Treatment of Liver Cancer, by Stage

Although the AJCC (TNM) staging system (see Liver Cancer Stages) is often used to describe the spread of a liver cancer, doctors use more practical system to determine a person’s treatment options:

• Potentially resectable cancer
• Potentially eligible for a liver transplant
• Unresectable (inoperable) cancer that has not spread
• Advanced cancer
• Recurrent liver cancer

Potentially resectable (removable) liver cancer

These cancers might be able to be removed (resected) completely by surgery.

If the cancer is at an early stage and the rest of your liver is healthy enough for you to have surgery, a partial hepatectomy (removing the part of the liver with the cancer) may cure you.

Only a small number of people with liver cancer can have this type of surgery. Important factors to consider include the size of the tumor(s) and if nearby blood vessels are affected. Larger tumors or those that invade blood vessels are more likely to come back in the liver or spread elsewhere after surgery. Your overall health and how well your liver is working are also important.

Clinical trials are now looking at if people who have a partial hepatectomy might be helped by getting other treatments in addition to surgery. But more research is needed to know is this is helpful.

Other options for people in this situation might include:

• Some type of ablation procedure such as radiofrequency ablation (RFA) or microwave ablation (MWA) to destroy the tumor, if it is small enough.
• Stereotactic body radiation (SBRT), which carefully focuses beams of high-dose radiation at the tumor from many different angles.
• A liver transplant. This is a complex operation that can have some long-term side effects, but removing and replacing the whole liver can lower the risk of developing a new liver cancer.

Potentially eligible for a liver transplant

If the cancer is at an early stage, but you wouldn’t have enough healthy liver left if the part with the cancer was removed, you may be able to be treated with a liver transplant. A transplant may also be an option if the tumor is in a part of the liver that makes it hard to remove (such as very close to a large blood vessel).

People who are eligible for a liver transplant might have to wait a long time for a donor liver to become available, and there’s a chance that the cancer might grow during that time to the point where surgery might no longer be possible. Because of this, people are often given other treatments, such as ablation or embolization, to help keep the cancer under control. This is known as bridge therapy.

Unresectable (inoperable) liver cancer that has not spread

These include cancers that haven’t yet spread to lymph nodes or distant parts of the body, but that can’t be treated safely with surgery (partial hepatectomy or liver transplant).

This might be because:

• The tumor is too large or is in a part of the liver (such as very close to a large blood vessel) that makes it hard to remove safely.
• There are several tumors.
• The person has other health issues that would make it unsafe for them to have liver surgery.

Treatment options might include ablation, embolization, or both for the liver tumor(s). Other options may include targeted therapy, immunotherapy, chemotherapy (either systemic or by hepatic artery infusion), and/or radiation therapy. These treatments aren’t likely to cure the cancer, but they can often reduce a person’s symptoms and help them live longer.

For some of these cancers, treatment may shrink the tumor(s) enough so that surgery (partial hepatectomy or transplant) may become possible.

Because these cancers can be hard to treat, clinical trials of newer treatments may be a good option in many cases.

Advanced (metastatic) liver cancer

Advanced liver cancer has spread outside the liver, either to the lymph nodes or to other organs. Because these cancers are widespread, they can’t be removed with surgery.

For people whose liver is functioning well enough, initial treatment options might include:

• The immunotherapy drug atezolizumab (Tecentriq) plus the targeted drug bevacizumab (Avastin)
• The immunotherapy drugs durvalumab (Imfinzi) and tremelimumab (Imjudo)
• The immunotherapy drugs nivolumab (Opdivo) and ipilimumab (Yervoy)
• Either of the targeted drugs sorafenib (Nexavar) or lenvatinib (Lenvima)
• The immunotherapy drug durvalumab alone

If these drugs are no longer working (or if they can’t be given for some reason), other options might include:

• Other targeted drugs such as regorafenib (Stivarga), cabozantinib (Cabometyx), or ramucirumab (Cyramza)
• Other immunotherapy drugs such as pembrolizumab (Keytruda), or nivolumab combined with ipilimumab
• Chemotherapy drugs

As with unresectable liver cancer that has not spread, clinical trials of newer treatments may be helpful.

Treatments such as radiation might also be used to help relieve pain and other symptoms. Please be sure to discuss any symptoms you have with your cancer team, so they can treat them effectively.

Recurrent liver cancer

Cancer that comes back after treatment is called recurrent. Recurrence can be local (in or near the same place it started) or distant (spread to organs such as the lungs or bone).

Treatment of liver cancer that returns after initial therapy depends on many factors, including where it comes back, which treatment(s) a person has had before, and how well the liver is functioning.

People with resectable cancer that recurs in the liver might be eligible for further surgery or local treatments like ablation, embolization, or radiation therapy.

If the cancer is widespread, targeted therapy, immunotherapy, or chemotherapy drugs may be options. A clinical trial testing a newer treatment might also be an option for some people.

Please be sure to tell your cancer care team about any symptoms you have. You can also get treatment to relieve pain and other side effects.