LIVER CANCER

TREATMENTS FOR HCC

After diagnosis, the treatment plan for liver cancer patients is discussed and agreed by a multidisciplinary team (MDT), also called a “tumour board”. This team includes a variety of doctors from different specialties including, for example: hepatologists (liver specialists); surgeons; oncologists (cancer specialists); interventional radiologists; pathologists; nuclear medicine physicians, palliative care specialists and nurses. This team will consider a variety of factors specific to the individual patient, including how advanced the cancer is, any underlying liver disease, and general health. These are discussed and reviewed in the context of national and international treatment guidelines to decide the best therapy for each individual case.
Multidisciplinary team (MDT)
HCC is commonly divided into four stages, with different treatment options available for each:

Early-stage HCC:

Surgical resection is the treatment of choice in suitable patients who have normal liver function.
Transplantation is recommended for patients who meet specific criteria. Patients who are accepted for transplant may also receive a ‘bridging therapy’ to control their cancer and stop it progressing while they wait for a suitable donor organ to become available.
Thermal ablation uses extreme heat or cold to destroy the tumour(s) in a minimally invasive (non-surgical) procedure. Ablation is the standard of care for patients not suitable for surgery and an alternative to resection for selected patients.

Selective Internal Radiation Therapy (SIRT) is another minimally invasive procedure now sometimes being used in early-stage patients:

  • To target a liver segment to destroy tumour(s) which cannot be accessed for thermal ablation
  • To target a complete lobe to encourage a size increase in the opposite lobe – this may enable the patient to undergo resection of the treated lobe on the basis that they will have adequate liver remaining (future liver remnant) after the surgery.

Intermediate stage:

Intermediate-stage therapies are minimally invasive (non-surgical) and take advantage of the liver’s unique blood supply; treatment is delivered via thin tubes called catheters that are passed through the hepatic artery to the tumour. The very targeted approach of these “liver-directed” therapies is designed to ensure the treatment has maximum impact on the tumour with minimal damage to the functioning liver tissue. As well as being used to treat intermediate-stage HCC, these therapies are also used to “bridge” transplant patients with early-stage disease.
Transarterial chemoembolisation (TACE) is a procedure where chemotherapy is delivered in a very targeted manner into the tumour-feeding vessels. These vessels are then blocked (embolised) to starve the tumour of blood supply and “lock in” the drug. Today, tiny drug-eluting beads (DEB) are commonly used for TACE; the chemotherapy drug is loaded into the beads which perform the dual role of embolising the vessels and releasing the drug in a controlled manner.
Selective Internal Radiation Therapy (SIRT), also called transarterial radioembolisation or TARE, uses even smaller beads (each one about a third of a width of a human hair). The beads contain a radioactive isotope called yttrium-90. They are delivered into the tumour(s) to deliver a very targeted, very powerful dose of radiation. The radiation destroys the tumour cells from within and has minimal impact on the surrounding healthy liver tissue.

Advanced-stage:

Systemic drug therapies (sorafenib or lenvatinib as first-line options) are the standard of care, but SIRT is increasingly being used for these patients – especially if they are unable to tolerate the side-effects of the systemic drugs or do not respond to them.

End-stage:

Patients that are not eligible for any other treatment should receive palliative care, including pain management, psychological support and nutrition.
The pace of innovation in research, technologies and drugs seen in the last decade has had a significant impact on the choice of treatment options available to multidisciplinary teams at each stage of the disease - and to the quality of life and prognosis of patients with HCC.
*AASLD: American Association for the Study of Liver Diseases
EASL: European Association for the Study of the Liver