What is liver cancer?
When we talk about liver cancer, we are referring to primary liver cancer (PLC), which is a common malignant tumor that starts insidiously and progresses rapidly, and most patients are already in the middle to late stages when diagnosed, often with a poor prognosis.
Primary liver cancer includes pathological types such as hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC) and mixed hepatocellular-cholangiocarcinoma.
Hepatocellular carcinoma accounts for more than 90% of these, and we often talk about hepatocellular carcinoma as well. This article focuses on transcatheter arterial chemoembolization (TACE) for intermediate to advanced hepatocellular carcinoma.
How is hepatocellular carcinoma staged? And what is intermediate to advanced hepatocellular carcinoma?
Before introducing the staging of hepatocellular carcinoma, it is important to introduce the concepts of hepatic functional status and physical activity status.
What is hepatic functional status (Child grade)?
The Child-Pugh grade was introduced by Pugh in 1973 based on the Child grade, which uses a scoring method to estimate the status of liver function and is now the common clinical method for grading liver function.
| Table 2 Liver Function Child-Pugh Classification | |||
|---|---|---|---|
| Indicators | Rating|||
| 1 | 23 | ||
| Total bilirubin (μmol/L) | Less than 3434 to 51 | More than 51 | |
| Serum albumin (g/L) | greater than 35 | 28 to 35 | Less than 28 |
| Prolonged prothrombin time | 1 to 3 seconds4 to 6 seconds | Greater than 6 seconds | |
| Abdominal fluid | Mild | Moderate amount | |
| None | 1 to 2 | 3~4 | |
| Note: According to the point method, 5~6 is A grade, 7~9 is B grade, 10~15 is C grade | |||
What is physical activity status?
The PS score is an evaluation of physical activity status.
The PS score is an assessment of a patient’s physical activity status (PS), which is a measure of a patient’s general health and ability to tolerate treatment in terms of their physical strength. The main components are as follows:
- Score 0: completely normal mobility, no difference from pre-onset mobility;
- 1 score: free to walk around and perform light physical activities, including general housework or office work, but not heavier physical activities;
- 2 score: free to walk around and perform light physical activities, including general housework or office work, but not heavier physical activities;
- 2 points: able to walk freely and live on his or her own, but has lost the ability to work, and can get up and move around no less than half of the daytime hours;
- 3 points: only partially able to take care of himself/herself, bedridden or wheelchair-bound for more than half of the day;
- 4 points: bedridden and unable to care for themselves;
- 5 points: death.
Barcelona staging of hepatocellular carcinoma
The most commonly used international staging for liver cancer is the Barcelona staging (Barcelona clinic liver cancer, BCLC), which is a guide for clinical treatment choices.
| BCLC staging for HCC | ||||
|---|---|---|---|---|
| Phases |
PS Rating | Tumor StatusLiver function status|||
| Number of tumors | Tumor size||||
|
Stage 0: very early stage |
0 | Single | less than 2cm | No portal hypertension |
| Stage A: Early | 0
Single |
Any |
Child-Pugh A-B |
|
| 3 or less | Less than 3cm | Child-Pugh A-B | ||
| Multinodular tumors | any | Child-Pugh A-B | ||
|
portal vein violation or N1, M1 |
any | Child-Pugh A-B | ||
| any | any | Child-Pugh C | ||
BCLC staging takes into account tumor, liver function (Child grade), and systemic conditions (PS score) in a comprehensive manner and is now widely adopted worldwide.
Can mid- to late-stage liver cancer be treated? Is it still worth treating?
There used to be a misconception that mid- to late-stage liver cancer was incurable and therefore untreatable and not worth treating. However, as medicine has evolved and more and more treatments are being used in combination for patients with liver cancer, mid- to late-stage liver cancer is completely treatable and has good outcomes.
Clinical studies have shown that patients with mid- to late-stage liver cancer, if left untreated and allowed to develop, will soon progress to end-stage liver cancer, with a survival period of less than 3 months. With a combination of interventional therapy and other methods, about 50% of patients with intermediate liver cancer have a survival of more than 3 years; for patients with advanced liver cancer, there is a 50% chance of survival of more than 1 year.
At the same time, the philosophy of oncologic treatment is being updated. It is now believed that the main goal of treatment for mid- to late-stage liver cancer is to control tumor progression, prolong patient survival, and improve quality of life. Interventional surgery, for example, is less invasive, has a faster postoperative recovery, and has minimal impact on life and work, which can significantly improve the quality of life of patients.
Therefore, for patients with mid- to late-stage liver cancer, treatment is not only worthwhile, but necessary.
Interventional treatment for mid- to late-stage liver cancer
At present, only a very small proportion of patients with intermediate to advanced hepatocellular carcinoma are suitable for surgical resection treatment, and the relatively high recurrence and metastasis rates after resection are related to the possible presence of microscopic disseminated foci or tumor multicentric occurrence before surgery. Moreover, once the tumor recurs in these patients, it often progresses rapidly and seriously endangers patients’ lives.
So, for patients with intermediate to advanced hepatocellular carcinoma, TACE-based interventional therapy is now recognized as the main recommendation internationally.
What is TACE?
What is TACE?
TACE (transcatheter arterial chemo embolization) is a type of interventional therapy for hepatocellular carcinoma. It usually involves a puncture in the femoral artery, a fine catheter is threaded in, and the catheter is delivered to the intrahepatic tumor focus through fluoroscopic guidance of a digital subtraction angiography machine to inject anticancer drugs and embolic agents into the intrahepatic tumor artery through the catheter.
TACE not only kills the tumor cells directly, but also blocks the blood supply to the tumor, leaving the tumor without nutrition and “starving” to death, and is now recognized as the treatment of choice for mid- to late-stage liver cancer at home and abroad.
What patients are suitable for interventional therapy?
What patients are suitable for intervention?
- Patients with intermediate to advanced primary liver cancer that cannot be surgically resected;
- Patients who can be surgically resected but are unable or unwilling to undergo surgery for other reasons (e.g., advanced age, severe cirrhosis, etc.);
- Patients with small hepatocellular carcinoma who are not suitable or unwilling to undergo surgery, local radiofrequency or microwave ablation.
What are the main roles of interventional therapy for hepatocellular carcinoma?
- Treatment of intermediate to advanced hepatocellular carcinoma that cannot be surgically resected;
- The application of interventional therapy before open liver tumor resection can reduce the tumor volume and facilitate surgical resection, as well as clarify the number of lesions;
- Control of local pain and bleeding as well as embolization of arteriovenous impotence;
- Some patients with large tumors and a high chance of postoperative recurrence can have postoperative prophylactic interventions about 1 month after surgery to kill possible residual active lesions and reduce the chance of recurrence.
What conditions are not suitable for intervention?
Can I re-intervene after a relapse?
After TACE treatment, the liver is not in good condition.
After TACE treatment, the lesion is stable and there is no clear active lesion, so regular review is sufficient.
If there is recurrence or residual activity after treatment, or if there is progression of the lesion, repeat TACE therapy is needed. The interval between TACE treatments can be 6 to 8 weeks, or longer, depending on the circumstances.