HCC Treatment - Hepatocellular Carcinoma Treatment

Liver cancer is two diseases at once, the tumor and the liver it grew in. Good treatment answers both.

A scan done for hepatitis, for cirrhosis, or for an unrelated reason has found a mass in the liver, and the report calls it hepatocellular carcinoma or asks whether it could be. Hepatocellular carcinoma, the commonest primary liver cancer, stands apart from other cancers in two ways. It almost always grows in a liver already scarred by hepatitis B, hepatitis C, alcohol or fatty liver disease, so every treatment has to spare a liver that is already struggling. And a typical pattern on scans diagnoses it without a biopsy. Treatment runs from ablation and surgery that cure small tumors, through transplantation, which cures the cancer and the cirrhosis together and gave 75 percent four-year survival in the trial that set its criteria, to embolization that controls tumors confined to the liver and, since 2020, an immunotherapy combination that keeps two thirds of patients with advanced disease alive at one year. This page walks through the stages, what each one is offered, what the evidence says, and how a stay in Istanbul is planned for each kind of treatment.

A cancer that grows in a damaged liver

HCC Treatment - Hepatocellular Carcinoma Treatment begins with a fact that shapes every decision afterwards. Hepatocellular carcinoma grows in a liver that is already sick. Four fifths of patients have cirrhosis, from hepatitis B, hepatitis C, alcohol or fatty liver disease, and the rest have chronic hepatitis B without cirrhosis. Liver specialists therefore follow this cancer alongside oncologists, and a treatment that would be simple in a healthy liver, removing a lobe, say, turns dangerous in a scarred one.

The cancer itself feeds on the hepatic artery, grows as one nodule or several, and spreads first into the portal vein and later to the lungs and bones. Caught small, it is cured. Caught late, drugs that did not exist a decade ago hold it for months to years.

Two questions decide everything. How much cancer, and how much liver. A tumor board answers both before it names a treatment, and the cause of the liver disease shapes the answer to the second.

Diagnosis without a biopsy

The scan is the proof

Few cancers are diagnosed without tissue. This one is. In a patient with cirrhosis, a nodule of a centimeter or more that lights up brightly in the arterial phase of a contrast CT or MRI and then washes out in the later phases is cancer by definition, and international guidelines accept the scan as proof. Biopsy stays in reserve for nodules with an unusual pattern, for patients without cirrhosis, and for cases where a drug trial requires tissue.

A patient who arrives with a scan from home has the images re-read here by a liver radiologist, since the diagnosis rests on them, and a repeat MRI with a liver-specific contrast agent is done when the home scan leaves doubt.

The five stages, and what each one is offered

The Barcelona Clinic Liver Cancer system, updated in the Journal of Hepatology in 2022, is the staging every guideline uses. It combines three things, the tumor, the liver and the patient, into five stages, and attaches a treatment to each.

Stage is a starting point. A patient at stage A whose liver is too weak for resection moves to ablation or transplant. A patient at stage B whose tumors respond to embolization becomes a transplant candidate. A patient at stage C who responds to drugs occasionally goes back to a treatment aimed at cure. The 2022 update calls this treatment stage migration and expects it.

Ablation, resection and transplant

Ablation comes first. For a single tumor under 3 centimeters, destroying it with heat or cold through a needle placed under ultrasound or CT guidance gives results close to surgery, with one night in hospital and no cut. Radiofrequency and microwave are the usual tools, and cryoablation is chosen for tumors near the surface or next to something that must be spared. Recurrence at the treated site runs higher than after resection for tumors over 3 centimeters, which is where surgery takes over.

Resection, removing the part of the liver that holds the tumor, is the treatment of choice for a single tumor in a patient without cirrhosis, and for a patient with cirrhosis whose liver function is preserved and whose portal pressure is normal. The surgeon leaves enough liver to do the work, which in a scarred liver means a smaller resection than the tumor alone would call for. Recurrence elsewhere in the liver over the following five years is the rule rather than the exception, because the cirrhosis that produced the first tumor produces others, and that is the argument for transplant.

A transplant, third, removes the cancer and the cirrhosis in one operation. The Milan criteria, published in the New England Journal of Medicine in 1996, define who benefits. A single tumor of 5 centimeters or less, or up to three tumors each of 3 centimeters or less, with no spread into vessels. Among 48 patients transplanted under those rules, four-year survival was 75 percent and recurrence-free survival 83 percent, and among the 35 whose removed liver confirmed the tumor was within the limits, 85 and 92 percent. Patients whose tumors turned out larger did far worse, at 50 and 59 percent.

