Staging
If liver cancer is diagnosed, the doctor needs to know the stage, or extent,
of the disease to plan the best treatment. Staging is an attempt to find
out the size of the tumor, whether the disease has spread, and if so,
to what parts of the body. Careful staging shows whether the tumor can
be removed with surgery. This is very important because most liver cancers
cannot be removed with surgery.
The doctor may determine the stage of liver cancer at the time of diagnosis,
or the patient may need more tests. These tests may include imaging tests,
such as a CT scan, MRI, angiogram, or ultrasound. Imaging tests can help
the doctor find out whether the liver cancer has spread. The doctor also
may use a laparoscope to look directly at the liver and nearby organs.
Treatment
Many people with liver cancer want to take an active part in decisions
about their medical care. They want to learn all they can about their
disease and their treatment choices. However, the shock and stress that
people often feel after a diagnosis of cancer can make it hard for them
to think of everything they want to ask the doctor. Often it helps to
make a list of questions before an appointment. To help remember what
the doctor says, patients may want to take notes or ask whether they may
use a tape recorder. Some patients also want to have a family member or
friend with them when they talk to the doctor -- to take part in the discussion,
to take notes, or just to listen.
At this time, liver cancer can be cured only when it is found at an early
stage (before it has spread) and only if the patient is healthy enough
to have an operation. However, treatments other than surgery may be able
to control the disease and help patients live longer and feel better.
When a cure or control of the disease is not possible, some patients and
their doctors choose palliative therapy. Palliative therapy aims to improve
the quality of a person's life by controlling pain and other problems
caused by the disease.
The doctor may refer patients to doctors who specialize in treating cancer,
or patients may ask for a referral. Specialists who treat liver cancer
include surgeons, transplant surgeons, gastroenterologists, medical oncologists,
and radiation oncologists.
Getting a Second Opinion
Before starting treatment, a patient may want to get a second opinion
about the diagnosis, the stage of cancer, and the treatment plan. Some
insurance companies require a second opinion; others may cover a second
opinion if the patient requests it.
There are a number of ways to find a doctor for a second opinion:
• The doctor may refer patients to one or more specialists. At cancer
centers, several specialists often work together as a team.
• The Cancer Information Service (1-800-4-CANCER) can tell callers
about treatment facilities, including cancer centers and other programs
supported by the National Cancer Institute, and can send printed information
about finding a doctor.
• A local medical society, a nearby hospital, or a medical school
can usually provide the names of specialists.
• The American Board of Medical Specialties (ABMS) has a list of
doctors who have met certain education and training requirements and have
passed specialty examinations. The Official ABMS Directory of Board
Certified Medical Specialists lists doctors' names along with their specialty
and their educational background. The directory is available in most public
libraries. Also, ABMS offers this information on the Internet at http://www.abms.org.
(Click on "Who's Certified.")
The doctor can describe treatment choices and discuss the results expected
with each treatment option. The doctor and patient can work together to
develop a treatment plan that fits the patient's needs.
Cancer of the liver is very hard to control with current treatments. For
that reason, many doctors encourage patients with liver cancer to consider
taking part in a clinical trial. Clinical trials are research studies
testing new treatments. They are an important option for people with all
stages of liver cancer.
The choice of treatment depends on the condition of the liver; the number,
size, and location of tumors; and whether the cancer has spread outside
the liver. Other factors to consider include the patient's age, general
health, concerns about the treatments and their possible side effects,
and personal values.
Usually, the most important factor is the stage of the disease. The stage
is based on the size of the tumor, the condition of the liver, and whether
the cancer has spread. The following are brief descriptions of the stages
of liver cancer and the treatments most often used for each stage. For
some patients, other treatments may be appropriate.
Localized resectable cancer
Localized resectable liver cancer is cancer that can be removed during
surgery. There is no evidence that the cancer has spread to the nearby
lymph nodes or to other parts of the body. Lab tests show that the liver
is working well.
