- Liver cancer
- Assessment for a liver transplant
- Waiting for a liver transplant
- Treatment overview
- Disease-directed treatments to eliminate and potentially cure HCC
- Disease-directed treatments to help patients live longer
- Other treatment options
- Physical, emotional, and social effects of cancer
- Metastatic HCC
- Remission and the chance of recurrence
- If treatment does not work
- Excellent Survival Rates for Liver Cancer Patients Undergoing Transplant
- Center for Liver Disease and Transplantation
- Surgery: Resection
- Surgery: Liver Transplantation
- ERCP for Management of Bile Duct Obstruction
- Local Therapy
- Systemic Chemotherapy
- Molecular and targeted therapies
- How long will I survive after a liver transplant?
- Curing Liver Cancer With a Liver Transplant
- Women Given Liver Transplants Outlive Male Recipients By Around 4 Years
Assessment for a liver transplant
Before you can have a transplant you have an assessment to check how well your liver is working and whether a transplant is the best treatment for you. You usually have these as an outpatient but you may need a short stay in hospital for this.
You have detailed blood tests called liver function tests as well as a number of other tests, such as an ultrasound scan.
Having a liver transplant involves a lot of careful preparation from a number of different health care professionals. You’ll meet these people during the assessment. Take this time to get to know them and ask as many questions as you want to. This helps you go into the operation feeling well prepared.
You’ll have several more tests before your surgery, if you and your doctor decide to go ahead with the liver transplant. This might mean going into hospital a few days before your operation.
Waiting for a liver transplant
To have a liver transplant you need a donor liver that is a close match to your own. Unfortunately there are more people needing a liver than there are livers available. It’s possible that you will have to wait a long time.
During this time the cancer can progress, which may mean you can’t have a transplant anymore. Because of this risk you might be offered other treatment to control the cancer while you are waiting. This treatment could include:
- treatment to destroy cancer cells (ablation)
- chemotherapy directly into the blood vessel feeding the liver cancer and blocking off the blood supply (chemoembolisation)
- targeted cancer drugs
ON THIS PAGE: You will learn about the different treatments doctors use for people with liver cancer. Use the menu to see other pages.
This section tells you the treatments that are the standard of care for HCC. “Standard of care” means the best treatments known. When making treatment plan decisions, patients are encouraged to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to treatment. Doctors want to learn whether the new treatment is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug, a new combination of standard treatments, or new doses of standard drugs or other treatments. Your doctor can help you consider all your treatment options. Learn more about clinical trials in the About Clinical Trials and Latest Research sections of this guide.
In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. Cancer care teams include a variety of other health care professionals, such as physician assistants, oncology nurses, social workers, pharmacists, counselors, dietitians, and others.
Treatment options and recommendations depend on several factors:
How much of the liver is affected by the cancer
Whether the cancer has spread
The patient’s preferences and overall health
The damage to the remaining cancer-free area of the liver
When a tumor is found at an early stage and the patient’s liver is working well, treatment is aimed at trying to eliminate the cancer. The care plan may also include treatment for symptoms and side effects, an important part of cancer care. When liver cancer is found at a later stage, or the patient’s liver is not working well, the patient and doctor should talk about the goals of each treatment recommendation. At this point, the goals of treatment may focus on slowing growth of the cancer and relieving symptoms to improve quality of life.
Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Talk with your doctor about the goals of each treatment and what you can expect while receiving the treatment. These types of talks are called “shared decision making.” Shared decision making is when you and your doctors work together to choose treatments that fit the goals of your different treatment options. Learn more about making treatment decisions.
The various disease-directed treatment options can be grouped according to whether they may cure the cancer or will improve survival but will most likely not eliminate the cancer. Descriptions of the most common treatment options, both disease-directed and those aimed at managing side effects and symptoms, are listed below.
Disease-directed treatments to eliminate and potentially cure HCC
These treatments are most likely to be recommended when the tumor has been found at an early stage. They may not be recommended to treat later stages of disease. These treatments are surgery, radiofrequency ablation, percutaneous ethanol injection, and radiation therapy.
