Well, thank you for coming in today to have some discussion
about management of the liver tumors that we found in you. So
maybe you could start off by just telling me a little bit
about what you know about liver tumors and different types of
treatments that are available for them.
Well, thank you, Doctor, for meeting with me today. I
understand that I have cancer because of my history with
hepatitis C.
Before and that there are many treatment options available to
me, but.
I'm a little confused as to how you arrive at the right
treatment for me right now. That's a great place to start,
so let's go ahead and talk a little bit about how we arrive
at different treatment decisions for liver tumors.
So you can see on this slide, if we look at the right hand side
that first of all we start off with being sure there's no
cancer outside of the liver.
And then when we're dealing with cancer within the liver, looking
at the size of individual tumors that a person has, how big they
are, as well as how many they have. And then the the second
thing that we think about is liver function. Some of the
treatments.
Can injure the liver, can affect how the liver functions, and so
we want to understand how the liver is functioning at baseline
and then the third thing is shown in the orange circle is a
person's performance status.
How they're doing overall, and if their general health is good?
So we'll talk about basically your overall well-being and how
functional you are in your everyday life.
Also, where do I fit on this chart doctor? Sure.
So so your your CAT scan is shown kind of to the the left of
the chart. So that kind of black image on the left hand side of
the screen, your livers kind of a kind of a dark Gray solid
structure on the left hand side and within your liver you can
see that we've found two tumors. Those are shown by the white
arrowheads.
And they look like kind of light white wispy round areas. So you
have two tumors that are about 2 centimeters in size.
On the rest of the abdomen, we did not find any evidence of
tumors and we also did a CT scan of the chest which didn't show
any spread of the tumors.
So going back to our chart of overall function and and and so
forth, you are functional. You continue to work your liver's
functioning well. So both of those are good. And so based on
the fact that you have two tumors and good performance
status and good liver function, so many of these options of
different types of treatment are available to you. So because you
got 2 tumors and they're in different parts of the liver.
Um, generally we're not going to consider surgery for them, but
that leaves us with the different local treatments that
that we can use for liver cancer, which are basically the
most common treatments that that we apply.
And I can also talk to you a bit about referral for consideration
of listing for a liver transplant, if if that's of
interest to you.
Well, well, well. I need chemotherapy.
So traditional chemotherapies generally reserved for more
advanced stages of liver cancer where the cancer is outside of
the liver. So we're not going to talk about that specifically
today. So let's start with treatments that you can get
within your liver locally.
How? How do they treat the?
Tumors in my liver? Sure. Let's go back to our to a different
slide here. So the first thing that we'll talk about is
ablation. So ablation as shown in the bottom of this slide
basically has two different types. You can see on the slide
it says radiofrequency ablation, which is abbreviated RFA or
microwave ablation, which is abbreviated MWA.
And so looking at this slide on the left hand side, there's a
mannequin shown in blue and what's being shown in that
diagram is that there's an ultrasound transducer outside of
the mannequin. So the ultrasound is used to localize the tumor
within the liver. And these procedures done under sedation,
either local sedation or general anesthesia, and then an ablation
catheter is passed through the skin.
And into the tumor, guided by the ultrasound. Then in the
middle diagram, the tan figure is lying on the table and you
can see that the ablation wand is being placed into a tumor in
the liver and it's hooked up to a machine. So the electrical
current is run through the catheter and into the tumor and
the tumor is killed by super heating and then the blue lines
show the.
Heat being pulled back out of the patient and grounded in the
machine, the.
The third cartoon over to the right hand side is of the liver
with a tumor in the middle, and there's a small ablation
catheter which is shown getting ready to go into the liver on
the right hand side.
So after an ablation, sometimes there can be, you know, a bit of
discomfort and sometimes the surgeon or interventional
radiologist will recommend that you get admitted to the hospital
for observation.
Well, how do we know that the cancer has been treated properly
with the use of the wand?
