In a related editorial also published this month in Liver Transplantation, Dr. Patrick Northup from the University of Virginia agrees and writes, “The Goldberg et al. study adds strength to the argument that the ‘sickest first’ policy may not be well served by the current allocation methods for HCC under the MELD system.” He proposes that the transplantation community strive to develop a more fluid allocation system that is responsive to new medical evidence. “The allocation system should be managed as a whole, rather than as isolated pieces, to ensure patients on the waitlist are prioritized based on the desire to minimize waitlist mortality.”
How is primary liver cancer diagnosed?
Primary liver cancer can be diagnosed using a combination of blood tests, diagnostic imaging and image-guided biopsy. The blood test that is most useful is AFP (alpha-fetoprotein).
These tumours will often show on an ultrasound scan, but for full assessment both CT and MRI scans are required.
A needle biopsy using ultrasound (or other imaging) guidance will usually confirm the diagnosis.
How is primary liver cancer treated?
Primary liver cancer is difficult to treat. Surgical removal is the best option but these tumours are often too large and too extensive for surgery.
For fit patients with limited tumours surgical removal may be possible. Liver transplant may also be an option.
Some tumours can be treated by injecting them with alcohol (PEI – percutaneous ethanol injection) or heating them with electrodes (RFA – radiofrequency ablation). This can be done by using needles passed through the skin or by using keyhole surgery.
A technique called TACE (transarterial chemoembolisation) can be used for more advanced tumours.
An interventional radiologist can place a catheter into the artery supplying the tumour and this can be used to deliver chemotherapy drugs mixed with a syrupy fluid directly to the tumour. This approach both delivers the cell-killing drug directly to the tumour and cuts off its blood supply.
Standard intravenous chemotherapy is occasionally used for inoperable tumours but any benefit is usually short lived.
Experimental treatments include biological agents such as cetuximab (eg Erbitux) and sorafenib or using catheters to deliver tiny radioactive pellets to the tumour (SIRT – selective internal radiation therapy).
Specialised techniques, involving the temporary placement of radioactive wires, can be used to treat certain primary cancers of the ducts within, or immediately adjacent to, the liver.
Unfortunately, survival rates for primary liver cancer are low – the three-year survival rate is less than five per cent.
Full citations: “Increasing Disparity in Waitlist Mortality Rates with Increased MELD Scores for Candidates with versus without Hepatocellular Carcinoma.” David Goldberg, Benjamin French, Peter Abt, Sandy Feng, Andrew M. Cameron. Liver Transplantation; (DOI: 10.1002/lt.23394) Published online: January 23, 2012; Print Issue Date: April 2012. http://onlinelibrary.wiley.com/doi/10.1002/lt.23394/abstract.
Editorial: “HCC and MELD Exceptions: The More We Understand, The More Challenging the Allocation Gets.” Patrick G. Northup and Carl L. Berg. Liver Transplantation; (DOI: 10.1002/lt.23409) Published online: Februar 10, 2012; Print Issue Date: April 2012. http://onlinelibrary.wiley.com/doi/10.1002/lt.23409/abstract.
About the Journal
Liver Transplantation is published by Wiley-Blackwell on behalf of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society. Since the first application of liver transplantation in a clinical situation was reported more than twenty years ago, there has been a great deal of growth in this field and more is anticipated. As an official publication of the AALSD and the ILTS, Liver Transplantation delivers current, peer-reviewed articles on surgical techniques, clinical investigations and drug research - the information necessary to keep abreast of this evolving specialty. For more information, please visit Liver Transplantation.
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