Surgery is the removal of the tumor and some surrounding healthy tissue during an operation. It is likely to be the most successful disease-directed treatment, particularly for patients with good liver function and tumors that can be safely removed from a limited portion of the liver. Surgery may not be an option if the tumor takes up too much of the liver, the liver is too damaged, the tumor has spread outside the liver, or the patient has other serious illnesses. A surgical oncologist is a doctor who specializes in treating cancer using surgery. A hepatobiliary surgeon also has specialized training in surgery on the liver and pancreas. Sometimes, liver transplant surgeons are involved in these operations. Before surgery, talk with your health care team about the possible side effects from the specific surgery you will have. Learn more about the basics of cancer surgery.
Two types of surgery are used to treat HCC:
Hepatectomy. When a portion of the liver is removed, the surgery is called a hepatectomy. A hepatectomy can be done only if the cancer is in 1 part of the liver and the liver is working well. The remaining section of liver takes over the functions of the entire liver. The liver may grow back to its normal size within a few weeks. A hepatectomy may not be possible if the patient has advanced cirrhosis, even if the tumor is small.
The side effects of a hepatectomy may include pain, weakness, fatigue, and temporary liver failure. The health care team will watch for signs of bleeding, infection, liver failure, or other problems that need immediate treatment.
Liver transplantation. Sometimes, a liver transplantation can be done. This procedure is possible only when specific criteria are met, including tumor size and number and whether a suitable donor is found. These criteria usually are a single tumor that is 5 cm or smaller or 3 or fewer tumors, all of which are smaller than 3 cm. It is important to understand that the number of available donor livers is very limited, so transplantation is not always an option.
After a transplant, the patient will be watched closely for signs that the body might be rejecting the new liver or that the tumor has come back. The patient must take medication to prevent rejection. These drugs can cause side effects, such as puffiness in the face, high blood pressure, or increased body hair. Liver transplant has significant risks of serious complications, including death from infection or the body’s rejection of the donor liver.
Liver transplantation is a particularly effective treatment for people with a small tumor because transplantation removes the tumor and the damaged liver. However, there are few donors, and people waiting for a liver transplant may have to wait for a long time before a liver becomes available. During this time, the disease may get worse. The transplant center will advise you on how long the wait is likely to be and what rules are used to prioritize people on the waiting list.
Radiofrequency ablation (RFA)
RFA and microwave therapy both use heat to destroy cancer cells. They may be given through the skin, through laparoscopy, or during a surgical operation while a patient is sedated. Sedation is giving medication to become more relaxed, calm, or sleepy. This treatment approach is also called thermal ablation.
Percutaneous ethanol injection
Percutaneous ethanol injection is when alcohol is injected directly into the liver tumor to destroy it. Side effects include fever and pain after the procedure. In general, the procedure is simple, safe, and particularly effective for a tumor smaller than 3 cm. However, if the alcohol escapes from the liver, a person may have brief but severe pain. This option is rarely used and has been largely replaced by RFA (see above).
Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist.
Stereotactic body radiation therapy (SBRT). SBRT is a term that describes several methods of delivering high doses of radiation therapy to a tumor while limiting the amount of radiation to nearby healthy tissue. This is important because healthy liver tissue can be damaged by radiation. SBRT effectively treats tumors that are about 5 cm or smaller. However, it is still considered investigational compared to RFA (see above) because there is not much available information about its long-term effectiveness.
Side effects may include damage to the stomach and lungs. However, these side effects can often be prevented. Talk with your health care team about avoiding and managing possible side effects. Learn more about the basics of radiation therapy.
Disease-directed treatments to help patients live longer
If the doctor feels the cancer cannot be cured using the treatments listed above, he or she may recommend 1 of the following options to shrink the tumor and/or slow tumor growth. While these treatments will most likely not eliminate the cancer, they have been shown to improve how long patients can live.
Chemoembolization and radioembolization
Chemoembolization is a type of chemotherapy treatment that is similar to hepatic arterial infusion (see below). Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing, dividing, and making more cells. During this procedure, drugs are injected into the hepatic artery, and the flow of blood through the artery is blocked for a short time so the chemotherapy stays in the tumor longer. Blocking the blood supply to the tumor also destroys cancer cells.
In addition to being used as a primary treatment for HCC, chemoembolization may be used to slow tumor growth for people who are on the waiting list for liver transplantation.
