Early diagnosis of a hepatoma (also called primary liver cancer, hepatocellular cancer, or HCC) gives the best chance of long term survival. Patients needing routine liver cancer surveillance are: 1) all patients with cirrhosis, and 2) patients with hepatitis B infection and detectable virus growing in their blood. The most common causes of cirrhosis in the United States are hepatitis C and/or B infection, alcohol over use, and fatty liver. Unfortunately, 7 out of 10 patients with liver cancer have advanced cancer when found and will not benefit from surgical removal or liver transplant.
Patient surveillance for liver cancer includes an imaging study of the liver using ultrasound and a blood test called an "alpha fetal protein" (AFP). Liver cancer surveillance should be done every 6 to 12 months. If a patient is found to have a abnormal liver nodule, further testing is needed. Below are the guidlines for further evaluation according to the American Association for the Study of Liver Disease (AASLD). A 4-phase multi-detector-CT scan or dynamic contrast enhanced MRI are confirmatory imaging studies to evaluate a suspicious liver nodule. A 4-phase study includes non-contast, arterial, portal venous, and delayed venous contrast imaging study. Because a non-contrast scout study is always obtained, the 4-phase study is more commonly called a triple-phase CAT or MRI scan.
In a patient that is found to have a nodule in the liver, a triple phase scan of the liver can be enough to make the diagnosis. A triple phase CAT or MRI scan has an arterial, portal venous and delayed venous phase. To make the diagnosis, the cancer becomes bright in the arterial phase, has the same density as the liver in the portal venous phase, and become darker than the liver in the delayed venous phase. Below are arterial, portal venous, and delayed venous phase CAT scan images of a hepatoma.
Patient surveillance for liver cancer includes an imaging study of the liver using ultrasound and a blood test called an "alpha fetal protein" (AFP). Liver cancer surveillance should be done every 6 to 12 months. If a patient is found to have a abnormal liver nodule, further testing is needed. Below are the guidlines for further evaluation according to the American Association for the Study of Liver Disease (AASLD). A 4-phase multi-detector-CT scan or dynamic contrast enhanced MRI are confirmatory imaging studies to evaluate a suspicious liver nodule. A 4-phase study includes non-contast, arterial, portal venous, and delayed venous contrast imaging study. Because a non-contrast scout study is always obtained, the 4-phase study is more commonly called a triple-phase CAT or MRI scan.
In a patient that is found to have a nodule in the liver, a triple phase scan of the liver can be enough to make the diagnosis. A triple phase CAT or MRI scan has an arterial, portal venous and delayed venous phase. To make the diagnosis, the cancer becomes bright in the arterial phase, has the same density as the liver in the portal venous phase, and become darker than the liver in the delayed venous phase. Below are arterial, portal venous, and delayed venous phase CAT scan images of a hepatoma.
Because liver cancer usually occurs with cirrhosis of the liver, only 1 out of 10 patients are eligible for surgical removal. In patients with early cirrhosis, surgery can be used when the patient has normal liver chemistries, a normal platelet count, and no evidence of portal hypertension. Most liver surgery for removal of a liver cancer can be performed laparoscopically "A Sling Technique For Laparoscopic Resection of Segment Seven of the Liver" in the Journal of the Society of Laparoendoscopic Surgery 2018 Apr-Jun; 22(2) was recently published by Dr de la Torre.
In patients with advanced cirrhosis and small cancers, liver transplant is a treatment option. Eligible patients either have a single cancer, less than 5 centimeters in size or no more than 3 cancers, each being no greater than 3 centimeters in size. There can be no cancer outside the liver or invasion of cancer into visible vessels in the the liver.
The liver is divided into compartments that can be used to guide surgery to remove a cancer. See picture below for description of liver compartments. Most liver cancers can be removed laparoscopically
In patients with advanced cirrhosis and small cancers, liver transplant is a treatment option. Eligible patients either have a single cancer, less than 5 centimeters in size or no more than 3 cancers, each being no greater than 3 centimeters in size. There can be no cancer outside the liver or invasion of cancer into visible vessels in the the liver.
The liver is divided into compartments that can be used to guide surgery to remove a cancer. See picture below for description of liver compartments. Most liver cancers can be removed laparoscopically
Patients with early stage liver cancer with advanced cirrhosis, portal hypertension, or poor liver function are eligible for a liver transplant. A patient has to meet the following conditions to be eligible: 1) a single cancer no more than 5 centimeters in size or no more than 3 cancers with none being larger than 3 centimeters in size, 2) no cancer outside the liver, and 3) the cancer cannot be invading any vessel (vein or artery) in the liver.
A patient with early stage liver cancer is given 22 MELD points and receives an additional point every 3 months while listed and waiting for an liver transplant.
The Model of Enstage Liver Disease or MELD score.
