Transplantation Is a Viable Treatment for Some Liver Cancer Patients
At the Podium – September 2006
By William Chapman, MD
For patients with both early stage hepatocellular carcinoma (HCC) and cirrhosis, the latest advance in treatment is liver transplantation. A new multidisciplinary clinic at the Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine makes this option available to patients through the expertise of the largest liver transplant program in the state. Beyond transplantation, the clinic provides access to diagnostic testing and other treatments not widely available at other medical centers.
The need for the clinic is clear when you consider that almost 2 percent of Americans have hepatitis C. In part, this occurred prior to 1991, when approximately 200,000 people a year were infected because there was not an effective blood-screening system in place. Although the rate of infection has fallen since that time, there are still numerous ways to contract the disease, from substance abuse and other high-risk behaviors to unclean tattoo needles.
The insidious nature of hepatitis C means most people remain asymptomatic for 15 to 20 years after first becoming infected. Only in the late stages of the disease do they present with cirrhosis, HCC or both of these complications.
The majority of patients with both HCC and cirrhosis are not candidates for surgical resection of their tumors for several reasons. First, when liver resection is performed, the remaining liver must be able to regenerate and function for the part that was removed. For patients with HCC and cirrhosis, that regeneration is not possible. Second, the factors that led to cancer development remain, and they will therefore cause recurrent cancers. Finally, it is not always possible to detect sites of small cellular implants within the remnant liver. Even for the small number of patients who can have their livers resected, about 80 percent will have tumor recurrence.
In the past few years, two factors played a role in making transplantation a viable option for patients with HCC and cirrhosis: Significant advances in transplantation techniques were made, and the criteria for allocating organs were changed to give priority to cirrhotic patients with early stage liver cancer. At Siteman, our results with transplantation have been excellent. In patients with the standard accepted transplant criteria for stage II cancer, the recurrence risk is less than 10 percent with long-term follow-up. This statistic also holds true for patients with stage III cancers when their tumors are first downstaged and observed for a period of time to ensure they are under control and have not metastasized.
The challenge of treating these patients, of course, is that they have two diseases: cancer and cirrhosis. And that’s why our multidisciplinary clinic is so important. In addition to liver surgeons, our team includes experienced hepatologists who help manage liver disease. In addition, medical oncologists and interventional radiologists provide care while patients await transplant. Available treatments include chemoembolization, which involves injecting chemotherapy drugs and embolic material into the tumor in order to control and shrink it. Also performed are complex procedures such as transjugular intrahepatic portosystemic shunts (TIPS), used to treat portal hypertension due to cirrhosis, and percutaneous ablation of tumors.
Beyond HCC, we are investigating transplantation as a treatment for unresectable cholangiocarcinoma, or cancer of the bile duct, also known as Klatskin tumor. This cancer is difficult to treat. For patients who can undergo tumor removal, the long-term survival rate is only about 20 percent. We have initiated a trial using chemoradiation followed by limited surgery to ensure there is no tumor spread, which is then followed by transplantation. Early results show this may be a successful strategy for some patients.
Also in the research arena, we have completed a study investigating a new type of PET scanning that uses an acetate-based tracer. This has proved to be a sensitive and accurate technique for detecting hepatoma, particularly for sites outside the liver. We also have an open trial looking at the best strategies for treating hepatitis C after transplantation. And we are continually working to find ways to minimize the side effects of immunosuppression while at the same time limiting the risk of rejection.
The success of our program has given us increased knowledge of which patients may be good candidates for transplantation. We no longer use the criterion of chronologic age. Rather, we evaluate patients’ physiologic age, how healthy their organ systems are and whether there are other factors that might prevent them from being successfully transplanted. In the past year, several of our transplant patients were in their 70s and are doing well.
Since 1985, our transplant surgeons have performed nearly 1,000 liver transplants, including those in patients with cancer. Our one-year survival rate is between 85 and 90 percent for all patients, including those who were very sick, and our three-year survival rate is above 70 percent. Now our transplant program is supported by a multidisciplinary clinic that offers better access to the full panel of specialists needed to care for patients with liver cancer. We see this as a wonderful opportunity to provide treatment to a group of patients who in the past had few options.