Surgery to remove part of the liver is called partial hepatectomy. The
extent of the surgery depends on the size, number, and location of the
tumors. It also depends on how well the liver is working. The doctor may
remove a wedge of tissue that contains the liver tumor, an entire lobe,
or an even larger portion of the liver.
In a partial hepatectomy, the surgeon leaves a margin of normal liver
tissue. This remaining healthy tissue takes over the functions of the
liver.
For a few patients, liver transplantation may be an option. For this procedure,
the transplant surgeon removes the patient's entire liver (total hepatectomy)
and replaces it with a healthy liver from a donor. A liver transplant
is an option only if the disease has not spread outside the liver and
only if a suitable donated liver can be found. While the patient waits
for a donated liver to become available, the health care team monitors
the patient's health and provides other treatments, as necessary.
Localized unresectable cancer
Localized unresectable liver cancer cannot be removed by surgery even
though it has not spread to the nearby lymph nodes or to distant parts
of the body. Surgery to remove the tumor is not possible because of cirrhosis
(or other conditions that cause poor liver function), the location of
the tumor within the liver, or other health problems.
Patients with localized unresectable cancer may receive other treatments
to control the disease and extend life:
• Radiofrequency ablation -- The doctor uses a
special probe to kill the cancer cells with heat. The probe contains tiny
electrodes that destroy the cancer cells. Sometimes the doctor can insert
the probe directly through the skin. Only local anesthesia is needed.
In other cases, the doctor may insert the probe through a small incision
in the abdomen or may make a wider incision to open the abdomen. These
procedures are done in the hospital with general anesthesia. Other therapies
that use heat to destroy liver tumors include laser or microwave therapy.
• Percutaneous ethanol injection -- The doctor
injects alcohol (ethanol) directly into the liver tumor to kill cancer
cells. The doctor uses ultrasound to guide a small needle. The procedure
may be performed once or twice a week. Usually local anesthesia is used,
but if the patient has many tumors in the liver, general anesthesia may
be needed.
• Cryosurgery -- The doctor makes an incision into
the abdomen and inserts a metal probe to freeze and kill cancer cells.
The doctor may use ultrasound to help guide the probe.
• Hepatic arterial infusion -- The doctor inserts
a tube (catheter) into the hepatic artery, the major artery that supplies
blood to the liver. The doctor then injects an anticancer drug into the
catheter. The drug flows into the blood vessels that go to the tumor.
Because only a small amount of the drug reaches other parts of the body,
the drug mainly affects the cells in the liver. Hepatic arterial infusion
also can be done with a small pump. The doctor implants the pump into
the body during surgery. The pump continuously sends the drug to the liver.
• Chemoembolization -- The doctor inserts a tiny
catheter into an artery in the leg. Using x-rays as a guide, the doctor
moves the catheter into the hepatic artery. The doctor injects an anticancer
drug into the artery and then uses tiny particles to block the flow of
blood through the artery. Without blood flow, the drug stays in the liver
longer. Depending on the type of particles used, the blockage may be temporary
or permanent. Although the hepatic artery is blocked, healthy liver tissue
continues to receive blood from the hepatic portal vein, which carries
blood from the stomach and intestine. Chemoembolization requires a hospital
stay.
• Total hepatectomy with liver transplantation
-- If localized liver cancer is unresectable because of poor liver function,
some patients may be able to have a liver transplant. While the patient
waits for a donated liver to become available, the health care team monitors
the patient's health and provides other treatments, as necessary.
Advanced
cancer
Advanced cancer is cancer that is found in both lobes of the liver or
that has spread to other parts of the body. Although advanced liver cancer
cannot be cured, some patients receive anticancer therapy to try to slow
the progress of the disease. Others discuss the possible benefits and
side effects and decide they do not want to have anticancer therapy. In
either case, patients receive palliative care to reduce their pain and
control other symptoms.
Treatment for advanced liver cancer may involve chemotherapy, radiation
therapy, or both:
• Chemotherapy uses drugs to kill cancer cells.
