Hepatocellular carcinoma (HCC) is the most prevalent form of liver cancer, originating in the liver’s primary cells. An “unresectable” diagnosis means the tumor cannot be entirely removed surgically due to factors like its size, location, or spread. However, unresectable HCC is treatable with various medical approaches.
Understanding Unresectable Hepatocellular Carcinoma
HCC develops from hepatocytes and is often associated with chronic liver disease, particularly cirrhosis. Surgical removal is deemed unsafe or ineffective for unresectable HCC due to tumor characteristics. These include very large size, multiple tumors (multifocal disease), or invasion into major blood vessels like the portal vein.
Liver health also determines resectability. Patients with poor liver function, often from severe cirrhosis, may not tolerate surgery. Clinicians use scoring systems like the Child-Pugh score to assess liver function and surgical risk. Additionally, cancer spread (metastasis) to distant organs or lymph nodes classifies HCC as unresectable for curative surgery.
Diagnosis of unresectable HCC involves imaging studies and blood tests. CT scans, MRI, and ultrasound visualize the tumor, assessing its size, location, relationship to blood vessels, and any spread. Blood tests often include measuring alpha-fetoprotein (AFP) levels, a tumor marker elevated in HCC patients. While biopsy confirms diagnosis, characteristic imaging findings often suffice in high-risk patients, avoiding invasive procedures. The Barcelona Clinic Liver Cancer (BCLC) staging system categorizes HCC based on tumor burden, liver function, and overall health, guiding treatment decisions.
Treatment Approaches
Treating unresectable HCC involves loco-regional and systemic therapies. Loco-regional therapies target the tumor directly within the liver, aiming to destroy cancer cells or limit their growth without extensive surgery. These methods are used when the disease is confined to the liver but cannot be surgically removed.
Transarterial chemoembolization (TACE) delivers chemotherapy drugs directly to the tumor via a catheter into the hepatic artery. The artery is then embolized to cut off the tumor’s blood supply and trap chemotherapy, increasing effectiveness while minimizing systemic side effects. Transarterial radioembolization (TARE), also known as Selective Internal Radiation Therapy (SIRT), uses a similar catheter to deliver microscopic beads containing a radioactive isotope, typically Yttrium-90, directly to the tumor. These microspheres emit radiation, selectively destroying cancer cells while sparing healthy liver tissue.
Radiofrequency ablation (RFA) and microwave ablation (MWA) are percutaneous techniques for smaller unresectable tumors. A probe is inserted into the tumor, guided by imaging, using heat to destroy cancer cells. External beam radiation therapy (EBRT) or stereotactic body radiation therapy (SBRT) deliver high doses of radiation from outside the body, precisely targeting the tumor while minimizing exposure to healthy tissue. SBRT is an advanced EBRT, delivering focused radiation in fewer sessions for specific tumor locations.
Systemic therapies treat cancer cells throughout the body, addressing the primary tumor and any microscopic spread. Targeted therapies, such as tyrosine kinase inhibitors (TKIs) like sorafenib and lenvatinib, block signaling pathways cancer cells use for growth and survival. These oral medications interfere with angiogenesis and cell proliferation, slowing tumor progression. Immunotherapy agents, including PD-1/PD-L1 inhibitors like atezolizumab with bevacizumab, or durvalumab with tremelimumab, harness the body’s immune system to attack cancer cells. These drugs block proteins cancer cells use to evade immune detection, unleashing the immune response.
Traditional chemotherapy drugs may be considered in specific cases when other options are unsuitable or exhausted. Clinical trials offer access to new and emerging therapies not yet widely available. These trials investigate the safety and effectiveness of novel treatments, providing an important avenue for patients seeking additional options.
Managing Symptoms and Well-being
Managing symptoms and supporting well-being are paramount for individuals with unresectable HCC. Common symptoms like pain, fatigue, nausea, and appetite loss are addressed with medications such as analgesics or antiemetics. Dietary adjustments, often guided by a nutritionist, help manage appetite loss. Fluid retention (ascites) is managed with diuretics and sometimes paracentesis, a procedure to drain excess fluid.
Maintaining good nutrition is important, as liver disease can impact metabolism and nutrient absorption. Patients receive guidance on appropriate diets, which may include managing protein intake or limiting sodium, to support liver function and prevent malnutrition. Psychological and emotional support is equally important. Counseling services, support groups, and coping strategies help patients and their families navigate emotional challenges, reduce stress, and improve mental well-being.
Palliative care services manage symptoms and improve quality of life from diagnosis onwards. These specialized teams work alongside oncology teams to provide holistic support, addressing physical symptoms, emotional distress, and spiritual needs. Palliative care provides comfort and dignity throughout the cancer journey.
Outlook and Prognosis
The outlook for individuals with unresectable HCC is influenced by cancer stage, liver function, treatment response, and overall health. These factors are assessed by the healthcare team to provide a personalized understanding of the disease.
Advancements in treatment have improved outcomes for many patients with unresectable HCC. Novel systemic therapies, like targeted agents and immunotherapies, have extended survival and improved quality of life by more effectively controlling tumor growth.
Prognosis remains highly individualized. Patients should engage in open discussions with their healthcare team regarding their specific circumstances. The medical team provides accurate information based on cancer characteristics, liver health, and treatment response. Continued monitoring and proactive management of the disease and its symptoms are important for optimizing long-term outcomes.