Liver Cancer (Hepatocellular Carcinoma)
Liver cancer is one of the most common malignant tumors in the world and is increasing rapidly in the United States. Tumors may arise from within the liver itself, or spread as metastases from other sites, such as the colon. Hepatocellular carcinoma (HCC) or hepatoma is the most common tumor type that grows from within the liver. HCC often arises in patients who have cirrhosis of the liver. Cirrhosis is a chronic, scar forming liver disease that may be caused by viral hepatitis or heavy alcohol consumption. Unfortunately, treatment options are limited for many patients due to excessive tumor growth and spread, in addition to the presence of cirrhosis. If your tumor is at an early enough stage and your liver function is adequate, there are many factors that determine what treatment approach will be safest and most effective. The treatment of HCC has evolved to include surgery, ablation using microwave devices, and other minimally invasive approaches.
Cirrhosis, which is severe scarring of the liver, results from a variety of different causes. Most commonly in the United States, cirrhosis develops due to viral hepatitis (B or C) or heavy alcohol consumption. Cirrhosis can be put into three classifications of severity using a simple scoring system called the Child Pugh Score. Child A is the least severe, and Child C cirrhosis is the most advanced stage of cirrhosis. Patients with Child C cirrhosis usually have less than a 50% chance of living another five years unless they receive a liver transplant. Cirrhosis can lead to a number of complications which include gastrointestinal bleeding, ascites (fluid in the abdomen), jaundice (yellow skin discoloration), confusion, infections, and liver cancer. Treatment of viral hepatitis or cessation of alcohol consumption are important measures to limit liver damage and allow the remaining normal tissue to recover.
Treatment options for HCC include surgical removal of the tumor, liver transplantation, minimally invasive ablation, special forms of radiation therapy, chemotherapy, and special procedures to interrupt the blood flow to the tumor (embolization). We consider several factors when deciding on how to best manage HCC:
If you have very little energy, to the point that you cannot get around and perform normal daily activities, you should not receive invasive therapy unless you are a candidate to receive a liver transplant.
Other serious medical conditions
The presence of heart disease, COPD, or severe kidney dysfunction may make the risks of tumor treatment excessive.
Severity of cirrhosis or liver dysfunction
Patients with the most severe stages of cirrhosis are at high risk for liver failure during or following certain treatments. For these patients, maintaining the liver function is the most important consideration.
The size of the tumor
Treatment results are best when a tumor is less than 3cm. However, larger tumors can be treated successfully when the cirrhosis is not severe.
The location of the tumor in the liver
Tumors that invade the major vessels coming into or exiting the liver may not be curable. Tumors that are diffuse and have spread throughout the liver also less likely to be curable. There are rare exceptions to this.
The number of tumors in the liver
Many patients have more than one tumor. The size and location of additional tumors will have an impact on what can be done. If the cancer has spread from the liver to other places in the body, then the emphasis shifts from treatment of the tumors in the liver to managing widespread disease. We generally advocate participation in clinical trials in these cases.
As mentioned above, there are several forms of therapy we apply to HCC.
Removal of the tumors is possible when they are small, few in number, and the remaining liver is healthy. The surgical oncologists at the Roger Williams Medical Center are highly trained in performing complex liver operations. Very often, surgical removal is not feasible or safe and we offer other treatment options.
Most patients who have developed cirrhosis and liver cancer eventually develop multiple liver tumors over time despite treatment. This risk is particularly in patients with hepatitis C. These patients are rarely ever cured from removing or destroying the liver cancer that is currently seen in the liver. For these patients, replacing the entire liver with a liver transplant is also the best way to cure liver cancer. As we do not perform transplants at the Roger Williams Medical Center, we will refer patients who may benefit from a transplant to an appropriate transplant center. Because the waiting time for a liver transplant may be up to two years, we may recommend that you undergo one or more treatments to try and stop your tumor from growing.
When a tumor cannot be surgically removed, we may use one of three techniques to destroy the tumor cells as a definitive treatment or as a bridge to transplantation. Tumor destruction or ablation may be achieved using radiofrequency or microwave generators. In essence, the tumor is heated to the point of cell death, while normal tissues are carefully protected. Microwave coagulation therapy (MCT) is the most recent development in the field of tumor ablation. Microwaves heat matter by agitating water molecules in the surrounding tissue, producing cellular death. Compared to radiofrequency ablation, MCT can treat larger areas with greater success in less time. No viable tumor cells are identified in over 90% of tumors up to 6 cm in diameter when treated by MCT. Alcohol injection is another technique that is used. Your surgical oncologists will often use a combination of ablation and removal of tumors in the operating room.
By using a small catheter placed in an artery in the thigh, the vessels feeding liver tumors can be blocked. The goal of embolization is to shrink or kill the tumor completely by cutting off its blood supply. Occasionally we give chemotherapy or radiation emitting particles with embolization procedures. These procedures are performed by our interventional radiology staff.