Liver Cancer (Primary)
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Liver Cancer (Primary)
Treatment for liver cancer
Treatment for HCC depends on the size of the cancer, how far it has spread within the liver and the body, whether any major blood vessels are involved and whether you have cirrhosis. Your doctor will also consider your age, your general health and the options available at your hospital.
Overview of HCC treatment
HCC that only involves the liver can be treated with a variety of options including surgery, liver transplant, thermal ablation (a treatment that uses heat to destroy the tumour), transarterial chemoembolisation or TACE (a treatment that delivers chemotherapy directly into the cancer), and radiation therapy. Your doctor will suggest different treatments depending on the health of your liver tissue, the number of tumours and your general fitness.
If the cancer has spread beyond the liver you may be able to have targeted therapy drugs. Sometimes if the liver is too sick from cirrhosis, you will have palliative treatment to manage symptoms.
The aim of surgery is to remove all the cancer from the liver, as well as a margin of healthy tissue. This is known as a liver resection or partial hepatectomy. Your surgeon will talk to you about the most appropriate surgery for you, as well as the risks and any possible complications.
Who it’s suitable for – Only a small number of people with liver cancer can have this surgery and it is usually done in specialist centres. The liver has to be working well because it needs to repair itself after the surgery. This means that people with no or early cirrhosis may be considered for surgery, but it is unlikely that people with more advanced cirrhosis will be offered surgery.
Types of surgery – Depending on the cancer’s size and position, the liver resection may be called a right or left hepatectomy (removes the right or left part of the liver), extended right or left hepatectomy (removes most of the liver), or segmentectomy (removes a small section of the liver). Sometimes the gall bladder may also be removed, along with part of the muscle that separates the chest from the abdomen (the diaphragm).
How the surgery is done – If you have a liver resection, it will be carried out in hospital under a general anaesthetic. Most operations for primary liver cancer are done through a large cut in the upper abdomen. This is called open surgery.
Some liver tumours are removed using keyhole (laparoscopic) surgery. The surgeon will make a few small cuts in the abdomen, then insert a tiny instrument with a light and camera (laparoscope) into one of the cuts. The surgeon inserts tools into the other cuts to remove the cancerous tissue, using images from the camera as a guide.
People who have laparoscopic surgery usually have a shorter stay in hospital, less pain and a faster recovery time. However, laparoscopic surgery is not suitable for everyone and is not available in all hospitals. Talk to your surgeon about the best option for you. Whether you have open or laparoscopic surgery, a liver resection is a major operation.
Sometimes the surgeon needs to remove so much of the liver that the remaining portion may not be large enough to recover. In this case, you may have a portal vein embolisation (PVE) about 4–8 weeks before the liver resection. A PVE is performed by an interventional radiologist after discussion with the liver surgeon and is normally done under general anaesthetic.
How a portal vein embolisation (PVE) is done
The portal vein divides into left and right branches as it enters the liver. A PVE blocks the branch of the portal vein that carries blood to the part of the liver that is going to be surgically removed. This means the other part of the liver will get bigger.
A transplant involves removing the whole liver and replacing it with a healthy liver from another person (a donor). This treatment is effective for HCC, but it is generally used only in people with a single tumour or several small tumours.
To be considered for a liver transplant, you need to be reasonably fit, not smoke or take illegal drugs, and have stopped drinking alcohol for at least six months. Currently, all liver transplants in Australia are performed in public hospitals and there is no cost for in-hospital services. You will usually have to pay for medicines you take at home.
Donor livers are scarce and waiting for a suitable liver may take many months. During this time, the cancer may continue to grow. As a result, most people have tumour ablation or TACE to control the cancer while they wait for a donor.
Unfortunately, in some people the cancer progresses despite treatment and a liver transplant will no longer be possible. In this situation, you will be removed from the liver transplant waiting list and your doctor will discuss alternative treatment options.
Recovering from a transplant – If you have a liver transplant, you will spend up to three weeks in hospital. It may take 3–6 months to recover and it will probably take time to regain your energy. You will be given drugs called immunosuppressants to stop the body rejecting the new liver. These need to be taken for the rest of your life. You may need a short course of antibiotics to reduce the chance of infections.
For tumours smaller than 3 cm, you may be offered tumour ablation. This destroys the tumour without removing it and may be the best option if you cannot have surgery or are waiting for a transplant. Ablation can be done in different ways, depending on the size, location and shape of the tumour.
Thermal ablation – This uses heat to destroy a tumour. The heat may come from radio waves (radiofrequency ablation) or microwaves (microwave ablation). Using an ultrasound or CT scan as a guide, the doctor inserts a fine needle through the abdomen into the liver tumour. The needle sends out radio waves or microwaves that produce heat and destroy the cancer cells.
Thermal ablation may be done using a local anaesthetic in the x-ray department or under a general anaesthetic in the operating theatre. Treatment takes 1–2 hours, and most people stay overnight in hospital. Side effects may include pain, nausea or fever, but these can be managed with medicines.
Alcohol injection – This involves injecting pure alcohol into the tumour. It isn’t available at all hospitals, but is used occasionally if other forms of ablation aren’t possible. The needle is passed into the tumour under local anaesthetic, using an ultrasound as a guide. You could need more than one injection over several sessions. Side effects may include pain or fever, but they can be managed with medicines.
