What are the treatment options for liver cancer?

Treatment Options for Liver Cancer

Treatment for hepatocellular carcinoma (HCC) should be determined by a multidisciplinary team and based on tumor stage, liver function, and patient performance status, with the Barcelona Clinic Liver Cancer (BCLC) staging system guiding treatment selection. 1

Staging and Assessment

Before initiating treatment, proper staging is essential:

• Imaging studies: Triphasic CT scan or MRI of the abdomen is preferred 1
• Liver function assessment: Child-Pugh classification and MELD score for transplant candidates 1
• Performance status: ECOG performance status
• Tumor characteristics: Size, number, vascular invasion, extrahepatic spread

Treatment Algorithm Based on BCLC Stage

Very Early Stage (BCLC 0) and Early Stage (BCLC A)

• Single tumor ≤5 cm or up to 3 nodules ≤3 cm, no vascular invasion
• First-line options:
  • Surgical resection: Best option for patients with preserved liver function (Child-Pugh A), normal bilirubin, and no portal hypertension 1
  • Liver transplantation: Optimal for patients meeting Milan criteria (single tumor ≤5 cm or up to 3 tumors ≤3 cm) with cirrhosis 1
  • Ablative techniques: Radiofrequency ablation (RFA) or percutaneous ethanol injection (PEI) for patients with small tumors (≤3 cm) who are not surgical candidates 1

Intermediate Stage (BCLC B)

• Multinodular tumors, no vascular invasion or extrahepatic spread
• Standard treatment: Transarterial chemoembolization (TACE) 1

Advanced Stage (BCLC C)

• Vascular invasion, extrahepatic spread, or cancer-related symptoms
• Standard treatment: Systemic therapy
  • First-line: Sorafenib for Child-Pugh A patients 1
  • Second-line: Regorafenib for patients previously treated with sorafenib 2

Terminal Stage (BCLC D)

• End-stage liver function or poor performance status
• Recommended approach: Best supportive care 1

Specific Treatment Modalities

Surgical Options

1. Liver resection:

   • 3-year survival rate of 54% in non-cirrhotic patients 1
   • Best for solitary tumors in non-cirrhotic liver or selected Child-Pugh A patients 1
   • Anatomical resections are preferred when possible 1

2. Liver transplantation:

   • Best long-term outcomes with 5-year survival up to 80% 1
   • Indicated for patients meeting Milan criteria or expanded UCSF criteria 1
   • May consider patients within "up-to-seven criteria" (sum of size in cm and number of tumors equals 7) 1

Locoregional Therapies

1. Ablative techniques:

   • RFA recommended for tumors ≤3 cm 1
   • PEI or microwave ablation (MWA) as alternatives 1

2. Transarterial chemoembolization (TACE):

   • Standard for intermediate-stage HCC 1
   • Not recommended for patients with decompensated cirrhosis, vascular invasion, or extrahepatic spread 1

Systemic Therapy

1. Sorafenib:

   • First-line for advanced HCC with Child-Pugh A liver function 1
   • Monitor for adverse effects including hand-foot skin reaction and diarrhea

2. Regorafenib:

   • FDA-approved for HCC patients previously treated with sorafenib 2
   • Monitor for hepatotoxicity with regular liver function tests 2

Important Considerations and Pitfalls

• Multidisciplinary approach: Treatment decisions should involve hepatologists, surgeons, oncologists, radiologists, and interventional radiologists 1, 3

• Liver function assessment: Treatment options are limited by underlying liver disease; Child-Pugh C patients generally only qualify for supportive care or transplantation within Milan criteria 1

• Bridging therapies: For patients awaiting liver transplantation, locoregional therapies may be used to prevent tumor progression 3

• Recurrence management: HCC has high recurrence rates even after curative treatments; surveillance and prompt management of recurrence are essential 1

• Hepatotoxicity monitoring: Regular liver function monitoring is crucial, especially with systemic therapies like regorafenib which can cause severe hepatotoxicity 2

• Avoid: Treating advanced HCC with systemic therapy in patients with decompensated cirrhosis (Child-Pugh C) as this can worsen outcomes and increase mortality 1, 2

By following this evidence-based approach to HCC management, clinicians can optimize outcomes and improve survival for patients with this challenging malignancy.