Liver Cancer Treatment Success Rate

Liver cancer treatment success rate - The treatment method for liver cancer - After the diagnosis of liver cancer (hepatocellular carcinoma: HCC) is formed and the type of tumor and level of spread of cancer has been determined, the doctor agreed with the patient a treatment (therapy) is done. The treatment method specifically suitable for the therapy of liver cancer are:

  • Operation (transfer of part of the liver or liver transplants)
  • Ethanol perkutan or injection acid acetate (PEI)
  • Radiofrequency ablation (RFA, RFTA, RITA)
  • Ablation microwave (MWA) and electrophoresis irreversible (IRE)
  • Embolization chemoembolization (chemo-) (TAE, TACE)
  • Radiation therapy selective internal (SIRT, TARE)
  • Radiotherapy external
  • Treatment with sorafenib, regorafenib and therapy line second
  • Immunotherapy by inhibiting the PD-1
  • Chemotherapy cytoreductive
  • Or a combination of forms of this therapy.

What kind of therapy comes in the respective case, depends on how far the disease at the time of diagnosis is advanced and the condition in which the liver is located. Also the age of the patient and his General state of health are taken into account in the choice of treatment method.
Liver Cancer Treatment Success Rate

The most important surgical procedure for the treatment of cancer of the liver, a partial liver removal, or the removal of the entire organ followed by liver transplantation. The latter, however, is only rarely (less than five percent of the patients) is feasible. The aim of surgery is to remove the Tumor completely in order to cure the disease. Liver partial removal, however, is only in question, as long as the Tumor is confined to the liver, and with a sufficient safety margin in the healthy tissue can be removed. In addition, in patients with liver liver function cirrhosis be good enough and there must be no more severe Portal hypertension, no bilirubin increase (> 2mg%), no splenomegaly or thrombocytopenia (< 100/nl).

In more than three-quarters of all cases currently, cancer of the liver may be at the time of diagnosis not surgically removed. As an alternative to surgery but also as a bridging measure until a liver transplant can be local, used the tumor-destroying (local ablative) procedures. Here, v. a. to call the radio-frequency Ablation (RFA) and microwave ablation (MWA). The radio-frequency Ablation for small liver cancers (up to 3 cm in diameter) of the surgical liver partial removal, effectiveness, healing opportunities and life extension equivalent. In principle, a cure is possible.

Liver Cancer Treatment Success Rate

The liver cancer cannot be removed surgically, locally-ablative be completely destroyed, the TRANS-arterial (Chemo - or Radio-) embolization and/or drug therapy. Drug treatment with multi-kinase inhibitors Sorafenib (first-line), and Regorafenib (second-line) is not a cure for advanced liver cancer. Sorafenib and Regorafenib can bring the growth of the tumor for a certain period of time to a standstill, tumor-related illnesses and to Survive longer.

Surgery / Liver Transplantation
The decision in favour of a surgery or a liver transplant is aimed, in particular, on whether, in addition to the tumor disease, cirrhosis of the liver ("shrink the liver") is present or not.

In countries with a rare liver cancers without underlying cirrhosis of the liver, the surgical removal of the tumor is the treatment of choice. Your goal is to remove the tumor tissue completely and to cure the disease permanently. It is therefore particularly important that the welded bead is detected at an early stage and with a safety margin in the healthy tissue can be removed. The surgeon removes not only the Tumor itself, but also beyond its borders, parts of healthy tissue. This is to ensure that no tumor cells remain in the body, which could grow to bead a new speed.

Often such surgery in patients with cirrhosis of the liver is no longer possible because the remaining liver tissue would not be sufficient to preserve the organ function of the liver in an upright position. Before each Operation, must therefore be examined in an interdisciplinary liver function and the risk of postoperative liver failure should be considered. The experienced surgeon and oncologist will consult the liver specialists (Hepatologists).

