Treatment for liver cancer

Tuesday 1 July, 2014

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On this page: SurgeryTumour ablation | Chemotherapy | Biological therapy | Radioembolisation | Endoscopic stent placement | Palliative treatment | Key points


Your treatment will depend on whether you have primary liver cancer or secondary cancer in the liver; the size and spread of the cancer; and whether any other disease, such as cirrhosis, affects your liver. Your doctor will also consider your age and general health, as well as the options available at your hospital.

  • Primary liver cancer – The most common treatments are tumour ablation using heat (radiofrequency or microwave ablation) and chemotherapy delivered directly into the cancer, known as transarterial chemoembolisation (TACE). Surgery is used for about 5% of people.
  • Secondary cancer in the liver – The main treatments are chemotherapy or a combination of surgery and chemotherapy.

Surgery

During surgery, part of the liver that contains cancer is removed.

Primary liver cancer

Only a small number of people are suitable for surgery. Your ability to have an operation depends on the size, number and position of the tumours, how much of the liver is affected and whether you have cirrhosis. Operating on patients with cirrhosis is complicated because the liver may not function well or regrow afterwards.

For some people, it is not possible to remove part of the liver. These patients may be considered for a transplant. This means the whole liver is replaced (see below).

Secondary cancer in the liver

Surgery may be possible if there is enough healthy liver and the cancer hasn’t spread to other parts of the body where it can’t be removed (such as the bones). Liver transplantation isn’t an option.

Some people need surgery for both the secondary cancer in the liver and the primary cancer. These operations may be done separately or at the same time.

"The hardest part of the operation was knowing how much progress I had to make after the operation. The nurses wrote some goals for me: pain control, breathing exercises, tubes out, getting out of bed." — Earl
Partial hepatectomy

Surgery to remove part of the liver is called a partial hepatectomy. The amount of liver removed depends on your circumstances. In some cases, the surgeons will remove one half of your liver (hemihepatectomy). In other cases they will only need to cut out a small section (segmentectomy). The gall bladder is also taken out, as it is attached to the liver on the border between the right and left sides. Occasionally, part of the diaphragm muscle may be removed.

The liver can repair itself easily if it is not damaged. The portion of the liver that remains after resection will start to grow, even if up to three-quarters of it is removed. The liver will usually be back to normal size within a few months, although its shape may be slightly changed.

Two-stage surgery (two-stage hepatectomy)

People with tumours in both sides of the liver sometimes need two operations:

  1. A partial hepatectomy is done to remove tumours from one side of the liver. Sometimes this operation is combined with tumour ablation (see below) or removal of the primary tumour. The patient is given about two months to recover. During this time, the liver may regrow. Before a second operation, the size of the liver will be checked.
  2. If enough of the liver has regrown, the tumours in the second side will be removed during another partial hepatectomy.
Surgical approaches

In the majority of liver operations, a large cut is made in the upper abdomen. This is called an open approach.

However, it’s becoming more common for some liver operations to be done with a smaller incision (known as keyhole or laparoscopic surgery). Your surgeon will make small cuts in the abdomen and use a camera to view the organs.

While recovery is faster after keyhole surgery, you will still be in hospital for at least one night and you will need pain medication.

Keyhole surgery is not available in all hospitals. Talk to your surgeon for information. 

Liver transplantation

Transplantation involves removing the entire liver and replacing it with a liver from another person (a donor). There is a possibility that this treatment could cure primary liver cancer, but it is generally only used in people with small tumours.

Several factors are taken into account before someone is eligible for a liver transplant. Their overall health must be good, they cannot smoke or take illegal drugs, and they must have stopped drinking alcohol.

Donor livers are scarce, and waiting for a suitable liver may take many months or years. During this time, the cancer may continue to grow. As a result, most people have other treatment to control the cancer while they wait for a donor.

If you have a liver transplant, it may take 3–6 months to recover. You will probably find it takes a while to regain your energy. You will also be given medications to reduce the chance of infection and stop the body rejecting the new liver (immunosuppressants). You will need to take immunosuppressants for the rest of your life.

After you return home, you will need frequent check-ups to monitor your health and the success of the transplant. 

