Overview of treatment options for primary liver cancer in adults

by Specialist

There are different treatments for adults with primary liver cancer.

There are different treatments for adults with primary liver cancer.Some treatments are standard of care (currently applied treatments), and some are in clinical trials.Clinical trials are studies designed to help improve current treatments or to get information about new treatments for people with cancer.When clinical trials show that a new treatment is better than the standard treatment, the new treatment may replace the standard treatment.Patients may want to consider whether to participate in a clinical trial.Some clinical trials only allow patients who have not yet started treatment to participate.

Patients with liver cancer are usually treated by a group of specialists in the field of liver cancer treatment.

Patients will be treated by an oncologist who specializes in cancer treatment.Oncologists may refer patients to other health care professionals who have received specialized training in the treatment of liver cancer.This may include the following professionals:

  • Hepatologists (liver disease specialists).
  • Surgical oncologists.
  • Organ transplant surgeons.
  • Radiation oncologists.
  • Interventional radiologists (physicians who use imaging and the smallest possible incisions to diagnose and treat disease).
  • Pathologists.

    There are eight standard treatments currently in use:

    Surveillance

    Surveillance is performed on lesions less than 1 cm that are detected by screening.Follow-up is usually every three months.

    Surgery

    Partial hepatectomy (surgery to remove the part of the liver where the cancer occurs) is feasible.In this procedure, a wedge of liver tissue, the entire lobe, or a larger portion of the liver along with some of the surrounding normal tissue may be removed.The remaining liver tissue can assume the function of the liver and can be regenerated.

    Liver transplantation

    In liver transplantation, the entire liver is removed and replaced with a healthy liver that is donated.Liver transplantation can be performed when the disease is confined to the liver and a donor liver source can be found.If the patient must wait for a donor liver source, other treatments may be performed as needed.

    Ablation therapy

    Ablation therapy is a treatment that removes or destroys tissue.There are several different types of ablative therapy for liver cancer:

  • Radiofrequency ablation: A special needle is inserted directly into the tumor site through the skin or through an incision in the abdomen.High-energy radio waves heat the needle and the tumor to kill the cancer cells.
  • Microwave therapy: A treatment that exposes the tumor to the high temperatures produced by microwaves.This treatment can damage and kill cancer cells, or increase their sensitivity to radiation or certain anticancer drugs.
  • Transdermal anhydrous ethanol injection: A cancer treatment that uses a fine needle to inject anhydrous ethanol (pure alcohol) directly into the tumor to kill the cancer cells.
  • Cryoablation: A treatment that uses an instrument to freeze and destroy cancer cells.This treatment is also called cryotherapy or cryosurgery.The doctor may use ultrasound to guide the instrumentation.
  • Electroporation: A treatment that kills cancer cells by conducting electrical impulses through electrodes placed in the tumor.Electroporation is currently being studied in clinical trials.

    Embolytic therapy

    Embolytic therapy is the use of substances to block or reduce the flow of blood through the hepatic artery to the tumor.When the needed oxygen and nutrients are not available, the tumor will not continue to grow.Embolization therapy is indicated for patients who cannot be removed surgically or who cannot receive ablation therapy and whose tumor has not spread outside the liver.

    The liver receives blood from the portal vein and the hepatic artery.Blood that enters the liver from the portal vein usually flows to healthy liver tissue.In contrast, blood from the hepatic artery tends to flow to tumor tissue.After embolization therapy is used to embolize the hepatic artery, normal liver tissue can still continue to receive blood from the portal vein.

    There are two main types of embolization therapy:

  • Hepatic artery embolization (TAE): A small incision is made in the medial thigh, and a catheter (thin bendable tube) is inserted and threaded into the hepatic artery.Once the catheter reaches the preset location, a substance is injected to block the hepatic artery, thus preventing blood flow to the tumor.
  • Thermoembolization of the hepatic artery (TACE): This treatment is similar to TAE except that an anti-cancer drug is added.During treatment, anticancer drugs may be attached to microbeads that are injected into the hepatic artery, or the anticancer drugs may be injected into the hepatic artery via a catheter followed by an embolus.Most of the anti-cancer drugs are confined to the vicinity of the tumor, with only a small amount reaching other parts of the body. This treatment is also known as chemoembolization.

    Targeted therapy

    Targeted therapy is a treatment that uses drugs or other substances to identify and attack specific cancer cells without damaging normal cells.Tyrosine kinase inhibitors are a class of targeted therapy drugs used in adults with primary liver cancer.

    Tyrosine kinase inhibitors are a class of small molecule drugs that cross cell membranes and block the signaling pathways needed for cancer cell growth and division within the cancer cell.Some tyrosine kinase inhibitors also have the effect of inhibiting angiogenesis.Sorafenib, lenvatinib, and regorafenib are all tyrosine kinase inhibitors.

