s quality of life. 3,4

For more information on SIR-Spheres Y-90 resin microspheres and the technique, please visit this page.

For more information on clinical evidence with SIR-Spheres Y-90 resin microspheres in HCC, please visit this page.

Sources:
https://www.britishlivertrust.org.uk/liver-information/liver-conditions/liver-cancer/
https://www.cancer.gov/

1. Soydal C et al. Nucl Med Commun 2016; 37: 646–9.
2. Kolligs FT et al. Liver Int 2015; 35: 1715–21.
3. Vilgrain V et al. Lancet Oncol 2017; 18: 1624–36.
4. Chow PKH et al. J Clin Oncol 2017; 35 (Suppl): Abs 4002




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