There is no cost for having a liver transplant in Australia, when it is performed in a public hospital. 

After surgery

You will spend 5–10 days in hospital after a partial hepatectomy, and up to three weeks in hospital following a transplant.

If you have a laparoscopy, the recovery time is shorter – you should allow about one week to recover before returning to your usual activities.

Drips and drains

Different tubes will be in place to drain post-operative fluids, urine and bile. You will also have a drip (intravenous tube) giving you fluids and nourishment, as you may not be able to eat or drink for a few days. When you are able to eat, you will be given clear fluids at first, and then solid foods.

Pain relief

As with many types of surgery, you may experience pain, as well as breathing difficulties and nausea. The hospital staff will try to make you comfortable by giving you pain relief. You may have a tube called an epidural catheter placed in your back to deliver pain medication, or you may be given what is known as an intravenous patient-controlled analgesic (PCA) system.

The PCA system allows you to control the pain by pressing a button to give yourself a dose of pain relief when you need it. It is not possible to give yourself an overdose of medication using a PCA system.

Let your doctor or nurse know if the pain control is not working, as it may be possible to adjust the medication or dosage.

Fatigue

You will probably feel quite tired and weak after the operation, but this should improve within a few weeks.

Mobility

A physiotherapist can help with your recovery by giving you exercises to improve your breathing, strength and ability to walk (mobility).

Check-ups

After you return home, you will need frequent check-ups to monitor your health and the success of the surgery. Your doctor will tell you how often you should have check-ups.

Tips
  • Start doing light exercise as soon as you are able to. Try walking slowly or standing while doing chores.
  • Wait six weeks and consult your doctor before doing vigorous exercise, such as running, weight-lifting or playing sport.
  • If you are taking strong (opioid) pain-killers, follow your doctor’s advice about driving.
  • If you have an incision, follow your health care team’s instructions about cleaning the area. Contact your doctor if it becomes red or inflamed.
  • Avoid alcohol for at least one month and only drink alcohol in moderation after this time. If you have cirrhosis, you must not consume any alcohol. Your medical team will talk to you about this.
"I had an 11 cm long hepatocellular carcinoma, but I was lucky that the tumour was operable. After surgery, the physiotherapy exercises helped my recovery." — Robyn

Tumour ablation

Tumour ablation is treatment that destroys a tumour. Ablation works best when there are only one or two small tumours (less than 3 cm in size). It is used most commonly for small primary liver cancers, and it is rarely used for secondary cancer in the liver.

The most common ablation treatments use radio waves (radiofrequency) or microwaves to heat and destroy cancer cells. This can be done with a needle inserted through the skin (percutaneously) or with a surgical cut.

Less common types of tumour ablation include alcohol injection and cryotherapy (see below).

Percutaneous ablation

During this procedure, a CT or ultrasound scan is used to guide a fine needle through the skin and into the tumour. Radio waves or microwaves are passed through the needle and into the tumour to destroy it. This is done in the x-ray department or operating theatre while you are under local or general anaesthetic. It takes 1–3 hours, but you will usually stay in hospital overnight.

Afterwards you will probably feel quite drowsy. Side effects, which include pain, nausea or fever, can be managed with medication.

Ablation with surgery

If the tumours are close to the surface of the liver, you may have an operation to avoid damage to the diaphragm muscle or nearby organs. A cut is made in the skin to access the liver, and probes are inserted to do the ablation.

Recovery from ablation with surgery is usually similar to liver surgery (see above).

Alcohol injection

During alcohol injection, pure alcohol is inserted directly into a tumour to destroy cancer cells. It isn’t available at all hospitals, but is occasionally used if other forms of ablation aren’t possible.

Treatment is given under local anaesthetic, and an ultrasound is used to guide the needle into the tumour. You may be given more than one injection over several sessions.

You may have some pain or a fever after the alcohol injection, but these side effects can be managed with medication.

Cryotherapy

Cryotherapy (or cryosurgery) is a procedure used to freeze and kill cancer cells, but it is not widely available.

You will be given a general anaesthetic, then a cut will be made in your abdomen. A probe is inserted through the cut into the centre of the tumour. The probe releases liquid nitrogen that freezes and kills the cancer cells.