The limits define the treatment. A patient just outside them is treated with embolization or ablation to bring the tumor inside, and reassessed. Whether a transplant is available to a particular patient depends on a donor, on the laws of the country where it is done and on the transplant program, and the review addresses that question directly rather than leaving it to the end.

Chemoembolization and radioembolization

A tumor confined to the liver that cannot be cut out, burned or transplanted is fed by the hepatic artery, and blocking that artery through a catheter is the treatment of intermediate-stage disease.

Two ways into the same artery

Both require a working liver. A bilirubin above about 2 milligrams per deciliter, fluid in the abdomen, or a tumor in the main portal vein rules out chemoembolization, and the liver tests weigh as heavily as the scan.

Immunotherapy and targeted tablets

Advanced disease, tumor in the portal vein or spread outside the liver, is treated with drugs, and two trials twelve years apart mark the distance traveled.

Twelve years apart

Sorafenib extended life in this cancer by three months, and no drug had done that before. The combination of an immune checkpoint inhibitor with an antibody that blocks tumor blood vessels replaced it as first-line treatment in 2020, and other combinations have followed. Bevacizumab raises the risk of bleeding from varices. An endoscopy to look for and treat them therefore comes before the first dose. Treatment continues for as long as it works and is tolerated, every three weeks by infusion, and an oncologist at home can give it on the protocol we write.

Treating the liver behind the cancer

Every patient with this cancer has a second diagnosis. Treating it is half of the work, and a treatment that shrinks the tumor and tips the liver into failure has not helped.

The Child-Pugh score, from A to C, and the newer ALBI grade summarize how the liver is doing. Both get recalculated before every treatment decision.

How the plan is made

The order of treatments

Cure, where possible, comes first. Where cure is out of reach, the treatment that controls the tumor with the least harm to the liver comes first, and drugs wait in reserve for progression. A scan at one to three months follows every treatment, and the board meets again. A good response can open a door that was shut at the start. A poor one closes a door without delay.

Liver surgery, ablation, embolization, radiotherapy on an Elekta Versa HD linear accelerator and medical oncology are all delivered at Biruni Hospital on the same site, and the board that reads your file is the team that carries out its decision.

What each treatment costs the body

One risk runs through every treatment, and it is liver failure. A tumor board that declines a treatment because the liver cannot bear it is protecting the patient.

The review says so in plain words when that applies to you, and it names the treatment the liver can bear instead.

Scans, markers and recurrence

Weeks in Istanbul by treatment

Combining visits

Many patients combine two lines. Staging and a first chemoembolization in a week. Ablation, and the start of hepatitis B tablets, in four days. The coordinator builds the calendar from the decision of the board, and a patient who wants everything in one trip is told what that trip would hold before booking a flight.

What a quote is built from

No figure appears on this page, because this cancer has six treatments with six different price structures, and the stage decides which one applies.

Six structures

Ablation carries the probe and one night in hospital. Resection by the operating time, the intensive care and ward days, and the extent of liver removed. Chemoembolization by the beads and the drug, multiplied by sessions. Radioembolization by the yttrium-90 dose, which is a licensed radioactive product, plus the mapping visit. Immunotherapy by the infusion, given every three weeks for as long as it works, which makes it the largest sum over a year even though each cycle is smaller than an operation. A transplant belongs to a different order of cost and comes as a quote only from a transplant program after assessment.

A quote you can compare names the stage the board assigned, the treatment it assumes, the number of sessions or cycles, and the hospital days, and it follows the free review rather than preceding it, because a figure given before the stage is known is a figure for the wrong treatment. Ask for it after.

Coordinator, language, companion

The hour that matters most is the one in which the board explains the stage. A family that has understood that hour makes every later decision more easily, and the interpreter sits in on it.

Biruni Hospital gives every international patient one coordinator from the first message, reachable on the same WhatsApp number afterwards, and the international patients team works in English, Arabic, French, Russian, Serbian, Romanian and Spanish with interpreters arranged for other languages.

Care at home

Once you get back home, the handover file goes to your liver specialist and your oncologist. It holds the stage, the decision of the board and its reasons, the treatment given with its dose and images, the hepatitis plan, the endoscopy findings, and the scan calendar.

HCC Treatment - Hepatocellular Carcinoma Treatment FAQ