KTPH Hepato–Pancreato–Biliary Surgery Service (HPB)
The decision on strategy for treatment of hepatocellular carcinoma (HCC) is determined by the stage of liver damage by cirrhosis, the extent of invasion, size and spread of the tumour, the medical condition and fitness of the patient, and their individual decision after consideration of the risks and potential benefits between methods of curative or palliative treatment, and best supportive care. The most common causes of death for patients with HCC are tumour progression, liver failure and tumour rupture.
The average life expectancy for patients with HCC (all stage) is about 11 months from the time of diagnosis. With treatment, about 20% of patients will survive 3 years or more. If the HCC is spread beyond the liver, or the patient has severe liver cirrhosis, the life expectancy is usually shorter than 6-8 months.
For HCC confined to the liver, surgical resection has the highest chance for eradicating the tumour and preventing recurrence in the same location, but is limited by having to preserve a sufficient amount of functioning liver, and the remaining liver can develop new areas of cancer in the future. In patients who are suitable for liver transplantation, this can be considered as an option to reduce the risk of future tumours occurring from the diseased liver. Certain smaller tumours (usually less than 2-3cm diameter) can be treated by thermal ablation probes with a success rate of >90%, with results equivalent to surgical resection.
If the stage of HCC or patient's medical condition is not suitable for curative therapy, other treatment options which focus on slowing the rate of cancer progression include using the arterial blood supply of HCC tumours to selectively deliver a dose of Trans Arterial Chemo Embolization (TACE) or Radio Embolization (TARE) to destroy tumour cells. 40-50% of patients have good tumour response, about 25% of lesions continue to grow, and another 25% progress with other lesions elsewhere in the liver. 50% of patients after TACE may have fever, nausea, abdominal discomfort, and loss of appetite for the 3-4 days following the procedure. 20% of patients have deterioration in liver function after the procedure and this can lead to death in 1%. Overall there is strong evidence that suitable patients for TACE/TARE with tumour confined to the liver have longer survivals than untreated patients with a median survival reported of about 3 years.
Targeted inhibitor systemic chemotherapy is taken orally or intravenously and can used even when the HCC has spread beyond the liver. It has been shown to have a modest survival benefit of about 3 months. Common side effects include tiredness, joint and muscle pain, mouth sores, redness with pain and tingling of the hands and feet, diarrhoea, constipation, reflux, nausea, loss of taste and appetite, hair thinning, high blood pressure, infection, anaemia, heart problems, easy bruising and bleeding, and slow wound healing.
Spontaneous rupture of the HCC occurs in up to 15% of patients with HCC, and especially in large tumours >5cm: this is associated with abdominal pain, rapid bleeding, and circulatory shock. Without treatment, the risk of on-going bleeding and death from the event is very high and most patients (>85%) will die from the bleed. With Trans Arterial Embolization (without Chemotherapy) about 75% of patients will successfully have their bleeding stopped and sufficiently recover from the bleeding episode to discharge home; most deaths are from complications of haemorrhagic shock and liver failure. For those who recover, their remaining life expectancy appears comparable to patients without rupture, especially with those who are fit enough to undergo a curative liver resection afterwards.
Patients with many significant co-morbid health problems or severe liver dysfunction and are unsuitable or choose not to have the treatments described above will be provided with best supportive care. This aims to ease the symptoms and discomfort of the disease with appropriate use of palliative medications, follow up visits, as well as psychological, social and spiritually support including home and inpatient hospice care.
