Treatment of Liver Metastases

Liver metastases, or secondary cancer of the liver, develop in spreading of the oncological process to the liver from other organs and body regions. Typically, liver metastases are indicative of stage IV cancer. Primary cancers of pancreas and stomach, kidneys, ovaries and uterus, colon and rectum, esophagus, lungs and breast are the most likely to spread to the liver. Considering the diversity of types of primary tumors, treatment of liver metastases is a challenging medical task. Nevertheless, clinicians in specialized hospitals use variety of modern therapeutic methods, so remission or even cure may be possible for some patients. Patients with stage IV liver cancer may benefit from targeted treatments and immunotherapy. Chemoembolization may be an additional option for patients with advanced cancer or first-line treatment for patients with small primary neoplasms or few liver metastases.

Content

1. Diagnostics of liver metastases
2. Surgical resection
3. Alcohol ablation
4. Radiofrequency ablation
5. Percutaneous embolization
6. Radiation therapy
7. Systemic treatments
8. Leading hospitals and cost of treatment of liver metastases
9. Treatment of liver metastases in the best hospitals with Booking Health

Diagnostics of liver metastases

Making the precise diagnosis of liver metastasis is the essential part of planning the therapeutic regimen. As a matter of fact, all organs need to be examined in order to detect the primary tumor and all possible secondary lesions. Laboratory tests that are aimed at assessing the general health state are also performed.

Diagnosis making starts from the anamnesis collection, i.e. discussing history of gastroenterological and oncological pathologies in the patient or his relatives. A doctor may also ask questions regarding working conditions, exposure to chemicals or radiation, etc. Anamnesis collection is followed by physical examination, laboratory tests and instrumental procedures.

Laboratory and instrumental diagnostics of liver cancer includes the following procedures:

• Liver function tests
• Ultrasound scan of the abdomen
• MRI and / or CT scan of the abdomen
• Angiogram (if necessary)
• Laparoscopy with biopsy

Laparoscopy allows harvesting tissue sample for the subsequent histological and immunohistochemical laboratory examination, so that the tumor type, its sensitivity to medications and other important factors can be determined.

Depending on the diagnostic data, surgery, alcohol or radiofrequency ablation, as well as different types of embolization and systemic cancer treatment are used.

Surgical resection

Possibility of surgical treatment in patients with liver metastases depends on the following factors:

1. Localization of the primary tumor. For instance, liver metastases in patients with bowel cancer are often treated by means of surgery.
2. Control of the primary oncological process. Surgery for metastatic lesions is indicated in the remission of the primary tumor, not in case of its active progression.
3. Number and size of liver metastases.
4. Spread of the metastatic process beyond the liver, presence of the secondary neoplasms in other organs.

Surgery for liver cancer treatment is called liver resection. Liver resection includes removing the part of a liver. Sometimes doctors need to remove the whole organ, which is called total hepatectomy. After the liver resection, the remaining part of the organ regenerates over time and manages to maintain normal function.

In order to facilitate regeneration, doctors may temporarily block the branch of the portal vein a few weeks before the intervention. When the whole organ is removed and no healthy tissue for the regeneration is left, liver transplantation is required in order to avoid liver failure.

Alcohol ablation

Alcohol ablation of liver metastases is the image-guided interventional therapy. It is efficient in patients with liver lesions that are less than 3-5 cm in size, which includes both liver metastases and primary liver cancer. These are mainly patients with spread of colorectal cancer, breast cancer or endocrine tumors to the liver. Candidates for alcohol ablation therapy should meet the following requirements:

1. The patient has less than three malignant loci in the liver
2. Each locus has distinct margins and fibrous encapsulation
3. Each locus should be located inside the liver, away from its surface

Alcohol ablation is performed under the ultrasound guidance. After performing anesthesia, a surgeon inserts a long thin needle inside the malignant locus. When the needle is in the correct position, a surgeon injects a concentrated alcohol solution through it. Concentrated alcohol causes necrosis of the malignant tissues. To destroy liver cancer completely, a patient may need few therapeutic sessions.

The procedure can also be performed in patients with concomitant liver cirrhosis. If benign liver cells have cirrhosis, they are less likely to suffer from the injection of concentrated alcohol.

This type of therapy should not be used in liver cancer patients who have chronic or acute liver failure, as they will not be able to tolerate it well.

Radiofrequency ablation

Radiofrequency ablation of liver metastases is aimed at direct destruction of the malignant loci without their surgical removal. Compared to surgery, this type of cancer therapy is less likely to cure the malignancy completely. Nevertheless, it improves survival and quality of life.

Actually, there are few types of non-chemical ablation of liver metastases. These are:

1. Radiofrequency ablation. Radiofrequency ablation destroys the target area with high-energy radio waves.
2. Microwave ablation. Microwave ablation includes targeted heating of the metastatic locus with the help of energy from electromagnetic waves.
3. Cryoablation (cryotherapy). Cryoablation, on the contrary, destructs liver cancer with the help of low temperatures.

Regardless of the type of ablation, the procedure includes insertion of a thin needle or a needle-like probe directly into the tumor. To make the process more comfortable for the patient, anesthesia is used. High precision of the procedure is due to the visual guidance of ultrasound or CT scan.

When a needle or a needle-like probe is in the target region, radio waves, electromagnetic waves, or cold gasses are passed through it. Once the therapy is completed, the patient is transferred to the general ward and discharged from the hospital the same day.

