Liver Cancer Treatment Options
The treatment of primary and malignant liver tumors depends on the extent of the disease within the liver as well as outside the liver, the overall health of the liver, and the overall health of the patient. The various options in the treatment of focal liver masses are as follows:Surgical options
- Resection (view types)
- Resection with radiofrequency ablation (Resection with RFA)
- Radiofrequency ablation alone (RFA alone)
- Microwave Ablation (MA)
- intra-operative Magnetic Resonance Imaging (iMRI)
- Unroofing and marsupialization
- Fenestration and resection
- Enucleation
- Transplantation
Non-surgical options
- Selective Internal Radiation Therapy (SIRT)
- Hepatic artery infusion (port or pump)
- Embolization and chemoembolization
- Alcohol ablation
New techniques such as enucleation or ablation are available where parenchymal sparing procedures are needed. In addition, other interventions such as hepatic artery embolization of tumors and, in some cases, portal vein embolization of a lobe or more have allowed preoperative downstaging of some tumors and the "remodeling" of nontumoral hepatic parenchyma
Selective Internal Radiation Therapy (SIRT)
Intra-arterial radiation therapy is an innovative means of treating liver tumors. In cases where it is not possible to surgically remove the liver tumors, radioactive microspheres can be used to deliver targeted, internal radiation therapy directly to the tumor. This new therapy is called Selective Internal Radiation Therapy also known as SIRT.How Does SIRT Work?
When tumors arise in the liver, their blood supply is derived from the hepatic artery; in contrast, normal liver tissue receives about 80% of its blood supply from the portal vein. SIRT takes advantage of this knowledge by using the portal vein as a direct route to deliver yttrium-90 radiation microspheres directly into the liver tumors. By selectively infusing radioactive material into the left, right or common hepatic artery, a concentrated dosage can be delivered directly into the tumor, while conserving normal liver tissue that surrounds the tumor.
These microspheres are very small, approximately 32 microns in size, and are about one-third the diameter of a strand of hair. SIRT is administered as an outpatient procedure by a specially trained physician known as an interventional radiologist. A small catheter is guided into the liver and the microspheres are infused through the catheter. The microspheres with the radioactive yttrium-90 are carried by the bloodstream directly to the tumors in the liver where they preferentially lodge in the small vessels feeding the tumor and deliver their dose of radiation. Unlike conventional external beam radiation, which can only be applied to limited areas of the body, SIRT microspheres selectively irradiate the tumors and therefore have the ability to deliver more potent doses of radiation directly to the cancer cells over a longer period of time.
There are currently two types of SIRT yttrium-90 microspheres that have been FDA approved for treatment of liver tumors. Therasphere® uses glass beads to deliver yttrium-90 radiation and Sir Spheres® uses resin beads. At Norton Healthcare, we offer both of these innovative procedures. Our liver cancer specialists work with the interventional radiologists, the radiation oncologists and the nuclear physicists to customize therapies and determine which treatment option offers the most benefit to the patient.
To see more, view the video clips below:Theraspere 1
Theraspere 2
Theraspere 3
Radiofrequency Ablation (RFA)
Radiofrequency ablation, also known as RFA, is an exciting, recently developed technique used to treat malignant liver tumors. Radiofrequency ablation uses electrical current, passed through a multiple small needles placed directly into a liver tumor, to destroy cancer cells with heat (view probe). The electrical current is actually passed across an array of hook electrodes that are deployed from the tip of the needle after the needle is placed into the tumor (view probe tip). The hook electrodes look like the ribs of an umbrella, with a diameter of 3.5 cm (slightly greater than an inch) when fully deployed. An ultrasound probe is used to guide the placement of the needle into the tumors to be treated, and after the needle is in the correct area, the hook electrodes are deployed into the liver tumor. The treatment is started by applying electrical current from a radiofrequency current generator. The amount of power supplied by the generator can be controlled precisely, and the generator is also used to monitor the treatment until complete heat-induced destruction of the tumor being treated occurs (view result).Radiofrequency ablation can be performed during an abdominal operation, using laparoscopic surgical guidance (so-called minimally invasive surgery), or by placing the needle through the skin directly into the tumor. The surgeons in the University of Louisville Division of Surgical Oncology can explain the different approaches to each patient. In addition some patients are best treated by combining the removal of the largest liver tumors with RFA of any smaller tumors during the same open operation. It is important to note that RFA performed laparoscopically or through the skin still requires anesthesia so the patient will feel no pain or discomfort during the treatment.