    See Drugs approved for hepatocellular carcinoma for more information.

    Immunotherapy

    Immunotherapy is a treatment that uses the patient’s immune system to fight the cancer.Substances made in the body or in the laboratory are used to boost, direct, or restore the body’s natural defenses against cancer.This type of cancer treatment is also known as biologic therapy or biologic treatment.

    Immune checkpoint inhibitor therapy is a form of immunotherapy.

  • Immune checkpoint inhibitor therapy: PD-1 is a protein on the surface of T cells that helps control the body’s immune response.When PD-1 binds to another protein on cancer cells called PDL-1, it prevents T cells from killing cancer cells.PD-1 inhibitors combine with PDL-1 to enable T cells to kill cancer cells.Nabumab is an immune checkpoint inhibitor.
    Immune checkpoint inhibitors.Checkpoint proteins, such as PD-L1 on tumor cells and PD-1 on T cells, help control the immune response.The binding of PD-L1 to PD-1 prevents T cells from killing cancer cells in the body (left).Blocking the binding of PD-L1 to PD-1 with an immune checkpoint inhibitor (anti-PD-L1 or anti-PD-1) allows T cells to kill cancer cells (right side).
    Immunotherapy mobilizes the body’s immune system to fight cancer.This animation shows an immunotherapy approach using immune checkpoint inhibitors to treat cancer.

    For more information, see Drugs approved for liver cancer.

    Radiation therapy

    Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or stop them from growing.There are two types of radiation therapy:

  • External radiation therapy refers to the use of instruments outside the body to send rays to the cancer site.Some radiation treatments prevent the rays from damaging adjacent healthy tissue.These external radiation treatments include the following categories:
  • Conformal radiation therapy: Conformal radiation therapy is a type of external radiation therapy that uses a computer to generate a three-dimensional (3-D) image of the tumor and tailor the beam to the shape of the tumor.This allows high doses of radiation to reach the tumor while causing less damage to adjacent healthy tissue.
  • Stereotactic radiation therapy: Stereotactic radiation therapy is a form of external radiation therapy. During each treatment, special equipment is used to keep the patient in a fixed position. The radiation therapy machine will irradiate the tumor site with a greater than usual dose once a day for several days. By keeping the patient in the same position during each treatment, the damage to the surrounding normal tissue is reduced.This treatment is also known as stereotactic external radiation therapy or stereotactic radiotherapy.
  • Proton beam radiation therapy: Proton beam radiation therapy is a type of high-energy external radiation therapy.The radiation machine applies a stream of protons (small, invisible, positively charged particles) to cancer cells to kill them.This treatment is less harmful to adjacent healthy tissue.  
  • Internal radiation therapy seals radioactive material in a needle, particle, wire, or catheter, the latter being placed directly inside or around the tumor.  

    The type of radiation therapy depends on the type and stage of the cancer.External radiation therapy is used in the treatment of primary liver cancer in adults.

    Newer treatments are being tested in clinical trials.

    Information about clinical trials is available from the NCI website.

    Treatment of primary liver cancer in adults may have side effects.

    For information about side effects of cancer treatment, see the side effects page.

    Patients may want to consider whether to participate in a clinical trial.

    For some patients, participating in a clinical trial may be the best treatment option.Clinical trials are part of the cancer research process.Clinical trials are conducted to determine if a new treatment is safe and effective, or if it is better than standard treatments.

    The current standard of care for many cancers is based on early clinical trials. Patients enrolled in a clinical trial may receive the standard treatment or may be among the first patients to receive the new treatment.

    Patients who participate in clinical trials can also help improve the way cancer is treated in the future.Even if clinical trials do not lead to effective new treatments, they can often answer important questions and help move research forward.

    Patients can join a clinical trial before, during, and after their cancer treatment.

    Some clinical trials enroll only patients who have not yet received treatment.Other trials evaluate new treatments in patients who have not improved with treatment. There are also trials that aim to evaluate new approaches that may stop cancer from coming back or reduce the side effects of cancer treatment.

    Clinical trials are being conducted in many areas within the United States.Information on NCI-supported clinical trials can be found on the NCI Clinical Trials search page.Clinical trials supported by other organizations can be found on the ClinicalTrials.gov website.

    Follow-up testing may be required.

    Some tests used for cancer diagnosis or cancer staging may need to be repeated.Some tests are repeated to see how well the treatment is working.The decision to continue, change, or stop treatment may depend on the results of these tests.

    Some tests continue after treatment ends. The results of these tests may show whether the disease has changed or whether the cancer has returned (come back).These tests are sometimes called follow-up tests or follow-up tests.