Treatments and Therapies for Liver Cancer

How We Treat Liver Cancer and Liver Tumors at Fred Hutch

Our world-class specialists treat more people with liver cancer than anywhere else in the Pacific Northwest. We care for patients with both the most common and the rarest forms of the disease. When it comes to liver cancer, Fred Hutch physicians are experts who use their deep knowledge and skills to give you the best possible care.

Liver Cancer Surgery

Surgery to remove tumors (surgical resection) is the time-tested, “gold standard” in liver cancer treatment.

If you have primary liver cancer (which starts in the liver) and your care team believes they can completely remove the cancer, they will probably recommend surgery to you.

Before recommending liver cancer surgery, your physician along with our whole team of liver tumor experts will also consider:

• Where the tumor is in your liver 
• How widely it has spread within your liver
• How healthy your liver is 
• How healthy you are overall

How Surgery Can Treat Liver Cancer

There are two main options for surgery: taking out part of your liver or taking out your whole liver and replacing it with a donor liver.

• Partial hepatectomy: A partial hepatectomy is surgery to remove the cancerous part of the liver. After surgery, your remaining healthy liver tissue will take over the function of your liver and may grow back (regenerate) within weeks.
• Liver transplant: A liver transplant is surgery to replace your damaged liver with a healthy liver from a donor. UW Medicine transplant specialists do transplants for hepatocellular carcinoma, hepatic epithelioid hemangioendothelioma and cholangiocarcinoma.

In certain cases, we offer a complex type of hepatectomy called ALPPS. ALPSS stands for associating liver partition and portal vein ligation for staged hepatectomy. It’s done in two steps.

• Step 1: The surgeon stops blood flow through a branch of the vein that carries blood to the liver (portal vein), and they make a cut on the liver where tissue will later be removed. This prompts the liver to start growing new healthy tissue.
• Step 2: The surgeon takes out the part of the liver where the tumors are. This is done after the new healthy tissue has grown enough to take over for the diseased part, usually only a week or two after the first step.

If you have liver cancer surgery, you will be treated at UW Medical Center – Montlake.

Learn more about the Liver Transplant Program.

Thermal Ablation for Liver Cancer

Thermal ablation is a minimally invasive procedure that uses heat or cold to treat liver tumors. It is sometimes used with other treatments.

This is one of many options for Fred Hutch patients through the Center for Advanced Minimally Invasive Liver Oncologic Therapy (CAMILOT) at UW Medical Center – Montlake.

Thermal ablation is done by an interventional radiologist (a physician who diagnoses and treats disease using minimally invasive image-guided procedures) or a surgeon.

• The physician puts a needle-like probe into the tumor.
• They use an ultrasound or computed tomography (CT) scan to guide the probe to the right place.
• The tip of the probe heats up using microwave energy (microwave ablation) or radiofrequency energy (radiofrequency ablation), or the probe is cooled using cold gasses (cryoablation).
• The heat or cold destroys the cancer cells.

Thermal ablation is done at UW Medical Center – Montlake. Usually, you can go home the same day.

Histotripsy for Liver Cancer

In histotripsy, an interventional radiologist destroys a tumor using ultrasound waves. This is a noninvasive treatment; it doesn’t involve inserting a probe in the body. You lie on a table, and the physician positions a device called a transducer over your body. The transducer sends focused pulses of sound waves through your skin to your tumor. This makes bubbles of gas within the tumor. The movement and popping of the bubbles destroy the cancer cells.

Histotripsy is done at the Fred Hutch Sloan Clinic. Patients normally go home the same day.

Irreversible Electroporation for Liver Cancer

Irreversible electroporation (IRE) uses electrical currents to open the membrane around a cancer cell. This destroys the cell without harming the surrounding tissues. IRE (sometimes called NanoKnife treatment) can be used if thermal ablation is not an option.

Only a few centers in the U.S. offer IRE.

How IRE works:

• An interventional radiologist or surgeon puts needle-like probes into the tumor.
• The physician uses an ultrasound or CT scan to guide the probes to the right place.
• Micropulses of electrical current are sent through the probes. This makes the cell membranes open, which destroys the cells.

IRE is done at UW Medical Center – Montlake. Most patients can go home the same day. If you also had surgery, you may need to stay in the hospital.

Chemoembolization for Liver Cancer

Chemoembolization delivers chemotherapy directly to liver tumors while also blocking part of the tumor’s blood supply. This helps damage cancer cells while allowing the healthy part of the liver to continue receiving blood. Chemoembolization is done at UW Medical Center – Montlake. Usually, you can go home the same day.

Radioembolization for Liver Cancer

Radioembolization treats liver tumors by delivering radiation directly to cancer cells through the liver’s blood supply. This approach helps slow or shrink tumors while limiting damage to healthy liver tissue. Radioembolization is done at UW Medical Center – Montlake. Most patients can go home the same day.

Targeted Therapy for Liver Cancer

Targeted therapies are medicines to treat cancer. They work differently than standard chemotherapy. Instead of killing all fast-growing cells or keeping them from dividing, targeted therapies work more selectively against cancer cells.