The Model for End-Stage Liver Disease (MELD) score has been in use since February 2002. It is used to measure a patient's risk of dying from chronic liver failure over a 90 day period from the day it was measured. It is used to determine the order and urgency of patients waiting for a liver transplant. The "MELD score" is a number scale. The range is from 6 (less ill) to 40 (gravely ill). The number is calculated using the following laboratory tests:
If the MELD score is greater than 10 patients are evaluated for a liver transplant. However, even if placed on the liver transplant list, patients are not actively called in for a liver transplant until their MELD score is 15 or greater. Bear in mind, a patient's chances of being alive at one year after receiving a liver transplant is between 85%-90%. A MELD score of 15 means a patient's chance of being alive in a year is about 85%. So a MELD of 15 is the break point favoring a liver transplant is when a patient has a higher chance of being a live with a liver transplant versus to dying from liver failure. As the MELD score increases, patients are progressively sicker and more debilitated.
Although patients are activated for liver transplant at a MELD of 15, patient debility usually significantly worsens at a MELD of 19 or greater. Unfortunately, MELD does not take into account patient debility (or performance status), fluid accumulation (ascites), or confusion (encephalopathy). However, a low serum sodium, lower than 131-134, has been shown to increase the risk dying while waiting for a liver transplant. There is a good chance a measure of sodium will be added to MELD to determine the urgency of need for a liver transplant. Beyond a MELD of 25, patients have a higher risk of dying even should they receive a liver transplant. However receiving a liver transplant still offers the best chance of long term survival.
A patient with early stage liver cancer is given 22 MELD points and receives an additional point every 3 months while listed and waiting for an liver transplant.
The Model of Enstage Liver Disease or MELD score.
The Model for End-Stage Liver Disease (MELD) score has been in use since February 2002. It is used to measure a patient's risk of dying from chronic liver failure over a 90 day period from the day it was measured. It is used to determine the order and urgency of patients waiting for a liver transplant. The "MELD score" is a number scale. The range is from 6 (less ill) to 40 (gravely ill). The number is calculated using the following laboratory tests:
- Total Bilirubin: a measure of how well the liver clears certain body wastes.
- INR (International Normalized Ratio or previously known as the prothrombin time): a measures the liver’s ability to make blood clotting factors.
- Creatinine: a measure of kidney function. Severe liver failure often results in kidney failure.
If the MELD score is greater than 10 patients are evaluated for a liver transplant. However, even if placed on the liver transplant list, patients are not actively called in for a liver transplant until their MELD score is 15 or greater. Bear in mind, a patient's chances of being alive at one year after receiving a liver transplant is between 85%-90%. A MELD score of 15 means a patient's chance of being alive in a year is about 85%. So a MELD of 15 is the break point favoring a liver transplant is when a patient has a higher chance of being a live with a liver transplant versus to dying from liver failure. As the MELD score increases, patients are progressively sicker and more debilitated.
Although patients are activated for liver transplant at a MELD of 15, patient debility usually significantly worsens at a MELD of 19 or greater. Unfortunately, MELD does not take into account patient debility (or performance status), fluid accumulation (ascites), or confusion (encephalopathy). However, a low serum sodium, lower than 131-134, has been shown to increase the risk dying while waiting for a liver transplant. There is a good chance a measure of sodium will be added to MELD to determine the urgency of need for a liver transplant. Beyond a MELD of 25, patients have a higher risk of dying even should they receive a liver transplant. However receiving a liver transplant still offers the best chance of long term survival.
The liver is different from other organs because it has a double blood supply; an artery (hepatic artery) and a vein (portal vein). 75% of the blood flow comes from the portal vein and 25% from the hepatic artery. Liver cancers receive their blood supply from the hepatic artery.
In patients who are not eligible for surgery, hepatic artery embolization (HAE) or chemoembolization (HACE) blocks the arterial blood supply to a liver cancer and can destroy a large part of the cancer and lengthen patient survival. Liver cancers are mainly fed through the arterial blood supply. Hepatic artery embolization uses tiny particles injected into the arterial blood vessels supplying a liver cancer. These particles can be used alone or combined with chemotherapy.
Hepatic artery embolization is used for patients that will not tolerate surgery due to poor overall health, have cirrhosis, or if the cancer is located such that it is not technically possible to remove with surgery.
The pictures below show a catheter that is placed into an artery in the groin and goes to the liver. Once the catheter is in the liver, tiny beads and chemotherapy are injected into the arteries supplying blood the the cancer. The cancer is starved of its blood supply and killed with the chemotherapy.
In patients who are not eligible for surgery, hepatic artery embolization (HAE) or chemoembolization (HACE) blocks the arterial blood supply to a liver cancer and can destroy a large part of the cancer and lengthen patient survival. Liver cancers are mainly fed through the arterial blood supply. Hepatic artery embolization uses tiny particles injected into the arterial blood vessels supplying a liver cancer. These particles can be used alone or combined with chemotherapy.
Hepatic artery embolization is used for patients that will not tolerate surgery due to poor overall health, have cirrhosis, or if the cancer is located such that it is not technically possible to remove with surgery.
The pictures below show a catheter that is placed into an artery in the groin and goes to the liver. Once the catheter is in the liver, tiny beads and chemotherapy are injected into the arteries supplying blood the the cancer. The cancer is starved of its blood supply and killed with the chemotherapy.
