Both in Europe and around the world, the number of cases of liver cancer is increasing. Of the oncological diseases of the liver, the most common are hepatocellular carcinoma of liver cells in adults (primary liver tumor), cholangiocarcinoma (the primary tumor of the bile ducts of the liver), as well as secondary tumors – metastases of various tumors in the liver in the liver. Hepatocellular carcinoma (HCC) accounts for about 75-80 percent. cases of liver cancer. It is the most common primary liver tumor, ranked fifth among oncological diseases in the world and second in terms of the number of deaths caused by it. Globally, about 854,000 new cases are detected per year, which accounts for as much as 7 percent of all tumors. About 810, 000 people die from this disease every year. In Europe, the incidence and mortality rates of hepatocellular carcinoma in adults are 65000 and 60240 cases respectively. About this threatening disease and innovative treatment options that respect the health of patients , the oncologist chemotherapist Vaida Gedaminienė and the head of the Interventional Radiology Department, doctor interventional radiologist Algimantas Šimkaitis, tell about this threatening disease and innovative treatment options that respect the health of patients.
The disease caused by chronic liver diseases is diagnosed in most cases in advanced stages
According to V. Gedaminienė, hepatocellular carcinoma in adults is an extremely aggressive type of cancer, the treatment options for which are limited. It is one of the most important causes of cancer deaths worldwide. In our country, about 190 new cases of HCC are diagnosed annually, about 40 of them – stages III-IV. Most often, this disease is detected in individuals aged 50-70 years.
According to the oncologist chemotherapist, hepatocellular carcinoma of liver cells in adults most often develops in patients with cirrhosis of the liver caused by chronic viral hepatitis C or B, alcohol abuse, rare liver diseases, obesity. This oncological disease develops from hepatocytes and is often associated with chronic liver diseases. At the beginning of the disease, inflammation of the liver develops, which can be caused by viral infection of hepatitis C and B, alcohol abuse, obesity, rare liver diseases. Subsequently, inflammatory changes progress to fibrosis and cirrhosis, which can transform into an adult hepatocellular carcinoma. As a rule, this disease is diagnosed already in the advanced stages. The prognosis in non-operated patients with adult hepatocellular carcinoma remains poor – the one-year survival rate from the beginning of diagnosis is less than 50 percent.
V. Gedaminienė says that the complaints of adult patients with hepatocellular carcinoma are not specific: fatigue, weakness, lack of appetite, weight loss, pain in the upper abdomen, a sucking formation in the upper abdomen, fever of unknown origin, nausea, increased abdominal volume, jaundice. Most often, these symptoms appear in the presence of an already advanced disease.
In order to detect HCC as early as possible, patients with cirrhosis of the liver are recommended to undergo an ultrasound scan of the liver every 6 months and check the concentration of the cancer marker alphafetoprotein (AFP) in the blood. When suspecting a disease, other radiological methods are used – computed tomography (CT), magnetic resonance imaging (MRI), a biopsy is performed and part of the liver tissue is examined microscopically.
Tactics for the treatment of hepatocellular carcinoma are selected by a multidisciplinary team
According to the oncologist chemotherapist, the treatment of each patient with HCC in the KUL is planned individually, selecting in each case the optimal method of treatment or their sequence. Treatment is scheduled during the discussion of a multidisciplinary team, where a surgeon, a radiologist, an interventional radiologist, an oncologist chemotherapist and an oncologist radiotherapist are present. When choosing a treatment, specialists take into account many factors – the patient’s age, general state of health, the size of the tumor, its type and spread, other important diseases that the patient suffers from. Having evaluated all of them, doctors select the tactics of treatment. The earlier the HCC stage is detected, the more radical the treatment can be applied. Liver resection or liver transplantation is performed when an early stage of the disease is detected. If surgical treatment is not possible, the possibility of radiofrequency ablation or trans-arthteric chemoembolisation (TACE) is assessed.
V. Gedaminienė says that advanced hepatocellular carcinoma in Lithuania is treated with a combination of certain medications (Atezolizumab and Bevacizumab). According to the specialist, this is the first and only cancer immunotherapy scheme registered in Europe that is not operable for the treatment of patients with HCC. This combination improves overall survival and progression-free survival compared to previous conventional treatment. The combination of athezolizumab and Bevacizumab is included in the recommendations of the European Society of Oncology and many other guidelines for clinical practice for the treatment of non-operable patients with HCC.
According to the results of the study, which showed that the combination of the above drugs reduced the risk of death – the overall survival (BI) reading increased by 42%, as well as the risk of disease progression or death – the indicator of progression-free survival (PFS) increased by 41% compared to the effect of sorafenib,” says the oncologist chemotherapist.
In strategies for the treatment of liver cancer, transarteric chemoembolization is successfully established
One of the most commonly used methods of treatment of interventional oncoradiology is trans-arteric chemoembolization (TACE).