Radioembolization is similar to chemoembolization, except that during radioembolization, a doctor places radioactive beads into the artery that supplies the tumor with blood. The beads deliver radiation therapy directly into the tumor when they become trapped in the small blood vessels of the tumor.
Targeted therapy is drug treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.
Recent studies show that not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. This helps doctors better match each patient with the most effective treatment whenever possible. In addition, many research studies are taking place now to find out more about specific molecular targets and new treatments directed at them. Learn more about the basics of targeted treatments.
For HCC, anti-angiogenesis drugs are the most common type of targeted therapy. Anti-angiogenesis therapy is focused on stopping angiogenesis, which is the process of making new blood vessels. Because a tumor needs the nutrients delivered by blood vessels to grow and spread, the goal of anti-angiogenesis therapies is to “starve” the tumor. Sorafenib (Nexavar) is believed to work through this process. Sorafenib is used to treat advanced HCC that cannot be completely removed with surgery. It is taken as a pill that is swallowed (orally). The side effects of sorafenib include diarrhea and certain skin problems.
In 2017, the U.S. Food and Drug Administration (FDA) approved the use of another targeted therapy, regorafenib (Stivarga), to treat people with HCC that was previously treated with sorafenib. Regorafenib also inhibits angiogenesis, and it is already used to treat colorectal cancer and gastrointestinal stromal tumors. It is taken as a pill that is swallowed (orally). Side effects include diarrhea and skin problems.
In 2018, the FDA approved another anti-angiogenesis targeted therapy, called lenvatinib (Lenvima). This drug is approved as a first treatment for HCC that cannot be removed by surgery. The most common side effects of this drug included high blood pressure, fatigue, diarrhea, appetite loss, joint and muscle pain, weight loss, abdominal pain, rash, redness, itching or peeling of the skin on the hands and feet, hoarseness, bleeding, change in thyroid hormone levels, and nausea.
Talk with your doctor about the possible side effects for a specific medication and how they can be managed.
Other treatment options
Immunotherapy, also called biologic therapy, is designed to boost the body’s natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function. In 2017, the FDA approved an immunotherapy called nivolumab (Opdivo) for the treatment of HCC. Nivolumab can be used to treat people who have already been treated with sorafenib. Other immunotherapy drugs are still being studied in clinical trials.
Different types of immunotherapy can cause different side effects. Common side effects include skin reactions, flu-like symptoms, diarrhea, and weight changes. Talk with your health care team about possible side effects for the immunotherapy recommended for you. Learn more about the basics of immunotherapy.
Other clinical trials
In addition to the treatment options described above, the doctor may suggest participating in a clinical trial that is evaluating a new treatment approach for HCC. This is particularly important for a disease like HCC, where options for treating advanced disease are very limited and there is ongoing research to find more treatment options. Learn more about Latest Research areas in HCC.
Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the cancer.
Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis. People who receive palliative care along with treatment for the cancer often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.
Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to get rid of the cancer, such as chemotherapy, surgery, or radiation therapy.
Before treatment begins, talk with your doctor about the goals of each treatment in the treatment plan. You should also talk about the possible side effects of the specific treatment plan and palliative care options.
During treatment, your health care team may ask you to answer questions about your symptoms and side effects and to describe each problem. Be sure to tell the health care team if you are experiencing a problem. This helps the health care team treat any symptoms and side effects as quickly as possible. It can also help prevent more serious problems in the future.
Learn more about the importance of tracking side effects in another part of this guide. Learn more about palliative care in a separate section of this website.
If HCC has spread to another location in the body, it is called metastatic cancer. People with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer because there can be different opinions about the best treatment plan. Learn more about getting a second opinion before starting treatment, so you are comfortable with your chosen treatment plan and cancer care team. This discussion may include clinical trials studying new treatments.
Your treatment plan may include a combination of chemotherapy, targeted therapy, radiation therapy, and/or other options. At this stage, the goal of treatment is typically to slow the cancer’s growth. Palliative care will also be important to help relieve symptoms and side effects.
For most patients, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.
Remission and the chance of recurrence
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.
A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the cancer returning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.
If the cancer returns after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).
