Types of treatment for liver cancer

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1 Useful information for cancer patients Contents This information is an overview of treatments for primary liver cancer. There are sections on Primary or secondary cancer The main treatments for primary liver cancer Surgery for primary liver cancer Radiofrequency ablation (RFA) Microwave ablation Injecting alcohol into the tumour Chemoembolisation Radioembolisation Biological therapy Chemotherapy Radiotherapy Liver cancer that comes back Controlling symptoms You can view this information in a larger print on our website. Primary or secondary cancer This information covers treatments for cancer that started in the liver (primary liver cancer). In other words, it is the liver cells themselves that have become cancerous. Most liver cancers diagnosed in the UK are secondary cancers. This means the cancer started somewhere else in the body and has spread to the liver. This is important because secondary cancers respond to the same treatments as their primary cancer. If you have cancer that has spread to your liver, this is not the right information for you. The main treatments for primary liver cancer The main treatment for early liver cancer is surgery. If you cannot have surgery, you may have treatments such as radiofrequency ablation, chemoembolisation or alcohol (ethanol) injection. For people with advanced hepatocellular cancer (HCC), you may have a biological therapy called sorafenib. You may have chemotherapy as part of a trial. In some people one type of treatment is all that is needed. However, sometimes treatments are used in combination. Your case will be looked at by several doctors who specialise in different aspects of treatment, but who work together in a team. The team may include A surgeon A specialist in liver diseases (hepatologist) A specialist in diseases of the digestive system (gastroenterologist) One or more cancer specialists (medical or clinical oncologists) An X-ray specialist who can give certain treatments directly to the cancer (such as radiofrequency ablation) and uses X-rays or scans to help guide them (interventional radiologist) 01

2 Which treatment is best for you will depend on The type of liver cancer you have and where it is in the liver The stage of your cancer How well your liver is working Your general health Surgery for primary liver cancer Surgery for liver cancer is the best treatment if the cancer hasn't spread. There are 2 main options A liver transplant Surgery to remove the cancer from your liver (liver resection) These operations are both treatments that could possibly cure the cancer. But unfortunately, only a small number of people have cancer diagnosed early enough to benefit from surgery. Your specialist will only consider surgery if the cancer is contained within the liver and has not spread to any other part of the body. Unfortunately, even if the cancer is completely removed there is still a risk that it could come back in the future. This is because cells may have broken away from the cancer before surgery and travelled to a different part of the body. Liver transplant Hepatocellular cancer (HCC) is more likely to develop in people with long term liver damage (cirrhosis). Your specialist may suggest a liver transplant if you have cirrhosis of the liver due to previous liver disease, infection with a hepatitis virus, or from long term drinking alcohol. Your doctor will only suggest a liver transplant if you have A single liver tumour that is 5cm across or less Up to 5 tumours that are all 3cm across or less A single tumour 5 to 7cm in size that has not grown for at least 6 months To have a liver transplant you need a liver from a donor. It can sometimes take months to find a donated liver that closely matches yours. During this delay, the cancer may continue to grow and you may need to have other treatment to try to control it, such as radiofrequency ablation or chemoembolisation. Unfortunately, if you have very severe cirrhosis you are not likely to be fit enough to have this major surgery. A specialist transplant surgeon will look at all your test results and decide whether you are likely to make a good recovery from the surgery. For most people with primary liver cancer, a transplant will not help them. It is too big an operation to survive if you are already very ill. Also, if your cancer has already spread outside the liver a transplant will not cure it. You would go through a very major operation, only to find that the cancer started to grow somewhere else. Likewise, if you have a large tumour in the liver or more than 5 tumours, the risk of the cancer coming back is too great to risk such a big operation. After a liver transplant, you have to take drugs to stop your body rejecting the donated liver. These drugs damp down the activity of your immune system and reduce its ability to control the cancer. Surgery to remove the cancer (liver resection) Depending on the site and size of the cancer, surgery can involve removing anything from a small wedge of liver to up to 80% of the liver. The liver tissue that is removed can grow back. Even if you have more than half your liver removed, it can grow back to normal size in a matter of weeks. But the liver does not grow back so well if you have cirrhosis. So you are more likely to have this type of surgery if you do not have cirrhosis. Fibrolamellar hepatocellular cancer develops more often in people who do not have cirrhosis. It is often possible to remove these cancers with surgery. 02

