There are Options to Treat Your Primary Liver Cancer

Understand your treatment plan and explore your therapy options

What is Adult Primary Liver Cancer?

Adult Primary Liver Cancer is a disease in which malignant (cancer) cells form in the tissues of the liver

The liver is one of the largest organs in the body and has two lobes that fill the upper right side of the abdomen inside the rib cage. The liver is vital to the major functions of the human body including filtering harmful substances from the blood, creating bile to aid in digestion, and storing glycogen (sugar) to use for energy.

There are two types of primary liver cancer, Hepatocellular Carcinoma (HCC), and Cholangiocarcinoma. Hepatocellular Carcinoma is the most common form of liver cancer and is the third leading cause of cancer-related deaths worldwide (1).

 

Anatomy of the liver. The liver is in the upper abdomen near the stomach, intestines, gallbladder, and pancreas. The liver has a right and a left lobe. Each lobe is divided into four segments (not shown).

What are the Stages of Liver Cancer?

Stage classification for Hepatocellular Carcinoma is determined by the specific characteristics of your HCC

Healthcare professionals assign stages to cancer to evaluate how severe the cancer is and how best to treat it. It’s important to understand the stage of your HCC liver cancer to better understand your treatment plan. To assign a stage to your liver cancer, physicians often use the Barcelona Clinic Liver Cancer (BCLC) staging system that considers tumor size, number of tumors, liver function, and other factors and connects the stage to a specific therapy (1, 2, 3). The BCLC system stages liver cancer from stage 0 to stage D (figure 1).

What are my Treatment Options?

Treatment options vary depending on the stage of your cancer but the only known cure for HCC is a complete liver transplant

Since only 5% of patients are suitable for transplantation, alternative options are considered. Early-stage cancers (stages 0 and A) are treated with curative options including ablation surgical removal of the tumors, and transplant. The intermediate stage is treated with transarterial embolization (figure 2). Stages C and D are considered advanced stages and treatment includes chemotherapy and supportive care.

Your physician will work with a team of doctors to determine a recommended course of treatment that is tailored to you. Your medical team may consist of surgical oncologists, gastroenterologists, radiation oncologists, interventional radiologists, nurses, and registered dieticians (4).

 

FIGURE 1

The Barcelona Clinic Liver Cancer staging system is a guideline that connects the cancer stage to a specific treatment

Together, your team will consider the available treatments which are listed below:

Transplant: surgical procedure that removes a liver that no longer functions properly (liver failure) and replaces it with a healthy liver from a deceased donor or a portion of a healthy liver from a living donor

Surgery or Resection: removing the cancerous piece of the liver. Surgery is only an option for early-stage cancer that is confined to only the liver

Ablation Therapy: this removes or destroys cancer in your liver using heat, freezing, lasers, microwave, or electrode. This is only an option if the tumor is 3 cm or smaller

Chemotherapy: a drug treatment that uses powerful chemicals to kill fast-growing cancer cells. This option is used either in combination with other treatments or if the cancer is at an advanced stage and other treatments are not good options

Radiation Therapy: uses high energy rays to destroy cancer cells or keep them from growing

Targeted Therapy: uses drugs or other substances to identify and attack specific cancer cells. Targeted therapies usually cause less harm to normal cells than chemo or radiation therapy

Immunotherapy: uses the patient’s immune system to fight cancer. Substances are added to the blood that boost, direct or restore the body’s natural defenses against cancer.

Embolization Therapy: highly selective therapy that uses substances to block, decrease or eliminate the blood flow that feeds the tumor. This therapy has minimal side effects since the therapy is largely confined to the tumor

Liver cancer is rarely diagnosed in early stages (stages 0 and A). More than half of patients diagnosed with HCC are diagnosed with advanced-stage disease and up to 30% of patients are diagnosed in the intermediate-stage (B)(5). Intermediate-stage HCC is often an extensive multi-focal disease, however, there are highly effective treatments that can themselves provide curative results or can downstage stage B cancer to stage A, where curative therapies will be used. The current standard of care recommended by BCLC for intermediate-stage HCC is Embolization Therapy.

 

FIGURE 2

In tumor embolization a microcatheter (green) is inserted through a small incision into the femoral artery in the groin (or radial artery in the wrist) and navigated upward to the liver tumor (yellow). Once in place, microparticles, containing anti-cancer drugs or radiation, are injected through the microcatheter into the tumor (red arrow).

What is Embolization Therapy?

Embolization therapy is a non-surgical, minimally invasive treatment for intermediate stage Hepatocellular Carcinoma

Tumor embolization is a very effective treatment option. Historically, tumor embolization has been palliative, however; very recent advancements appear to have shifted specific types of this treatment into the curative range. Doctors that use these advanced embolization methods perform the procedure with “curative intent”*. These tumor embolization advancements are new and the data on their effectiveness is still emerging, however, the results are positive and encouraging.

As seen in figure 2, tumor embolization is done by inserting a small tube called a microcatheter into an artery through a pin size incision and moving the tip of the microcatheter to a location near the tumor. Once in place, tiny particles that contain either chemotherapy or radiation are injected through the microcatheter and into the tumor. The microparticles fill the arteries in the tumor and block blood flow, starving the tumor of oxygen, and delivering a very high dose of drug or radiation directly into the tumor.