Is, apart from the Tumor, in addition to cirrhosis of the liver in early tumor complete removal of the liver with subsequent liver transplantation stages of the appropriate therapy. It not only eliminates the liver tumor but also the underlying liver disease. However, the transplant is only a small number of patients feasible. A prerequisite is that the Tumor is confined to the liver and no metastasis, for example in the lymph nodes. A transplant is out of the question, it is checked whether or not the cancer can be surgically removed. The sense of a resection of liver cancer depends on the size and location of the tumor, from the liver function, the Presence of portal vein pressure (portal Hypertension) and General condition of the Patients. In selected patients with good liver function (Child Pugh A cirrhosis) and a small singular HCC, the 5-year Survival following hepatic resection after liver transplantation is comparable.

Local (local) methods of treatment
Percutaneous Ethanol or acetic acid injection (PEI)

In the case of percutaneous Ethanol injection under ultrasound or CT is injected with the help of a fine needle 95 - percent alcohol into the Tumor. As a result, the tumor dies the tissue. The surrounding healthy liver tissue is damaged hardly. The treatment is usually performed in several sessions spaced two to four weeks. Often, they must be after a few months repeatedly. A cure of the cancer with this treatment, in principle, possible. In this country, the Ethanol-injection, because it has been replaced in the last few years, in almost all facilities (almost) completely from the radio-frequency Ablation. The radio-frequency Ablation is the Ethanol and the acetic acid injection, its effectiveness is superior and therefore preferable.

Liver Cancer Treatment Success Rate: Radio-Frequency Ablation

In the case of the radio-frequency Ablation (=radio frequency-induced thermal therapy/thermal ablation: RFA, RFTA, RITA) will be introduced under ultrasound or CT control, a probe into the Tumor. Through this probe, radio-frequency waves are introduced to heat the tumor tissue (more than 100°C). Tumor areas of up to 3-5 cm in diameter, may be overcooked with this method, literally"". For the treatment of several tumor in the case of more than one meeting a herd of mostly – under short General anesthesia.

The effectiveness of local ablative (=locally-limited, tumor-destroying) therapy procedure could be proven in numerous studies for cancer of the liver up to a size of 3-5 cm. The treatment was well tolerated. The effectiveness of RFA for tumors up to 3 cm in diameter in relation to the surgical results of partial liver resection equivalent. In comparative prospective studies were herds of the survival times of the patients with small Tumor (< 3 cm) who were treated either by RFA or liver resection. Especially in the case of a few (<4), small tumor herds (< 3 cm), there are very good prospects of success.

Micro-wave ablation (MWA) and irreversible electroporation (IRE)
In addition to the radio-frequency Ablation (RFA), microwave ablation (MWA), and, although rarely applied, the irreversible electroporation (IRE), the laser-induced thermo-therapy and cryotherapy as a local ablative procedures, may establish. In comparison to the RFA may be generated in the micro-wave ablation (MWA), even higher temperatures up to 160° C. HCC-foci, which are close to large and well-perfused vessels (portal vein, hepatic veins the star), therefore treated preferably by means of the MWA.

The irreversible electroporation (IRE) is a novel, minimally invasive technique for the targeted destruction of cells due to strong, localized electric fields. The past experiences suggest that in this technique, in contrast to other local treatment to the tumor cells targeted to be destroyed. Other structures, such as blood, are not damaged vessels, on the other hand permanently. Due to the short availability and limited experience of the use of IRE is limited to a few centres.

The use of locally-ablativer procedure does not preclude later implementation of a liver surgery. Often, ablative procedures, bypass locally-even the waiting time to liver transplantation. Local-ablative procedures are increasingly used in combination with TRANS-arterial (Chemo -) embolization. In particular, in the case of cancer of the liver of 3-5 cm in diameter, the Tumor is marked first by the (Chemo-) embolization and reduced in size, then the RFA. Combined treatment approaches are referred to as "multimodal therapy."