3 Radiofrequency ablation (RFA) Ablation means destroying. This treatment uses radio waves to heat up the cancer cells until they are killed off. You may have RFA under local or general anaesthetic. You have an ultrasound or CT scan during treatment so that the doctor can see where the cancer is. You have a needle put through the skin directly into the tumour. Radio waves pass down the needle, heating the cancer cells and killing them. Side effects can include pain and sometimes a fever. Your doctor will give you medicines to control these side effects. You may have this treatment in the outpatient department and be able to go home afterwards, or you may have a short stay in hospital. In some situations, you may have RFA while you are having another operation - either during a laparoscopy or during open surgery. You may need RFA more than once. You cannot have RFA if the cancer is very big (usually not over 3 or 4 cm) or is close to any major blood vessels. Microwave ablation Microwave ablation is a newer treatment. It is similar to radiofrequency ablation, but it uses slightly different energy waves - microwaves - to destroy the liver cancer. The microwaves heat and kill the cancer cells. You can have this treatment for more than one liver cancer tumour. The doctor puts a thin needle into each tumour. The microwaves are released through the needles. For larger tumours, you may have a number of needles put in, all attached to the microwave generator. For this treatment, you have a general or local anaesthetic. You may not be able to have this treatment if the tumour is too close to another organ, such as the bowel. Injecting alcohol into the tumour This is called a percutaneous ethanol injection (PEI). It means injecting alcohol (ethanol) through the skin, directly into the cancer in the liver. You have this treatment during an ultrasound scan so that the doctor can see exactly where to inject the alcohol. The alcohol kills the cancer by dehydrating the tissue and stopping its blood supply. This type of treatment is most useful for people who have a small number of tumours, often measuring less than 2cm. You are most likely to have this done under local anaesthetic. During each session, you may have 1 or 2 injections. The number of treatment sessions you have will depend on the size and number of tumours in your liver. You may have some pain or a high temperature (fever) after this treatment. These side effects can be controlled with medication. Chemoembolisation Chemoembolisation, also called trans arterial chemoembolisation (TACE), means you have chemotherapy directly into the liver. Embolisation is a way of cutting off the cancer's main blood supply. After giving the chemotherapy drug, the doctor injects tiny plastic beads or a gelatin sponge. These block the blood vessels to the area of the liver containing the cancer cells. This reduces the supply of oxygen and food to the cancer, and may make it shrink. This may help to control the cancer and reduce symptoms, but it generally cannot cure hepatocellular cancer (HCC). This treatment can cause side effects such as pain, sickness, and a raised temperature for several days after the treatment. Rarely, chemoembolisation can cause damage to the liver which may result in liver failure. So if you have moderate or severe liver cirrhosis you are unlikely to have this treatment. Doctors may use chemoembolisation alone or in combination with other treatments, such as surgery or radiofrequency ablation. 03

