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I./4.4.: Therapy
In the treatment of liver cancer a close cooperation, consultation between specialists of oncology, hepatology, surgery and radiology is essential. The choice of therapy is significantly influenced by tumor stage.
Of the therapeutic possibilities primarily surgical resection should be chosen in patients with HCC of very early stage if conditions are appropriate and no extrahepatic propagation can be detected. The operation is determined by tumor size, location, and hepatic function. The 5 year survival may be 70% after surgeries performed in Child-Pugh A stage.
The other therapeutic possibility is liver transplantation, where both the Milan and the San Francisco criteria systems are accepted. According to the Milan criteria, if the tumor is solitary its diameter should not exceed 5 cm, or at most three tumors should be present in the liver and their diameter should not exceed 3 cm individually. According to the extended San Francisco criteria, in patients with a solitary tumor, transplantation can be performed if the size of the tumor does not exceed 6.5 cm; or there are at most 3 tumorous lesions of which the largest is smaller than 4.5 cm, and the total tumor size does not exceed 8 cm. The 5 year survival after liver transplantations performed according to the Milan criteria is about 61%.
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A significant advance in the therapy of liver cancer was brought by the revolutionary changes in the area of interventional radiology. Percutaneous alcohol infiltration was partly replaced by percutaneous ablation techniques, such as radiofrequency ablation (RFA), laser ablation, or microwave tumor destruction. Ablation therapies are recommended in patients where a surgical resection is unfeasible, or where it is worthwhile to wait for the assessment of the process’ extensiveness prior to the planned major liver surgery; or in patients where tumor size can be reduced by local therapy (down-staging) in order to keep them on the liver transplantation list.
Endovascular treatments are also used for palliative purposes; these include transarterial embolization (TAE) and transarterial chemoembolization (TACE). Accuracy and effectiveness of the interventions have been further increased by drug-releasing embolization beads. Radioembolization with yttrium-90 (Y-90) destructs the tumor in part by embolization, in part by high-dose radiation with no considerable injury of the hepatic parenchyma.
In patients with advanced hepatic tumors, when even no interventional radiologic intervention is feasible, but hepatic function is preserved (Child-Pugh A stage), targeted molecular therapy may be considered. In patients with hepatic carcinoma the multikinase inhibitor oral sorafenib was the first systemic neoangiogenesis inhibitor with which a survival benefit has been demonstrated. Sorafenib inhibits, among others, serine/threonine kinases, VEGF and PDGF receptors which play an important role in the formation of the tumor. Its common adverse effects include diarrhea, hand-foot skin reaction and weight loss.
At present systemic chemotherapy has no place in the therapy of hepatocellular carcinoma.
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