Procedure Guides
Oncology

Liver Cancer Work Up

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Screening

  • AASLD recommends hepatocellular carcinoma (HCC) screening with US +/- AFP every 6 months. Not recommended for Child Pugh class C unless a transplant candidate given poor overall survival.

  • Multiphasic CT/MRI not recommended as primary means of screening unless US is likely to be or has been inadequate.

  • AFP helpful if HCC is an AFP producer but a third don’t

Disease Severity

  • Barcelona Clinic Liver Cancer (BCLC) - most widely used, updated in 2022, can use this calculator

    • (0) single lesion 2 cm or less, PS 0; (A) up to 3 lesions up to 3 cm, PS 0; (B) multinodular, preserved liver function, PS 0; (C) portal invasion, extrahepatic spread, PS 1-2; (D) any tumor burden with end stage liver function, PS 3-4

  • American Joint Committee on Cancer (AJCC) TNM system exists but is used less to guide therapy

  • MELD, MELD-Na, PELD

  • Child-Pugh Score - old score for mortality risk with cirrhosis

    • Newer scores shown to be better but still used

    • 5-6 = class A, 100% one year survival

    • 7-9 = class B, 80% one year survival

    • 10-15 = class C, 45% one year survival

  • ALBI (Albumin-Bilirubin) Grade for HCC, good for marginal cases, e.g., CP B

    • <-2.60 = grade 1, median survival 18.5-85.6 mo

    • >-2.60 to <-1.39 = grade 2, median survival 5.3-46.5 mo

    • >-1.39 = grade 3, median survival 2.3-15.5 mo

  • Performance status (ECOG)

    • 0 = fully active, same as predisease

    • 1 = symptomatic, ambulatory, able to carry out light work, e.g., house work or desk job

    • 2 = <50% of day in bed, unable to work but able to care for oneself

    • 3 = >50% of day in bed, limited self care

    • 4 = bedbound

    • 5 = death

Treatment Options

  • Transplantation - only truly curative treatment for primary liver cancer

    • Need to meet Milan criteria (some use UCSF criteria)

      • Milan criteria: single lesion <5 cm or up to three lesions <3 cm

      • UCSF criteria: single lesion <=6.5 cm or up to three lesions  with largest <=4.5 cm and total tumor diameter <=8 cm

    • Via UNOS/OPTN policy with urgency based on MELD (>11 yo) or PELD (<12 yo)

      • Status 1A and 1B receive highest priority where death is imminent without a liver, e.g., anhepatic, transplant failure within 7d, acute fulminant liver failure

      • Exception points: specific policies for CCC, HCC, cystic fibrosis, rare genetic conditions

        • Most based on age, median MELD at transplant (MMaT) for given transplant center, +/- tumor markers (CA 19-9 and AFP)

        • For HCC lesions to count, they need to be at least 2 cm and less than 5 cm; can downstage lesions 5-8 cm with LDT; receive 28 pts after 6 mo wait with additional 3 pts per 3 mo up to 34

    • AFP <500: if greater, there is often concern for microvascular invasion among transplant surgeons

  • Resection - ideal for small accessible tumors/mets (<3 cm)

    • Need preserved liver function, HVPG <10 (some say 8), BCLC 0/A

    • Need future liver remnant (FLR) to be at least 20% liver volume for non-cirrhotic, 40% for cirrhosis

      • Options for stimulating FLR hypertrophy:  portal vein embolization vs lobar radioembolization, also ALPS surgery but seems to increase size of FLR without function and high risk so fallen out of favor

        • PVE gives faster and sometimes better FLR hypertrophy but doesn’t treat the underlying tumor and has been shown to stimulate contralateral tumor growth in the CRC literature.

    • <10% of patients with HCC are candidates to resection at presentation

  • Ablation - generally comparable to resection in terms of outcomes

  • Radioembolization (TARE) - superior to TACE if sufficient liver function

    • Comparable results to ablation for single lesions up to 8 cm when dose is >400 Gy

    • Need preserved liver function (e.g. bilirubin <3), low enough shunt fraction

  • Chemoembolization (TACE) - better than systemic therapy and can be used in pts with worse liver function or in combination with ablation and/or TARE

    • cTACE, DEB-TACE, etc all likely similar in terms of outcomes

    • Stanford prefers cTACE for potentially less post-embolization syndrome and ability to visualize lipiodol staining; however, cTACE has more systemic side effects of the chemotherapeutic agent

  • Other options: systemic therapy (atezo + bev > sorafanib), SBRT

    • IMBRAVE 150 trial showed superiority of atezolizumab and bevacizumab (“atezo bev”) to sorafanib (mOS 19.2 vs 13.4 mo, ORR 30 vs 11%)

    • HIMALAYA trial showed superiority of STRIDE to sorafenib (mOS 16.4 vs 13.8 mo, ORR 20 vs 5%)

    • COSMIC 312 trial showed superior ORR (11 vs 4%) but not mOS (15.4 vs 15.5 mo) for cabozantinib/atezolizumab vs sorafenib

Neuroendocrine Tumor

  • Liver is key organ in metastatic NET as often it is the only site of progression and main cause of death is liver failure

  • On average, liver directed therapy controls symptoms in 75%, CR or PR in 55-60%, local control for ~18 mo

  • Serious adverse events ~5%, mortality 0-2%

  • PRRT (NETTER-1 trial): less ORR at 18% but longer response with medial PFS 28.4 mo, serious AE 9% if early line but very high if late, works better for smaller tumors (e.g. <3cm) 

  • Evirolimus: ORR <5%, PFS 13 mo, serious AE 5-9%

  • Cap-Tem: ORR 33%, PFS 23 mo, serious AE 8-13%