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Surgery/Intervention of liver cancer

The liver has a great ability to regenerate. If 50% of the liver is removed, the remaining liver cells will divide and the liver will increase in volume. After a few months, the liver will be close to its original size. The ability of the liver to regenerate is poorer in patients with cirrhosis, or liver damage from alcohol, or hepatitis B or C.

Hepatocellular carcinoma (HCC) is often associated with cirrhosis. In the planning for a liver resection, it is often feasible to perform a biopsy from the healthy party of the liver to determine the degree of cirrhosis. It is also recommended to assess the degree of cirrhosis based on the Child-Pugh score.

Child-Pugh score classification
Parameter Points
1 2 3
Bilirubin mmol/l < 25 25–30 > 40
INR < 1.3 1.3–1.8 > 1.8
Albumin g/l > 35 28–35 < 28
Ascites None Easily treatable Difficult to treat
Encephalopathy None Mild–moderate Stupor–coma

Child-Pugh A: < 6 points, Child-Pugh B: 7–9 points, Child-Pugh C: > 10 points

Primary liver surgery

The main focus is to assess whether the patient can be treated with a liver resection or a liver transplant. A study indicates that patients with a cancer occurring with the Milan Criteria have the best recurrence-free survival after a liver transplantation, and this is comparable to other indications for liver transplantation (> 75% 5 year survival) (2):

  • Single tumor < 5 cm
  • Maximally 3 tumors < 3 cm

In Norway, access to a liver transplant is better than in most other countries. A liver transplant can therefore be offered based on extended criteria:

  • Single tumor < 10 cm
  • Maximally 5 tumors < 5 cm
  • More than 5 tumors < 2 cm

Data are available indicating that the result after a transplant with respect to recurrence is better than after a resection, even if the liver tissue is normal. The assessment of whether a liver resection or transplant should be performed is done at a competent with a transplant surgeon as member of the multidisciplinary team. It is recommended that patients with Child B and C are not resected since the results are very poor. A transplantation should only be carried out if there is no extrahepatic spread.

The problem with a liver resection is unfortunately the high recurrence, which is 60-80% within 5 years. After a transplantation according to the criteria, a lower frequency of recurrence can be expected. However, there are no prospective studies available, and the patient populations of resected/transplanted cases differ. This applies especially to the frequency of blood vessel invasion and the size of the tumor.

Spread from HCC occurs mostly hematogenously. Microscopic vessel infiltration is a poor prognostic sign. Therefore, some believe that a formal anatomical liver resection provides better long-term survival than non-anatomical, however there are no results from controlled studies. The usual recommendation is therefore that patients with HCC who have a healthy liver, or patients with a liver disease classified as Child A, have a liver resection. For recurrence, a liver transplantation should seriously be considered.

Patients in category Child B and C should primarily be assessed for a liver transplantation.

Currently, patients with intrahepatic cholangiocarcinoma (IHCC) are not offered a liver transplantation since existing data shows very low or no long-term survival.

Radiofrequency ablation

Radiofrequency ablation (RFA) is used at larger treatment centers. This treatment is only an alternative when the patient's liver function is determined to be too poor to tolerate a resection or the patient for some other reason cannot be operated. Size is the limitation.

Radical ablation can be achieved if the tumor is less than 3-4 cm. If the tumor is located close to another organ, for example the stomach, this may contraindicate RFA due to the risk of thermal damage and perforation. An alternative local ablation technique may be a percutaneous ethanol injection (PEI) which is performed using ultrasound guidance. This method, however, is not frequently used in Norway.

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