Types of treatment for liver cancer

This section of CancerHelp UK covers treatments for cancer that started in the liver. In other words, it is the liver cells themselves that have become cancerous. Most 'liver cancers' in the UK are secondary cancers. That means the cancer started somewhere else in the body and then the cancer cells broke away from the main tumour and travelled to the liver. This is important because secondary cancers respond to the same treatments as their primary cancer. If you are looking for information about a secondary liver cancer, you need to look at information about your particular type of primary cancer.

The main treatments for primary liver cancer are surgery and chemotherapy. Radiofrequency ablation is starting to be used more now. Occasionally other treatments such as biological therapy, giving chemotherapy directly into the liver, radiotherapy, or alcohol (ethanol) injection may be used. In some people one type of treatment is all that is needed. However, sometimes treatments are used in combination. Your case will be considered by several doctors who specialise in different aspects of treatment, but who work together in a team. The team may include

• A surgeon
• A specialist in diseases of the digestive system (gastroenterologist)
• A specialist in liver diseases (hepatologist)
• One or more cancer specialists (medical or clinical oncologists)

Which treatment is best for you will depend on

• The type of liver cancer you have and where it is in the liver
• The stage of your cancer
• Your general health

Your specialist may suggest a single type of treatment or a combination of treatments, depending on your circumstances.

Surgery for liver cancer is the best treatment if the cancer hasn't spread. There are two main options

• A liver transplant
• Surgery to remove the cancer from your liver

These operations are both treatments that could possibly cure the cancer. But unfortunately, only a small number of people have cancer diagnosed early enough to benefit from surgery. Many people are not able to have the cancer removed. Surgeons are able to remove less than a third of hepatocellular cancers (hepatomas) when they are diagnosed. Your specialist will only consider surgery if the cancer is contained within the liver and has not spread to any other part of the body. Unfortunately, even if the cancer is completely removed there is still a risk that it could come back in the future because cells may have broken away from the cancer and travelled to a different part of the body.

Liver transplant

Hepatocellular cancer (HCC) is more likely to develop in people with long term liver damage (chronic cirrhosis). Your specialist may suggest a liver transplant if you have cirrhosis of the liver due to previous liver disease, infection with a hepatitis virus, or from drinking alcohol. 

Your doctor will only suggest a liver transplant if you have 

• A single liver tumour that is less than 5cm across
• Up to 3 tumours that are all less than 3cm across
• A single tumour 5 to 7cm in size that has not grown for at least six months

To have a liver transplant you need a liver from a donor. It can sometimes take months to find a donated liver that closely matches yours. During this delay, the cancer may continue to grow and you may need to have other treatment to try to control it.

Unfortunately, if you have very severe cirrhosis you are not likely to be fit enough to have this major surgery. A specialist transplant surgeon will look at all your test results and decide whether you are likely to make a good recovery from the surgery. Liver surgery in people with advanced cirrhosis can make the liver stop working altogether.

For most people with primary liver cancer, a transplant will not help them. It is too big an operation to survive if you are already very ill. Most importantly, if your cancer has already spread outside the liver a transplant will not cure it. You would then go through a very major operation, only to find that the cancer started to grow somewhere else. After a liver transplant, you have to take drugs to stop your body rejecting the donated liver. These drugs damp down the activity of your immune system and reduce its ability to control the cancer.

Surgery to remove the cancer

Depending on the site and size of the cancer, surgery can involve removing anything from a small wedge of liver to up to 80% of the liver. The liver tissue that is removed can grow back. Even if you have more than half your liver removed, it can grow back to normal size in a matter of weeks.  But the liver does not grow back so well if you have cirrhosis.

Fibrolamellar hepatocellular cancer develops more often in people who do not have cirrhosis. It is often possible to remove these cancers with surgery.

Your specialist may suggest chemotherapy for liver cancer to try to shrink a tumour that cannot be removed with surgery. The aim of the treatment is to try to slow the growth of the cancer and help control symptoms. Generally speaking, chemotherapy has limited benefits for primary liver cancer. If your specialist suggests this treatment, it may be within a clinical trial to test a new drug or combination of drugs. Or you may have a different type of therapy called chemoembolisation.   

In hepatoblastoma, the type of liver cancer that affects children, chemotherapy is commonly used. Your child's specialist may suggest it before surgery to shrink the cancer, or after surgery to try to stop the cancer from coming back. 

Biological therapies are treatments that use natural substances from the body or drugs made from these substances. Sorafenib is a type of biological therapy called a tyrosine kinase inhibitor (TKI). Tyrosine kinase is a protein which acts as a chemical messenger. 

Sorafenib has been shown in clinical trials to extend the lives of people with liver cancer. Sorafenib was approved for use in the European Union in October 2007. However, both the National Institute for Health and Clinical Excellence (NICE) and the Scottish Medicines Consortium have issued guidance stating that sorafenib is not approved for NHS use because it is not cost effective.

