Treatment and care of people with cancer is usually provided by a team of health professionals, both medical and allied health, called a multidisciplinary team.

Treatment for liver cancer depends on:

• the stage of the disease
• the severity of symptoms
• whether you have cirrhosis
• your wishes and preferences
• your general health.

Treatment may involve the following.

Surveillance^[1]

If the liver tumour is very small, treatment may not be recommended straight away. This is called ‘surveillance’. You may need to have follow-up appointments every 3 months to make sure the cancer is not growing.

Surgery^[2],[3]

There are many kinds of surgery to treat liver cancer. The type of surgery you have depends on the size of the tumour, how many tumours there are, where they are located, and if you have cirrhosis.

Liver resection^[7]

If your liver is working well (for example, if you have no or early cirrhosis), you might have surgery to remove the cancer from the liver, as well as some healthy tissue around the cancer. This is called a liver resection or partial hepatectomy. Your liver must be working well as it needs to repair itself after the procedure.

There are different types of liver resection, depending on the cancer’s size and location. These include:

• right or left hepatectomy – this removes the right or left part of the liver; in an extended right or left hepatectomy, most of the liver is removed
• segmentectomy – this removes a small section of the liver

The gall bladder may also be removed, as well as the diaphragm (the muscle that separates the chest from the abdomen).

Liver resection is done under general anaesthetic in a hospital. It can be:

• open surgery – where an incision (cut) is made in your upper abdomen
• laparoscopic surgery (called ‘keyhole’ surgery) – where several small cuts are made in your abdomen and the cancer is removed using special surgical instruments.

After surgery, the liver that remains in your body will start to grow. It usually takes a few months for the liver to regrow to its normal size, but its shape may be different.

Portal vein embolisation^[4],[10]

If there won’t be enough of your liver left after surgery to recover, you may have a portal vein embolisation (PVE). This is done about 4–8 weeks before your liver resection.

The liver receives blood from the portal vein, which branches into the left and right part of the liver.

A plastic tube (catheter) is inserted into the portal vein that leads to the cancerous part of the liver (the part that will be removed). Tiny plastic beads, soft gel sponges or metal coils are inserted into the vein through the catheter. These block blood flow to the damaged part of the liver, which causes the other part of the liver (the part that won’t be removed) to get bigger.

If your liver has grown enough, you will then have a liver resection.

Liver transplant^[9],[5],[6]

A liver transplant is where the whole diseased liver is removed and replaced with a healthy liver from a donor. This may be done when the cancer is in the liver only. You can also just have a portion of your liver replaced.

To be eligible for a liver transplant, you need to be reasonably fit, not smoke or take drugs, and have not drunk alcohol for at least 6 months.

After a liver transplant, you will need to take drugs called immunosuppressants. These stop your body from rejecting the new liver. These need to be taken for the rest of your life.

Tumour ablation^[11]

If your primary liver tumour is small and surgery is not an option, you may have tumour ablation. This destroys the tumour without needing to remove it.

The type of ablation you have depends on the size, shape and location of the tumour. They include:

• thermal ablation, which uses heat to destroy the tumour – a fine needle inserted into the tumour sends out radio waves (called radiofrequency ablation) or microwaves (called microwave ablation) that produce heat and destroy the liver cancer cells
• Alcohol injection, where pure alcohol is injected into the tumour
• Cryotherapy (also called cryosurgery), which destroys the cancer cells by freezing them – a probe that gets very cold is inserted into the tumour.

Side effects of tumour ablation may include pain or fever, but these can be managed with medicines.

Transarterial chemoembolisation^[7]

If you can’t have surgery or are waiting for a liver transplant, you may have transarterial chemoembolisation (TACE). This is a way of delivering high doses of chemotherapy directly to the tumour while also blocking its blood supply (embolisation).

A plastic tube (catheter) will be passed through a small cut in your groin into the hepatic artery (a blood vessel that supplies oxygenated blood to the liver). The chemotherapy drugs are injected into the liver through the catheter. Tiny plastic beads or soft gel sponges are also injected to block the blood supply to the cancer. This may stop the cancer from growing, or even cause it to shrink.

Common side effects of TACE treatment include fever, pain, tiredness and flu-like symptoms, but these usually pass quickly or can be managed with medicines.

Radiation therapy^[11]

There are 2 types of radiation therapy that may be used to treat liver cancer:

• Selective internal radiation therapy (SIRT), also known as radioembolisation: small radioactive beads are inserted into the hepatic artery to target the cancer with high doses of radiation; this may be used when surgery is not an option, or to shrink the tumour before surgery or a liver transplant
• Stereotactic body radiation therapy (SBRT): a machine directs focused beams of high-dose radiation at the liver tumour; this may be used when surgery, tumour ablation or TACE are not possible, or to shrink tumours before a liver transplant.

Targeted therapy^[11]

Targeted therapy refers to treatment with medicines that are designed to specifically attack cancer cells without harming normal cells. These types of medicines affect the way that cancer cells grow, divide, repair themselves or interact with other cells.

Medicines used for targeted therapy of liver cancer include sorafenib or lenvatinib. These are tyrosine kinase inhibitors (TKIs) that block signals the cancer cells need to grow and divide.^[8]

Side effects of these medicines may include:

• skin rash
• diarrhoea
• high blood pressure
• fatigue.

Immunotherapy^[9]

Immunotherapy uses medicines to stimulate the immune system to attack cancer cells.

Immune checkpoint inhibitors block proteins on immune system cells that stop these cells from attacking other cells in the body. This can help boost the immune system’s response against cancer cells. Types of immune checkpoint inhibitors used for liver cancer treatment include:

• atezolizumab
• pembrolizumab
• nivolumab
• ipilimumab.

Side effects of these type of drugs include:

• feeling weak or tired
• fever
• nausea and loss of appetite
• skin rash
• muscle or joint pain.

Treatment for secondary cancer in the liver^[10]

Secondary cancer in the liver is cancer that has spread (or metastasised) to the liver from another part of the body. Secondary cancer in the liver is much more common than primary liver cancer in Australia.

Treatment for secondary cancer in the liver depends on where the original cancer started, the size and number of tumours, and your age and general health. The main treatment is chemotherapy, or a combination of surgery and chemotherapy. You may also receive radiation therapy or targeted therapy.

Follow-up^[14],[11]

After treatment, you might have regular visits with your doctor for physical examinations, blood tests, X-rays or scans. These show if your condition has changed or if the cancer has recurred (come back).

You should let your doctor know if you notice any symptoms between appointments.

Recurrent cancer^[12]

Primary liver cancer can come back (recur) after treatment. If liver cancer has come back, the treatment you have will depend on the type of cancer, where it has spread, the type of treatments you have already had and your general health.