Surgery for liver cancer

Surgery is sometimes used to treat liver cancer. The type of surgery you have depends mainly on the stage of the cancer and whether the cancer can be completely removed by surgery. When planning surgery, your healthcare team will also consider other factors, such as whether the cancer has spread to blood vessels and other organs, the number of tumours and the amount of scarring in your liver (called cirrhosis).

Before the doctor offers surgery for liver cancer, they will make sure you are healthy enough to have and recover from surgery. This is based on your Child-Pugh score, which grades how damaged your liver is from cirrhosis. The Child-Pugh score is an important part of prognosis for liver cancer.

The following types of surgery are used to treat liver cancer. You may also have other treatments before or after surgery.

A liver resection removes the tumour along with some healthy liver tissue around it (called the surgical margin). It is done only if tests show that the liver left after surgery will be healthy enough to work normally. A liver resection is sometimes called a partial hepatectomy.

A liver resection is the main treatment when there is no cirrhosis of the liver and:

• there is only one tumour that is less than 2 cm in size
• the tumour hasn’t grown into blood vessels in the liver

A liver resection may be offered to people who have cirrhosis if:

• the Child-Pugh score is A, or in rare cases, B
• the BCLC stage is stage 0 or stage A

• there is no portal hypertension or there is only mild portal hypertension

During a liver transplant, the surgeon removes the diseased liver and replaces it with a healthy liver from an organ donor. A liver transplant is the main treatment for people who have severe cirrhosis and whose liver would not work normally after a liver resection. This includes liver cancer that is BCLC stage 0 or A and certain stage B cases. Because a liver transplant treats both the liver cancer and cirrhosis, it can be used when the Child-Pugh score is B or C. It is the only treatment option for Child-Pugh score B cirrhosis.

To be eligible to have a liver transplant, you have to be healthy enough for surgery and the liver cancer must meet certain criteria. If you are on the transplant list, your healthcare team may offer radiofrequency ablation (RFA), transarterial chemoembolization (TACE) or other treatments. These treatments keep the tumour small enough to meet the transplant eligibility criteria (called bridging therapy) while waiting for an available donor liver. You may also be offered these treatments to shrink or destroy some tumours in more advanced liver cancer in order to meet the eligibility criteria for liver transplant (called downstaging therapy).

A liver transplant is done only in a hospital with a transplant program. The transplant team gives you information and support through the process. You will have tests to find out if you are a good candidate for a liver transplant. You may be eligible if:

• the cancer has not spread outside the liver
• the cancer is not in the major blood vessels of the liver
• there is only one tumour that is smaller than 6 cm, or there are smaller tumours whose total volume is less than 115 cm³

• the blood tumour marker alpha-fetoprotein level is less than 400

In Canada, only a small number of people with liver cancer will have liver transplant surgery. This is because the healthy liver used in a transplant most often comes from someone who has died and donated their organs. Only a small number of donated livers are available, so you may have to wait until a liver becomes available. Unfortunately, the wait for an organ donor may be too long for some people with liver cancer. The cancer may continue to grow and they may no longer be healthy enough to have surgery. Some people die from liver cancer before a donor liver becomes available.

Another option may be a living donor transplant. An adult donor gives part of their liver (usually the right lobe) to the person with cancer. A living donor transplant is possible because the liver can regrow itself after surgery. A living donor transplant may mean that the donation is available while the person with liver cancer is still healthy enough to have the surgery and before the cancer spreads outside the liver. As with any surgery, the donor may have side effects and must consider the risk. The transplant team will discuss these risks with people who are offering to donate part of their liver. In Canada, living donor transplant is done only by transplant programs with experience in this type of transplant.

If you have any type of liver transplant, you will need to take immunosuppressive medicines. These drugs help stop your body from rejecting the donated liver.

Side effects can happen with any type of treatment for liver cancer, but everyone's experience is different. Some people have many side effects. Other people have only a few side effects.

If you develop side effects, they can happen any time during, immediately after or a few days or weeks after surgery. Sometimes late side effects develop months or years after surgery. Most side effects will go away on their own or can be treated, but some may last a long time or become permanent.

Side effects of surgery will depend mainly on the type of surgery and your overall health. People with cirrhosis are more likely to have side effects after surgery and those side effects are usually more severe than in people without cirrhosis.

Surgery for liver cancer may cause these side effects:

• high blood pressure in the portal vein (called portal hypertension) caused by scar tissue
• bleeding
• blood clots
• abnormal liver function
• liver failure
• infection
• rejection of the donated liver

Tell your healthcare team if you have these side effects or others you think might be from surgery. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Find out more about surgery and side effects of surgery. To make the decisions that are right for you, ask your healthcare team questions about surgery.