Surgery So far, surgery is the only reasonable chance of curing liver cancer, either by resection (tumor removal) or liver transplantation. If all known malignancies in the liver have been successfully removed, you will have the best chance of survival. Partial hepatectomy Surgery to remove a portion of the liver is called a partial hepatectomy. This procedure should only be attempted if it is possible to remove the entire tumor and preserve enough healthy liver. Unfortunately, most malignant tumors of the liver cannot be completely removed. Often the malignancy has spread outside the liver, has become quite large or is present in too many different parts of the liver, or the patient is no longer physically able to tolerate surgery. In the United States, 80% of patients with liver cancer also have cirrhosis. If you have severe cirrhosis, removing even a small portion of liver tissue at the margin of your malignancy may not preserve enough liver to perform its essential functions. Only patients with cirrhosis who have small malignant tumors and still have an adequate amount of liver function are eligible for surgery. Doctors usually assess liver function by giving a Child-Pugh (liver function grading) score, which is a way to evaluate cirrhosis based on certain laboratory tests and symptoms. Patients in category A are most likely to have adequate liver function for surgery. Patients in category B are less likely to be eligible for surgery. Patients classified as Category C are usually not candidates for surgery. Possible risks and side effects: Hepatectomy is a major and important procedure that should only be performed by skilled and experienced surgeons. Because other parts of the liver are often damaged, the surgeon needs to remove enough of the liver to attempt to remove the entire tumor, while preserving enough of the liver to adequately perform liver function. A large amount of blood flows through the liver at any given time, so postoperative bleeding is a major concern. In addition, and more importantly, the liver usually produces substances that help the blood to clot. Damage to the liver (both preoperatively and intraoperatively) may exacerbate potential bleeding problems. Other possible problems are similar to those that occur after some other major surgeries, including infection, anesthesia complications, and pneumonia. Another problem is that patients sometimes develop new liver cancer after surgery because the remaining portion of the liver still has potential disease that can cause cancer. Liver Transplantation For some patients with small liver malignancies, liver transplantation is the best option, if possible. Currently, liver transplantation is indicated for patients with small tumors (a single tumor less than 5 cm in diameter or two to three tumors no larger than 3 cm) and who have not yet invaded adjacent blood vessels. In most cases, liver transplantation is indicated for tumors that cannot be completely removed, either because of the sensitive location of the tumor or because the liver is so dysfunctional that the patient cannot tolerate partial removal. According to the Organ Donation and Transplantation Network, approximately 1,600 liver cancer patients underwent liver transplantation in the United States in 2008, the last year in which this information was made available to the general public. The five-year post-operative survival rate for these patients ranged from approximately 60% to 70%. This is not only because patients are at a significantly lower risk of reoccurring liver cancer a second time, but also because the new liver will function properly. Unfortunately, the opportunities for liver transplantation are very limited. Each year, 6,000 livers are available for transplantation, but the majority of these livers are used for patients with other diseases. Increasing awareness of the importance of organ donation is an important public health goal that could lead to the use of liver transplantation as a treatment for more patients with liver cancer and other serious liver diseases. One practice that has become increasingly popular in recent years is the donation of a portion of the liver for transplantation by a living organ donor, usually a close relative of the patient. This approach may be successful, but carries risks for the donor. Approximately 250 living transplants are performed each year in the United States. Only a small percentage of these operations are performed on patients with liver cancer. Patients who need a liver transplant must wait a period of time until a suitable liver source is available, and for some liver cancer patients, the wait may be too long. In many cases, patients can receive other treatments such as embolization or ablation (described in the following sections) while waiting for a liver transplant.