The patient may receive one drug or a combination of drugs. The doctor
may use chemoembolization or hepatic arterial infusion. Or the doctor
may give systemic therapy, meaning that the drugs are injected into a
vein and flow through the bloodstream to nearly every part of the body.
The doctor may call this intravenous or IV chemotherapy.
Usually chemotherapy is an outpatient treatment given at the hospital,
clinic, or at the doctor's office. However, depending on which drugs are
given and the patient's general health, the patient may need to stay in
the hospital.
• Radiation therapy (also called radiotherapy)
uses high-energy rays to kill cancer cells. Radiation therapy is local
therapy, meaning that it affects cancer cells only in the treated area.
A large machine outside the body directs radiation to the tumor area.
Side Effects of Treatment
Because cancer treatment may damage healthy cells and tissues, unwanted
side effects often occur. Side effects depend on many factors, including
the type and extent of the treatment. Side effects may not be the same
for each person, and they may even change from one treatment session to
the next. The health care team will explain the possible side effects
of treatment and how they will help the patient manage them.
Surgery
It takes time to heal after surgery, and the time needed to recover is
different for each person. Patients are often uncomfortable during the
first few days. However, medicine can usually control their pain. Patients
should feel free to discuss pain relief with the doctor or nurse. It is
common to feel tired or weak for a while. Also, patients may have diarrhea
and a feeling of fullness in the abdomen. The health care team watches
the patient for signs of bleeding, infection, liver failure, or other
problems requiring immediate treatment.
After a liver transplant, the patient may need to stay in the hospital
for several weeks. During that time, the health care team checks for signs
of how well the patient's body is accepting the new liver. The patient
takes drugs to prevent the body from rejecting the new liver. These drugs
may cause puffiness in the face, high blood pressure, or an increase in
body hair.
Cryosurgery
Because a smaller incision is needed for cryosurgery than for traditional
surgery, recovery after cryosurgery is generally faster and less painful.
Also, infection and bleeding are not as likely.
Percutaneous Ethanol Injection
Patients may have fever and pain after percutaneous ethanol injection.
The doctor can suggest medicines to relieve these problems.
Chemoembolization and Hepatic Arterial Infusion
Chemoembolization and hepatic arterial infusion cause fewer side effects
than systemic chemotherapy because the drugs do not flow through the entire
body. Chemoembolization sometimes causes nausea, vomiting, fever, and
abdominal pain. The doctor can give medications to help lessen these problems.
Some patients may feel very tired for several weeks after the treatment.
Side effects from hepatic arterial infusion include infection and problems
with the pump device. Sometimes the device may have to be removed.
Systemic Chemotherapy
The side effects of chemotherapy depend mainly on the drugs and the doses
the patient receives. As with other types of treatment, side effects are
different for each patient.
Systemic chemotherapy affects rapidly dividing cells throughout the body,
including blood cells. Blood cells fight infection, help the blood to
clot, and carry oxygen to all parts of the body. When anticancer drugs
damage blood cells, patients are more likely to get infections, may bruise
or bleed easily, and may have less energy. Cells in hair roots and cells
that line the digestive tract also divide rapidly. As a result, patients
may lose their hair and may have other side effects such as poor appetite,
nausea and vomiting, or mouth sores. Usually, these side effects go away
gradually during the recovery periods between treatments or after treatment
is complete. The health care team can suggest ways to relieve side effects.
Radiation Therapy
The side effects of radiation therapy depend mainly on the treatment dose
and the part of the body that is treated. Patients are likely to become
very tired during radiation therapy, especially in the later weeks of
treatment. Resting is important, but doctors usually advise patients to
try to stay as active as they can.
Radiation therapy to the chest and abdomen may cause nausea, vomiting,
diarrhea, or urinary discomfort. Radiation therapy also may cause a decrease
in the number of healthy white blood cells, cells that help protect the
body against infection. Although the side effects of radiation therapy
can be distressing, the doctor can usually treat or control them.
Information provided by the National Cancer Institute (www.cancer.gov)