Living Longer: Early Stage Liver Cancer (BCLC A)

Introduction

For early stage liver cancer (BCLC A), average survival is around 36 months without treatment.

BCLC A

Early stage liver cancer (BCLC A) is when:

  • Single liver tumor > 2cm or 3 liver tumors < 3cm each
  • Good liver function (Child Pugh A)
  • Good performance status

Treatment options are:

  • Liver tumor resection (if tumor is single, tumor <5 cm and no vascular invasion)
  • Tumor ablation
  • Liver transplantation

With treatment:

  • Average survival improves to 5-year survival of 50% (multifocal/ portal hypertension present) – 70% (preserved liver function) with resection or ablation.
  • Liver transplantation would offer a 5-year survival rate of 70% irrespective of liver function
Screen Shot 2018-05-31 at 1.37.23 AM
Barcelona Clinic Liver Cancer (BCLC)

Resection of Liver Tumor

If tumor resection is possible, partial liver resection of the affected side offers high cure rate and is the first option.

The advantage of surgery was more evident for Child-Pugh class A patients and for single tumors of more than 3 cm in diameter (Vivarelli, 2004) as compared with radio frequency ablation (RFA).

16FF1
One- and 3-year survival were, respectively, 83 and 65% for surgical resection vs. 1- and 3-year survival were 78 and 33% for RFA group (Vivarelli, 2004).
Screen Shot 2018-07-16 at 5.03.23 PM.png
More than 50% patients live beyond 5 years (potentially curative) with liver resection for early HCC within Milan criteria.

Conversion therapy

Sometimes, liver resection is unable to be done due to larger size of the tumor beyond the recommended size OR anticipated inadequate liver function post liver resection.

Conversion therapy is important here to render some unresectable tumor due to larger size or insufficient future liver remnant to become resectable and with aim for cure.

To convert unresectable liver tumor to resectable liver tumor, two conditions need to be fulfilled

  • Regression of tumor size
    • Trans-arterial chemo embolisation (TACE); most widely used, disease control in 40%
    • Selective internal radiation therapy (SIRT); effective to down-staging of locally advanced HCC, higher disease control (>70%) and suitable for portal vein invasion
  • Increase in size of future liver remnant (FLR)
    • Selective internal radiation therapy (SIRT); Y90-SIRT, compensatory hypertrophy of contralateral lobe, which increases the size of FLR!
    • Portal vein embolisation; initiate hypertrophy of the anticipated future liver remnant (FLR).
pev21.png
Portal vein embolisation (MSKCC)
pev31
Enable an extended resection in a patient with normal liver or major resection in a well-compensated cirrhotic patient that would otherwise leave a remnant liver insufficient to support life following liver resection (MSKCC)

Liver Transplantation

Liver transplantation is recommended if poor liver function, presence of portal hypertension or where pathology/ radiological features showing microscopic vascular invasion and/or satellites (higher risk of recurrence)

With shortage of liver donor and long waiting time, the risk of tumor progressing to higher stage is real.

In order to overcome this problem, use of adjuvant treatment to delay progression (chemoembolisation, ablation) is recommended if waiting time for liver transplant is more than 6 months (bridging).

Adjuvant treatment is also used to reduce (downstage) size of liver tumor to fit transplant criteria.

Liver transplant uses strict Milan criteria. The shortage of donors justifies strict selection of candidates to ensure post-transplantation success.

Milan criteria are as follows:

  • one lesion smaller than 5 cm; alternatively, up to 3 lesions, each smaller than 3 cm
  • no extrahepatic manifestations
  • no evidence of gross vascular invasion

Benefits of liver transplantations are the abilities to potentially cure both the liver cancer and the underlying liver disease (liver cirrhosis).

Disadvantages: risk to a live donor, high cost and lifelong immunosuppression.

1733-PB5-R1.png
Outcomes of liver cancer patients who underwent liver transplantation under Milan criteria

Tumor Ablation

Tumor ablation to cause tumor cells death/ necrosis is also recommended treatment for BCLC A.

Radiofrequency ablation (RFA) and percutaneous ethanol injection (PEI) are two common ablative method but RFA was proven to be more effective in recent studies.

Few studies (GT Huang, 2005; MS Chen, 2006) did show comparable survival results for tumor ablation when compared to resection of liver tumor.

The effectiveness of tumor ablation reduced when tumor size exceeds 3 cm or when more than 2 nodules are targeted.

Conclusion

The above treatments are summarised to provide basic information regarding recommended treatments for early stage liver cancer (BCLC A).

I recommend you to get inputs from your oncologist, gastroenterologist, hepatobiliary surgeon and interventional radiologist before deciding on your treatment plan.

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