At Mount Sinai, we can diagnose and treat a wide variety of liver cancers. Primary liver cancer—cancer that starts in the liver—is called hepatocellular carcinoma (HCC). It is the sixth most-common form of cancer worldwide, but the third leading cause of death from cancer. HCC almost always occurs in people who have had liver disease for many years. The most common cause of liver cancer in the United States is hepatitis C virus infection.
Historically, around half of our HCC patients at Mount Sinai have had hepatitis C. This figure has been rapidly shrinking since the introduction of effective hepatitis C treatment in 2014. However, HCC caused by alcoholic liver disease is becoming more common. Even more significant is the increase in fatty liver disease. This stems from the rising rates of obesity and diabetes. The condition, called nonalcoholic steatohepatitis, is rapidly becoming a leading cause of HCC. The Mount Sinai Hospital is located on the edge of Harlem. Due to high rates of hepatitis C, alcohol abuse, and fatty liver disease, the incidence of liver cancer in Harlem is around 20 cases per 100,000 people.
Around the world, hepatitis B virus is the leading cause of liver cancer. Nearly seven percent of people in China have hepatitis B. New York City, the most ethnically diverse city in the United States, is home to more than one million people born in Asia. About 15 percent of these one million people have hepatitis B. At Mount Sinai, about 25 percent of our HCC patients are Asian.
Most people who develop HCC have cirrhosis, which is a build-up of scar tissue due to years of liver damage. Since HCC usually grows slowly in its early stages, it can often be cured if discovered early enough.
People with any type of cirrhosis are at risk of developing HCC. Doing scans every six months has been proven to save lives. While screening with ultrasound is relatively inexpensive and widely available, we have found that as many as 30 percent of early cancers can be missed by ultrasound. For this reason, at Mount Sinai we prefer to use more sensitive methods like computerized tomography or magnetic resonance imaging.
To diagnose most types of cancer, doctors take a tissue sample (biopsy) and look at it under a microscope. This is not always necessary for HCC, though. We can usually use computerized tomography or magnetic resonance imaging scans with dye injection to make a diagnosis. If a person with cirrhosis has a mass in the liver with a characteristic-rich blood supply, we can diagnose HCC. Sometimes, though, we still need to perform a biopsy. We also use biopsies for genetic analysis, which may be necessary to develop personalized treatment plans.
To determine how advanced your cancer is and to create the most effective treatment plan, we do something called “staging the cancer.” For most types of cancer, we use guidelines from the American Joint Commission on Cancer. But for liver cancer, we use the Barcelona Clinic Liver Cancer staging system. This system, created by Mount Sinai Liver Cancer Research Director Josep Llovet, MD, and colleagues, is used throughout the United States and Europe. The chart below outlines the four classes of liver cancer, tumor size, and survival estimates.
|0||<2 cm||Cure is possible|
|A||1 tumor any size or 2-3 tumors all ≤ 3 cm Confined to liver||Cure is possible|
|B||2-3 tumors > 3 cm or 4 or more tumors confined to liver||Cure is less likely, but we can usually control the cancer for several years *|
|C||Invaded blood vessels or spread beyond the liver||Treatment is possible *|
|D||Same as C but patient cannot tolerate treatment||Supportive care is recommended|
* Some patients even with very advanced liver cancer can now be cured with immunotherapy.
Our goal for treating HCC is to remove or destroy the tumor before it grows larger or spreads to another organ. Some treatments that can destroy the cancer may not be good for liver function; this can be especially complicated if you also have cirrhosis. The most effective approach varies from person to person. At Mount Sinai, we take a team approach to developing a personalized treatment plan for you.
Surgical resection: If you have normal liver function and only one tumor, we can usually remove the part of the liver that contains the tumor. The liver regenerates (grows back) within around six weeks.
Liver transplantation: If your liver does not function normally, we may be unable to remove only part of it. In this case, the best option is often transplant. Patients with early-stage HCC who can’t have resection are eligible for priority on the liver transplant waiting list. Even with priority, though, you can wait more than a year for a donor liver. While you are waiting, we use nonsurgical treatments to keep the cancer under control. In addition, Mount Sinai has a living-donor program that can dramatically shorten the wait for patients who have a qualified and willing donor.
Locoregional therapy: We can often destroy tumors smaller than three centimeters in diameter, and control the growth of larger tumors that can’t be removed surgically, with these nonsurgical approaches:
- Thermal ablation, which uses a special needle to heat the tumor with microwaves
- Chemoembolization, which means injecting beads containing chemotherapy into the tumor’s blood supply
- Radioembolization, which means injecting radioactive beads into the tumor’s blood supply
- Stereotactic body radiotherapy, which uses high doses of radiation focused on the tumor
Systemic therapy: Until a few years ago, patients with class C HCC could only hope to live for about a year after diagnosis. Traditional chemotherapy doesn’t work for HCC, but new medicines called targeted drugs have been proven to make people with HCC live longer by stopping the cancer from growing, often for many months.
Even more exciting is the development of immunotherapy. Our immune system is meant to identify and get rid of cancer cells. Cancer develops when cancerous cells find a way to hide from the immune system by putting up “stop signs” called checkpoints. These keep the immune system from attacking and killing them. We now have medicines called checkpoint inhibitors that can get rid of the stop signs and allow the immune system do its job. While these drugs don’t work for everyone, when they do they can give dramatic and long-lasting results and even cure some patients with very advanced cancer. A top priority of our research is to figure out why immunotherapy works for some patients but not others.