Can liver cancer be operated on in cirrhosis?

Sometimes, yes. Resection is considered in compensated cirrhosis without clinically significant portal hypertension, provided enough liver will remain after surgery. If cirrhosis is compensated but resection is risky because of portal hypertension, ablation is often chosen; in decompensated cirrhosis, transplantation becomes the main option if the tumor meets its criteria. The decision is made after assessing liver function, not just tumor size.

Is a biopsy required for the diagnosis?

Not always. In a patient with cirrhosis, the typical appearance of a nodule of 1 cm or larger on multiphase contrast-enhanced CT or MRI often allows the diagnosis to be made without a biopsy. If the appearance is atypical or there is no cirrhosis, a biopsy is needed.

Which is better, resection or ablation?

For the smallest tumors, up to about 2 cm, the results are comparable, and the choice depends on the location of the nodule and the condition of the liver. For nodules of 2–3 cm both methods remain options, and for tumors larger than 3 cm resection usually has the advantage if it is safe for the liver. The choice is discussed by the MDT.

When is liver transplantation considered?

When there are few tumors and they are small, but the liver is so affected by cirrhosis that resection is dangerous. Transplantation removes both the tumor and the diseased liver. Eligibility and priority are determined by the transplant center; while the patient waits, the tumor is usually controlled with local treatments.

Can liver cancer come back after surgery?

It can, because the diseased liver remains. That is why regular CT or MRI and treatment of the cause (hepatitis, alcohol-related or metabolic liver disease) are needed after treatment. A recurrent tumor found early can often be treated locally again.

Liver cancer (hepatocellular carcinoma): when resection is possible

Hepatocellular carcinoma is the most common primary liver cancer. It usually develops in a liver already affected by chronic disease, so the treatment decision depends not only on the tumor but also on how well the liver itself works. Resection is possible when liver function is preserved and enough healthy tissue will remain after surgery. If not, ablation, transplantation, intra-arterial treatment or systemic therapy are discussed.

Kateryna Valikhnovska, MD, surgical oncologist, during a laparoscopic operation — The laparoscopic stage of an operation: the lights in the operating room are dimmed because the surgeon works from the camera image on the monitor.

Why hepatocellular carcinoma develops

This tumor grows from the liver’s own cells, the hepatocytes. The main risk factor is cirrhosis, the replacement of liver tissue with scar tissue, whatever its cause. Cirrhosis and cancer can result from:

chronic viral hepatitis B and C; with hepatitis B, cancer can develop even without cirrhosis;
alcohol-related liver disease;
metabolic dysfunction-associated steatotic liver disease, linked to obesity, type 2 diabetes and lipid disorders; its share among causes is growing, and cancer can also arise in it without cirrhosis;
rarer causes such as hemochromatosis, autoimmune and other chronic liver diseases.

Liver cancer is often confused with liver metastases. These are different diseases: metastases are cells of a tumor from another organ, most often the bowel, and they are treated by different rules. They are covered on the pages colorectal liver metastases and liver metastases from other tumors. A tumor arising from the bile ducts inside the liver is also considered separately: intrahepatic cholangiocarcinoma.

Are there symptoms

In the early stages, usually not. A small tumor does not hurt and does not impair liver function, so it is found on ultrasound during routine surveillance for cirrhosis or an examination for another reason. Later there may be heaviness or pain under the right ribs, weight loss, weakness, abdominal swelling from ascites, and jaundice.

In people with cirrhosis, a decline in health is often attributed to the cirrhosis itself, and the tumor is noticed late. That is why people with cirrhosis, as well as patients with chronic hepatitis B whose risk the hepatologist rates as increased, are advised to have regular liver ultrasound, usually every six months, with an alpha-fetoprotein test when needed. The aim of this surveillance is to find the tumor while it can still be removed or destroyed.

Examinations needed

Multiphase contrast-enhanced CT or MRI of the liver is the main examination. In a patient with cirrhosis, the typical appearance of a nodule of 1 cm or larger on such a scan often allows the diagnosis to be made without a biopsy.
Biopsy is needed when the appearance is atypical or the tumor has arisen in a liver without cirrhosis: then the diagnosis is not made without histology.
Assessment of liver function: blood tests (bilirubin, albumin, clotting), the Child-Pugh and MELD scores, and specialized function tests when needed.
Signs of portal hypertension: esophageal varices on endoscopy, platelet count, spleen size. Whether resection is safe depends largely on them.
Volumetry: a CT-based calculation of how much liver will remain after surgery.
Alpha-fetoprotein: a marker that helps with diagnosis and follow-up, although a normal level does not rule out a tumor.
Chest CT, to rule out spread beyond the liver.

