Tackling the Toughest of Cancers
A team of experts coordinates treatment to extend survival and improve quality of life for people with liver cancer.
By the time Donald Fransee learned he had colon cancer, it had already spread to his liver. Despite surgery to remove the colon cancer, his prognosis wasn’t good: liver metastasis is a leading cause of death for patients with colon cancer. Fransee’s oncologist was concerned and thought surgery might provide a curative option.
That was more than three years ago. After aggressive surgical intervention at Froedtert & the Medical College of Wisconsin, Fransee shows no sign of cancer.
Liver cancer — whether it starts in the liver or spreads to the liver from somewhere else — is notoriously difficult to treat. But there’s hope. At Froedtert & the Medical College, a team of experts coordinates the best possible treatment for each patient. “We take a multidisciplinary, multimodality approach to liver cancer,” said Edward Quebbeman, MD, PhD, Medical College of Wisconsin surgeon. Surgeons, radiation oncologists, medical oncologists, hepatologists, radiologists and pathologists combine science with compassion to form individualized treatment plans. Survival rates are increasing and so is quality of life.
Primary liver cancers result from liver disease. Hepatocellular carcinoma, or HCC, is cancer of the liver cells. It is often caused by hepatitis B or C or alcohol abuse, which can lead to cirrhosis (scarring) of the liver, a risk factor for developing liver cancer. Like most cancers, the earlier liver cancer is found, the easier it is to treat.
Unfortunately, the disease is often advanced by the time it is discovered. Underlying liver damage also presents a challenge. To effectively treat liver cancer, physicians must remove cancerous tissue, while preserving enough healthy liver tissue to sustain life.
Scoring First Downs“Today, with proper monitoring and preventive treatment, fewer people have to die of primary liver cancer,” said Rajiv Varma, MD, Medical College of Wisconsin hepatologist. “This is very different from five years ago.”
People who have chronic, progressive liver disease need treatment to prevent cirrhosis and liver cancer. Dr.Varma and other specialists at Froedtert & the Medical College emphasize this approach: “With early diagnosis of liver disease, we have a much better chance of preventing cirrhosis — and if it does occur, preventing it from developing into liver cancer. In fact, using a team approach that includes a transplant surgeon, we can cure both diseases if they are diagnosed early enough.”
Froedtert & the Medical College also have advanced imaging equipment, allowing physicians to find even the smallest tumor.
Even if the cancer is found later, there is hope.“ Advancements in surgery, chemotherapy and interventional therapies have come a long way,” said Bill Rilling, MD, Medical College of Wisconsin interventional radiologist and director of Vascular and Interventional Radiology. “We can now treat a lot of patients who previously would have been told, ‘There’s nothing we can do for you.’”
A Team of ExpertsDon Fransee was receiving chemotherapy when his oncologist referred him to Froedtert & the Medical College. “Dr. Quebbeman told me, ‘Stop the chemo. We’re going to do surgery,’” Fransee said. “They lopped off 70 to 75 percent of my liver, gallbladder and part of my diaphragm. The surgery was supposed to last three-and-a-half hours and went six-and-a-half. Dr. Quebbeman still wipes his brow every time he sees me.”
“The best treatment for tumors in the liver is to remove them — whether they’re metastatic or primary,” Dr. Quebbeman said. Kathleen Christians, MD, Medical College of Wisconsin surgeon agrees, adding: “Only a surgeon who is well experienced with liver disease should decide whether a liver tumor can be removed surgically. Studies tell us high volumes correlate with improved outcomes. At Froedtert, experience shows we can safely remove up to 70 to 80 percent of a healthy liver with very low risk to the patient. That’s a major improvement over past decades.”
At Froedtert & the Medical College, specialists meet twice a month to decide the best treatment for patients with liver cancer. “Our multidisciplinary meeting involves radiologists, surgeons, medical oncologists and interventional radiologists. We present each patient’s case, discuss it and form the best plan, knowing we may change it as we go,” said Jose Franco, Medical College of Wisconsin hepatologist. “Patients get 15 or 16 expert opinions.”