The liver is different from other organs because it has a double blood supply; an artery (hepatic artery) and a vein (portal vein). 75% of the blood flow comes from the portal vein and 25% from the hepatic artery. Liver cancers receive their blood supply from the hepatic artery.
Selective Internal Radiation Therapy (SIRT) using Yttrium-90 infusion is for patients who are not eligible for surgery with multiple or large liver cancers. Yttrium-90 therapy uses injection of tiny radioactive beads (microspheres) through the hepatic artery directly into the cancer. Yttrium-90 therapy has less side effects because the injection is only into the liver. Yttrium-90 therapy has 2 stages. The first stage is to map the hepatic artery blood supply to and in the liver. Patients are also tested to make sure minimal blood passes through the liver into the lung, "shunting into the lung". If the mapping is acceptable, patients return 2 weeks after for injection of Yttrium-90 microspheres into the liver cancer.
The pictures below show a catheter that is placed into an artery in the groin and goes to the liver (A & B). Once the catheter is in the liver, Yttrium-90 microspheres are injected into the arteries supplying blood the the cancer. (C)
Selective Internal Radiation Therapy (SIRT) using Yttrium-90 infusion is for patients who are not eligible for surgery with multiple or large liver cancers. Yttrium-90 therapy uses injection of tiny radioactive beads (microspheres) through the hepatic artery directly into the cancer. Yttrium-90 therapy has less side effects because the injection is only into the liver. Yttrium-90 therapy has 2 stages. The first stage is to map the hepatic artery blood supply to and in the liver. Patients are also tested to make sure minimal blood passes through the liver into the lung, "shunting into the lung". If the mapping is acceptable, patients return 2 weeks after for injection of Yttrium-90 microspheres into the liver cancer.
The pictures below show a catheter that is placed into an artery in the groin and goes to the liver (A & B). Once the catheter is in the liver, Yttrium-90 microspheres are injected into the arteries supplying blood the the cancer. (C)
In patients not eligible for surgical removal, local ablation can be performed using Radio Frequency Ablation (RFA) or Microwave ablation (MA). RFA and MA can be performed using ultrasound guided laparoscopic surgery or directly through the skin (percutaneous). Cancers less than 5 centimeters in size are suitable for this type of treatment. For cancers less than 3 centimeters in size, injection of alcohol into the cancer can also be used. Radiofrequency ablation, Microwave ablation or alcohol injection are used for patients that will not tolerate surgery due to poor overall health, cirrhosis, or if the cancer is located such that it is not technically possible to remove with surgery. The cancer is usually located using ultrasound or CAT scan guidance. The nodule can be ablated directly through the skin or, if necessary, laparoscopically. The picture below shows use of a laparoscopic ultrasound to guide the ablation device or needle for alcohol injection. For cancers less than 2 centimeters in size, RFA is almost as good as surgical removal when patients are followed for up to 2 years.
First Line Treatment
Sorafenib tosylate (Nexavar®) and lenvatinib (Lenvima®) are small molecule Raf kinase and VEGF receptor kinase inhibitors FDA approved for first line treatment of patients with unresectable liver cancer. These agents work by 1) blocking a cancer cell's machinery to divide and reproduce, and 2) blocking a cancer's ability to fool a patient's body to build a blood supply to feed the cancer. These actions combined block liver cancer growth.
Second Line Treatment
Pembrolizumab (Keytruda®) is a monoclonal antibody that blocks the PD-1 receptor, an immune regulator of T cells that fight cancers. Some cancers turn on PD-1 to turn off the body's immune responses against cancer cells. Drugs that block the PD-1 receptor from its binding partner, PD-L1, can restore T-cell immune activity against cancer. Pembrolizumab (Keytruda®) is approved for people with liver cancer who were previously treated with Sorafenib tosylate (Nexavar®)
Cabozantinib (Cabometyx®) is another small molecule multikinase inhibitor approved for people previously treated for liver cancer
Sorafenib tosylate (Nexavar®) and lenvatinib (Lenvima®) are small molecule Raf kinase and VEGF receptor kinase inhibitors FDA approved for first line treatment of patients with unresectable liver cancer. These agents work by 1) blocking a cancer cell's machinery to divide and reproduce, and 2) blocking a cancer's ability to fool a patient's body to build a blood supply to feed the cancer. These actions combined block liver cancer growth.
Second Line Treatment
Pembrolizumab (Keytruda®) is a monoclonal antibody that blocks the PD-1 receptor, an immune regulator of T cells that fight cancers. Some cancers turn on PD-1 to turn off the body's immune responses against cancer cells. Drugs that block the PD-1 receptor from its binding partner, PD-L1, can restore T-cell immune activity against cancer. Pembrolizumab (Keytruda®) is approved for people with liver cancer who were previously treated with Sorafenib tosylate (Nexavar®)
Cabozantinib (Cabometyx®) is another small molecule multikinase inhibitor approved for people previously treated for liver cancer
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