Classification of Liver Cancer based on Resesctability
Potentially resectable or transplantable cancer
This category includes TNM stage I and II liver cancer that can be completely removed with surgery or treated with liver transplant and patient is healthy enough (sufficient liver function) to tolerate the surgical treatment. The decision to go for local therapy or liver transplant is taken based on many parameters like size and number of tumors (UNOS criterion for liver transplant), liver functional status (child pugh grade and functional liver residue), availability of donor, fitness for transplant, etc. Local therapy may be done with surgical resection or ablation of liver tumor depending on size and location of tumor, along with other factors.
This category includes TNM stage III liver cancer that cannot be completely removed with surgery as it has invaded important blood vessels or other structures. The patient may or may not have sufficient liver function.
Inoperable with only local disease
This category includes TNM stage I and II liver cancer that has not invaded important structures but the patient is not healthy enough (liver function is significantly compromised or poor performance status) to tolerate surgery.
Advanced (metastatic) cancer
This category includes TNM stage IV liver cancers that has spread to distant body parts and cannot be surgically removed. The patient may or may not have sufficient liver function. The liver cancer treatment options depends on many factors including but not limited to the type of liver cancer, stage of the disease, liver function, performance status of the patient, along with other factors.
Treatment of Liver Cancer based on Stage and Resectability
Potentially resectable or transplantable
In patients with potentially resectable liver cancer and adequate liver function, Surgery (partial hepatectomy) is considered the preferred treatment approach. For patients who are the candidates for liver transplantation, treatments like ablation or embolization may be employed until as a bridge for transplantation.
In patients with some advanced stage cancer that are considered unresectable due to invasion into blood vessels or large tumor size, treatments like ablation and/or embolization are generally preferred, depending on the location and the extent of invasion. Targeted therapy or chemotherapy may also be employed.
Inoperable with only local disease
In some cases, the tumor is limited to a part of the liver (which can be removed with surgery) but patients cannot have surgery due to poor liver function or performance status. Thus, treatments like ablation or embolization are usually employed in such cases. Targeted therapy or chemotherapy may also be considered.
For patients with advanced liver cancer that has spread to distant body parts, targeted therapy or chemotherapy are generally considered.
Surgery provides significantly longer survival and is considered as the treatment of choice for most early-stage liver cancers. Sometimes, surgery is employed to relieve symptoms of advanced stage disease like bleeding and pain. The following types of surgery may be used for the treatment of Liver cancer:
In this surgery, only the liver tissue containing cancer and some of the nearby tissue is removed leaving the rest of the liver in place. This is generally preferred in case of early-stage disease where the tumor is limited to a part of the liver (not affecting major blood vessels) and when liver function is adequate.
In this surgical procedure, the entire liver is removed and replaced by a liver donated by some other individual. This is generally used to treat patients with small tumors (either 1 tumor smaller than 5 cm across or 2 to 3 tumors no larger than 3 cm) that have not invaded nearby major blood vessels, with poor liver function. However, a patient who is a good candidate for transplantation may have to wait until availability of the donated liver, which may take too long. Thus, these patients generally receive other treatment(s) during this time to keep the liver cancer in check.
Ablation is a technique in which tumors are destroyed without actual removal from the body. This technique is generally used for patients with small tumors (usually <3 cm) when surgery is not an option due to location of the tumor, poor performance status of the patient, etc. Ablation can destroy cancer cells along with some of the nearby tissue, and hence, it is not used for the treatment of tumors invading blood vessel or important structures. High-energy radio waves are utilized in radiofrequency ablation (RFA), microwaves are used in microwave ablation (MWA) technique, while very cold gases are used in cryoablation to destroy tumors. Imaging techniques are utilized along with these ablation techniques to accurately locate the target tumors.
in this technique liver cancer is destroyed by blocking the blood supply to the cancer cells with the help of some inert tiny particles (particles are loaded with drugs in chemo-embolization and with a radioactive substance in radio-embolization) that are injected directly in the artery supplying blood to cancer cells. This technique is generally employed in patients who cannot undergo surgery and in those waiting for liver transplantation. Embolization can be employed for large tumors (>5 cm) and can also be used in conjunction with ablation.
Targeted therapy has been found very effective in treatment of Hepatocellular Carcinoma. This is mainly indicated for unresectable and/or metastatic disease. Sorafenib is preferred targeted drug in cases of Child Pugh A liver cancer, unresecatble or metastatic disease.
Chemotherapy means treatment with anti-cancer drugs that kill or decrease the growth of rapidly growing cancer cells. It is not very effective in treating liver cancer and is not commonly employed for its treatment.