One of the feared complications of Hepatitis C is HepatoCellular Carcinoma (HCC) aka Liver Cancer. While anyone can get this type of cancer it is most common in patients who have liver cirrhosis from any cause. We look for it using a blood test for AlphaFeto Protein (AFP) and/or Ultrasound, CT or MRI.
Ok, so the news has come back that you have an HCC. What are the treatment options?
- Do Nothing
- Chemotherapy with Sorafenib or Cabozantinib
- RFA
- TACE
- Resection
- Transplantation
- Experimental/Unproven/Deprecated Procedures
For a detailed rundown of current best practice please see https://bestpractice.bmj.com/topics/en-us/369
For a brief executive summary, please read on.
Do Nothing
While this sounds (and is) very nihilist the reality for some unfortunate patients is that nothing we do is likely to help.
Chemotherapy
Sorafenib, and more recently Cabozantinib are tyrosine kinase inhibitors. They are both tablets and can both slow down the progression of HCC in some patients. The key words are "slow down" and "in some patient" because neither drug can cure the HCC and they don't work in all patients.
Details on Sorafanib can be found here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2702892/
Details on Cabozantinib (the new kid on the block) can be found here: https://www.nejm.org/doi/full/10.1056/NEJMoa1717002
While Cabozantinib is probably better than Sorafanib, it is yet to be widely available. I have had a single patient who was already failing Sorafenib get 2 good extra years on Cabozantinib, but eventually, that too failed.
RFA
RFA stands for Radio Frequency Ablation. The simplest way to look at it as like this. We have a needle we stick into the tumour and the tip of it is like a miniature microwave oven. We then switch this on an cook the surrounding tissue. The idea is to kill all the cancer tissue and the minimal amount of surrounding healthy tissue. All things going well it can cure an HCC. For more details on the procedure: https://en.wikipedia.org/wiki/Radiofrequency_ablation
And for an analysis of the success rates: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5011083/
TACE
TACE stands for Trans Arterial Chemo Embolisation. It is a little like RFA but in this case the "needle" is flexible, and rather than stick it straight through the skin we thread it up through an artery. This bit is similar to an angioplasty for the heart. We continue threading it up the arteries until we find the artery that is supplying the tumour. We then inject some stuff to block off this artery and release some very toxic routine chemotherapy medications (doxorubicin or cisplatin). The idea is that everything downstream is killed. All things going well it can cure HCC. For more details on the procedure: https://en.wikipedia.org/wiki/Transcatheter_arterial_chemoembolization
And for an analysis of the success rates: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4915316/
Resection
If the HCC is in a favourable position in the liver it may be possible to cut it out. You don't need all your liver so throwing a segment, or a 1/2 of it out is possible.
Transplantation
Where resection is not possible, complete replacement of the liver may be possible. This becomes impossible if the tumour invades vital structures like the blood supply pipes or the bile ducts. Transplantation is complicated, expensive, requires long term immune supression, and there are not enough donor livers or transplant centers available.
Experimental/Unproven/Deprecated Procedures
TARE
TARE stands for Trans Arterial Radio Embolisation and in principle is like TACE except instead of chemotherapy laden spheres being use, radioactive spheres are used. For more information https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5497664/
Ethanol Ablation
The technique of Ethanol Ablation is similar to that of RFA in that a needle is inserted into the tumour through the skin, thus the other name PAE (Percutaneous Alcohol Ablation). It has largely fallen out of favour as it is not as effective as RFA and has more side effects. For more information https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3296972/
Naturopathy
It remains possible that there are natural medicines, largely unknown to science that may impact on HCC. I am personally aware of one patient who appears to have been cured using this modality.
Recurrence
The sad reality is that the cirrhosis that predisposes to getting one HCC predisposes to getting another, so curing one fixes the immediate problem, but more tumours may appear in the future. Long term follow up and monitoring is vital.
Hepatitis C and HCC
In the context of having Hepatitis C it's important to treat the HCC first, then treat the Hep C. For more details please see https://fixhepc.com/blog/item/108-daas-and-hcc-when-to-do-what-in-plain-english.html
The Good News Front
Without SVR one study showed liver cancer rates of 2.63% per year falling to 0.55% per year so Hep C treatment drops the risk of HCC development to about 1/5 of what it is untreated.
