My Mother Was Diagnosed With Hepatocellular Carcinoma

Q. My mother was diagnosed with hepatocellular carcinoma in 2007. This diagnosis was based on a recent MRI scan which revealed a large tumour (around 8cm) that extends from the capsule surface right down to the porta hepatis.

The appearance was typical of HCC and there was also evidence of recent haemorrhage within the tumour. AFT levels exceeded 2000ng/ml. Prior to the diagnosis, her health has deteriorated rapidly; she was experiencing severe right upper quadrant pain which radiated to her back and kept her awake at night.

She was also diagnosed with chronic Hepatitis C in 2001. Although interferon/ ribavirin dual therapy was commenced in 2002, it was ineffective. Cirrhosis was diagnosed after a liver biopsy. There is no concurrent problem to note and her health was good until late August 2007. We were informed that curative treatment was not an option as the tumour did not fulfil the Milan criteria for resection, chemotherapy would not be efficacious, and the tumour was too large for radiofrequency ablation. The last option presented was chemoembolisation.

Unfortunately her liver function was poor, she was in Child Pugh group C, and this treatment can only be given to those in Child Pugh group A or B as the risk of adversity in these groups is low. The only feasible option given was palliation and letting the disease progress and take its natural course but this is not acceptable to us. If there is no evidence of extra-hepatic spread of the cancer, would a transplant be possible?

A. It is an extremely difficult decision to decide on the best treatment for a patient with a large HCC and decompensated liver disease. You are quite right in thinking that currently, there is no curative treatment for such a condition except for liver transplantation which would treat her liver cancer together with her decompensating liver cirrhosis.

In many centres, due to acute shortage of cadaveric donor livers, patients with liver cancer beyond the Milan criteria are not transplanted. However, there are centres such as ours where living donor liver transplantation (LDLT) is widely practiced and often patients with large tumour, way beyond Milan criteria but with no extra-hepatic metastastes and also no large venous involvement such as the large hepatic veins and the main portal vein, are being transplanted successfully. The majority of patients transplanted in Asia using LDLT are beyond the Milan criteria as there is no other alternative treatment.

The 3 year survival rate for this group has ranged from 25-40% and it is well known that for patients who have survived the 3 years are likely to continue living beyond this period as the recurrence rate decreases markedly after the first 12-18 months. The main constraint to LDLT is, of course, the availability of a suitable donor.