FIGURE 3

Balloon Microcatheter

Embolization therapy aggressively attacks cancer without exposing the rest of the body to the effects of the embolic agents, or anti-cancer drugs. The delivery of the microparticles is primarily performed using a:

1) Standard Microcatheter or

2) Balloon Microcatheter

The objective of the procedure is to fill the tumor with tiny microparticles. Filling the tumor with the microparticles is the key to achieving a Complete Tumor Response (CR)** or tumor kill, and is essential to enable the technique to have an exceptional outcome (2).

Standard microcatheters have been used since the 1970s, however, they typically do not completely fill the tumor, resulting in less-than-optimal outcomes. A new embolic delivery technology was developed between 2015 and 2019. The device based on this technology has a tiny balloon near the tip (figure 3) of the catheter which enables tumors to be filled to a greater extent, leading to better outcomes.

*Curative intent is the term used for a treatment that can have results similar to the Curative Treatments listed on the BCLC algorithm

**Complete Response (CR), hereafter called Tumor Kill, is the term used to describe the absence of all detectable cancer, however, there still may be cancer that is not detectable

Are You A Good Candidate for Embolization Therapy?

Not every patient with HCC is a good candidate for Embolization therapy

There are certain criteria that each HCC patient must meet to receive this type of treatment. Eligible patients must have adequate liver function and have tumors that cannot be removed or resected by surgery, are too large to be treated with ablation (usually larger than 3 cm across), and have not spread outside of the liver. Embolization can reduce some of the blood supply to the normal liver tissue, so it may not be a good option for some patients whose liver has been damaged by diseases such as hepatitis or cirrhosis (6).

FIGURE 4

Each of the 5 studies is presented across the figure. The vertical axis is the complete response (tumor kill)  rate. By way of example, the first study is authored by Golfieri and shows a tumor kill rate with a balloon of 59.3% and a standard microcatheter rate of 41.8%. The average of all studies shows an improvement of 40%.

Why Balloon Embolization?

Balloon Embolization can be done with Curative Intent and can prevent the need for a second procedure

To date, there have been 5 clinical studies including 914 patients comparing balloon embolization to standard embolization, all showing a large improvement in tumor kill when a balloon catheter is used (figure 4). In combination, these studies show a 40% increase in tumor kill (7, 8, 9, 10, 11).

Another study published in 2021 shows that a balloon microcatheter produced a tumor kill of 73% and another shows a tumor kill rate of 88% (12). The physicians that conduct these balloon microcatheter procedures, do so with curative intent.

 

Standard Microcatheter with Incomplete Tumor Fill

X-ray image taken during a procedure using a standard microcatheter. The physician was unable to fill the tumor as indicated by the light stain within the tumor (13).

Balloon Microcatheter with Complete Tumor Fill

X-ray image taken during a procedure using a balloon microcatheter. You can see the balloon is inflated and the tumor has a dark stain, indicating that the tumor is filled (13).

Established Embolization Therapy Centers

 Check out a few of the top medical facilities around the country utilizing this cutting edge technology. For more information on available treatment centers contact us today!

REFERENCES

Click the links below to view the full article

  1. Adult Primary Liver Cancer Treatment (PDQ®) – Patient Version was originally published by the National Cancer Institute (2021)
  2. BCLC Staging System and the Child-Pugh System (2021)
  3. Brian Kouri “Balloon Occlusion for Hepatic Malignancy.” Embolx, Vimeo January 2021
  4. Liver Cancer was originally published by the Cancer Council Victoria
  5. Prince D, Liu K, Xu W Management of patients with intermediate stage hepatocellular carcinoma (2020)
  6. Embolization Therapy Treatment Henry Ford Health System

    CASE STUDIES:

  7. Golfieri R, Bezzi M, Verset G, Fucilli F, Mosconi C, Cappelli A, Paccapelo A, Lucatelli P, Magand N, Rode A, De Baere T. Retrospective European multicentric evaluation of selective transarterial chemoembolisation with and without balloon-occlusion in patients with hepatocellular carcinoma: a propensity score matched analysis. Cardio Intervent Radiol (2021) https://doi.org/10.1007/s00270-021-02805-5
  1. Irie T, Kuramochi M, Kamoshida T, Takahashi N. Selective balloon-occluded transarterial chemoembolization for patients with one or two hepatocellular carcinoma nodules: retrospective comparison with conventional super-selective TACE. Hepatology Research (2016) 46:209-214.
  2. Arai H, Abe T, Takayama H, et al. Safety and efficacy of balloon-occluded transcatheter arterial chemoembolization using miriplatin for hepatocellular carcinoma. Hepatology Research (2015) 45: 663-666.
  3. Lucatelli P, De Rubeis G, Rocco B, Basilico F, Cannavale A, et al. Balloon occluded TACE (B-TACE) vs DEM-TACE for HCC: a single center retrospective case control study. BMC Gastroenterology (2021) 21:55 1-9.
  4. Ogawa M, Takayasu K, Hirayama M, et al. Efficacy of a microballoon catheter in transarterial chemoembolization using miriplatin, a lipophilic anticancer drug: short-term results. Hepatology Research (2016) 46: E60-69.
  5. Lee KS, Madoff DC. Segmental balloon-occluded transarterial chemoembolization of hepatocellular carcimoma. SIR 2021, Abstract
  6. Fischman A, Singh A. Balloon occlusion microcatheter use with microwave ablation to treat HCC with complete response outcome. Mount Sinai. Case Report.

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