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Managing liver cancer: New breakthroughs

General surgeon Dr Stephen Chang from GLAD Clinic talks about what is new in managing liver cancer.

Liver is the largest organ inside the body. Protected behind the ribs, it is an important organ that plays a vital role in processing and storing nutrients absorbed by the intestine. In addition, it produces proteins such as those that help blood to clot, and breaks down unwanted substances in the blood such as old red blood cells (which leads to bile formation) and chemicals such as alcohol. 

Primary liver cancers are cancers that originate in the liver. The most appropriate treatment for liver cancer is surgery which involves either the resection of the diseased portion or removal of the diseased portion with the whole liver and replacing it with a portion of healthy liver through liver transplant.

Minimally invasive surgery makes resection safer and less painful

In the past, liver resection operations were risky and invasive and transplants were only appropriate in a subset of patients. However, over the years, surgical treatment of liver cancer has advanced. Surgeons have developed new surgical techniques to reduce pain, blood loss and morbidity during resections. At the same time, liver transplant is also gaining ground as a solution to patients with liver cancer.

As with many other cancers, the main surgical advancement in the resection of liver tumours is the development of minimally invasive surgery. Previously, liver surgeries require big incisions to expose the liver, which is well hidden by the rib cage. However, with minimally invasive surgery, surgeons are now able to make much smaller cuts through which a telescope can be introduced to visualise the liver. More recently, it may even be possible to use single-port laparoscopic surgical technique to remove small liver tumours through a small scar at the belly button so that no scar is visible.

Compared to traditional surgical methods, minimally invasive surgery reduces blood loss, pain, morbidity and reduces the length of hospital stays. In addition, there is no difference in survival rate between laparoscopic surgery and open resection.

Transplants gain ground

Even as surgeons improve their surgical techniques to make liver resection safer and less painful, separately, development in transplantation technique and safety has resulted in an increase in the utilisation of liver transplants as a solution for people with liver cancer.

By transplanting a healthy liver into a patient, it is now possible to cure the patient of the liver tumour and at the same time, eradicate the cause of the liver tumour such as hepatitis. In recent years, with the discovery of new medications, up to 70 per cent of people with Hepatitis C may be cured of it with a liver transplant. Being cured of hepatitis is important because chronic hepatitis infection may lead to cirrhosis, which is scarring of the liver, which in turn increases the risk of liver cancer.

Studies have also found that patients with liver cancer have a better chance of long-term survival following liver transplant than many other non-operative management.

Transplants are also an option for some patients who have previously undergone resections. These patients are observed carefully to see if they develop recurrences. If a recurrence occurs, a subsequent transplantation, known as salvage transplantation, can be done.

Living donors create a paradigm shift for transplants

In the past, most liver transplants have been relying mainly on deceased donors which may not be readily available. The patient’s liver tumour may therefore, progress beyond a transplantable state while waiting for a deceased donor. As results of living donor liver transplants improve, it therefore,  becomes a more suitable option.

In most countries, patients with large tumours would not normally be eligible for transplantations from deceased donors. However, given that in a living donor liver transplant, the donor is usually a relative of the patient; ethically, it may not be correct to refuse the option of a liver transplant provided the donor knows that there may be a higher chance of recurrence of the tumour. After all, it is the donor’s desire to extend the life of a loved one.

Resection is still recommended in cases of people with small tumours and whose livers are functioning well. However, even here, studies show that if there are more than three small tumours, there may be a survival benefit in opting for a liver transplant over resection.

Non-operative therapies

Apart from surgery, there are non-operative therapies such as using heat, cold or chemicals to kill off small tumours. While this can be very effective in curing small cancers, the curative rate is very low for big tumours. These non-operative therapies are appropriate in cases where surgery is not an option for the patient.

Surgeons are also benefitting from new tools such as the NanoKnife. This is a minimally invasive option for patients with tumours located next to important structures that need to be preserved. Instead of using heat or cold, it uses an electrical current to destroy the tumour. Electrodes in the form of thin needles are placed around the tumour and the NanoKnife system sends electrical pulses between sets of the needles to puncture nanometer-sized holes into the tumour. This process triggers cell “suicide” and destroys the tumour.

For patients with liver cancer, new treatments and new studies offer hope for long-term survival. Better surgical techniques, a greater understanding of the potential of transplants, the availability of living donors and the development of new tools means that surgeons now have more options than ever before in treating liver cancer.

About liver cancer

• Liver cancer can be primary, originating in the liver itself, or secondary (metastatic), where a cancer originating elsewhere results in secondary deposits being formed in the liver.
• Liver cancer is usually treated by surgery. The diseased portion may be resected or the entire liver removed and replaced with a portion of a healthy liver through a transplant.
• Men are twice as likely as women to suffer from primary liver cancer. Worldwide, it is the fifth most common cancer in men, and seventh in women. Every year, some 600,000 cases of primary liver cancer are diagnosed around the world.
   

Written by Jimmy Yap