When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence. After this testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the treatments described above, such as surgery and radiation therapy, but they may be used in a different combination or given at a different pace. Your doctor may suggest clinical trials that are studying new ways to treat this type of recurrent cancer. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.
People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. Learn more about dealing with cancer recurrence.
If treatment does not work
Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.
This diagnosis is stressful, and for many people, advanced cancer is difficult to discuss. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.
Patients who have advanced cancer and who are expected to live less than 6 months may want to consider a type of palliative care called hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment can make staying at home a workable option for many families. Learn more about advanced cancer care planning.
After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.
The next section in this guide is About Clinical Trials. It offers more information about research studies that are focused on finding better ways to care for people with cancer. Use the menu to choose a different section to read in this guide.
Excellent Survival Rates for Liver Cancer Patients Undergoing Transplant
MEDIA CONTACT: Trent Stockton
E-mail: [email protected]
October 30, 2003
EXCELLENT SURVIVAL RATES FOR LIVER CANCER PATIENTS UNDERGOING TRANSPLANT
More than 60 percent of liver transplant patients with advanced liver cancer are still alive after five years, compared to nearly zero survival for those patients who did not undergo transplant, according to a study by Johns Hopkins researchers.
“This is good news for patients with liver cancer. If diagnosed early, transplantation is the treatment of choice for patients with liver cancer and advanced cirrhosis,” says Paul Thuluvath, M.D., associate professor of medicine at Johns Hopkins and lead author of the report published in the Dec. 1 issue of the Journal of Clinical Oncology and available online after Oct. 27.
Thuluvath emphasizes that regular screening of patients with cirrhosis, a risk factor for liver cancer, is needed to detect the cancer early and ensure the best possible outcome.
In addition to the favorable five-year survival rates, Thuluvath and colleagues found that survival rates increased steadily over the last decade, suggesting that criteria for patient selection established by other experts may assist physicians in selecting those patients most likely to respond well to the procedure.
Using the United Network for Organ Sharing (UNOS) database, the researchers collected data on 48,887 patients who underwent liver transplantation in the United States between 1987 and 2001. Patients were excluded if they had undergone multiple organ transplantation or retransplantation, were less than 18 years of age, or lacked survival data.
Of the remaining patients included in the final analysis, 985 had liver transplantation for liver cancer and 33,339 patients had liver transplantation for other reasons (control group). Both the liver cancer and control groups were divided into three different five-year time periods: 1987 – 1991, 1992 – 1996, and 1997 – 2001.
Researchers found significant and steady improvement in survival over time among liver transplant patients with liver cancer, especially in the last five years. Five-year survival improved from 25.3 percent during 1987-1991 to 47 percent during 1992-1996, and 61.1 percent during 1996-2001.
According to the Johns Hopkins Gastroenterology and Hepatology Resource Center, liver cancer, also called hepatocellular carcinoma or hepatoma, is one of the most common cancers in adults, with more than 1 million new cases diagnosed each year. It is twice as common in men as in women.
Other authors are Hwan Y. Yoo, Cary H. Patt, and Jean-Francois Geschwind, all from Johns Hopkins. The research was supported by AASLD/Schering Advanced Hepatocellular Carcinoma Fellowship Award.
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- Huber C, Niederwieser D, Schönitzer D, Gratwohl A, Buckner D, Margreiter R. Liver transplantation followed by high-dose cyclophosphamide, total-body irradiation, and autologous bone marrow transplantation for treatment of metastatic breast cancer. A case report. Transplantation. 1984 Mar;37(3):311–312.
Dr. Robert Brown A simple blood test may better predict which patients diagnosed with liver cancer will experience disease recurrence, according to new research from Weill Cornell Medicine scientists. The findings may help physicians determine who would benefit most from a liver transplant.
Depending on disease severity, oncologists may recommend liver transplantation for patients whose tumors have not yet metastasized. Physicians have traditionally used a special set of criteria, based on the size and number of tumors, to assess patients’ risk of cancer reoccurrence if they receive a new organ – the findings from which ultimately determine if transplantation is the appropriate treatment.