Ransarterielle (Chemo-)embolization (TAE/TACE)
The TRANS-arterial chemo-embolization (TACE) is a local treatment method, in which the two principles of embolization and chemotherapy are combined. The interventional active Radiologist (x-ray doctor) after local anesthesia of the groin from a catheter to the hepatic artery. The hepatic artery branches in the liver in small arteries. Any tumor of the liver is supplied by one or more of these small arteries with blood. In the case of the embolization through the catheter small plastic particles are injected into the Tumor supplying vessel, until the vessel is blocked and the blood supply is stopped to the Tumor. Since the necessary nutrients and oxygen fail to die, the tumor cells in this area. Is additionally injected with a chemotherapeutic agent through the catheter and directly at the Tumor ("local chemotherapy"), it is called chemo embolization. Also, the chemotherapeutic agent causes the death of the cancer cells. Currently, the TRANS-to be considered (HCC) arterial Embolisation and TRANS-arterial chemoembolization are equivalent in terms of their effectiveness.

In the case of liver cancer in the early stages of the (Chemo is not used) Embolisation in the rule; here the ablative procedure or a liver surgery, the success of locally-promising. The Chemo-embolization is used primarily for the treatment of many tumor foci or large, surgically not removed tumors that cannot be treated locally-ablative. The Chemo-embolization, the tumor growth can be delayed. The treatment should only be performed in patients with good liver function. The chemo-embolization has been used in the last years also increasingly as a bridging treatment before a liver transplant. The TRANS-arterial Chemo-embolization (in the course) often combines with drug treatment (Sorafenib) or with other local ablative procedures (e.g., radio-frequency Ablation).

Liver Cancer Treatment Success Rate

The importance of the more frequently used "drug-eluting beads (DEB)"-TACE (usually with Doxorubicin loaded; DCBead) is not sufficiently clear. In the currently available and published studies, a Superiority showed neither compared to a sole embolization (without chemotherapy), a Meta-analysis failed to show a Superiority compared to conventional TACE.

Selective internal radio therapy (SIRT), TRANS arterial radio embolization (TARE)
For patients with liver limited liver cancer that can be treated neither surgically nor local ablative, shows a new procedure-prospects promising: TRANS-arterial radio embolization (TARE), often also called selective internal radiotherapy (SIRT). In the case of selective internal radiation therapy (SIRT) is a novel local irradiation in the treatment of liver tumors from the inside.

In this method, the smallest spheres which contain a radio-active substance with a very short rich, be introduced directly into the liver supplying vessels. The micro spheres encapsulated 90-Yttrium, a so-called beta emitter is injected, via a catheter, which is inserted after a local anaesthetic on the bar of the patient, directly into the liver artery. The tumors are exposed to a high local dose of radiation, at the same time the Tumor-supplying vessels, blood closed. The exact application of the radioactivity in the hepatic artery or its Branches is crucial here, because the Outflow of the radioactive micro-spheren in the blood vessels of the abdominal cavity can lead to significant side effects.

The SIRT has become in recent years a firm place in the treatment of liver cancer. The advantage of SIRT, compared with the TRANS-arterial (Chemo-) embolization is that it can be usually as a single session, i.e., in the context of a single hospital stay and in patients with occluded portal vein applied. Yet she was among other things due to the cost intensity only at the individual clinics and for the few patients available. Currently, the SIRT procedure in the context of clinical studies with other therapy, in particular with the drug Sorafenib combined and compared (SIRVENIB [NCT01135056], SARAH [NCT01482442], SORAMIC [NCT01126645], STOP-HCC [NCT01556490]).

So far, studies that have compared the SIRT with TACE/TAE is a lack of controlled prospective. The currently available data, however, speak for an equivalent efficacy of the two techniques (SIRT, TACE) liver cancer.

External Beam Radiation Therapy (Radio Therapy)
For large, fixed-limited liver cancers, which can be destroyed neither surgically with minimally invasive local procedures, the externally applied radiation treatment (external Radiatio/ konformale radio therapy, stereotactic Radiatio) a meaning. Stereotactic radiation treatment achieves high response rates; it is currently developed in the framework of studies and is often combined with drug therapy.

