Cancer in the Liver: Treatment and side effects

Treatment will depend on whether you have primary liver cancer or secondary cancer in the liver.

Surgery

Surgery for liver cancer is called liver resection. It removes the part of the liver that contains the cancer. There are different types of surgery. Occasionally a whole liver transplant may be able to be done.

Primary liver cancer:

• Only a small number of people are suitable for surgery.
• It depends on the number and position of the tumours, how much of the liver is affected, and whether cirrhosis is present.

Secondary cancer in the liver:

• If there is enough healthy liver, surgery may be possible.
• Surgery is more possible if the cancer hasn't spread to other parts of the body where it can't be removed (e.g. the bones).
• Some people need surgery for both secondary cancer in the liver and the primary cancer. These operations may be done separately or at the same time.

Partial hepatectomy:

• Surgery to remove a part of the liver.
• The gall bladder is also removed, and sometimes part of the diaphragm.
• The liver can repair itself if it is not damaged and will grow back to its normal size within a few months.
• If only a small segment of your liver is removed it is called a segmentectomy.

Two-stage surgery (two-stage hepatectomy):

• If tumours are in both sides of the liver, two operations may be done.
• In the first operation (stage), the tumours are removed from one side of the liver only. The patient is given time to recover, and the liver is given time to re-grow.
• In the second stage, the liver is checked to make sure it has grown enough. Then the tumours in the second side are removed in another partial hepatectomy.
• The operations occur about two months apart.

Laparoscopic liver surgery:

• If tumours are small and near the surface of the liver, keyhole surgery (laparoscopy) may be done.
• Small cuts are made in the abdomen, and the tumour is removed or destroyed.
• Recovery is faster than for open (non-keyhole) surgery.

Liver transplant:

• Surgery to remove the liver completely and replace it with a liver from another person.
• Not everyone is eligible for a liver transplant. Patients are assessed on their overall health and what type of cancer they have. They also cannot be a current smoker, cannot take illegal drugs, and must have stopped drinking any alcohol.
• A suitable donor will have to be available. Waiting for a donor can take months or years. During this time, the cancer may continue to grow. In some cases, patients will need to have other treatment.
• If you have a transplant, it may take 3-6 months to recover. You will be monitored very closely after the operation.

After an operation

• You will probably be in hospital for 10 days after a partial hepatectomy or 3 weeks after a transplant.
• You will have tubes to drain post-operative fluids, urine and bile.
• You will also have a drip giving you fluids and nourishment, as you may not be able to eat for a few days. Later you will start with clear fluids before progressing onto solid food.
• You will probably experience some pain, breathing difficulties and nausea due to the large cut made in your upper abdomen. You will be given pain relief, either by an epidural catheter in your back, or an intravenous patient-controlled analgesic (PCA) system, allowing you to control your pain by pressing a button.
• A physiotherapist will help your recovery by giving you exercises to improve your breathing, strength and ability to walk.
• After you return home, you will need frequent check-ups to monitor your health and the success of the surgery.

Tips

• Don't lift anything for about six weeks after surgery.
• Avoid driving if you are on strong painkillers.
• Avoid alcohol for at least two months. After that time, only drink in moderation. If alcohol is a problem for you, seek advice from your GP.
• Start light exercise as soon as you are able to, and continue physiotherapy exercises, if appropriate.
• Wait at least four weeks before swimming and six weeks before starting heavy exercise.

Tumour ablation

• Treatment that destroys a tumour without removing it from the body.
• There are different types available.
• Works best when there are only one or two small tumours less than 3cm in size, but surgery is not possible.
• Most commonly used for primary liver cancer.
• Rarely used for secondary cancer in the liver.

Percutaneous ablation

• A type of treatment that uses radio waves or microwaves to heat and destroy cancer cells.
• A needle is inserted into the tumour after you have had a local or general anaesthetic.
• The radio waves or microwaves are passed through the needle into the tumour, destroying the cells.
• Takes about 1-3 hours.
• Side effects, such as pain, nausea and fever, can be managed with medication. You will also feel quite drowsy.
• You will usually stay in hospital overnight.

Ablation with surgery

• If tumours are close to the surface of the liver, you may also have surgery to avoid damage to the diphragm or nearby organs.
• A cut is made in the skin to access the liver.
• Probes are inserted to do the ablation.
• Recovery is similar to having liver surgery.

Alcohol injection

• Pure alcohol is injected through the skin directly into the tumour to destroy the cancer cells.
•  The treatment is given under local anaesthetic and an ultrasound is used to guide the needle into the tumour.
• You may have more than one injection over several treatment sessions.
• You may have some pain or a fever but this can be managed with medication.
• This procedure is not widely available.

Cryotherapy (cryosurgery)

• A procedure that freezes and kills cancer cells.
• You will have general anaesthetic and a cut is made in the abdomen.
• A probe is inserted into the tumour and liquid nitrogen is injected. This freezes the cells.
• It takes about an hour.
• Recovery is similar to having surgery.
• This procedure is not widely available.