In their study, published Sept. 16 in the Annals of Surgery, Weill Cornell Medicine investigators demonstrate that measuring the concentration of molecules in the blood that increase in the presence of liver cancer can discern which patients will experience disease relapse more effectively than the current model. The scientists say the new criteria, known as the Model of Recurrence After Liver Transplant – or MORAL score – can help ensure that those who are selected for liver transplants have the best chance of staying cancer-free after surgery.
“At the end of the day, our goal is to use better predictors to provide patients with improved treatment options,” said Dr. Robert Brown, the Gladys and Roland Harriman Professor of Medicine at Weill Cornell Medicine and co-creator of the MORAL criteria. “By using pre-transplant biomarkers focused more on the growth and aggressiveness of liver cancer, we can determine which patients will do better with a liver transplant and which patients would benefit from more aggressive pre-transplant therapies to control their cancer.”
In conjunction with surgeon Dr. Karim Halazun, an assistant professor of surgery at Weill Cornell Medicine, and other surgeons from NewYork-Presbyterian, Brown prospectively studied a cohort of 339 patients with hepatocellular carcinoma who had undergone liver transplantation to determine whether the MORAL criteria, compared with the traditional Milan criteria, could better predict cancer recurrence. Measuring common blood tests – including the breakdown of the white blood cells, specifically the neutrophil and lymphocytes, and the amount of a tumor marker protein, the alpha-fetoprotein, in the blood – correctly predicted cancer recurrence 91 percent of the time, while the Milan criteria only yielded a 63 percent accuracy rate, Brown said.
“Using our MORAL score, we want to help patients lead longer lives,” said Brown, director of the Center for Liver Disease and Transplantation and a hepatologist at NewYork-Presbyterian Weill Cornell Medical Center. “By combining this score with therapies we are developing to selectively change immune suppression in high-risk patients, we would be able to tell patients the risk of their cancer returning and at the same time tell them we have a plan for reducing that risk – that we can do something about it.”
Center for Liver Disease and Transplantation
If the tumor is detected at an early stage, when it is typically a single lesion, and there is no significant liver disease, surgeons at the CLDT may be able to surgically remove the tumor. This is called resection. For tumors which are very small, typically less than 2-3 cm, sometimes the tumor can be ablated, or destroyed, most often using radiofrequency ablation. Resection is an option for about 10 to 20% of patients in the US with HCC.
Surgery: Liver Transplantation
Because most patients with primary hepatocellular carcinoma in this country have underlying liver disease, liver transplantation allows the best chance for cure. NewYork-Presbyterian/Columbia also offers liver transplantation for select patients with bile duct cancers (we are one of only a few centers in the nation to offer this option). For patients whose bile duct cancer can not be removed surgically, transplantation can offer an unprecedented chance for cure.
The Milan Criteria is the internationally accepted guideline used to select patients for liver transplantation. According to these criteria, patients may be eligible for liver transplantation if they have a single tumor 5 cm or smaller, or 3 or fewer tumors that are each 3 cm or less in size, and no obvious invasion of the blood vessels on imaging before the transplant. Patients who have more than one tumor above the sizes specified by these criteria are usually not eligible for transplantation unless the tumor can be “downsized” or shrunk. In some cases, tumors can be reduced sufficiently through chemoembolization, radiation, or other approaches.
Liver Transplantation at the Center for Liver Disease and Transplantation
NewYork-Presbyterian/Columbia University Medical Center boasts one of the largest and most experienced liver transplantation programs in the nation, offering living donor liver transplantation and employing minimally invasive surgical approaches whenever possible.
Liver transplant procedures at the CLDT take advantage of the most sophisticated medical knowledge and surgical technology available today, including living donor transplantation, partial liver transplantation, advanced organ preservation techniques, liver transplantation in HIV- and Hepatitis C co-infected individuals, and antiviral therapy to prevent or treat recurrent hepatitis C after liver transplantation.
Jean C. Emond, MD, Vice Chair and Chief of Transplantation, was a member of the team that pioneered living donor liver transplantation, now considered one of the most important advances in the treatment of severe liver disease. The Living Donor Liver Transplant program is now one of the largest living donor liver programs in North America, and has performed more than 220 living donor liver transplants since its inception. We have performed more left lobe donations than any other living donor liver program inNorth America and introduced fully laparoscopic donation for all pediatric liver donor liver transplants in 2009. Approximately 15 to 20 percent of the center’s transplant patients currently receive a liver from a living donor.