Proton therapy
With proton therapy of tumors can be targeted to combat than with conventional radiotherapy. However, there are no controlled trials for hepatocellular carcinoma for this purpose so far. Individual small pilot studies show encouraging results and justify to continue to pursue this approach.

Drug treatment with the tyrosine kinase inhibitor Sorafenib
Drug treatment with Sorafenib
Targeted drugs (Target drugs), engage in various signaling pathways of tumor metabolism and therefore appear to be targeted against malignant tissue. For the treatment of colorectal-, breast-, prostatic -, and lung-cancer medications are available for several years, which specifically inhibit growth signals and growth factors. In the year 2007 was approved with Sorafenib, the first drug for the treatment of liver cancer.

Approximately seven out of ten patients, the liver cancer is advanced at the time of diagnosis, so that surgical removal or local removal of the tumor is possible. Systemic chemotherapy is - except possibly in HCC patients without underlying cirrhosis of the liver – very effective and brings no survival advantage. The treatment attempts with hormones and Hormone-substitutes were so far unsuccessful.

New, at the molecular level acting drugs have finally brought some progress in the drug treatment of liver cancer. These novel drugs directed against one or more of the factors that promote the growth of the liver cancer. A large proportion of liver cancer cases has, on the surface of the cancer cells increased the binding sites (receptors) for these growth factors. As a result, these can exert their effect on the tumor cells. The novel targeted agents to stop it by, for example, the binding of growth factors to block or in the tumor cell-borne growth signal inhibit. As a result, the tumor growth can be stopped, at least temporarily.

Tyrosine Kinase Inhibitor Sorafenib
Two large studies conducted world wide have been able to show in front of almost 10 years, agreed that the drug Sorafenib extends the survival time of patients with advanced liver cancer. Sorafenib inhibits kinases, the Tyrosine enzymes, and delayed the growth of tumor cells and their supplying blood vessels. Sorafenib was the first and up to the year 2016 the only drug for which a life-prolonging effect in liver cancer (two Phase 3 studies) was assigned. Thanks to the recently published RESORCE study a second effective drug for the treatment of HCC in the second-line is now available with Regorafenib (see below).

A number of clinical studies investigated whether in advanced liver cancer, the multi-modal treatment consisting of Sorafenib plus TAE/TACE and Sorafenib plus SIRT/TARE of the respective single-arm treatment strategy is superior. In the context of current studies is therefore combined Sorafenib with the TRANS-arterial (Chemo) embolization, but also with the SIRT (TARE). In addition, Sorafenib in a recent, prospective, Phase III will be compared to study head-to-head with the SIRT. In ongoing studies include to name TACE-2 [NCT01324076], ECOG-E1208 [NCT01004978], SIRVENIB [NCT01135056], SARAH [NCT01482442], SORAMIC [NCT01126645, STOP-HCC [NCT01556490]:.

In addition to Sorafenib, have been and are still investigating other targeted drugs on their efficacy and safety in the treatment of liver cancer. However, the drugs Sunitinib, Linifanib, Brivanib and Erlotinib in HCC patients in large Phase III studies, no survival benefits compared with Sorafenib. In recent years, a total of eight Phase III trials (Sunitinib, Linifanib, Brivanib, Sorafenib plus Erlotinib and Sorafenib plus Doxorubicin in first-line), (Brivanib, and Everolimus, as well as Ramucirumab in second-line) in advanced HCC have failed in its primary endpoint (improvement in overall survival). Similarly, drugs are currently playing from the group consisting of mTOR inhibitors (Sirolimus, Everolimus, Temsirolimus) have a role in the systemic therapy of HCC.

