The last issue of Liver Health Today featured HCC, covering risk factors, symptoms, screening, and prevention of this frequently deadly cancer.  The focus of this issue is staging, treating and living with HCC.

Staging Liver Cancer

Once diagnosed, HCC is evaluated to determine how advanced it is. This is called staging. Staging is much like receiving a grade in school in that it defines the situation. Selection of a specific treatment option is based on the staging information.

First, the tumor is measured. Is there more than one tumor, and if so, how many? Is the tumor contained or has it spread? Has it invaded nearby blood vessels, lymph nodes or other parts of the body?

Liver cancer that has spread to other body parts is said to have metastasized. For instance, if liver cancer cells are found in the lungs, this is due to metastasis. Tests are done to determine if HCC has spread. These may include chest X-ray, CT scan, MRI, and a bone scan.

For adults, the stages of primary liver cancer are:

Stage I: There is only one tumor, which is small, less than 2 centimeters and has not spread.

Stage II: There is only one tumor from 2 to 5 centimeters, or two to three tumors, all less than 3 centimeters. The cancer has not spread beyond the liver

Stage III: There is one tumor greater than 5 centimeters, or two to three tumors, with at least one tumor greater than 3 centimeters, and there is no spread beyond the liver.

Stage IV: The cancer has either invaded major blood vessels in the liver, spread beyond the liver to local lymph nodes, or metastasized to other parts of the body.

The best possible news is that there is no sign of cancer. However, if there is a tumor, then a small one of less than two inches is the next best possible news. These tumors can be surgically removed with a good outcome if there is no underlying cirrhosis. Tumors that are larger may have already invaded other areas of the body, particularly the lungs or lymph nodes. In “Hepatitis and Liver Disease,” Melissa Palmer, M.D. writes that “without therapy, only 1 percent of these people will survive two years from the time HCC is detected.”

Treating Liver Cancer

Weale’s HCC was in stage II. “The road was long and had more turns than a roller coaster,” he recalls, “but through it all, my doctors were there for me, giving me much strength. One thing I would say to anyone with liver cancer—let the doctors do their job.”

The specialists who treat liver cancer are hepatologists, gastroenterologists, liver transplant surgeons, hepatobiliary surgeons, and oncologists. HCC is treated in multiple ways. Treatment depends on the cancer stage and the patient’s medical condition. It is necessary to know if there is cirrhosis, and how well the liver is working. The patient’s age, other health problems, and social support are all considered.

There are a number of treatment options. Treating liver cancer is different for children than for adults. This article focuses on adults. The most common HCC therapies are:

• Surgery
• Liver transplantation
• Ablation
• Embolization
• Chemotherapy

If HCC is found in later stages, some of these treatments may be used in order to alleviate symptoms or to prolong life. This is known as palliative treatment.

Surgery

Surgical resection (removal of the tumor) is performed if the tumor is less than 2 inches and has not spread beyond the liver. If the patient doesn’t have cirrhosis, 80 percent of the liver can be removed and the remainder will regenerate to its original size in just a few weeks. This is a major operation, has some risks, and a bit of recovery time. There may be some pain and other mild side effects, for which medication may be prescribed.

People under the age of 50, who are healthy and have a small isolated tumor, have an excellent prognosis. Sadly, only about 5 to 15 percent of HCC cases are detected early enough to be eligible for surgical resection. More than half of all surgically resected HCC returns, usually around two years after surgery. The five-year survival rate for patients who undergo surgical removal of HCC is less than 50 percent.

Liver Transplantation

Liver transplantation is another option for HCC patients. This option potentially cures HCC, as well as the underlying liver disease, since the entire organ is removed, rather than just the tumor. This is a better option for patients with cirrhosis, because transplantation gives them an organ that is both tumor and cirrhosis free. Five-year survival estimates range from 50 to 75 percent. The HCC recurrence rate is low following liver transplantation.

This option looks fairly good except for the sad shortage of donated livers. The need for organs far outpaces the numbers that are actually donated. Transplantation waiting times are long, and waiting is not practical when a tumor is involved. Living donor transplantation cuts waiting times, but it is a serious commitment that is not entered into lightly. If transplantation is considered, sometimes options for shrinking the tumor are tried while waiting for an available organ.

Transplantation is major surgery. In addition to the surgical risks, pain, and recovery, there is a chance that the body will reject the liver. To minimize this risk, patients will need to take anti-rejection medications that often have side effects.

Ablation

Ablation is a general term meaning to remove or destroy tissue. There are various types of ablations. The most common ablation for HCC is radiofrequency ablation (RFA). This is done for small tumors when surgery or transplantation is not feasible. A probe is inserted into the tumor and cancer cells are heated and destroyed using radio waves. This is usually done under anesthesia in an outpatient setting by either a radiologist who can puncture the liver through the skin or a surgeon who can reach the liver using a laparoscope. Risks are minimal, and recovery is quick. The five-year survival rate for RFA is around 50 percent—about the same as surgical resection.

