Liver Cancer (cont.)
Proton beam therapy
This technique is able to deliver high doses of radiation to a
defined local area. Proton beam therapy is used in the treatment of other solid
tumors as well. There are not much data yet regarding the efficacy of this
treatment in liver cancer. The ideal patient is one with only asmall(<5 cm) solitary lesion. To
have this procedure done, the patient actually is fitted with a body cast so
that he or she can be placed in the identical position for each session. Therapy
is conducted daily for 15 days. Preliminary data from the U.S. suggest similar
effectiveness as seen with TACE or ablation therapy. It is not known, however,
whether this type of radiation treatment prolongs the life of the patient.
How do these various medical treatment procedures compare to each other? We
really don't know because there are no head-to-head studies comparing
chemotherapy, chemoembolization, ablation techniques, and proton beam therapy to
each other. Most reports deal with a heterogeneous group of patients who have
undergone only one specific treatment procedure or another. Therefore, selection
of a treatment option for a particular patient will depend primarily on the
expertise of the doctors in the patient's area. Studies are also needed to
evaluate combinations of these procedures (for example, proton beam and TACE). Now,
what about surgery?
Surgery
Surgical options are limited to individuals whose tumors are less than 5 cm
and confined to the liver, with no invasion of the blood vessels.
Liver resection
The goal of liver resection is to completely remove the tumor and the
appropriate surrounding liver tissue without leaving any tumor behind. This
option is limited to patients with one or two small (3 cm or less) tumors and
excellent liver function, ideally without associated cirrhosis. As a result of
these strict guidelines, in practice, very few patients with liver cancer can undergo
liver resection. The biggest concern about resection is that following the
operation, the patient can develop liver failure. The liver failure can occur if
the remaining portion of the liver is inadequate to provide the necessary
support for life. Even in carefully selected patients, about 10% of them are
expected to die shortly after surgery, usually as a result of liver failure.
When a portion of a normal liver is removed, the remaining liver can grow
back (regenerate) to the original size within one to two weeks. A cirrhotic
liver, however, cannot grow back. Therefore, before resection is performed for
liver cancer, the non-tumor portion of the liver should be biopsied to determine whether
there is associated cirrhosis.
For patients whose tumors are successfully resected, the five-year survival
is about 30 to 40%. This means that 30 to 40 % of patients who actually undergo
liver resection for liver cancer are expected to live five years. Many of these patients,
however, will have a recurrence of liver cancer elsewhere in the liver. Moreover, it
should be noted that the survival rate of untreated patients with similar sized
tumors and similar liver function is probably comparable. Some studies from
Europe and Japan have shown that survival rates with alcohol injection or
radiofrequency ablation procedures are comparable to the survival rates of those
patients who underwent resection. But again, the reader should be cautioned that
there are no head-to-head comparisons of these procedures versus resection.
Liver transplantation
Liver transplantation has become an accepted treatment for patients with
end-stage (advanced) liver disease of various types (for example, chronic hepatitis B
and C, alcoholic cirrhosis, primary biliary cirrhosis, and sclerosing
cholangitis). Survival rates for these patients without liver cancer are 90% at one year,
80% at three years, and 75% at five years. Moreover, liver transplantation is
the best option for patients with tumors that are less than 5 cm in size who also
have signs of liver failure. In fact, as one would expect, patients with small
cancers (less than 3 cm) and no involvement of the blood vessels do very well.
These patients have a less than 10% risk of recurrent liver cancer after transplant. On
the other hand, there is a very high risk of recurrence in patients with tumors
greater than 5 cm or with involvement of blood vessels. For these reasons, when
patients are being evaluated for treatment of liver cancer, every effort should
be made to characterize the tumor and look for signs of spread beyond the liver.
There is a severe shortage of organ donors in the U.S. Currently, there are
about 18,000 patients on the waiting list for liver transplantation. About 4,000
donated cadaver livers (taken at the time of death) are available per year for
patients with the highest priority. This priority goes to patients on the
transplant waiting list who have the most severe liver failure. As a result, in
many liver cancer patients, while they are on the waiting list, the tumor may become too
large for the patient to benefit from liver transplantation. Doing palliative
treatments, such as TACE, while the patient is on the waiting list for liver
transplantation is currently being evaluated.
The use of a partial liver from a healthy, live donor may provide a few
patients with liver cancer an opportunity to undergo liver transplantation before the
tumor becomes too large. This innovation is a very exciting development in the
field of liver transplantation.
As a precaution, doing a biopsy or aspiration of liver cancer should probably be
avoided in patients considering liver transplantation. The reason to avoid
needling the liver is that there is about a 1-4% risk of seeding (planting)
cancer cells from the tumor by the needle into the liver along the needle track.
You see, after liver transplantation, patients take powerful anti-rejection
medications to prevent the patient's immune system from rejecting the new
liver. However, the suppressed immune system can allow new foci (small areas) of
cancer cells to multiply rapidly. These new foci of cancer cells would normally
be kept at bay by the immune cells of an intact immune system.
In summary, liver resection should be reserved for patients with small tumors
and normal liver function (no evidence of cirrhosis). Patients with multiple or
large tumors should receive palliative therapy with intra-arterial chemotherapy
or TACE, provided they do not have signs of severe liver failure. Patients with
an early stage of cancer and signs of chronic liver disease should receive
palliative treatment and undergo evaluation for liver transplantation.
Next: Is there a role for routine screening for liver cancer? »
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