Regorafenib and second-line therapies
The oral multi-kinase Inhibitor Regorafenib was tested in a Phase III study in second-line (after failure of Sorafenib) against Placebo (RESORCE study). Regorafenib significantly extended overall survival (almost 3 months) and progression-improved also-free Survival and time to Progress. As the drug safety and toxicity was within the expected range, it is considered by many experts to Regorafenib as the new Standard in the drug second-line therapy of HCC after sorafenib failure. Since 2007, Regorafenib is the first innovative drug with a significant survival advantage provided for HCC patients, the goods for a locally-regionäre treatment unsuitable. With regulatory approval of Regorafenib for the treatment of HCC is expected in the year 2017.

In the year 2012 could be demonstrated for the drug Tivantinib, a so - called MET Inhibitor, in a Phase II study, a positive effect in Sorafenib-pretreated patients. Patients whose liver cancer had the protein MET in a high-density, experienced a significant survival advantage by treatment with Tivantinib. Currently, Tivantinib is being developed as a new drug in a clinical Phase III study in MET-positive HCC (METIV).

Immunotherapy with PD-1 inhibitors
Immune therapies with innovative drugs, in particular, the so-called Checkpoint inhibitors are the new hope of the tumor medicine. So a good safety profile showed that HCC patients of the PD-1 Inhibitor Nivolumab, even in patients with active Hepatitis B or Hepatitis C infection. In the previously published Phase I/II studies, a long sustained Response in all dose levels were observed. In addition to a promising response rate, overall impressed, the survival rate after 12 months was 62%. Due to the lack of Kontrollarms but can not be currently evaluated the efficacy of Nivolumab in conclusion. Nivolumab is currently being tested in first-line against Sorafenib in a Phase III study (NCT02576509, first study results expected in June 2019). In addition, studies will be designed in the second-line comparison of Regorafenib with the immune therapy.

In addition to Nivolumab patients PD-1 are studied in HCC-inhibitors (immune checkpoint inhibitor) and a number of innovative antibody in Phase I/II studies.

Cytoreductive Chemotherapy
The cytoreductive chemotherapy has here no significance in HCC patients with advanced liver cirrhosis (Child Pugh stage B or C). In Asia and Africa, many people suffer from chronic Hepatitis B are diagnosed, but, in a hepatocellular carcinoma without already a cirrhosis of the liver developed. In this group of patients, the various chemotherapy were studied strategies, including Cisplatin+gemcitabine, Cisplatin+Interferon+Doxorubicin+5-FU, Doxorubicin+Cisplatin, Doxorubicin monotherapy, Capecitabine monotherapy and 5-Fluorouracil plus Oxaliplatin. The combination of 5-Fluorouracil (5-FU) and Oxaliplatin has acquired in some countries in Asia already have a certain clinical significance.

In the Western world, but there is still no evidence that the addition of a Cytostatic drug like Doxorubicin to a further improvement in the Sorafenib achieved a survival advantage. However, it comes with the combination of Sorafenib and Doxorubicin to an increase in side effects and toxicity. A recently published Phase III study shows that Doxorubicin has no role in the systemic treatment of HCC. Overall, not to continue the assessment of many experts that in Germany, a conventional chemotherapy in HCC in combination with Sorafenib, is useful.

In patients with good liver function (especially without cirrhosis and in good General condition), in which the Sorafenib therapy see due to side effects operations had to be aborted and will not be eligible for second-line treatment with Regorafenib in question, can be discussed in individual cases, the use of conventional chemotherapy (German S3-guideline). The majority of data available currently for Capecitabine or Oxaliplatin-based regimen (5-Fluorouracil (FOLFOX) or gemcitabine (GEMOX). Overall, it must be stressed, however, that the use of conventional chemotherapy in HCC, both in the First, Second and third line of the majority of experts (from Western countries) as critical will be assessed.

Pain treatment
In the advanced stage of the cancer, the pain is in the foreground, which can reduce quality of life significantly for patients often. One of the most important measures for the effective pain control is in this case. With today's available medications and methods tumour pain mostly well alleviate. In the foreground is the treatment with pain pills is that in the case of very severe pain even with morphine. The pain therapy is adjusted individually to the pain situation of the patient. Pain clinics and palliative stations, there are many clinics in Germany, in the territory of a particularly competent professionals.