Cryotherapy takes about 60 minutes, and recovery is similar to having surgery.

Chemotherapy

Chemotherapy is the use of drugs to kill, shrink or slow the growth of tumours.

Depending on the type of cancer you have, you will either have chemotherapy that spreads throughout your body (systemically) or goes directly into the tumour (TACE).

Systemic chemotherapy

Systemic chemotherapy is generally not used to treat primary liver cancer unless the cancer has spread to other parts of the body. It may occasionally be used to shrink a secondary cancer enough so that it can be operated on later. It can also be used as palliative treatment to slow down cancer growth and reduce pain.

Chemotherapy may also be given following other treatment, such as cryotherapy or surgery, to get rid of any remaining cancer cells. This is called adjuvant chemotherapy. If given systemically, you may have intravenous chemotherapy (through a drip) or tablets over weeks or months.

Systemic chemotherapy can cause side effects because the drugs circulate through the whole body and affect normal, healthy cells.

Whether or not you have chemotherapy depends on factors such as your overall health, liver function, and if you have advanced cirrhosis. 

Transarterial chemoembolisation (TACE)

Chemoembolisation, or TACE, is a way of delivering chemotherapy directly into a primary cancer. By targeting the tumour directly, stronger drugs can be used without causing many of the side effects of systemic chemotherapy.

TACE is rarely used for secondary cancers.

You will be given a local anaesthetic before TACE, and possibly some medication to relax (a sedative). During treatment, chemotherapy drugs are injected through a thin tube (catheter) that has been inserted into the hepatic artery. Tiny plastic beads or soft, gelatine sponges may be placed in the smaller arteries that lead to the tumour. This blocks the arteries, keeping the chemotherapy in the tumour and starving the cancer of oxygen and nutrients.

Usually treatment is given only once, or once every few months. It is done in the hospital x-ray department. After each TACE treatment, you will need to remain lying down for about four hours. You may also need to stay in hospital overnight or for a few days.

Side effects of chemotherapy

The side effects of chemotherapy vary, depending on if you have systemic chemotherapy or TACE.

Side effects of systemic chemotherapy depend on the drugs used. Temporary side effects may include:

  • nausea and loss of appetite
  • tiredness
  • hair loss and skin changes
  • tingling or numbness in fingers and toes
  • mouth sores
  • increased risk of developing infections.

After chemoembolisation (TACE), it is common to develop a fever the next day, but this usually passes quickly. Other side effects, such as pain, are less common, but can be severe. You will be given medication to help control your side effects.

There are many ways to manage side effects. For information, talk to your medical team, call Cancer Council 13 11 20 or read our chemotherapy section.

Biological therapy

Biological therapies (also called biotherapies) are a range of treatments derived from natural substances in the body, which are concentrated and purified for use as drugs. The therapies work against cancer cells by either stopping their growth and the way they function, or by helping the body’s immune system destroy them.

Biotherapies may be used after or in conjunction with other treatments for primary liver cancer or secondary cancer in the liver.

Side effects of biological therapies depend on the types used. Your doctor will discuss any possible side effects with you.

Radioembolisation (selective internal radiation therapy)

Radioembolisation (also known as selective internal radiation therapy or SIRT) is a type of treatment that targets liver tumours directly with high doses of internal radiation placed in tiny radioactive beads.

SIRT is used for both primary and secondary cancers in the liver when the tumours can’t be removed with surgery. It’s often used if there are many small tumours spread throughout the liver.

Before treatment (work-up day)

If SIRT is an option, you will have a number of tests, including an angiogram and a simulation of the treatment. An angiogram shows up the blood vessels in the liver and helps to map where the radioactive beads need to go.

This test takes about 90 minutes and you will be observed for 3–4 hours afterwards. You may also have CT and lung scans, which take about an hour. If the results of these tests are good, treatment will be scheduled for about 1–2 weeks later.

During treatment (delivery day)

You will have another angiogram. Afterwards, the tiny radioactive beads, which are known as SIR-Spheres®, are inserted through a catheter that leads from your groin to your liver.

