Treatment

Treatments

There are different types of treatment for patients with liver cancer, depending on whether the tumor is primary (originated in the liver) or metastatic from another organ; the stage of the cancer and the person’s overall health. At Siteman, each cancer has a wide range of treatments that can be used alone or in combination to give the best outcome for your specific cancer, including standard therapies and novel therapies only available in clinical trials. That’s why careful diagnosis is so important.

As part of a research medical center, physicians at the Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine in St. Louis have access to a wide range of clinical trials to test new therapies as they emerge.

Many of our doctors are principle investigators in these trials, which cover medical, surgical, and radiation therapies. Discuss with your physician how your cancer might benefit from clinical trials.

The standard treatments for liver cancer include surgery, radiation therapy, chemotherapy, chemoradiation and regional therapy. Clinical trials are testing many other approaches, some of which are becoming standard of care.

Standard Treatments for Liver Cancer

Active surveillance: For single tumors under a centimeter in diameter, regular observation can track its growth.

Surgery and Other Procedures

Surgery is performed for both primary tumors which started in the liver and for secondary tumors (also called “metastatic”) that travelled to the liver form a different organ such as the colon, lung or breast.

Partial hepatectomy (liver resection) is performed for both primary and secondary tumors: Surgery can remove the part of the liver where cancer is found. It might be a wedge of tissue, or as much as 75 percent of the liver. The aim is to remove the tumor, along with some of the healthy tissue around it. The remaining liver tissue takes over the functions of the resected liver and will regrow in most cases to the size of the original liver. Chemotherapy is frequently used as an adjunct when secondary tumors are removed to lessen the chance of cancer coming back.

Staged partial hepatectomy: When tumors are very large or multiple, the surgery may be performed in two stages. This safer way for such tumors is done with a multi-disciplinary team. Tumors are cleared from one side of the liver in the first procedure. An interventional radiologist may block blood flow to the other side of the liver to encourage growth in the side which has been cleared of tumors. After giving time for the cleared side to grow, the tumors in the other side of the liver are removed in the second stage.

Liver transplantation: In this procedure which is mainly used for primary tumors, the whole liver is removed and replaced with a healthy donor liver. The cancer must be confined to the liver. While on the waiting list for a new liver, other treatment may be done. Eligible patients with the common kind of liver cancer can be accepted on the liver transplantation list if they have a single tumor that is kept below 5 centimeters (about 2 inches) in diameter or three tumors less than 3 centimeters in diameter. Larger or more tumors may become eligible after treatment.

After surgery, some patients are given chemotherapy and/or to kill any remaining cancer cells and lessen the chances the cancer will come back.

Interventional radiology: Other procedures can treat the cancer without surgery. These interventional procedures target the tumor and leave most of the liver intact, so the procedure can be repeated if necessary or can be used sequentially for the same patient. Many patients are likely to need repeated treatments because they are prone to developing new primary or recurrent metastatic liver tumors.

Chemoembolization: In this procedure, chemotherapeutic drug(s) are delivered into the liver to the site of a tumor through a catheter along with a blood vessel blocking agent. The result is that a very highly concentrated dose of the drug is delivered to the tumor and the blood vessels are partially blocked to starve the tumor of its blood supply to slow or stop tumor growth, and sometimes shrink it.

Radioembolization: This procedure is similar to chemoembolization but with radiation instead of drugs.

Portal vein embolization: This procedure is used to prepare patients for a liver resection. If the tumor is in one side, the blood supply to that side can be blocked or embolized, allowing the other side to grow and provide enough liver to sustain life. It can turn patients who are not surgical candidates into surgical candidates in about four weeks.

Biopsy: A tumor sample can be obtained via a needle through the skin for diagnosis or to identify genetic markers for hereditary types and to tailor therapy to the specific genetic type of tumor.

Ablation Therapy: This type of treatment uses different techniques to destroy abnormal liver tissue without surgery and is useful for certain tumors where location or general health of the patient make surgical resection too risky. It may include:

  • Radiofrequency ablation: Through special needles inserted directly into the tumor, high-energy radio waves heat the needles and tumor, killing cancer cells.
  • Microwave therapy: In this type of treatment, the tumor is exposed to high temperatures created by microwaves to damage and kill cancer cells, or make them more sensitive to the effects of radiation and certain anticancer drugs.
  • Cryoablation: A special instrument freezes and destroys cancer cells under ultrasound guidance.
  • Electroporation therapy: Currently being studied in clinical trials, this treatment sends electrical pulses through an electrode placed in a tumor to kill cancer cells.

Chemotherapy

Chemotherapy plays a smaller role in the treatment of liver cancer, but is given on occasion.

Regional Therapy

Local therapy, like surgical resection of a tumor, ablation, stereotactic radiation, or proton beam works well when there are one to three tumors identified. When the cancer is more diffuse, a regional approach that will address multiple tumors is more effective than systemic treatment. That would include things like:

  • Staged surgery to resect tumors, then allow the liver to grow until others can be reached more effectively
  • Liver transplant to replace a liver affected with multiple tumors that are confined to the liver
  • Catheter delivery of chemotherapy or radiation into the liver
  • Radioembolization to block arteries that feed the tumors

Radiation oncology has active trials for minimizing the duration and amount of radiation a patient receives to reduce long-term side effects. No one should be over or undertreated. Siteman is a leader in using shorter radiation durations than the national average with the same outcomes.

MRI-guided adaptive radiation therapy:  Siteman cancer center is the only center in the world performing MRI-guided adaptive radiation therapy.  By using an MRI to guide the radiation therapy; Siteman radiation oncologists can adjust, or adapt, the radiation to the patient every day.

Stereotactic body radiation therapy uses special equipment to position a patient and deliver radiation directly to the tumors. The total dose of radiation is divided into smaller doses given over several days. This type of radiation therapy helps prevent damage to normal tissue, and is being studied in clinical trials.

Proton-beam radiation therapy is a type of high-energy radiation therapy that uses streams of protons (small, positively-charged particles of matter) to kill tumor cells. This type of radiation therapy is being studied in clinical trials. In some cases, it may spare normal liver tissue better than stereotactic radiation.

Different combinations of therapies may be used depending on the stage of the cancer and the health of the patient. New combinations of therapies are always being tested in clinical trials and are available at Siteman Cancer Center before other places may have access to them.

One that is showing progress is the use of radioembolization to quickly determine if it would be helpful in slowing tumor growth. Novel imaging with PET-MRI can measure response. If response is not optimal, clinicians can move on quickly to other treatments or supplement it with another approach.