4 Radioembolisation Radioembolisation is a new treatment that is being used in a number of UK hospitals. It is similar to chemoembolisation, but instead of chemotherapy it uses radiation. Millions of tiny beads (sometimes called microspheres) are fed into the hepatic artery, the main blood vessel which supplies the liver. These beads block the supply of blood to the cancer. They contain a radioactive substance called yttrium-90, so they also work by sending out radiation. This helps to kill off the cancer cells. This treatment may also be called selective internal radiation therapy (SIRT). Doctors generally use radioembolisation to help with the symptoms of liver cancer, rather than to cure it. It can also be used to treat cancer that has spread to the liver (liver metastases). The National Institute for Health and Care Excellence (NICE) has issued guidance about radioembolisation for primary liver cancer. They say that there is limited evidence about how well it works, but it may be helpful for some people with liver cancer. They say it should be a treatment option for people as long as the doctor explains How you have radioembolisation The uncertainty around how well it works The possible risks and benefits NICE says that doctors should monitor patients closely and register them on the SIRT register. This register aims to find out more about how well this treatment works and monitors side effects. They also recommend that if possible, people should have this treatment as part of a clinical trial. Biological therapy Biological therapies are treatments that act on processes in cells or change the way that cells signal to each other. They can stimulate the body to attack or control the growth of cancer cells. If you have an advanced hepatocellular cancer (HCC), you may have sorafenib to help control the cancer's growth. Sorafenib is a type of biological therapy called a tyrosine kinase inhibitor (TKI). Tyrosine kinase is a protein which acts as a chemical messenger. Chemotherapy Your specialist may suggest chemotherapy for an advanced liver cancer. The aim of the treatment is to try to slow the growth of the cancer and help control symptoms. Generally speaking, chemotherapy has limited benefits for hepatocellular cancer (HCC), and may cause more severe side effects in people with cirrhosis. If your specialist suggests this treatment, it may be within a clinical trial to test a new drug or combination of drugs. In hepatoblastoma, the type of liver cancer that affects children, chemotherapy is commonly used. Your child's specialist may suggest it before surgery to shrink the cancer, or after surgery to try to stop the cancer from coming back. Radiotherapy Doctors do not often use radiotherapy to treat liver cancer as radiation can damage the healthy liver cells. It may be used to treat bile duct cancer (cholangiocarcinoma), but is not usually used for hepatocellular cancer (HCC). If you have liver cancer that has spread to other areas of the body, such as the bones, you may have radiotherapy to help treat the area and control symptoms such as pain. Liver cancer that comes back If cancer comes back after its initial treatment, this is called a recurrence. Liver cancer can come back in the liver, in nearby organs, or in other parts of the body, such as the lungs and bones. 04

5 If your liver cancer comes back, your specialist may suggest more surgery or one of the other treatments mentioned in this information. This will depend on the type of cancer you have, the treatment you have had before, where the cancer has spread and your general health. Controlling symptoms You may hear people refer to cancer treatments as radical or palliative. Radical treatments aim to get rid of the cancer completely. Palliative treatments are used to slow down the growth of the cancer and to relieve symptoms. Palliative treatment may help someone to live longer and to live more comfortably, even if their cancer cannot be cured. Palliative treatment includes painkillers and anti sickness drugs, and treatment to relieve symptoms without aiming to cure the cancer. Surgery, biological therapy,chemotherapy and radiotherapy can all be used as palliative treatments. Your doctor may offer treatment to help control symptoms such as pain, breathing problems, weight loss and jaundice. Sometimes people with liver cancer and cirrhosis may get a build up of fluid in the abdomen (ascites). Your doctor may drain some of the fluid away or prescribe water tablets (diuretics). Your specialist may talk to you about palliative treatment if you have primary liver cancer that is quite advanced and not possible to cure. Sometimes people who have liver cancer may be too ill to cope with some of the treatments, particularly if they have other conditions such as cirrhosis or hepatitis. If the cancer has spread outside the liver before it is diagnosed, it cannot be cured. Most cancers cannot be completely cured once they have spread. For more information, visit our website You will find a wide range of detailed, up to date information for people affected by cancer, including a clinical trials database that you can search for trials in the UK. Our information is based on the best current scientific evidence and reviewed regularly by leading clinicians and experts in health and social care. For answers to your questions about cancer call our Cancer Information Nurses on am till 5pm Monday to Friday. Adapted from Cancer Research UK s website in March Cancer Research UK s website is not designed to provide medical advice or professional services and is intended to be for educational use only. The information provided through Cancer Research UK s website and our nurse team is not a substitute for professional care and should not be used for diagnosing or treating a health problem or disease. If you have, or suspect you may have, a health problem you should consult your doctor. Copyright Cancer Research UK Cancer Research UK is a registered charity in England and Wales ( ), Scotland (SC041666) and in the Isle of Man (1103) 05

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