Treatment of liver cancer

This type of procedure cannot be performed in all individuals, as the tumor often arises in a liver already affected by cirrhosis. In such cases, extensive resections are not feasible due to the risk that the liver may not function properly after surgery. If the patient has cirrhosis without impaired liver function, a careful assessment is required to evaluate the risk of liver decompensation or postoperative complications.

One of the key parameters to assess is the presence of portal hypertension (increased pressure in the portal vein, which delivers nutrient-rich blood from the stomach and intestines). This parameter is closely related to the degree of liver fibrosis and the severity of cirrhosis, and it is essential for identifying ideal candidates for surgical resection.

In well-selected cases, liver resection is very safe (perioperative mortality below 1%) and offers a five-year survival rate of over 70% in patients with hepatocellular carcinoma, and 40–50% in those with cholangiocarcinoma. Despite strict candidate selection and excellent survival outcomes, the recurrence rate after complete resection remains very high, reaching 50–70% at five years.

To date, no treatment has proven effective in preventing tumor recurrence. Therefore, close follow-up of all patients who have undergone liver cancer surgery is crucial, with the aim of detecting tumor recurrence early and offering effective additional treatments.

In hepatocellular carcinoma, liver transplantation is the treatment of choice for individuals with impaired liver function and a limited tumor burden (based on the number and size of the tumors). It is especially indicated when liver function is insufficient to allow for other treatment options.

The possibility of undergoing liver transplantation is limited by the risk of tumor recurrence, that is, the tumor returning after transplant. Therefore, it is essential to carefully select patients who are most likely to benefit from the procedure. The risk of recurrence depends primarily on tumor burden: the larger the tumor or the more nodules present, the higher the risk. As a result, strict limits on the number and size of lesions are set, and not everyone with hepatocellular carcinoma qualifies for transplantation.

Liver transplantation has the advantage of being a highly effective treatment that can completely eliminate the tumor while also curing the underlying chronic liver disease. However, following the transplant, lifelong medication is required to prevent rejection of the transplanted organ. This immunosuppressive therapy comes with long-term side effects and requires ongoing medical monitoring.

Cholangiocarcinoma is generally considered a contraindication for liver transplantation due to the high risk of post-transplant recurrence. Only in highly selected cases can transplantation be considered, and only when outcomes are expected to be comparable to those of hepatocellular carcinoma.

It is the treatment of choice for individuals with early-stage hepatocellular carcinoma when surgical resection is not possible or liver transplantation is contraindicated.

Tumor ablation can be performed by directly instilling chemical substances, mainly ethanol, into the tumor, or by modifying the tumor’s internal temperature, as in the case of radiofrequency or microwave ablation. Another method of ablation is through radiotherapy.

Currently, radiofrequency ablation (RFA) is considered the standard technique. This treatment is ultrasound-guided and involves inserting a thin, needle-like probe through the skin into the tumor. A high-frequency electrical current is then passed through the tip of the probe, which heats the tumor and destroys the cancer cells. It is a very safe treatment, typically requiring only one day of hospitalization, and it is highly effective for tumors smaller than three centimeters offering results comparable to surgical resection in patients with solitary tumors of two centimeters.

The feasibility of this therapeutic approach depends largely on the tumor’s location and patient characteristics. In some cases, the lesion may be difficult or risky to access, which requires considering other treatment options. As with surgical resection, the main drawback of percutaneous ablation is the high likelihood of recurrence even when the tumor appears to have been completely eradicated initially.

In cholangiocarcinoma, ablation is also possible in a specific group of patients those with small tumors located within the liver for whom surgical resection is not feasible.

Chemoembolization, also known as TACE (Transarterial Chemoembolization), is the treatment of choice for patients with intermediate-stage hepatocellular carcinoma who have preserved liver function.

This procedure involves injecting a chemotherapeutic agent directly into the tumor (or tumors, depending on the case). Additionally, the arterial blood flow feeding the tumor is blocked using a coagulant substance, helping to limit tumor growth.

TACE typically requires a hospital stay of about two days. Although it is generally well tolerated, it can cause side effects such as abdominal pain, fever, nausea, and vomiting in the days following the procedure. To achieve maximum effectiveness, the treatment is usually repeated several times at spaced intervals.

As with surgical resection and ablation, the main drawback of TACE is that most patients experience disease progression despite an initially good response. Therefore, close follow-up is essential in all cases.

In the case of cholangiocarcinoma, its efficacy has not been demonstrated, so it is not a recommended treatment.