Froedtert Today

January 2011

Complete and Focused Team Offers Best Outcomes for Liver Tumors

While many cancers are becoming less common, liver cancer is on the rise. New therapies are helping many patients survive much longer, but the disease remains difficult to cure. The key to the best outcomes is a complete physician team that offers the full range of treatment options.

In October 2006, Bob Scheldroup of Hales Corners came home at lunchtime with flu symptoms. “I actually went to bed, and that is not like me,” he said. “I stayed in bed until the next morning. I just could not get up.”

The next day he asked his daughter to look up “appendicitis” in a first aid book. Sure enough: abdominal pain, nausea, fever, chills. The symptoms matched.

Bob, then 48, headed to the emergency room of a local hospital, where he had a CT scan. It confirmed his diagnosis of appendicitis, but it revealed something else as well — a shadow on his liver. There can be several reasons for an abnormal liver scan, so Bob was told not to worry.

He had a liver biopsy, and then underwent surgery on his appendix. The news came a few days later as Bob was preparing to leave the hospital.

“The surgeon walked in and told me I had liver cancer,” he said. “I couldn’t believe it. I was shocked. I really thought I was a goner, because I didn’t know anything about liver cancer.”

A Growing Problem

Many people with liver cancer are taken by surprise, because it often develops without symptoms. When symptoms like jaundice appear, they are frequently a sign of advanced disease.

According to experts, most liver tumors are metastatic cancers that have spread to the liver from other parts of the body. But about 25,000 people every year develop primary liver tumors — cancer that originates within the liver itself. Primary liver cancer is a rapidly growing problem in the United States thanks to the spread of hepatitis and the increase of fatty liver disease.

Patients with any form of liver cancer usually require several different kinds of treatment. At Froedtert & The Medical College of Wisconsin, the Liver Program addresses this complex need: it features a complete team of physicians who work together to care for patients with liver tumors.

T. Clark Gamblin, MD, MS, Medical College of Wisconsin surgical oncologist and chief of Surgical Oncology joined the program in July 2010. “Our physicians are among the most experienced in the United States and offer treatment options not available elsewhere,” Dr. Gamblin said.

Options are important, because there are now a wide variety of therapies that can help liver cancer patients like never before.

Exploring the Possibilities

The liver is the largest organ in the human body — and maybe the most versatile. It produces bile to aid in the digestion of food; it processes nutrients and stores them for future use; it makes clotting factors that help stop bleeding, and filters toxins out of the bloodstream.

But along with this versatility come unique challenges and risks. Treating the liver requires extraordinary expertise. After Bob Scheldroup’s tumor was discovered, he met with an oncologist to discuss his options. The possibilities seemed limited. “He said that if he were me, he would get a second opinion,” Bob said.

That advice led Bob to Kathleen Christians, MD, Medical College of Wisconsin surgical oncologist. Dr. Christians reviewed his case with colleagues during their regular liver tumor conference. Together, the multidisciplinary team developed a promising alternative.

“I remember looking at my scans with Dr. Christians,” Bob said. “She was pointing to this big area and talking about a liver resection — cutting the cancerous portion out and leaving just the good part.”

According to Dr. Christians, not all patients are candidates for resection. “A lot depends on where the tumor is located and how many there are,” she said. “It also depends on the patient’s overall health and whether the patient’s condition is complicated by hepatitis or cirrhosis.”

What makes surgery possible at all is the liver’s unique ability to regenerate. “You can remove up to 80 percent of the liver and it will grow back in a matter of weeks,” Dr. Christians said. Since Bob had no other liver disease and showed no evidence that his cancer had spread, there was a good chance tumor resection could lead to a cure. Dr. Christians explained the procedure and the risks involved.

New Options

Physicians of the Liver Program are leaders in several areas of care. Dr. Gamblin has pioneered laparoscopic surgery for liver cancer. For patients with smaller tumors, this approach offers a minimally invasive alternative to a traditional open procedure.