It's a good question. So basically contrast CAT scans or
MRI's are done number of weeks after the procedure and those
will tell us the tumor has has been well treated.
So let's move on to another type of local cancer treatment that
I'd also like to tell you about.
This one has kind of a long name which is shown at the top of the
slide which is transarterial, chemoembolization or tastes and
another form of this therapy is transarterial radioembolization
which is called tear.
So as shown in the diagrams on the slide, this type of
treatment is done by interventional radiology as
shown on the leftmost panel. They place a small tube or
catheter in an artery, generally in the leg, but at times in the
arm, and they advance the catheter as shown on the left
hand slide up into the main blood vessel. The main artery in
the body which is called the aorta, passed the catheter out
the aorta.
And as shown in the metal panel, um, they can access the arteries
going into the liver, which give blood to the tumors so they can
pass the catheters out into the liver. And then, as shown on the
right hand side, they can inject tiny beads, which are shown in
white directly in the blood vessels which perfuse the tumor
and that can kill off the tumor possibly either with
chemotherapy or with.
Radiation. If it's a radio embolization.
So.
They if they decide to use the particles that deliver
radiation, you might need a separate appointment before your
treatment session. And again with this procedure you'll be
sedated after the procedure. Pain or nausea are common, and
again they they may recommend that you get admitted for
observation.
Let me ask you something.
If there are all these treatment options available.
Why do I need a liver transplant?
It isn't that difficult to get.
Well, that's that's true. Let me let me just briefly mention one
other form of of local therapy.
And that is a radiation targeted radiation therapy, which is
something else that we sometimes think about now. Well, we'll
talk about liver liver transplant right after that. So
another form of therapy is what we call SBRT stereotactic body
radiation therapy, which is shown on this slide. And in the
picture to the right, we see a mannequin lying on a table.
And the radiation is the orange light, which is being shown on
the slide. Basically, you know passing through the the
mannequin and it's being used to get targeted radiation into a
small area of a tumor. In this case in the liver and the
cartoon on the left hand side shows the liver with a small
tumor in it. And you can see the radiation waves that are, you
know, being used to.
Target the liver externally.
So at times before starting this type of treatment, which is
given by radiation oncologists, they may need to inject some
tiny markers into the liver near the cancer. You are sedated for
that procedure. Sometimes the markers need to be confirmed by
CAT scan to be sure that they're that they're placed correctly.
Now in terms of transplant, you're right that the number of
patients who need liver transplant is, you know, much
greater than the number of organs that are available. So
even if we refer you for a liver transplant in the future, it's
important to get one of these cancer treatments. Now we can
certainly discuss liver transplant referral in more
detail if you're interested.
Yes, doctor, I'd like to hold off on on the transplant. I'm
not sure yet.
But between the options you discussed, which one do you
think would be best for me?
Well, I'm going to be talking over your case with some of my
colleagues next week. We have our liver tumor board. Let me
just mention to you briefly about this. So like you can see
on the slide, we have a multidisciplinary tumor board
conference where different clinicians as shown on the left
hand side of the slide, radiation oncologists,
radiologists, medical oncologists, liver specialist
surgeons, interventional radiologists.
Get together, and of course the patient is at the center of that
diagram because the patients, you know the the person who's of
course getting the treatment from these different
specialists. But we all sit down together or meet together as
shown on the right hand side of the slide with blue figures
sitting with the green figures there and discuss your case.
We'll review your information and make a recommendation for
treatment after the conference will reach out to you about the
treatment recommendations and answer.
Any additional questions that you have?
You'll also be able to meet with the person who will do your
procedure and discuss the process in more detail. There's
more information available on the VA official website,
www.hepatitis.va.gov, that you can review if you want even more
information or have follow-up questions.
Thank you, doctor. I wanna thank you for meeting with me today.
And I know I'll have more questions when we get to the
follow up.
Yeah, it was my pleasure talking with you. And I'll look forward
to working with you as we work our way through this process.