According to Algimantas Šimkaitis, TACE stands out from other treatments in many respects. One of the advantages of this method over surgical treatment of a tumor is that the procedure is performed without an incision – thin catheters are introduced through a millimeter incision in the skin. There is also no need for general anaesthesia (anaesthesia) – during treatment, only the catheter entry point in the skin is anaesthetized. In comparison with systemic treatment, when intravenously administered chemotherapeutic agents circulate throughout the body, as well as acting on areas not damaged by the tumor, particles saturated with chemopreparations during the TACE procedure are injected directly into the focus of the disease, thus acting on the target in high concentrations, while at the same time sparing adjacent tissues and not compromising the patient’s quality of life. This is an extremely accurate and safe method that allows you to affect only the tumor without damaging not only other organs, but also a healthy part of the liver. In addition, the drug absorbed on the surface of the microspheres acts on the inflamed liver tissue for significantly longer than with other methods of treatment.
“However, like many other methods of treating an oncological disease (surgery, ablation, systematic methods of treatment, irradiation), trans-artoeric chemoembolization has only a certain place in the treatment algorithms – the rules of treatment, and is applied in the decisions of a multidisciplinary team, in which professionals from several fields select the most optimal individual treatment plan for each patient. According to the algorithms, TACE can be used to prepare the patient for further treatment (bridging principle). With this method, it is possible to reduce the volume of the tumor, thereby creating conditions for operative removal of the tumor or a liver transplant. TACE can also be used as an independent treatment for individual non-operated foci,” the interventional radiologist shares the possibilities of an innovative treatment method.
Transarteric chemoembolization – not only extremely effective, but also well tolerated
Algimantas Šimkaitis says that before performing TACE, very fine particles – microspheres – of the size suitable for this procedure are selected in each case. Their sizes can be from 100-200 to 400 microns. According to each specific case, a chemotherapeutic preparation is selected, with which the microspheres of the selected size and amount are saturated in the morning of the day of the procedure. In this way, this drug in high concentrations is “locked” in the prepared microspheres. Upon the patient’s arrival at the interventional radiology operating room, long thin (~1mm in diameter) catheters are introduced through a topically anaesthetic point. With them, under the control of the angiography apparatus, the tumor is reached, the peculiarities of its blood circulation are evaluated, even thinner microcathets are selected, through which microspheres saturated with chemotherapeutic drugs are injected into the focus, protecting healthy tissues.
One of the effects of TACE is the blocking of the tumor by embolizing its blood circulation, causing its ischemia, infarction. The second effect is a drug released from the injected microspheres only in that damaged area, acting only on the tumor in high concentrations, at the same time can be detected in the systemic circulation only in extremely low concentrations. It is also important that treatment with TACE can be and is often repeated several times. The duration of the procedure, depending on the number, size and anatomical complexity of the foci, is different in each case – from 30 minutes to 1.5 hours.
After the procedure, the patient is returned to the department for further observation. In isolated cases, soreness may appear on the doctor’s side, the patient may feel nauseous, the temperature may rise, but these known symptoms are observed, so an effective treatment that suppresses them is prescribed in a timely manner. The increasingly common practice of performing TACE in day inpatient conditions, and the patient is discharged into the house in the evening of the same day, suggests that the procedure is tolerated well enough.
Algimantas Šimkaitis, head of the interventional radiology department, says that TACE is an opportunity for a person struggling with an oncological disease to receive the most suitable treatment for him in accordance with modern treatment guidelines. This procedure in our country is reimbursed by the budget of the Compulsory Health Insurance. For a doctor oncologist who leads the patient on a journey through the disease, transarteral chemoembolization is another instrument in the entire palette of possibilities, which allows you to unrestrictedly select the most optimal treatment for each particular case, the ability to control the progress of the disease, demonstrate good indicators of relapse and survival.
“By performing transarteral chemoembolization in the KUL branch “Klaipėda Hospital”, we can offer effective treatment to any patient with an oncological disease who applies to us without reservations. In the Center for Interventional Radiology, in addition to TACE, an interventional oncoradiologist may prescribe such therapeutic procedures as destruction-ablation of foci (cold, radiofrequency or microwave), electrochemotherapy, trans-arterial embolization without chemotherapy (TAE). It is also important that the interventional radiologist is involved even at the stage of detection of the disease by performing a biopsy. In cooperation with the professionals of the oncoradiology department of the radiology clinic, patients are guaranteed both early diagnosis and subsequent tracking – monitoring of the effectiveness of treatment,” says A. Šimkaitis. Concluding the conversation, the physician interventional radiologist says that the progress of modern medicine is ensured by both the latest scientific achievements, new studies, and technological progress – the latest equipment, the technologies that are modernizing every day, including the integration of artificial intelligence at all stages. The modern, constantly renewing KUL branch “Klaipedos hospital” and the constantly raising qualifications of specialists working here can guarantee safe, individualized, effective services to a patient facing any health problem