There is more information about sorafenib in the liver cancer research section, and in the cancer drug section of CancerHelp UK.  

Transarterial infusion chemotherapy means giving chemotherapy directly into the main artery of the liver. This gives a very high dose of chemotherapy to the liver cancer. Usually you have the chemotherapy through a pump that is placed inside the body. The pump gives a steady dose of chemotherapy every day. It can shrink the tumour and has fewer side effects than chemotherapy into a vein.

Chemoembolisation for liver tumours uses chemotherapy given directly into the liver. Embolisation is a way of cutting off the cancer's main blood supply.  In addition to the chemotherapy drug, the doctor also injects tiny plastic beads or a gelatin sponge. These block the blood vessels to the area of the liver containing the cancer cells. This reduces the supply of oxygen and food to the cancer, and may make it shrink. This can cause side effects such as pain, sickness, and a raised temperature for several days after the treatment.

Chemoembolisation can be used alone or in combination with other treatments such as surgery, radiotherapy, or radiofrequency ablation. There is more about chemoembolisation in the chemotherapy for liver cancer section.

Ablation means destroying. This treatment uses radio waves to heat up the cancer cells until they are killed off. You may have it under local anaesthetic or you may have a general anaesthetic. You have an ultrasound scan during treatment so that the doctor can see where the cancer is. You have a needle put through the skin directly into the tumour. Radio waves pass down the needle, heating the cancer cells and killing them. Side effects can include pain and sometimes a fever, but these can be controlled with medication.

You may have this treatment in the outpatient department and be able to go home afterwards, or you may have a short stay in hospital. In some situations, you may have RFA while you are having another operation - either during a laparoscopy or during open surgery.

The National Institute for Health and Clinical Excellence (NICE) guidance on RFA for primary liver cancer says that

• RFA seems useful enough and safe enough to use for hepatocellular cancers that cannot be completely removed with surgery
• You should have a CT scan or an ultrasound to guide the RFA
• Patients should be under the care of a multidisciplinary team, including a liver surgeon

You can't always have RFA for primary liver cancer. It isn't suitable if the cancer is very big or is close to any major blood vessels because of the risk of severe bleeding.

This is called a percutaneous ethanol injection. It means injecting alcohol (ethanol) through the skin, directly into the cancer in the liver. You have this treatment during an ultrasound scan so that the doctor can see exactly where to inject the alcohol.

The alcohol kills the cancer by dehydrating the tissue and stopping its blood supply. This type of treatment is most useful for people who have a small number of tumours measuring no more than 3cm across. You are most likely to have this done under local anaesthetic. During each session, you may have 1 or 2 injections. The number of treatment sessions you have will depend on the size and number of tumours in your liver.

You may have some pain or a high temperature (fever) after this treatment. These side effects can be controlled with medication.

Radiotherapy is not often used to treat liver cancer as radiation can damage the healthy liver cells.  It may be used to treat bile duct cancer (cholangiocarcinoma), but is not usually used for hepatocellular liver cancers.

Cryotherapy is also called cryosurgery. This treatment may be useful if surgery is not an option for you, although it is not often used for primary liver cancer. The doctor puts a metal probe into the part of the liver that contains the cancer. The probe contains liquid nitrogen, which is extremely cold. It freezes the tissue nearest to it. So if put into or next to a tumour, it destroys the cancer. You may have this treatment during surgery or during a laparoscopy.

This treatment can be painful. The pain is usually controlled with painkillers and only lasts for a short period of time after treatment. Some people develop a fever afterwards, but this can also be controlled with medication.

If cancer comes back after its initial treatment, this is called a recurrence. Liver cancer can come back in the liver, in nearby organs, or in other parts of the body, such as the lungs and bones.

If your liver cancer comes back, your specialist may suggest more surgery, chemotherapy or one of the other treatments mentioned above. This will depend on the type of cancer you have, the treatment you have had before, where the cancer has spread and your general health.

You may hear people refer to cancer treatments as radical or palliative. Radical treatments aim to get rid of the cancer completely. Palliative treatments are used to slow down the growth of the cancer and to relieve symptoms. Palliative treatment may help someone to live longer and to live more comfortably, even if their cancer cannot be cured.

Your specialist may talk to you about palliative treatment if you have primary liver cancer that is quite advanced and not possible to cure. Sometimes people who have liver cancer may be too ill to cope with intense chemotherapy, radiotherapy or surgery if they have other conditions such as cirrhosis or hepatitis. If the cancer has spread outside the liver before it is diagnosed, it cannot be cured. Most cancers cannot be completely cured once they have spread.

Palliative treatment includes painkillers and antisickness drugs, and treatment to relieve symptoms without aiming to cure the cancer. Chemotherapy, radiotherapy and surgery can all be used as palliative treatments. Your doctor may offer treatment to help control symptoms such as pain, breathing problems, weight loss and jaundice. The coping physically section of CancerHelp UK has information about pain control, coping with sickness and other symptoms.