Another type of ablation is percutaneous ethanol injection. This is suitable for small tumors, recurrent HCC, or for patients with advanced cirrhosis. Alcohol is injected directly into the liver cancer cells, usually in an outpatient setting. The risk, pain, and recovery are minimal, but this technique is not widely used in the United States.

Embolization

Embolization is an option for those with a mid-size tumor or multiple tumors and for those who cannot have surgery or a liver transplant. It is also used to control tumor growth before a liver transplant. A catheter is inserted into an artery in the thigh and threaded up to a major vessel in the liver—the hepatic artery. Various substances are used to deliberately block the flow of blood to the tumor, causing it to die. The liver continues to function because it receives blood from another source—the hepatic portal vein. Radioembolization involves the insertion of high-dose radiation through the artery.

Chemotherapy and Chemoembolization

Chemotherapeutic agents have not been found to be effective weapons against HCC, although these may be used in conjunction with other forms of treatment.  A variety of drugs may be used and the side effects depend on which drugs are given. Physicians could administer chemotherapy to reduce a tumor in an effort to improve the chance for surgical resection.  Chemotherapy is also administered for the treatment of secondary liver cancer.

Chemoembolization is the most commonly used embolization technique for HCC. Chemotherapy is injected directly into the tumor. Since there is no blood flow to the tumor, the chemotherapeutic drug stays in the area longer. Chemoembolization is done under sedation and may require a brief period of hospitalization. Common side effects include abdominal pain, nausea, vomiting, fatigue and possibly fever. The five-year survival rate is about 25 percent.

“Recent published reports synthesizing the literature on chemoembolization clearly shows that life can be significantly prolonged using one or more embolization sessions,” reports hepatologist Emmet B. Keeffe, M.D., MACP, Professor of Medicine Emeritus, Stanford University Medical Center.

Weale vividly remembers his chemoembolization experience. “It was rough. I never felt so ill in my life. But in time I recovered.” The tumor shrank which bought him some time. Shortly after he was listed for transplant, he received a liver.

Other Treatment Options

If surgery, transplantation and other options are not feasible, then targeted therapy may be considered. The oral drug sorafenib (Nexavar) was the first targeted therapy approved for HCC. This drug slows tumor growth and may increase survival time, from a median survival period of approximately eight months to nearly 11 months, although it does have many side effects.

Although not typically used to treat HCC, radiation is sometimes used to shrink the tumor and help relieve cancer pain. It also may be used in conjunction with another form of treatment.

Doctors are constantly pursuing innovative treatments for HCC. For example, a handful of surgeons are using a technique for patients with advanced HCC. They remove the entire liver, cool it, extract the tumor and reconstruct the liver’s blood supply before returning the liver back to the body.

Complementary and Alternative Medicine

To date, no complementary or alternative therapies have been found that effectively reduce or destroy liver cancer cells. However, complementary and alternative medicine (CAM) offers a variety of tools that may help patients deal with symptoms, pain and treatment side effects. Acupuncture, visualization, therapeutic touch, and affirmative prayer are just a few techniques that may offer relief without injuring the liver.

It is best to consult with a medical professional when pursuing CAM. Since everything goes through the liver, use caution with herbs or supplements and inform your medical team before taking them.

Living with Liver Cancer

For some, the emotional side is the hardest part of living with cancer. The diagnosis can be shocking. This is usually followed by intense feelings, such as denial, anger, fear, guilt, or sadness. Although this is normal, extreme feelings are not healthy. Denial to the point of not seeking treatment is not good. Depression, anxiety, and rage may need medical attention.

Support is critical. Support takes many forms, such as information, help at home, or in groups with others of similar interests. Your family, friends, social workers, the medical team and other cancer patients may all serve as part of your support system. The broader your network is, the more information you will have. 

Before starting treatment, you may want a second opinion. “Many large medical centers have put together multidisciplinary teams of specialists, hepatologists, oncologists, radiologists, surgeons, and other specialists, who can provide a consensus second opinion on the best treatment options for an individual patient with one visit,” says Dr. Keeffe. “This not only gets a patient with HCC a second opinion but also provides a comprehensive evaluation of the pros and cons of different treatment options.”

Patients do not need to worry about what their medical providers will think, as most professionals welcome a second opinion, but action should be taken quickly. Delaying treatment for a few weeks is usually not a problem; however, ask your medical provider how much time you have to seek another opinion.

Follow-up care is an essential part of living with liver cancer, particularly after it has been treated. Your medical provider will recommend a specific follow-up regimen based on your situation. Regular medical visits improve the chances of survival.

The chances are good that Weale will never have to deal with HCC again. He does have to take good care of himself and his new liver. “How lucky I am to go on and live my life,” he says. “I live it to the fullest, doing the things I want to do and seeing the places I want to see. I just got back from Egypt. Yes, I’m so thankful and lucky.”