Other team members, like James Thomas, MD, PhD, Medical College of Wisconsin medical oncologist and section chief of Solid Tumor Oncology, are on the forefront of efforts to provide more effective drug therapies.

“Historically, standard chemotherapy drugs have not worked well against liver cancer,” Dr. Thomas said. “The chief reason is that the liver’s main job is actually to get rid of poisons in the body.”

Newer “targeted” drugs are showing promise against primary liver tumors. One example is sorafenib, an oral drug that inhibits liver tumors from forming their own blood vessels. “Sorafenib does not cause many cancers to shrink, but it can help people live longer and their tumors grow more slowly.”

According to Dr. Thomas, drug therapy is making headway against metastatic liver cancer. “Newer chemotherapy methods for colorectal metastases have become increasingly effective. Now we can often shrink liver tumors to the point where they are more amenable to treatment by other modes.”

For an increasing number of patients, that means a minimally invasive procedure performed by an interventional radiologist, often in an outpatient clinic. Interventional radiologists offer several options for patients with liver cancer, including:

Destroying small liver tumors with heat energy or freezing them with cryogenic probes either in the hospital or as an outpatient procedure
Performing portal vein embolization, a procedure that blocks the blood flow to cancerous liver tissue while causing healthy liver tissue to grow
Treating extensive cancers by depositing drug-releasing or radiation-emitting beads that block the blood vessels supplying the tumor

According to William Rilling, MD, Medical College of Wisconsin interventional radiologist and director of Vascular and Interventional Radiology, embolization procedures can serve as a “bridge therapy” for patients awaiting a liver transplant.

“If a patient’s tumor grows while on the transplant waiting list, he or she may no longer meet eligibility criteria for a transplant,” Dr. Rilling said. By keeping tumor size in check, embolization can often help patients remain eligible for a donor liver.

That’s important, according to Dr. Gamblin, because transplant can lead to a cure for patients with early-stage liver cancers. The first liver transplant in Wisconsin took place at Froedtert & The Medical College in 1983 by a team that included Medical College of Wisconsin surgeon Edward Quebbeman, MD, PhD, who continues to treat liver patients at Froedtert & The Medical College. Since then, Medical College of Wisconsin surgeons have performed more than 600 liver transplants.

Continuous Discovery

One of the strengths of the Liver Program is its emphasis on pursuing the latest knowledge. “Researchers have found that while you can’t treat the whole liver to a high dose of radiation, you can treat small portions with very high doses,” said Beth Erickson, MD, Medical College of Wisconsin radiation oncologist.

According to Dr. Erickson, the key is using image guidance and motion control to tightly shape the radiation dose to the tumor target while sparing some of the remaining normal liver. The result is precise radiation therapy delivered at high enough doses to eradicate the cancer. This can be done with a short course of treatments known as stereotactic body radiation therapy (SBRT) for small, peripheral lesions or through a longer course of treatment for central lesions.

“The nice thing for patients about SBRT is that it requires fewer treatment visits,” Dr. Erickson said.

A Second Chance

Bob Scheldroup’s surgery took place in January 2007. In a 10- hour procedure, Dr. Christians removed more than three-quarters of his liver, including a tumor more than seven inches wide.

Bob has been cancer-free for four years now and has never required additional therapies. “I have been feeling good ever since,” Bob said.

His experience with Froedtert & The Medical College has given him a new outlook on the health-care professions. “Most people go to their job and do what they have to do and then go home,” he said. “Doctors and nurses are really committed.” His experience has also given him a new outlook on life: “It’s changed the way I look at things. Every day’s a blessing, you know.” Bob hopes his story might inspire other people diagnosed with liver cancer. “I’m just glad to have gotten a second chance from Froedtert.”

Complete Care

The Liver Program offers patients prompt access to a complete team of physician experts who provide fully coordinated care for patients with liver tumors. To find out more, visit froedtert.com/cancer. To make an appointment or receive a second opinion, call 414-805-0505 or 866-680-0505.

Source: Froedtert Today

Date: January 2011