Cryotherapy – Also known as cryosurgery, cryotherapy kills cancer cells by freezing them. This treatment is not widely available. Under a general anaesthetic, a cut is made in the abdomen. The doctor inserts a probe through the cut into the tumour. The probe gets very cold, which freezes and kills the cancer cells. Cryotherapy takes about 60 minutes. It usually involves a faster recovery than liver resection, but there is still a risk of bleeding and damage to the bile ducts.
Traditional chemotherapy is rarely used for primary liver cancer. Instead, transarterial chemoembolisation, or TACE, is used to deliver high doses of chemotherapy directly to the tumour. It is usually given to people who can’t have surgery or ablation, or are waiting for a liver transplant.
TACE step by step
Transarterial chemoembolisation (TACE) delivers chemotherapy directly to a tumour while blocking its blood supply (embolisation). It is done by an interventional radiologist.
- Before TACE, you will have a local anaesthetic and possibly a sedative to help you relax.
- The interventional radiologist will make a small cut in the groin, then pass a plastic tube called a catheter through the cut and into the hepatic artery.
- The chemotherapy drugs are injected into the liver through the catheter. Tiny plastic beads or soft gelatine sponges are also injected to block the blood supply to the cancer. This may make the cancer shrink or stop growing. In some cases, beads that contain chemotherapy are given at the same time.
- After TACE, you will have to remain lying down for about four hours. You may also need to stay in hospital overnight or for a few days.
- You will have a CT or MRI scan about six weeks after the procedure to see how well the treatment has worked.
Side effects of TACE – It is common to have a fever the day after the procedure, but this usually passes quickly. You may feel some pain, which can be controlled with medicines. Some people feel tired or report flu-like symptoms for up to a week after the procedure.
Radiation therapy is emerging as a treatment option for primary liver cancer. Two techniques may be offered in specific cases.
SIRT – Selective internal radiation therapy (SIRT) may be offered for HCC when the tumours can’t be removed with surgery or to shrink tumours before surgery or a liver transplant.
SBRT – Some cancer centres offer a form of external radiation therapy called stereotactic body radiation therapy (SBRT). You will lie on a treatment table and a machine will deliver tightly focused beams of high-dose radiation precisely onto the tumour from many different angles. SBRT may be offered to people with HCC tumours that can’t be removed with surgery or treated with tumour ablation or TACE. SBRT may also be offered to people to shrink tumours while they are waiting for a liver transplant.
This is a type of drug treatment that attacks specific features of cancer cells to stop the cancer growing and spreading. People who have advanced HCC and meet certain criteria may be offered targeted therapy drugs such as sorafenib or lenvatinib. These are given as tablets that you swallow. Your doctor will explain how to take them.
The side effects of sorafenib and lenvatinib may include skin rash, diarrhoea, fatigue and high blood pressure. These can usually be managed without having to completely stop treatment. It is important to have a plan for managing any side effects before starting treatment. Your treatment team will monitor you while you are taking targeted therapy drugs.
Generally, targeted therapy is continued for as long as there is benefit. If liver cancer progresses despite treatment with sorafenib or lenvatinib, your doctor may suggest another targeted therapy, but the cost may not be subsidised by the Pharmaceutical Benefits Scheme. You might also be able to join a clinical trial to access new drugs.
If primary liver cancer is advanced when it is first diagnosed or returns after initial treatment, your doctor will discuss palliative treatment for any symptoms caused by the cancer.
Palliative treatment aims to help maintain a person’s quality of life by managing the symptoms of cancer without trying to cure the disease. It can help at any stage of advanced liver cancer. It is not just for people at the end of their life and does not mean giving up hope. Rather, it is about living as fully and comfortably as possible.
As well as slowing the spread of cancer, palliative treatment can relieve pain and other symptoms. Treatment may include chemotherapy, targeted therapy, other medicines or insertion of a stent.
Palliative treatment is one aspect of palliative care, in which a team of health professionals aims to meet your physical, emotional, cultural, social and spiritual needs. The team also provides support to families and carers.
This information is reviewed by
This information was last reviewed June 2020 by the following expert content reviewers: Dr David Yeo, Hepatobiliary/Transplant Surgeon, Royal Prince Alfred, Chris O’Brien Lifehouse Cancer Centre and St George Hospitals, NSW; Dr Lorraine Chantrill, Head of Department Medical Oncology, Illawarra Shoalhaven Local Health District, NSW; Michael Coulson, Consumer; Dr Sam Davis, Interventional Radiologist, Staff Specialist, Royal Brisbane and Women‘s Hospital, QLD; Prof Chris Karapetis, Network Clinical Director (Cancer Services), Southern Adelaide Local Health Network, Head, Department of Medical Oncology, Flinders Medical Centre and Flinders University, SA; Dr Howard Liu, Radiation Oncologist, Princess Alexandra Hospital, QLD; Caitriona Nienaber, 13 11 20 Consultant, Cancer Council WA; Lina Sharma, Consumer; Dr Graham Starkey, Hepato-Biliary and General Surgeon, Austin Hospital, VIC; Catherine Trevaskis, Gastrointestinal Cancer Specialist Nurse, Canberra Hospital and Health Services, ACT; Dr Michael Wallace, Western Australia Liver Transplant Service, Sir Charles Gairdner Hospital,