Our program routinely achieves excellent outcomes for donors and recipients. Our recipients have 97.1 percent one-year survival after transplantation and a three-year survival of 93.3 percent. Additionally, nearly all donors are very satisfied or satisfied with the experience of donating a portion of their liver. After surgery, we also offer specialized nursing, nutritional support, smoking cessation, weight loss and pain management.
Learn more about liver transplantation here.
ERCP for Management of Bile Duct Obstruction
Blockage of the bile duct is a potential complication of liver tumors, liver surgery, and bile duct cancer. Our interventional endoscopists often utilize endoscopic retrograde cholangiopancreatography (ERCP) to relieve bile duct obstructions. During this procedure, a physician inserts a stent into the duct to relieve the obstruction and allow drainage to proceed into the intestine, sparing the patient from having to wear an external bag on the abdomen to drain fluids. This approach improves the patient’s quality of life and relieves symptoms associated with jaundice.
Localized therapy, also called locoregional therapy, includes the following approaches:
Radiofrequency or Microwave Embolization
The tumor is destroyed with highly targeted radiowave or microwave energy.
Radio arterial embolization
Tiny spheres of a radioactive substance (yttrium-90) are delivered to the tumor site via the hepatic arterial system. The radioactive substance then kills cancer cells at the tumor site.
Several centers, including ours, are also examining new forms of targeted external beam radiation, particularly for trying to shrink the tumor out of the portal vein. This also looks very promising, potentially with less toxicity than with Y-90.
Chemotherapy (injected into the hepatic artery via a catheter) may be used to target larger tumors. The chemotherapy is combined with a substance that temporarily blocks off the hepatic artery, trapping much of the chemotherapy near the tumor. This approach spares nearby healthy tissue from the toxic effects of chemotherapy.
In some cases, chemotherapy can reduce the size of a tumor enough that it can be surgically removed. Most often, this is delivered locally using beads treated with different types of chemotherapy agents, a therapy called chemoembolization. By inserting them into the tiny blood vessels that feed the tumor, the radiation effectively targets the cancer cells without affecting the whole body. Chemoembolization therapies most commonly include drug-eluting beads labelled with doxorubicin or irinotecan.
Chemotherapy (systemic therapy) is offered to patients who are not good candidates for surgery or locoregional therapy. Chemotherapy drugs are designed to kill cancer, and are generally given in cycles, with a period of treatment followed by a period of rest. These drugs can be administered before surgery, after surgery, or both. When given before surgery, chemotherapy is called neoadjuvant. When given after surgery, chemotherapy is called adjuvant. Chemotherapy can be administered orally, by injection, or intravenously depending on the regimen and the drug. The best course of therapy is selected after considering the specific characteristics of the patient’s cancer to maximize the results of the treatment and increase survival.
Traditional chemotherapy medications historically have not been very successful in HCC patients because many are metabolized in the liver, which is not functioning normally in many patients, and because many HCCs have “pumps” which can get the chemotherapy out of the cancer cells, and thus make them resistant.
Adjuvant chemotherapy is usually administered after surgery or liver transplantation, although there adjuvant therapy in HCC has not yet been proven effective. A large trial of sorafenib found it to be ineffective after surgery (STORM Trial). The CLDT has just completed a multi-center dose-finding trial of sorafenib after liver transplant (NewYork-Presbyterian/Columbia was the lead site), which found the maximum tolerated dose is 200 mg twice a day (half of the usual dose). Both sorafenib and m-TOR inhibitors (which also work as immunosuppressants) are being studied to determine whether they prevent recurrent liver cancers after transplant.
For advanced liver cancer with blood vessel invasion or metastatic disease, the standard of care now is a drug called sorafenib (nexavar), which has been shown to improve survival for patients with advanced liver cancer, kidney cancer, and thyroid cancer. It acts by blocking pathways that cause blood vessels to grow. As such, it is considered a “targeted” therapy. Given in pill form, it is usually taken twice a day on an empty stomach. Side effects include redness of the hands and feet (which can be lessened by using urea cream twice a day while on the drug), diarrhea, fatigue, and high blood pressure.
