Localized Unresectable

If your cancer cannot be removed by surgery, you might be a candidate for a liver transplant.

• Total hepatectomy and liver transplant - The surgeon removes your entire liver (total hepatectomy) and replaces it with a healthy liver from a donor. After a transplant operation, you will take medications to prevent your body from rejecting the transplanted liver. A liver transplant is most effective in people with small tumors and cirrhosis of the liver, and it can treat both the cancer and the liver disease that led to the cancer.

A liver transplant is possible only when a donated liver is available. Relatively few livers are available for transplant into people with liver cancer because they are usually used for people with liver diseases that are more likely to be cured. In some cases, living donors give part of their liver for transplant to a close relative. However, this is risky for the donor and very few living donor transplants are done for patients with liver cancer in the United States.

If a liver transplant is not an option for you, your doctor might recommend ablation or embolization of the tumor. Ablation destroys the tumor without removing it. The doctor places needles into the tumors and kills the tissue next to the needles by injecting alcohol or by heating or freezing the cells. The placement of the needles is usually guided by CT scans or ultrasound. In some cases, the needle is inserted during surgery or laparoscopy. However, ablation is usually done by an intervention radiologist who inserts the needle directly into the skin.

Ablation is a good option for patients with small liver tumors who cannot have their tumors removed by surgery.

• Radiofrequency ablation - This technique uses thin electrodes that release high-frequency, alternating electrical current. The doctor inserts a probe into the center of the tumor. The probe pushes the electrodes, which are shaped like prongs, further into the tumor. The electrical current that flows from the electrodes heats the tumor to 80° C to 100° C (coagulative necrosis), which kills the cancer cells. Radiofrequency ablation can be used to treat small liver tumors that cannot be removed by surgery. It is also used to treat some of the symptoms of metastatic liver cancer.
• Ethanol ablation (percutaneous ethanol injection, or PEI) - The doctor injects pure alcohol (ethanol) through a very thin needle into the tumor. The alcohol dries out the cancer cells, which kills them. Ethanol ablation can be used to treat small tumors or to reduce the symptoms of metastatic liver cancer. Five or six ethanol ablation sessions might be needed to completely destroy the cancer.
• Cryosurgery (cryotherapy) - The doctor uses liquid nitrogen to cool a stainless steel probe (cryoprobe). The very cold probe is then inserted into the tumor, where it is left for 15 minutes. This cools the surrounding tissue to minus 190° C, which kills the cancer cells. The area is thawed for 10 minutes and then frozen again for another 15 minutes. This technique does not affect healthy liver cells, so it has very few side effects. Cryosurgery can kill larger tumors than radiofrequency ablation or ethanol ablation. It is sometimes used in combination with surgery, chemotherapy, or other treatments.
  

Embolization stops blood from flowing to the tumor by injecting substances that plug the hepatic artery. This procedure does not affect healthy liver cells, which get their blood from the portal vein. The portal vein delivers blood that is rich in nutrients to the liver from the intestines.

• Hepatic artery embolization - The doctor threads a catheter (thin, flexible tube) into an artery in the inner thigh and up into the hepatic artery. When the catheter reaches the liver, the doctor injects small particles to plug the artery.

Embolization reduces some of the blood supplied to normal liver tissue. This could be dangerous if you have hepatitis, cirrhosis, or another disease that affects the noncancerous part of the liver.

Embolization is sometimes combined with chemotherapy or radiation therapy.

• Chemoembolization - The doctor threads a catheter (thin, flexible tube) into an artery in the inner thigh and up into the hepatic artery, which delivers oxygen-rich blood that tumors need to survive. The doctor then injects a dye into the bloodstream and watches the dye move up the catheter through angiography, an x-ray procedure used to look at blood vessels. When the catheter reaches the liver, the doctor injects small particles containing chemotherapy into the hepatic artery. The particles block the flow of blood to the liver through the hepatic artery. Once the blood stops flowing, the tumor is soaked in a high concentration of chemotherapy drugs for a long time because no blood comes into the tumor to wash the drugs out. As a result, the tumor cells die very quickly. The procedure usually takes about 2 or 3 hours.
• Radioembolization - The doctor injects small radioactive beads or oils into the hepatic artery through the catheter. These beads or oils release small amounts of radiation into the tumor without affecting healthy cells.
  