“With any kind of cancer in the liver, it’s important to be seen by physicians who have a vast amount of experience — who can offer all the different therapies,” Dr. Rilling said.
Individualized Game Plans“In the liver, the size, location and number of tumors are important in determining therapy,” said Beth Erickson, MD, Medical College of Wisconsin radiation oncologist. The extent of underlying liver damage also influences treatment.
Surgery is almost always considered first. “The premise is that if it’s resectable, always resect,” Dr. Erickson said. Depending on the size and location of their tumors, patients may have a large resection, or a smaller, wedge resection, which removes only a portion of the liver. Surgery can drastically improve a patient’s chance of survival. “With metastatic colon cancer, if we think we’ve gotten the entire tumor, patients have at least a 30 percent chance of long-term, disease-free survival,” Dr. Quebbeman said. “That doesn’t sound like much, but with chemotherapy alone, it’s far less.”
If a patient is not a candidate for liver resection, the team considers transplantation. “If the patient has a single tumor less than five centimeters in size, or three tumors or less, with all the tumors less than two centimeters — and the disease is confined to the liver, the patient is a candidate for liver transplantation,” said Brian D. Shames, MD, Medical College of Wisconsin transplant surgeon. In a liver transplant, the cancerous liver is replaced with a healthy donor liver. Survival rates are excellent: more than 60 percent of liver transplant patients are still alive after five years.
But not every patient is eligible for surgery or transplantation. Other options include radiofrequency ablation or cryoablation — “heating the cells until they die or freezing them to death,” Dr. Rilling said. These are outpatient procedures: “A patient can walk in the door with a liver tumor and walk out the same day with that tumor treated.”
“If our interventional radiologists can’t get to the tumor, we can still perform ablation with laparoscopic surgery,” Dr. Christians said. “We are developing more advanced laparoscopic skills and technology and will soon be able to remove many liver tumors using a minimally invasive approach.”
While ablation techniques are useful for relatively limited disease, regional therapies, including chemoembolization and TheraSphere®, treat entire segments of the liver. Chemoembolization is a minimally invasive procedure in which medication is injected through blood vessels directly to the tumor site. The blood flow to the tumor is then blocked, trapping the chemotherapy.
“TheraSphere® uses the same concept of delivery,” Dr. Rilling said. “But instead of delivering chemotherapy, we deliver microscopic glass beads impregnated with radiation.” Froedtert & the Medical College were one of the first medical centers in the country to offer this innovative therapy, which is as effective as chemoembolization, but produces fewer side effects. Patients may experience mild flu-like symptoms, compared with a seven to 14-day recovery.
Ablation and regional techniques may also be used while patients wait for a liver transplant. “We try to stop the cancer from growing so much that when a liver becomes available, you’re no longer a candidate,” Dr. Franco said.
Radiotherapeutic options include external radiation, brachytherapy and TomoTherapy™. Radiation is particularly useful for patients with cholangiocarcinoma, which frequently spreads throughout the liver before causing any symptoms. Radiation is also used after surgery as a precautionary treatment, for inoperable tumors and for palliation when a cure is no longer possible. “Radiation is always considered,” Dr. Erickson said. “When used selectively, it can be a very effective treatment.”
Reaching the GoalDon Fransee underwent two more surgeries with Dr. Quebbeman: one to remove an additional spot on the liver and another to remove a cancerous lymph node. The lymph node surgery was a first for Fransee and for Froedtert & the Medical College. While Dr. Quebbeman initially advised watchful waiting, Fransee was eager to have the cancerous node removed. Dr. Quebbeman researched a new “node seeker” technology, brought it to the hospital and successfully removed Fransee’s lymph node. It’s the kind of innovative therapy Fransee has come to expect from Froedtert & the Medical College.
“Be objective and deal with the facts,” Fransee said. “It’s never as bad as you fear.”
Source: Froedtert Today
Date: September 2006