Chemotherapy

Chemotherapy is the treatment of cancer with anti-cancer (cytotoxic) drugs.

The aim of chemotherapy is to kill cancer cells while doing the least possible damage to healthy cells. There are two types used in cancer affecting the liver: systemic chemotherapy and transarterial chemoembolisation (TACE).

Systemic chemotherapy:

• Refers to treatment that circulates through all systems in the body.
• It is mainly used for secondary cancer in the liver.
• It is not used to treat primary liver cancer unless it has spread. In this case, it is used to reduce pain and discomfort (palliative treatment).
• Side effects are usually temporary.

Transarterial chemoembolisation (TACE):

• Refers to treatment that is delivered directly to the part of the liver with cancer. This means stronger drugs can be used without creating many side effects.
• Done in the x-ray department of a hospital
• Treatment is given only once, or once every few months.
• Chemotherapy drugs are injected into the liver through the hepatic artery.
• The hepatic artery is blocked by tiny plastic beads or pieces of soft gelatine sponge. This blocks the artery, keeping the chemotherapy in the tumour and starving the oxygen of cancer.
• You will be given a local anaesthetic beforehand.
• Afterwards you need to remain lying down for about four hours.
• You may need to stay in hospital overnight or for a few days.

Side effects of chemotherapy

The side effects of chemotherapy vary according to the drugs used. Side effects for chemoembolisation, which include pain and fever, are less common but sometimes more severe.

Your doctor will talk to you about side effects and how to manage them.

For more information, see Understanding Chemotherapy.

Biological therapy (biotherapies)

• May be used after or in conjunction with other treatments for primary liver cancer or secondary cancer in the liver.
• Include treatments derived from natural substances in the body, which are concentrated and purified for use as drugs.
• The therapies work against cancer cells by stopping their growth and the way they function, or by helping the immune system destroy them.
• Side effects depend on the types used. Your doctor will discuss possible side effects with you.

Selective internal radiation therapy (SIRT)

• A type of treatment that targets liver tumours directly with high doses of internal radiation.
• Radiation is put in tiny pellets to make them radioactive.
• SIRT is used for both primary liver cancer and secondary cancers in the liver when the tumours can't be removed with surgery. Typically there may be many small tumours spread throughout the liver.
• Before treatment you will need a number of tests to check it will be suitable for you.
• The actual treatment takes about an hour, and you will be monitored closely for 3-4 hours before being taken to a general ward where you will recover overnight.
• Side effects include flu-like symptoms, nausea, pain and fever. These can be treated with medication.
• The procedure is not available in all hospitals.
• In most states, you will need to fund the treatment yourself if you don't have private health insurance.

Endoscopic stent placement

In some patients, cancer in the liver can obstruct the bile ducts, causing jaundice, itchiness, pale stools and dark urine. Your doctor may recommend a thin tube (stent) is placed in the liver to drain the bile and ease symptoms. The earlier the stent is placed, the less severe the symptoms.

• Done as a day procedure.
• You will have a local anaesthetic.
• A tube with a camera and light on it (endoscope) is inserted through the mouth and stomach and then into the bile duct. Pictures of the area are taken so the doctor can see where to place the stent.
• The stent is put in via the endoscope, and then the endoscope is removed.
• Recovery is fairly fast. You may have a sore throat afterwards.
• The procedure is done by a gastroenterologist or a surgeon.

Palliative treatment

Palliative treatment helps improve people's quality of life by alleviating symptoms of cancer, without trying to cure the disease.

Often treatment is concerned with pain relief and stopping the spread of cancer, but it can also involve the management of other physical and emotional symptoms. Treatment may include radiotherapy, chemotherapy, endoscopic stent placement or medications.

Which health professionals will I see?

Your general practitioner (GP) will arrange the first tests to assess your symptoms.

If these tests do not rule out cancer, you will usually be referred to a gastroenterologist (a specialist doctor) who will arrange further tests and advise you about treatment options.

You will be cared for by a range of health professionals who specialise in different aspects of your treatment. This is called a multidisciplinary team. The team may include:

• hepatobiliary surgeon - a surgeon who specialises in surgery of the liver and surrounding organs
• gastroenterologist - a specialist in diseases of the digestive system
• medical oncologist - plans and administers chemotherapy
• radiation oncologist - plans and administers radiotherapy
• hepatologist - a gastroenterologist who has further specialised in liver and gall bladder disease
• cancer nurse coordinators and nurses - give you the course of treatment and support and assist you through all stages of your treatment
• social worker, physiotherapists, occupational therapist - link you to support services and help you to resume normal activities
• dietitian - recommends an eating plan for you to follow while you are in treatment and recovery
• palliative care team - assists you with symptom management and emotional support for you and your family.