The procedure takes about 60 minutes and you will be monitored closely for 3–4 hours before being taken to a general ward where you will recover overnight.

Side effects of SIRT can include flu-like symptoms, nausea, pain and fever. These can be treated with medication, and you usually can go home within 24 hours. 

SIRT is not available in all hospitals, and in most states and territories you will need to fund the treatment yourself if you don’t have private health insurance. Talk to your doctor about SIRT and the costs involved. 

Endoscopic stent placement

Sometimes cancer in the liver can obstruct the bile ducts, particularly if it started in the ducts. If this happens, bile builds up in the liver and can cause symptoms of jaundice, such as yellowish skin, itchiness, pale stools or dark urine.

Your doctor may recommend that a thin tube (stent) is placed in your liver to drain the bile and ease your symptoms. The earlier the stent is inserted, the less severe the symptoms.

Endoscopic stent placement is done as a day procedure. You will have a local anaesthetic and possibly a sedative to reduce discomfort.

A gastroenterologist or a surgeon inserts a long, flexible tube with a camera and light on the end (endoscope) through your mouth, stomach and small bowel into the bile duct. Pictures of the area show up on a screen so that the doctor can see where to place the stent. The stent is put in via the endoscope, which is then removed.

Recovery from endoscopic stent placement is fairly fast. Your throat may feel slightly sore for a short time and you may be kept in hospital overnight.

There is a risk of infection of the bile duct and inflammation of the pancreas after stent placement – your doctor will talk to you about this.

Palliative treatment

Palliative treatment helps to improve people’s quality of life by reducing symptoms of cancer without trying to cure the disease. It is particularly important for people with secondary cancer. However, it is not just for end-of-life care and it can be used at different stages of cancer.

Often treatment is concerned with pain relief and stopping the spread of cancer, but it also involves the management of other physical and emotional symptoms. Treatment may include chemotherapy, endoscopic stent placement or medications.

Call the Cancer Council 13 11 20 for free resources about palliative care and advanced cancer.

"The chemotherapy has stopped the secondary cancer from spreading further, but it makes me very tired." — Barbara

Key points

  • The most common treatments for primary liver cancer are radiofrequency tumour ablation and transarterial chemoembolisation (TACE).
  • The most common treatments for secondary cancer in the liver are chemotherapy or a combination of surgery and chemotherapy.
  • Surgery is used to remove tumours that are small, accessible and haven’t spread widely throughout the liver.
  • Some people with primary liver cancer are able to have a transplant, but it can take many months before a donor becomes available.
  • After surgery, you will need a number of days in hospital to recover. You will be monitored closely during this time.
  • Tumour ablation is localised treatment that destroys the tumour. Ablation techniques include the use of radio waves or microwaves to heat the tumour, cryotherapy to freeze the tumour, and alcohol injection.
  • Chemotherapy is medication that kills or slows the growth of cancer cells. It is given intravenously, as tablets, or as transarterial chemoembolisation (TACE), which delivers chemotherapy directly into the tumour.
  • Other treatments for cancer in the liver include biological therapies and selective internal radiation treatment (SIRT). These are also used when tumours can’t be surgically removed.
  • Palliative treatment helps improve quality of life by reducing symptoms. Chemotherapy, medications and endoscopic stent placement are options. 

Reviewed by: A/Prof Vincent Lam, Sydney Medical School Hepatobiliary, Pancreatic and Transplant Surgeon, Westmead Hospital, NSW; Prof Peter Angus, Medical Director, Director of Gastroenterology and Hepatology and Professorial Fellow, Austin Hospital and University of Melbourne, VIC; Jenny Berryman, Consumer; Ann Bullen, Cancer Care Coordinator, Royal Brisbane and Women’s Hospital, QLD; Prof Jonathan Fawcett, Director, Queensland Liver Transplant Service, Professor of Surgery, University of Queensland, QLD; Dr Dan Madigan, Interventional Radiologist, Royal Adelaide Hospital, SA; Dr Monica Robotin, Medical Director, Cancer Council NSW; and Dr Simon So, Interventional Radiologist, Westmead Hospital, NSW.

Updated: 01 Jul, 2014