What Targeted Therapies Do

Targeted therapies do one of three things:

• They target a gene or protein that causes cancer growth.
• They damage cancer cells directly.
• They tell your immune system to attack certain cells. This is also called immunotherapy.

How Targeted Therapy Can Treat Liver Cancer

Your care team at Fred Hutch may recommend targeted therapy if surgery or other procedures are unlikely to help or cancer has spread to other organs beyond your liver.

Targeted therapies for liver cancer include:

• Kinase inhibitors: These medicines help stop cancer growth by blocking certain proteins. Examples are cabozantinib, lenvatinib, regorafenib and sorafenib.
• Monoclonal antibodies: The type used against liver tumors helps to stop the growth of new blood vessels that tumors need. Examples are bevacizumab and ramucirumab.

Fred Hutch researchers are studying new ways to use these medicines along with therapies that are specifically meant for the liver. Your Fred Hutch team will tell you about any medications that might be right for you, including ones available through clinical trials.

Immunotherapy for Liver Cancer

Immunotherapies use the power of your immune system to fight your cancer. There are several types of immunotherapies, used against different forms of cancer.

How Immunotherapy Can Treat Liver Cancer

If you have hepatocellular carcinoma and sorafenib didn’t work for you, your physician might prescribe an immunotherapy medicine called an immune checkpoint inhibitor.

Your immune system has built-in checkpoints that help it find invaders to attack, like bacteria or tumors. Cancer cells can trick these checkpoints by sending false signals. This disguises tumors so they appear harmless. As a result, immune cells called T cells don’t attack the tumors. Immune checkpoint inhibitors block cancer’s false signals. This frees up your immune system to attack.

Immune checkpoint inhibitors for liver cancer include atezolizumab, dostarimab, durvalumab, ipilimumab, nivolumab, pembrolizumab and tremelimumab.

At Fred Hutch, we’re also studying other immunotherapies to treat liver cancer. One example is T-cell therapy. T cells are a type of white blood cell that helps boost your body’s natural immune response to infections and tumors.

Learn more about immunotherapy.

Radiation Therapy for Liver Cancer

Radiation therapy (also called radiotherapy) uses high-energy beams to damage the DNA inside cancer cells. After enough damage, the cells cannot multiply, and they die. You may have radiation therapy to help shrink tumors in your liver and control symptoms.

How Radiation Therapy Can Treat Liver Cancer

Your care team may recommend one of these types of radiation therapy:

• Conventional external-beam radiation therapy (EBRT): This therapy uses a machine called a linear accelerator to send beams of high-energy X-rays at your cancer. There are several forms of EBRT. One type is stereotactic body radiation therapy, which focuses many high-energy beams on the tumor to destroy it.
• Proton therapy: This is another type of EBRT. It uses beams of charged particles called protons, rather than X-rays, to kill cancer cells. Protons can be aimed exactly at the tumor, reducing radiation exposure for healthy tissue in the liver or nearby organs. So, proton therapy can help control tumors with less side effects and complications. It can be useful for people with poor liver function, very large tumors or tumors that had radiation in the past.

If your physician recommends proton therapy, you will be treated at Fred Hutch Cancer Center – Proton Therapy, which is the only proton treatment facility in the Pacific Northwest.

“Because of the underlying bad health of the liver when we treat liver cancer, stakes are high,” said Smith Apisarnthanarax, MD, a Fred Hutch radiation oncologist who specializes in gastroenterological cancers, especially liver cancers. “Further damage to the liver can severely affect the patient’s life.

“In the world of proton therapy, liver cancer — especially large tumors — is one of the disease areas where most providers agree it’s an important treatment tool,” Dr. Apisarnthanarax said.

Learn more about proton therapy.

Hepatic Artery Infusion (HAI) Therapy for Liver Metastases

HAI therapy may be an option for you if:

• You have colorectal cancer that has spread (metastasized) to your liver.
• You have intrahepatic cholangiocarcinoma and surgery to remove the cancer isn’t an option for you.

It’s a way to get high-dose chemotherapy to your liver tumors with little to no effect on your healthy liver cells or other tissues. A surgeon implants a small pump under the skin on your abdomen. Every two weeks, you come to a clinic visit to have the pump refilled.

This may be an option to help shrink your liver tumors, relieve your symptoms or prevent tumors from coming back after surgery.

Learn more about HAI therapy.

Nutrition During Liver Cancer Treatment

When you have liver cancer, nutrition is important. Changing your diet may help you avoid problems with how well your liver works. For example:

• You may not be able to digest food as well as you used to, but certain proteins may help your digestion.
• You may have less energy and need to eat often throughout the day. This is because your liver may not store glycogen as well as it did when it was healthy.
• If you have fluid build-up in your abdomen, too much sodium may be part of the problem. A low-sodium diet can help.

A Fred Hutch registered dietitian can help you understand how nutrition is affecting your health and make the diet choices that are best for you.

Learn more about Fred Hutch Medical Nutrition Therapy Services.