Your doctor might recommend that you receive chemotherapy, either alone or in combination with other treatments. Certain chemotherapy drugs can shrink some liver tumors. The drugs that seem to be most effective for liver cancer are:

• Adriamycin^® (doxorubicin) - Doxorubicin hydrochloride is an anthracycline antibiotic. Doxorubicin stops the growth of cancer cells, causing them to die. This drug is given by a shot in a vein over about 15 minutes. The dose and how often you get the medicine depend on your size, your blood counts, how well your liver works, and the type of cancer you have.
• Adrucil^® or Efudex^® (5-fluorouracil or 5-FU) - 5-FU is an antimetabolite drug. 5-FU prevents cells from making DNA and RNA, which stops cells from growing. 5-FU is given as a shot in the vein over 5 to 10 minutes or 20 to 60 minutes, or continuously over 22 to 24 hours for 1 to 4 days or longer. The treatment can be repeated every week, every other week, or every 3 weeks. The dose depends on your size.
• FUDR^® (floxuridine) - Floxuridine is an antimetabolite drug. It stops cancer cells from growing, which kills them. Floxuridine is delivered by a pump into the hepatic artery. It is usually given continuously over 14 to 21 days. The dose depends on your size.
• Platinol^® (cisplatin) - Cisplatin is a platinum compound chemotherapy drug that acts like an alkylating agent. It stops cancer cells from growing, which kills them. Cisplatin is given by an injection into the vein over at least 1 hour. Your dose depends on the type of cancer you have, your size, and how well your kidneys work.
  

Chemotherapy can be classified into regional chemotherapy, systemic chemotherapy, and chemoembolizaton. Regional chemotherapy is the most common way to deliver chemotherapy for liver cancer.

• Regional (intra-arterial) chemotherapy - The doctor makes an incision under the ribs and places a small pump under the skin. The pump injects chemotherapy drugs into a thin tube that is placed in the hepatic artery, delivers oxygen-rich blood from the heart to the liver. This technique allows the doctor to deliver a much higher dose of chemotherapy directly into the liver with fewer side effects. FUDR is the most commonly used drug for regional chemotherapy treatment of liver cancer.
• Systemic chemotherapy - Systemic chemotherapy affects the entire body. You take systematic chemotherapy drugs in pill form or by injection into the vein. Because they affect normal cells and cancer cells, these drugs often cause side effects, such as nausea, loss of hair, and fatigue. These side effects usually stop when you complete the chemotherapy treatment.
• Chemoembolization - The doctor threads a catheter (thin, flexible tube) into an artery in the inner thigh and up into the hepatic artery, which delivers oxygen-rich blood that tumors need to survive. The doctor then injects a dye into the bloodstream and watches the dye move up the catheter through angiography, an x-ray procedure used to look at blood vessels. When the catheter reaches the liver, the doctor injects small particles containing chemotherapy into the hepatic artery. The particles block the flow of blood to the liver through the hepatic artery. Once the blood stops flowing, the tumor is soaked in a high concentration of chemotherapy drugs for a long time because no blood comes into the tumor to wash the drugs out. As a result, the tumor cells die very quickly. The procedure usually takes about 2 or 3 hours.
• Targeted therapy - Targeted therapy blocks the steps involved in the growth and proliferation of cancer cells. Targeted therapy drugs may be taken by mouth or in a pill form. The main targeted therapy for liver cancer is a drug called Nexavar® (sorafenib tosylate).

Another treatment option for localized unresectable liver cancer is radiation therapy, which might be given alone or in combination with other treatments. Radiation therapy uses high-energy x-rays or other types of radiation to kill cancer cells.

• Internal radiation therapy (brachytherapy or interstitial radiation therapy) - Tiny pellets (or “seeds”) that contain radioactive materials are injected into your bloodstream and guided to the hepatic artery. Tumor blood vessels are smaller than the blood vessels of healthy tissue. As a result, the seeds get stuck in the small blood cells that feed the tumors; however, they pass right through the larger blood vessels that feed healthy liver tissue. The pellets release their radiation slowly into the tumor without damaging healthy tissue. Brachytherapy lets the doctor use a higher dose of radiation than EBRT. This type of treatment involves a one-time procedure.
• External beam radiation therapy (EBRT) - Radiation from a high-energy x-ray machine (linear accelerator) outside the body is focused on the cancer cells. EBRT can harm both the cancer cells and nearby healthy tissue. Most people are treated with EBRT for a few minutes 5 days a week for 3 to 5 weeks as an outpatient. This technique is rarely used for liver cancer.
  

This content has been reviewed and approved by Myo Thant, MD.