Liver Cancer: Hepatocellular Carcinoma
Guest: Dr. David Koch – Gastroenterology-Hepatology
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. David Koch who is Assistant Professor of Medicine and a specialist in liver disease here at the Digestive Disease Center. Dr. Koch, I want to talk a little bit, if we could, about primary liver cancer, or hepatocellular carcinoma, as a gastroenterologist might call it. What are the first symptoms a patient might notice if they have a primary liver cancer, that is, cancer that actually starts in the liver as opposed to one that spreads to the liver?
Dr. David Koch: In general, most patients are actually asymptomatic or do not know that they have a tumor in the liver. It is most commonly seen in patients who have underlying cirrhosis. Frequently it is done because we know that they are at increased risk for liver cancer and screening measures are obtained as far imaging is concerned. In other words, a patient will be thought to have cirrhosis. They will have an image done of their liver, whether it is ultrasound, CT or MRI, and it recognizes a lesion in the liver that is concerning for hepatocellular carcinoma.
Dr. Linda Austin: I see. So, somebody at risk, then, would be followed with a scan and then in the scan, you would see it, rather than someone coming in with an ache or a pain, or something like that? Is that right?
Dr. David Koch: Correct. In general, most patients who are diagnosed with liver disease undergo screening for hepatocellular carcinoma and, in general, that is checking the blood for alpha fetoprotein, or AFP, which is a potential marker for liver cancer, as well as abdominal ultrasound imaging every six months. Also, when someone is initially found to have liver disease, or suspected of cirrhosis, many physicians will obtain an image of the liver in their initial work-up of their liver disease. In that setting, they may also find liver cancer at that time.
Dr. Linda Austin: Now, you mentioned that there are several imaging studies that could be done. Where do you start? What would be the first you would order?
Dr. David Koch: If we are doing the screening measures, which are done every six months, we use ultrasound because it does not have any radiation. Screening every six months with CT scan would give the patient a significant amount of a radiation dose. It is easy, relatively inexpensive, so, in general, patients with cirrhosis are screened with ultrasound.
Dr. Linda Austin: Okay. So, let’s imagine that something suspicious-looking comes up. What would be the next step?
Dr. David Koch: If there is a suspicious lesion on ultrasound, generally, at our institution, we get an MRI of the liver. The MRI, based on different imaging characteristics of the lesion, can very reliably be characterized as hepatocellular carcinoma, or not necessarily a malignancy. The radiologists are very adept at determining whether it is in fact hepatocellular carcinoma even without the need for biopsy.
Dr. Linda Austin: Really? So, they can just look at the image and pretty much know if it is a significant form of cancer?
Dr. David Koch: Correct. They are very good at helping us determine whether or not the lesion is hepatocellular carcinoma. It [MRI] is also very good at determining the size of the lesions and number of lesions in the liver, which are important.
Dr. Linda Austin: So, how do you determine, then, what the next step is?
Dr. David Koch: The next step can be a bit complicated but, in general, there are several things that go into our decision making. Number one: when someone has hepatocellular carcinoma, the first thought is whether or not they would be a transplant candidate. There are specific criteria, then, if they were to be a transplant candidate to determine if the lesions meet listing criteria. In other words, the cancer cannot be too large or there cannot be too many of them. Otherwise, they would not be a candidate for transplant.
There are also different treatment modalities that we can use to try to ablate the tumor, which is done by interventional radiology. Finally, there are, now, newer oral agents, or chemotherapeutic agents, that are shown to increase life expectancy but generally are used in patients who are not transplant candidates. So, there are actually several different routes that we can do to treat the cancer from that point. A lot of it depends, though, on whether or not the patient could undergo transplant and their overall health status.
Dr. Linda Austin: We have done some podcasts with Renan Uflacker and somebody listening to this could go to learn about some of the interventional radiologic treatments for liver cancer. I believe that is cryotherapy. Is that right?
Dr. David Koch: There are several different treatments. One that we use is called RFA, or radio frequency ablation. It is essentially a microwave or heating of the tumor. Other options are transarterial chemoembolization (TACE) in which a chemotherapeutic agent is infused to the liver tumor through the artery by interventional radiology. Therospheres are another option that we are using as a possible treatment by interventional radiology for hepatocellular carcinoma.
Dr. Linda Austin: I would imagine, also, that part of the decision is based on whether the cancer has spread beyond the liver?
Dr. David Koch: Correct. In general, when we do the initial evaluation, we will obtain an image of the chest and also bone scan to see if the tumor has spread outside of the liver or the abdomen, into the chest, or to the bones, that would make the disease metastatic or more advanced. Certainly, that would affect how we would treat the patient.
Dr. Linda Austin: It used to be that liver cancer was a very scary diagnosis. It still is a frightening diagnosis, no doubt. But, I wonder if you could comment on how much progress has been made in the last 5 or 10 years in treating liver cancer.
Dr. David Koch. Well, I would say a lot of progress has been made, particularly in the number of options that we have to treat liver cancer. But, ultimately, I think the prognosis is best determined, again, as to whether or not the patient is a liver transplant candidate, or would potentially be a candidate for resection. If they are not able to undergo transplantation or surgical resection then, certainly, mortality is greatly influenced by the diagnosis of hepatocellular carcinoma, whether or not we use some of these other modalities.
Dr. Linda Austin: So, just to translate, then, if a patient can basically have the lesion removed altogether, either by transplant or resection, where you cut off part of the lobe of the liver, that is the best case scenario? It becomes more concerning long-term if you are unable to do that. Is that right?
Dr. David Koch: That is correct.
Dr. Linda Austin: One last question: I understand that we are looking at some new clinical trials here at the medical university and that those will come about over what period of time, would you guess?
Dr. David Koch: We are trying to devise a definitive protocol in order to, first, have a standardized way of approaching these patients because, as I mentioned, there are so many different potential therapeutic options, whether it be transplant, resection, interventional radiology treatment or the chemotherapeutic agents. So, what we are hoping to do first is to set a standardized protocol for managing these patients. Then, once we have that in place, we can look at our experiences so that we can potentially start some trials from there.
Dr. Linda Austin: Dr. Koch, thank you so much.
Dr. David Koch: Thank you.
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