Treatment

Depicted below is an overview of the different treatment modalities for the treatment of liver cancer.

Surgery

Nowadays, surgery is the best curative treatment option for most malignant liver tumours. In order to be found eligible for surgery, patients have to be in a good physical condition. After removal of the tumour, a minimum of 30% functioning liver volume is required for adequate functioning of the liver. When the remaining functional liver function is less than 30% after removal of the tumour, a portal vein embolization can be performed.

Leveroperatie

Liver surgery

The portal vein is the large blood vessel running from the intestines to the liver. Portal vein embolization decreases a large portion of the blood supply to a part of the liver, causing the other part to work harder to ‘compensate’ for this loss. As a result, the part of the liver working overtime will become bigger (hypertrophy). The main goal is to increase the liver volume in order to take over the entire workload of the liver. The aim of portal vein embolization is to generate sufficient (30%) remaining functional liver tissue to enable an operation. During portal vein embolization, a needle is placed percutaneously (through the skin) into the liver and the portal vein is embolized. Various different materials can be used to achieve this. Another way is to surgically remove one of the large branches of the portal vein. 4-6 weeks following the embolization procedure, a CT-scan is made to evaluate whether enough liver volume has been generated in order to proceed to surgery. Portal vein embolization is performed by radiologists.

There are different types of surgery, including removal of half of the liver or a smaller portion of the liver (a liver segment). Based on the liver vascularization, the liver is divided into eight segments (see anatomy). Often, liver surgery makes use of this segmental organization of the liver. Better understanding of liver anatomy, improved pre-operative diagnostics methods, new and optimized operation techniques and hospital care decreases the risk of intraoperative mortality (5%). Currently, the risk of complications during hospital stay is around 25%. Most common complications include haemorrhage, bile leakage, infections and failure of liver functions.

Unfortunately, surgery is not always an option, either because of the location of the tumour, the number of tumours or tumours located in other organs of the body. In this case there are other treatment options, including laser therapy (LITT), radiofrequency ablation (RFA), alcohol injection (PEI) or chemotherapy.

Chemotherapy

Infuus

A drip

Chemotherapy is a treatment method for cancer, in which cytostatic drugs are used that inhibit the cell growth. After administration, the cytostatic drugs are absorbed in the blood flow and distributed throughout the whole body, allowing them to reach virtually all cancer cells. Chemotherapy is often aimed to decrease the disease or to prevent and/or limit the complaints caused by the disease.

Cytostatic drugs do not only affect cancer cells, but also healthy cells in the human body. Especially highly proliferating cells are affected by chemotherapy, including the inner layer of the mouth and intestines, causing pain, diarrhoea, and sensory disturbances of the extremities. The type and amount of cytostatic drug that is administered, determines the side effect profile.

Ablation

For local ablation, laser induced thermotherapy (LITT) or radiofrequency ablation (RFA) is used. Both methods use thermal energy (heat) in order to locally destroy the tumour. Laser therapy results in absorption of light energy by the tumour cells, followed by heating and destruction of the tumour cells. In radiofrequency ablation tumour destruction is achieved through alternation current. Treatment can either take place through the skin or with surgery. Using ultrasound, the tumour is located and punctured and heated with either a laser probe or electrode. Both LITT and RFA occur under general anaesthesia.

An overview of the techniques used to perform an ablation is listed below.

Laser therapy
For local ablation, laser induced thermotherapy (LITT) can be used. The aim of LITT is to gain local destruction of the tumour. During treatment, light energy of the laser is absorbed by the tumour, causing heat and destruction of the tumour cells. This therapy is a surgical procedure. During the procedure, a laser probe is positioned in the tumour under ultrasound guidance. The maximum heating area of the laser is 10 cm in diameter. Therefore, only tumours with a maximum size of 8 cm in diameter are eligible.

A maximum number of 10 tumours are treated in one session. Treating more than 10 tumours is time-consuming and associated with poor outcome due to aggressiveness of the tumour. The goal of laser therapy is to destroy the tumour and at the same time minimize damage to healthy liver tissue. This treatment results in decreased tumour size and tumour growth leading to improved quality of life and survival. The number of complications is much lower with ablation compared to liver surgery. Following this treatment, a CT or MRI scan is made to evaluate recurrence or growth. The first scan is performed one week after the procedure.

Radio frequency ablation
Another technique for local ablation is radiofrequency ablation (RFA). RFA uses alternating current to generate heat and destroy tumour cells. The choice between laser therapy and RFA depends on availability, local expertise and preference of the surgical team. Treatment occurs by means of surgery and the procedure is similar to laser therapy.

Ethanol injection
Percutaneous ethanol injection involves injection of 100% ethanol into the tumour lesion. Ethanol is extremely toxic for the tumour and results in cell death. The side effects are mild and easy to cope with, however the treatment has to be repeated multiple times to achieve better destruction of the tumour. Since the availability of laser therapy and RFA, ethanol injections became less frequently used. Ethanol injection is performed by a radiologist and can be administered through the skin.

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