When surgery is possible

Three conditions must be met for resection: the tumor is confined to the liver, liver function is preserved, and the remaining tissue is sufficient to sustain life. More of a healthy liver can be removed than of a cirrhotic one: a cirrhotic liver regenerates less well, and an overly large resection risks liver failure.

The best candidates for resection are patients with a single tumor, without cirrhosis or with compensated cirrhosis without clinically significant portal hypertension. Size alone is not always an obstacle: large single tumors in a healthy liver are also removed if the vessels and the remnant volume allow it.

Small tumors, usually up to 2–3 cm, can also be destroyed by ablation: through a needle guided by ultrasound or CT, or during laparoscopy. For tumors up to 2 cm, ablation is considered an equivalent alternative to resection, and for 2–3 cm one of the options; the choice depends on the location of the nodule and the condition of the liver.

If resection is not possible

Ruling out resection does not mean there is no treatment. The options depend on the stage, liver function and general condition:

liver transplantation: for some patients with cirrhosis and a small number of small tumors, it removes both the cancer and the diseased liver at once; eligibility is determined by the transplant center, and before transplantation the tumor is often controlled with ablation or embolization;
ablation, for small nodules, including when resection is contraindicated because of the condition of the liver;
chemoembolization and other intra-arterial treatments, for several nodules in the liver without spread beyond it, with preserved liver function and without tumor invasion of major vessels: the drug is delivered directly into the arteries that feed the tumor;
systemic therapy: immunotherapy combined with an anti-angiogenic drug or with a second immunotherapy drug, and targeted drugs when immunotherapy is contraindicated; it is given for advanced tumors or when local treatments have been exhausted, provided liver function is adequately preserved.

Sometimes, after intra-arterial or systemic treatment, the tumor shrinks enough for resection or transplantation to be reconsidered. That is why the decision is reviewed on follow-up scans, and the final plan is determined by the MDT.

How the operation is performed

The extent of resection is determined by the tumor’s location, its relation to the vessels and the condition of the liver. When the tumor’s location and the condition of the liver allow, an anatomical resection may be chosen: removal of the segment or lobe supplied by the same portal vein branch as the tumor. This makes it easier to remove small nearby satellite lesions as well, although its advantage over non-anatomical resection has not been definitively proven. In cirrhosis, by contrast, the aim is to preserve as much tissue as possible, and the extent is weighed especially carefully.

During surgery the liver is inspected and examined with an ultrasound probe to find lesions not visible on scans and to define the resection margins precisely. If the remnant volume is borderline, portal vein embolization can be performed before surgery: the part of the liver that will remain enlarges over several weeks.

When the tumor’s location and the extent of resection allow, the operation is performed laparoscopically, through several small incisions. In patients with cirrhosis this may reduce some of the complications associated with a large incision.

With liver cancer, I assess two organs in one: the tumor that has to be removed and the liver that has to work after surgery. The second matters no less than the first.

Kateryna Valikhnovska, MD, surgical oncologist

Recovery after surgery

Care follows the enhanced recovery after surgery (ERAS) protocol: early mobilization, early feeding, controlled pain relief. In the first days, liver function is monitored especially closely: bilirubin, blood clotting, fluid accumulation in the abdomen. A healthy liver regains its volume within a few weeks; in cirrhosis recovery is slower, and treatment of the underlying liver disease continues after surgery.

The length of the hospital stay depends on the extent of resection, the approach and the condition of the liver, and is determined individually.

Follow-up

After resection or ablation the risk of a new tumor remains, because it can arise again in a liver affected by chronic disease. Follow-up is therefore long: in the first years, contrast-enhanced CT or MRI and alpha-fetoprotein every few months, then less often. The exact schedule is set by the doctor.

Treating the cause is just as important: antiviral therapy for hepatitis B or C, stopping alcohol, correcting weight and metabolism. A recurrent tumor found early can often be removed again, destroyed by ablation, or considered for transplantation.

What to bring to the consultation

discs of contrast-enhanced liver CT or MRI and the reports;
blood tests: complete blood count, biochemistry, coagulation panel, alpha-fetoprotein;
information on the liver disease: hepatitis, its treatment, hepatologist’s reports;
the report of upper endoscopy, if it was done;
the histology report and slides, if a biopsy was done;
discharge summaries of previous treatment: ablation, embolization, systemic therapy.

If some materials are missing, that is no reason to postpone the consultation: some examinations can be done on site.

The consultation is free of charge. How it goes and how long it takes is described on the page “Oncologist Consultation”.