Surgery
Most primary liver cancers are best treated by surgical removal of the diseased portion of the liver. Until the early 1980s, surgery to remove primary liver tumors was rarely done. Today at Memorial Sloan-Kettering, highly complex liver operations are performed with great frequency, success, and safety. Our investigators have shown that hepatobiliary surgery can be performed on elderly patients with good outcomes that are comparable to those of younger patients, and that age should not be the sole determinant when deciding whether a patient over the age of 70 is a candidate for surgery.
Full liver transplant is restricted to select cases. Whether a patient can be considered as a candidate for full liver transplant depends on the size and quantity of the tumors, and also depends on whether he or she has a coexisting liver disease, such as cirrhosis.
Operating on the liver is difficult for several reasons. Many of the major blood vessels running to and from the heart pass behind or through the liver. In essence, the liver is "attached" to the heart. Also, the anatomy of the liver is not always obvious from the surface. The organ itself is large, dense, and delicate, and is covered, in part, by the rib cage. It tears easily and bleeds profusely when injured. Many surgeons are not experienced in liver surgery. Our surgeons perform the highest number of liver surgeries of any cancer center in the country -- 200 to 300 per year.
The liver is one of the two organs in the human body that has the capacity to regenerate. Up to 80 percent of the liver can be surgically removed and, within several weeks, it will have entirely regenerated itself. If one lobe -- along with its associated blood vessels -- is surgically removed, the remaining lobe will compensate for the loss. A new technique, which stimulates regeneration before surgery, is also being evaluated at Memorial Sloan-Kettering. The technique is called pre-operative portal vein embolization. If doctors feel the portion of the liver remaining after surgical resection would be too small to allow for a good outcome, they can shift the blood supply to the healthy portion of the liver before the resection is done. That healthy area grows larger, and when it reaches sufficient size, then the resection can be performed.
Our doctors also use "liver-sparing" surgical techniques that leave more of the healthy liver intact and aid regeneration. Also, recent improvements in surgical techniques have led to less blood loss during surgery. This results in a quicker and less complicated patient recovery period.
Our surgeons are also pioneering laparoscopic surgical methods for hepatobiliary cancers. In this type of surgery, a small incision is made in the abdominal wall and a thin, lighted tube with a camera at its tip is passed through the abdominal wall to inspect the inside of the abdomen and remove tissue samples. The instrument used is called a laparoscope. This technique is sometimes used to stage or determine the extent of a cancer, eliminating the need for open exploratory surgery in some patients. It has also been used to biopsy tumors (by removing a small piece of tumor for a pathologist to examine further); or, in selected cases, to remove part of the liver (partial hepatectomy). Since the procedure is less invasive than traditional surgery, a patient's recovery time is quicker.
When a person has liver cancer and another coexisting disease, such as cirrhosis, it makes surgery more complicated and sometimes impossible. Cirrhosis dramatically weakens the liver and often leaves it permanently damaged with limited regenerative capacity. If this is the case, it is more likely that the patient will be treated with a method other than surgery. Some of these treatment options are listed below.
Image-Guided Therapies
Although surgery remains the best hope for cure for most patients with primary liver cancer, many individuals are not candidates for surgery by the time their cancer is detected. For some of these patients, minimally invasive, image-guided treatments provide therapeutic alternatives to surgery. These image-guided procedures are performed percutaneously -- meaning they are performed through the skin without the need for incisions. They can be very effective but are usually intended to control cancer rather than cure it.
Interventional radiologists use image guidance to perform arterial embolization, thermal ablation, and chemical ablation. In some cases, treatment with more than one technique is used.
Ablative therapies can also be used alone or in combination with surgical removal of a tumor. For example, a patient with hepatocellular cancer who is not a candidate for surgery may first be treated with embolization, described below, to shrink the tumor so that it is small enough to make another form of ablative therapy or surgery possible.
Embolization
The hepatic artery provides very little blood flow to healthy liver tissue, but it is the main source of blood supply for most liver tumors. This allows a treatment to be administered into the artery that supplies the cancer with little or no effect elsewhere in the body. Over 300 embolization procedures are performed each year at Memorial Sloan-Kettering.
Embolization is performed by threading a small tube, or catheter, into the artery that supplies the tumor using image guidance and injecting very small particles in order to block the blood flow to the cancer. The procedure deprives the tumor of nutrients and oxygen, and results in tumor cell death.
Thermal Ablation
Patients with primary liver cancer who have fewer than four tumors may be treated with the image-guided application of either heat or cold to kill the tumor within the liver. Whether the cancer cells are killed by freezing or heating methods depends on the size, location, and shape of the tumor being treated. The procedure is typically performed with general anesthesia, using CT scans or ultrasound for image guidance. As one of the most common image-guided therapies used to treat these tumors, over 200 percutaneous ablative procedures are performed at Memorial Sloan-Kettering each year.
Chemical Ablation
Although rarely used, another way to kill tumor cells is to inject a chemical agent directly into a tumor. Absolute alcohol, also known as ethanol, is the agent most commonly used, and the procedure is called percutaneous ethanol injection therapy (PEIT). This method has been used to treat primary liver cancer for many years, but it is not generally used to treat cancer that has spread to the liver from elsewhere in the body. As with thermal ablation, chemical ablation is recommended for patients with three or fewer tumors; is performed with either deep sedation or general anesthesia; and patients typically remain in the hospital overnight. Chemical ablation is only used in patients who are not candidates for thermal ablation.
Adjuvant Therapy
Adjuvant therapy is treatment given after the primary treatment to increase the chances of a cure and may include chemotherapy, radiation therapy, or any other form of treatment that is given after a tumor is surgically removed. Radiation therapy is not often used for this kind of cancer because the liver has poor tolerance for it. This therapy can sometimes cause an inflammation in the liver called radiation hepatitis.
Chemotherapy
There is no chemotherapy "standard of care" for primary liver cancer. However, many medical oncologists believe that chemotherapy can help in certain cases. Sometimes chemotherapy is administered to shrink a tumor in order to increase the chances of surgical resection.
Doxorubicin remains the most commonly used chemotherapy for primary liver cancer. However, response rates in patients have varied and have been difficult for oncologists to interpret. Used alone or in combination with cisplatin, 5-flurouracil and interferon (a combination known as PIAF), these chemotherapy approaches have provided some benefit to some patients but not to all.
General side effects -- such as fatigue, nausea, and diarrhea -- can be expected from any chemotherapy drug or combination of drugs, but these side effects vary from patient to patient. Before starting a chemotherapy treatment regimen, it is important to talk to your doctor about possible side effects so you know what to expect.