Combinations of particular chemotherapy agents may be more effective than single drugs, and are under study at our center and elsewhere. Based on a study from Asia, a regimen called FOLFOX (oxaliplatin and 5-fluorouracil) has now been approved there. The Center for Liver Disease and Transplantation is currently conducting clinical trials assessing sorafenib in combination with other agents for patients with hepatocellular carcinoma. Our center has completed the first ever dose-finding study of sorafenib in the post-transplant setting, and we led a multicenter study using bevacizumab in HCC. Together with our colleagues at several other centers, we recently completed a randomized trial of sorafenib compared with bevacizumab and erlotinib, another targeted therapy, in patients with advanced HCC.
Molecular and targeted therapies
Many other targeted agents are being studied in clinical trials. These include MET-inhibitors, mTOR inhibitors, demethylating agents, and immunotherapies, among many other types of targeted therapies. Our center is actively involved in pursuing all of these options, and also in developing the science to identify which subjects may benefit from which targeted therapies. We now have the capability to identify novel targets in each cancer patient’s tumor, so that we can try to identify new therapies which might not have ordinarily been considered for them.
Patients with advanced liver cancer or invasion of the blood vessels may be eligible to participate in one of the clinical trials underway at NewYork-Presbyterian/Columbia.
How long will I survive after a liver transplant?
Share on PinterestAfter surgery, most people will remain in the intensive care unit for several days.
Immediately after surgery, most people will stay in the intensive care unit (ICU) for a day or two. They will remain on a ventilator to help them breathe and be closely monitored to ensure the new liver is working properly.
They will also be given immunosuppressant (anti-rejection) medications to help prevent their body from destroying the donor liver. People who have an organ transplant must take immunosuppressant drugs for the rest of their lives.
When the person is ready, doctors will move them from the ICU to a regular room in the hospital. After the surgery, a person who has had a liver transplant will need to spend around 2 weeks in the hospital before going home.
Many people require 2 or 3 months before they feel well enough to return to everyday activities. Also, it can take years for the full effect of the surgery to be realized.
Most people who have donor livers will also need to make certain lifestyle changes to keep their new liver healthy.
These changes include:
- eating a healthful, balanced diet, given to them by a nutritionist or dietitian as part of the transplant process
- staying hydrated
- quitting smoking
- avoiding alcohol
- taking all medications exactly as prescribed
- attending all medical appointments
- avoiding raw or undercooked eggs, meats, and seafood
- avoiding unpasteurized foods
- cutting down on foods that are hard for the liver to digest, such as fats, cholesterol, sugars, and salt
- avoiding contact with people who are sick
- talking with a doctor immediately if sick
- avoiding exposure to dirt by wearing shoes, socks, long pants, etc.
- avoiding known allergens
- avoiding contact with reptiles, rodents, insects, and birds
- avoiding eating grapefruits and drinking grapefruit juice
- avoiding strenuous activity within the first 3 months after surgery and talking to a doctor before resuming vigorous activities or exercises
- talking to a doctor before using any new over-the-counter medications, vitamins, or supplements
- wearing insect repellent when outside in the spring or summer and not spending a lot of time outdoors during dawn or dusk
- avoiding swimming in lakes and other freshwater bodies
- talking to a doctor before planning any trips, especially to developing nations
- talking to a doctor before using contraceptives or trying to get pregnant
Infection and rejection
Infection and organ rejection can lead to sepsis, multiple organ failure, and death. Therefore, it is essential that people with donor livers know how to recognize the signs of these potential complications. They should always seek medical attention as soon as possible to prevent further complications.
Signs of infection include:
- fever or chill
- stuffy nose
- vomiting and nausea
- sore throat
Organ rejection does not always cause noticeable symptoms, but symptoms can include:
- exhaustion, regardless of the amount of sleep
- yellowing of the skin and whites of the eyes
- pain and tenderness in the abdomen
- very dark urine
- lighter than normal stools
Curing Liver Cancer With a Liver Transplant
For liver cancer patients whose tumors cannot be surgically removed, there is another possibility — liver transplantation. In this procedure, the cancerous liver can be removed and replaced with a healthy one.
