Treatment

The treatment of HCC depends on the size and location of the tumor, whether the cancer has spread, and the patient’s overall health. In many cases, a team of doctors will work with the patient to determine the best treatment plan.

This section outlines treatments that are the standard of care (the best treatments available) for this specific type of cancer. Patients are also encouraged to consider clinical trials as a treatment option when making treatment plan decisions. A clinical trial is a research study to test a new treatment to prove it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, visit the Clinical Trials section.

Surgery, radiation therapy, and chemotherapy are the main treatment options for HCC; targeted therapy and other treatment options are also used in specific circumstances. Each therapy is described below. The type of treatment selected for an individual depends on a number of factors:

• Whether the cancer is only in the liver
  
  
• Whether the cancer is only in the area where it started or has spread widely throughout the liver
  
  
• The patient’s general health
  
  
• The extent of damage to the remaining (tumor-free) area of the liver

Surgery

Two types of surgery are used to treat HCC. The affected part of the liver may be removed, or a liver transplantation may be done. Both procedures are described below. Surgery is likely to be the most successful treatment; it is most successful in patients with small tumors (smaller than 5 cm). However, the tumor has spread outside the liver, or if the patient has other serious illnesses, surgery may not be an option.

Hepatectomy. When a portion of the liver is removed, the surgery is called a hepatectomy. A hepatectomy can be done only if the cancer is limited to one part of the liver, and the liver is otherwise functioning well. The remaining section of liver takes over the functions of the entire liver and can, in some cases, regrow to its normal size within a few weeks. A hepatectomy may not be possible if the patient has an advanced stage of cirrhosis even if the tumor is small.

The side effects of a hepatectomy may include pain, weakness, and fatigue, and a temporary period of liver failure. The health-care team will watch for signs of bleeding, infection, liver failure, or other problems requiring immediate treatment.

Liver transplantation. Sometimes, a liver transplantation can be done. This procedure is possible only when the cancer is confined to the liver, a suitable donor is found, and very specific criteria are fulfilled.

After a transplant, the patient will be watched closely for signs that the body might be rejecting the new liver, or that the tumor has recurred. The patient must take medication to prevent the rejection, and the drugs can have side effects, such as puffiness in the face, high blood pressure, or increased body hair.

Liver transplantation is a particularly effective treatment for people with small tumors, as the transplant removes both the tumor and the liver dysfunction that often accompanies HCC. However, there is only a limited number of donors, and people awaiting a liver transplant may have a long waiting period until a liver becomes available. The disease may continue to advance during the waiting period. The transplant center will advise you as to how long the wait is likely to be, and what rules are used to prioritize people on the waiting list.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. External-beam radiation therapy is radiation given from a machine outside the body. This approach is seldom used for HCC.

Some centers are now using internal radiation therapy or brachytherapy for HCC, which is radiation treatment using implants. Internal radiation therapy for HCC involves placing radioactive beads into the artery that supplies the tumor with blood in a manner similar to chemoembolization (see below).

Depending on the type of radiation therapy used, your doctor will explain radiation protection issues and the side effects that may be expected. The general side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished. For internal radiation therapy, there may be such side effects as damage to the stomach and lungs. However, these can often be avoided by special pre-treatment preventive measures.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. The patient may receive one drug or a combination of drugs. Two types of delivery are used to treat HCC:

Systemic chemotherapy treatment. Systemic chemotherapy is typically injected into a vein, so that it travels through the bloodstream to the whole of the body with the aim of killing cancer cells both inside and outside the liver.

Regional chemotherapy treatment. A small pump is surgically placed in the body to deliver anticancer drugs directly to the blood vessels that feed the tumor.

Common side effects include nausea and vomiting, loss of appetite, diarrhea, fatigue, low blood count, bleeding or bruising after minor cuts or injuries, numbness and tingling in the hands or feet, headaches, hair loss, and darkening of the skin and fingernails. Side effects usually go away when treatment is complete.

The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications you've been prescribed, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions through Cancer.Net’s Drug Information Resources, which provides links to searchable drug databases.

Targeted therapy

Targeted therapy is a treatment that targets faulty genes or proteins that contribute to cancer growth and development. Anti-angiogenic drugs are a type of targeted therapy that block the formation of new blood vessels that are needed for a tumor to grow and spread. This is one of the ways sorafenib (Nexavar), a drug that is being studied for HCC, is thought to work. Sorafenib is administered orally (by mouth). In current research, significant improvements were seen in survival in people with advanced HCC (from about 8 months to 10.5 months), with only modest side effects that include diarrhea and certain skin complications. In November 2007, the Food and Drug Administration (FDA) approved sorafenib for the treatment of patients with advanced HCC.

Other options

All treatment is more effective when the tumor is small; many doctors will not use these treatments if the tumor is larger than 5 cm in diameter.

• Radiofrequency ablation (RFA) and microwave therapy both use heat to kill the cancer cells. It may be applied under sedation through the skin, through laparoscopy, or during a surgical operation.
  
  
• Percutaneous ethanol injection uses alcohol injected directly into the liver tumor to kill it. Side effects include fever and pain following the procedure, but the procedure is generally very simple, safe, and particularly effective for tumors smaller than 3 cm in diameter. If the alcohol escapes from the liver, however, there may be a brief episode of severe pain.
  
  
• Cryosurgery uses extreme cold to freeze and kill cancer cells.
  
  
• Hepatic arterial infusion uses an anticancer drug injected into a catheter that has been placed in the major artery supplying blood to the liver. This treatment is a type of chemotherapy, but it does not have as many side effects.
  
  
• Chemoembolization is a procedure similar to hepatic arterial infusion. However, with this method, the flow of blood through the artery is blocked for a short time, so the anticancer drug stays in the tumor longer. The blocking of the blood supply to the tumor also kills cancer cells. Recently, two clinical trials (research studies) have provided evidence that this form of treatment can prolong survival in some patients. In addition to being used for primary treatment of the HCC, chemoembolization may be used to slow down the growth of a tumor in people who are on the waiting list for liver transplantation.
  
  
• Biologic therapy (also called immunotherapy) uses the body's own immune system to fight cancer. Materials (made by the body or in the laboratory) enhance or restore the body's natural defenses against cancer. Side effects of biologic therapy are similar to the flu and can include fatigue, fever, chills, muscle pain, and headache.

In addition to the treatment options described above, the doctor may suggest that the patient enroll in a clinical trial, which is a research study that evaluates new treatments.

Advanced HCC

Advanced HCC is cancer that has spread throughout the liver and to other parts of the body. At this stage, the goal of treatment is typically not to cure the cancer, but to slow the disease’s growth and make the patient more comfortable. Therapy for advanced HCC may include chemotherapy (including sorafenib, see Targeted therapy above), radiation therapy, or both. Palliative care can reduce pain, control symptoms, and make the patient’s quality of life better.

To learn about the terms used in this section, read the Cancer.Net Feature: Cancer Terms to Know: During Treatment.