Percutaneous embolization

The general term "embolization" means manipulating on the hepatic artery that feeds healthy liver tissue and liver cancer. Reducing blood supply and depriving liver metastases from oxygen and nutrients leads to their shrinkage or even total destruction. Combination medical therapies with additional administration of chemotherapeutic drugs or radioactive substances are also used:

1. Trans-arterial chemoembolization (TACE).
2. Drug-eluting bead chemoembolization (DEB-TACE).
3. Radioembolization (selective internal radiation therapy, SIRT).

Trans-arterial embolization (TAE) starts from making a small incision in the groin and inserting a catheter into the femoral artery. Step by step, a catheter is guided towards the liver and reaches the artery that feeds a tumor. Once a catheter is inside the target blood vessel, a doctor injects an oily liquid or foam through it. Injected substances exclude the artery from the systemic circulation, which reduces viability of liver cancer and leads to its destruction.

In TACE and DEB-TACE, the procedure is complemented by the local introduction of a chemotherapeutic drug. High local drug concentration may be achieved without affection of healthy tissues. Due to the slow Nevertheless, in some patients with liver metastases from neuroendocrine tumors TAE is even preferred to TACE, as it has comparable anti-tumor effect alone with somewhat better tolerability.

Radiation therapy

Radiation therapy is not a common therapeutic option for liver malignancies, as healthy hepatocytes are extremely sensitive to the irradiation. Patients with hepatitis or cirrhosis are also not the best candidates for this procedure. So, risks and benefits of the radiation therapy performing are always assessed before the treatment start. In most patients, radiotherapy is a part of the combination liver cancer treatment scheme.

There are three main types of radiation therapy:

1. External beam radiation therapy (EBRT) uses sources of radiation that are located outside a patient’s body. The procedure is somewhat similar to the X-ray examination, but it uses higher doses of irradiation. EBRT usually takes several weeks, as small irradiation doses are given to a patient daily.
2. Stereotactic body radiation therapy (SBRT) allows reducing radiation damage to the healthy hepatocytes. In SBRT high-dose radiation beams are focused on the tumor precisely. Compared to the EBRT, a course of SBRT is shorter, as higher doses of radiation are given daily.
3. Selective internal radiation therapy (SIRT), or radioembolization, is performed like a conventional embolization procedure. The difference is, SIRT includes additional introduction of microspheres with radioactive substance prior to the hepatic artery blockage. In SIRT, healthy liver cells are not affected.

Systemic treatments

Systemic treatments are given intravenously or orally, so that the drug enters the systemic circulation and reaches not only liver metastases, but also all organs. Depending on the drug type, systemic treatments are divided into:

• Chemotherapy. The most efficient option is administering combinations of chemotherapeutic drugs. Unfortunately, the clinical response to chemotherapy usually does not last long in patients with liver metastases.
• Hormone therapy. If the primary tumor is sensitive to hormones (e.g. in case of prostate cancer or breast cancer), hormone therapy is indicated in the secondary liver tumors as well.
• Immunotherapy. This group of drugs influences proteins that are responsible for recognizing and attacking the tumor by a patient's own immune cells.
• Targeted cancer drugs. These are monoclonal antibodies, PARP inhibitors, cancer growth blockers, angiogenesis blockers. Targeted cancer drugs interfere with specific tumor’s molecules or conditions that are essential for tumor growth and survival.

Leading hospitals and cost of treatment of liver metastases

Hospitals that admit patients for liver cancer treatment should have the most advanced equipment for the precise diagnosis making, access to the innovative medicines and treatment techniques, as well as highly trained healthcare professionals. The following hospitals are among TOP healthcare institutions that offer liver cancer treatment:

1. University Hospital of Ludwig Maximilian University of Munich, Germany
2. University Hospital Duesseldorf, Germany
3. University Hospital Heidelberg, Germany
4. Memorial Sisli Hospital Istanbul, Turkey
5. University Hospital Ulm, Germany

Prices for liver cancer treatment depend on the chosen procedure. Prices for the surgery, radiation therapy, image-guided interventional procedures and systemic therapies are as follows:

1. Diagnosis of liver metastases – from 1,686 EUR
2. Treatment of liver metastases with alcohol or radiofrequency ablation – from 4,727 EUR
3. Treatment of liver metastases with surgical resection – from 20,865 EUR
4. Treatment of liver metastases with percutaneous embolization or chemoembolization – from 4,756 EUR

After the completion of the main treatment course, a patient may stay under the distant supervision of the foreign physician or repeatedly come to the foreign hospital for control examinations and recurrent liver cancer prevention.

Treatment of liver metastases in the best hospitals with Booking Health

Patients with liver metastases are free to undergo advanced treatment in any hospital in the world due to the work of international medical tourism provider Booking Health. Booking Health specialists consider all the peculiarities of treating people with liver metastases and offer help in:

• Choosing the most relevant hospitals based on their specialization and success rates
• Making appointment with the chosen doctor
• Avoiding long waiting for the medical program start
• Elaborating the preliminary medical program in advance, considering the available medical records
• Providing favorable cost of treatment for liver metastases, without extra fees for foreign patients (saving up to 50%)
• Help in buying and forwarding drugs and the required medical products
• Communication with hospitals after cancer treatment completion
• Cost of treatment control, return of unspent funds
• Organization of additional procedures and rehabilitation (if necessary)
• Offering non-medical service of the highest level: transfer, booking hotels and plane tickets, interpreting services

To start planning liver cancer treatment, please leave the request on the website of Booking Health. A medical advisor or patient case manager will contact you the same day and explain your further steps.

Authors: Dr. Nadezhda Ivanisova, Dr. Sergey Pashchenko