That being said, getting a transplant may be easier said than done. Livers for transplantation are not easy to come by. There’s a waiting list for healthy livers.
Liver Cancer: How Advanced Is Too Advanced?
Doctors usually use a set of rules called the Milan criteria to decide who is a candidate for successful liver transplantation for liver cancer. These criteria include limitations on the size of the tumor — if there is only one tumor, it should be 5 cm or less. If there are multiple tumors in the liver, there can be a maximum of three, and the largest must be 3 cm or less. In addition to meeting these criteria, patients with liver cancer must not have any spread of the cancer outside of the liver for transplantation to be effective.
However, as transplantation for primary liver cancer has become more common, some medical centers are expanding their criteria for offering this procedure. Patients with one tumor less than 8 cm in size may be eligible under these expanded criteria (known as the UCSF criteria), as well as those with up to three tumors of which the largest is 4.5 cm or less, and where the size of all tumors combined is less than 8 cm.
Liver Cancer: Liver Transplantation Success Rate
Many studies have been done to see how long patients with liver cancer can live after they have had a liver transplant. One study, published in 2003, found that more than 60 percent of the patients were still alive five years after their transplant. Dr. Sorscher adds that this could be as high as 70 percent. “But,” he cautions, “they’re a select group of patients. You have to catch the disease early enough and if you do, and you’re at a center that performs liver transplantation, then you might have a survival rate of up to 70 percent at four years.”
Over the years doctors have been getting better at identifying which patients with liver cancer would likely do well after transplantation. So by choosing patients with better odds, their overall success rates are climbing.
Liver Cancer: Risks of Liver Transplantation
Any organ transplantation surgery has risks due to both the surgical removal of the cancerous liver itself and the actual transplantation. Risks include:
- The new organ not “taking” and being rejected by the body’s immune system
- Liver cancer returning
- Reactions to the medications needed after the transplantation
- Increased bleeding, difficulty clotting
- Reaction to anesthetic during surgery
Liver Cancer Transplantation: Living with a New Liver
If you’ve had liver cancer that was treated by a transplant, you’ll have to make some adaptations in your life — most notably, taking anti-rejection medications to keep your body from rejecting your liver and monitoring your health closely for any signs of rejection or return of liver cancer. The medications you take to prevent rejection can make you more susceptible to developing severe infections.
So, is a liver transplantation the answer? If you meet the criteria (small tumor size without spread outside the liver) it depends on the availability of a cadaveric liver (liver donated after death). If you have someone willing to donate a portion of his own healthy liver (which will grow to normal liver size in the recipient), you may be able to have a transplant without the sometimes prolonged wait for a non-living donor. There is some risk to the donor in this situation, so this type of a transplant requires careful consideration.
For those who meet the criteria for liver transplantation, the odds of success are good. Talk to your oncologist to find out if it is a possibility for you.
Women Given Liver Transplants Outlive Male Recipients By Around 4 Years
And while younger people tend to live longest of all, they also stand to lose more years of their life compared with those who have not had liver transplants, the research shows.
The research team assessed the life expectancy and years of life lost of 2702 people who had received a liver transplant between 1985 and 2003, and who had survived more than six months afterwards..
The information was taken from the National Transplant Database, held by UK Transplant, and compared with that from healthy people matched for age and sex.
The analysis showed that, on average, after reaching the critical six month period, survival time for liver transplant recipients was 22 years compared with 29 years for the general population.
The life expectancy of male liver transplant recipients was 18 years compared with 26 years for women.
This compares with 27 years for men and 31 years for women in the general population, equating to twice as many years of life lost for male transplant recipients compared with their female counterparts.
Those aged between 17 and 34 had the highest life expectancy of 28 years after a liver transplant. But this compares with a life expectancy of 51 years for their peers in the general population.
Transplant recipients with primary liver disease fared significantly better than those undergoing the procedure because of hepatitis C infection, cirrhosis, or cancer.
The authors note that while one year survival rates have increased over time, death rates beyond this period have remained more or less the same.
They attribute this to the types of patients undergoing the procedure, who now include older, sicker patients, as well as the use of more “marginal” livers.