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 a more practical system to determine treatment options. Liver cancers are often categorized as:

• Potentially resectable or transplantable cancer
• Unresectable (inoperable) cancer that has not spread
• Advanced cancer

Potentially resectable or transplantable liver cancer (stage I and some stage II cancers)

Potentially resectable

If your cancer is early stage and the rest of your liver is healthy, surgery (partial hepatectomy) may cure you. Only a small number of people with liver cancer are in this category. Important factors that may influence the outcome are 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. How well your liver is working and your general health are also important. For some people with early-stage liver cancer, a liver transplant could be another option.

Clinical trials are now looking at whether patients who have a partial hepatectomy will be helped by getting other treatments in addition to surgery. Some studies have found that using chemoembolization or other treatments along with surgery may help some patients live longer. More research is needed to know the value (if any) of adding other treatments to surgery.

Potentially transplantable

If your cancer is at an early stage, but the rest of your liver isn’t healthy, 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). Candidates for liver transplant might have to wait a long time for a liver to become available. While they are waiting, they are often given other treatments, such as ablation or embolization, to keep the cancer under control.

Unresectable (inoperable) liver cancer that has not spread

Unresectable cancers include cancers that haven’t yet spread to lymph nodes or distant parts of the body, but that can’t be removed safely by partial hepatectomy. This might be because:

• The tumor is too large to be removed safely.
• The tumor is in a part of the liver that makes it hard to remove (such as very close to a large blood vessel).
• There are several tumors or the cancer has spread throughout the liver.
• The person isn't healthy enough for 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. For some of these cancers, treatment may shrink the tumor(s) enough so that surgery (partial hepatectomy or transplant) may become possible.

These treatments are very unlikely to cure the cancer, but they can reduce symptoms and may even help a person live longer. Because these cancers can be hard to treat, clinical trials of newer treatments may offer a good option in many cases.

Advanced (metastatic) liver cancer (includes all N1 or M1 tumors)

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

For people whose liver is functioning well enough (Child-Pugh class A or B), initial treatment options might include:

• The immunotherapy drug atezolizumab (Tecentriq) plus the targeted drug bevacizumab (Avastin)
• Either of the targeted drugs sorafenib (Nexavar) or lenvatinib (Lenvima)

If these drugs are no longer working, other targeted drugs, such as regorafenib (Stivarga), cabozantinib (Cabometyx), or ramucirumab (Cyramza) are possible options. Immunotherapy drugs such as pembrolizumab (Keytruda), or nivolumab (Opdivo) combined with ipilimumab (Yervoy), might also be helpful.

As with unresectable liver cancer that has not spread, clinical trials of newer targeted therapies, immunotherapy, new approaches to chemotherapy (new drugs and ways to deliver chemotherapy), new forms of radiation therapy, and other new treatments may be helpful. These clinical trials are also important for improving the outcome for future patients.

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, the type of initial treatment, 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 or embolization.

If the cancer is widespread, targeted therapy, immunotherapy, or chemotherapy drugs may be options. Patients may also wish to ask their doctor whether a clinical trial may be right for them.

Treatment can also be given to relieve pain and other side effects. Please be sure to discuss any symptoms you have with your cancer care team, so they may be treated effectively.