RFA is a relatively new, but very exciting treatment for patients with some types of malignant liver tumors. The treatments have been safe and well tolerated in the overwhelming majority of patients. RFA has opened more options to patients who previously would not have been considered for aggressive surgical treatments because of the number of tumors, location of tumors too near major blood vessels, problems with cirrhosis, or inability to remove the entire tumor while leaving behind enough normal liver. The University of Louisville, Division of Surgical Oncology-- who continues to develop improved equipment to treat larger tumors--uses RFA, often in combination with other types of treatments, in hopes of eradicating all the patients malignant cells.
If you believe that you are a candidate for RFA, click here
To see more, view the video clips below:Clear body to liver
RFA 1
RFA 2
Staged ablation
Microwave Ablation (MA)
Microwave ablation is a promising treatment for unresectable liver tumors. Unlike radiofrequency ablation, microwave ablation may be performed with multiple simultaneously active antennae.
To see probe, click here
intra-operative Magnetic Resonance Imaging (iMRI)
A note-worthy recent advancement in treating tumors of the liver is the use of iMRI (intra-operative Magnetic Resonance Imaging). Liver tumors often occur next to critical areas of the body, such as the diaphragm, colon, stomach, and gallbladder. Using the iMRI, surgeons are able to pinpoint the exact size and location of the tumor. Precise real-time imaging capabilities allow the tumors to be destroyed while the surgeons observe--literally. The removal of liver tumors had to be done traditionally in open surgery. With the iMRI, the ablation process is carried out using a very thin, minimally invasive needle instrument. iMRI is especially advantageous in treating recurring liver tumors--including those patients who have had prior operations. The ability to treat them as they occur drastically reduces the risk and stress on the body. Thus the iMRI can significantly prolong survival, as well as, allow much quicker recoveries and higher levels of patient comfort throughout the treatment process.Portal Vein Embolization
Recently, preoperative percutaneous portal vein embolization has been used to induce hypertrophy of the future liver remnant before surgery. This technique is currently used in patients in which a complex extended hepatectomy is anticipated and the future liver remnant is small or functionally compromised. The recent advent of helical computed tomography (CT) allows accurate 3 dimensional measurements before and after portal vein embolization preoperatively.Chemoembolization
Chemoembolization is the administration of antineoplastic agent together with an embolizing vehicle. This allows slow release of the agent as well as obstruction of the blood supply to the neoplasm.Clinical Trials
Some patients may be eligible to take part in studies, called clinical trials, which test new treatments. These treatments may include new chemotherapy drugs or new combinations of different drugs. Radiation therapy treatments are sometimes a part of these clinical trials. As more effective drugs become available, the treatment options for liver cancer may change. Your doctor will discuss the risks and benefits of various treatment options with you and your family.To learn more about clinical trials currently underway, follow the link below.
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Multi-disciplinary Approach to HCC
The treatment of hepatocellular carcinoma (HCC) is quite challenging and requires a multi-disciplinary approach. A recent review of patients with HCC indicated that, of the population at risk for HCC, 23.9% were due to hepatitis C virus (HCV), approximately 10% were due to hepatitis B virus (HBV), and approximately 41% related to daily alcohol consumption, while in 25% no clear cause could can be identified. At least 50%-60% of all HCC patients seen have associated liver cirrhosis which can be clinically diagnosed. The presence of liver cirrhosis presents a major challenge to the treatment of hepatocellular carcinoma. Associated low platelets (thrombocytopenia), low white blood cell count (neutropenia), fluid in the patients abdomen (ascites), elevated bilirubin all must be considered when treatment is being planned. Patients who have severe confusion (encephalopathy and liver failure) are more likely to die from liver failure rather than from HCC. Thus, treatment of hepatocellular carcinoma has to take into consideration the residual functioning liver reserve.Small HCC liver lesions may be managed by interventions such as resection, radio frequency - or cryo-ablation, alcohol ablation, or even orthotopic liver transplantation (OLT). Obviously, such interventions are limited by the size, the number, the location of tumors and the underlying liver reserve. Most importantly, none of these interventions will deal with micrometastatic disease or additional primary lesions present in the liver or outside the liver.
