Liver Cancer: Treatment

Liver cancer is treated with surgery (Transplantation and resection), local therapies, systemic treatments, radiation or with combinations of these

Surgery

Liver Transplantation Because most patients with primary HCC in this country have underlying liver disease, liver transplantation allow the best chance for cure. NewYork-Presbyterian/Columbia University Medical Center boasts one of the largest and most experienced liver transplantation programs in the nation, offering living donor liver transplantation and employing minimally invasive surgical approaches whenever possible.

Liver transplant procedures at the CLDT take advantage of the most sophisticated medical knowledge and surgical technology available today, including living donor transplantation, partial liver transplantation, advanced organ preservation techniques, liver transplantation in HIV- and Hepatitis C co-infected individuals, and antiviral therapy to prevent or treat recurrent hepatitis C after liver transplantation.

The Living Donor Liver Transplant program is one of the largest living donor liver programs in North America. We have performed more than 220 living donor liver transplants since its inception. We have performed more left lobe donations than any other living donor liver program in North America and introduced fully laparoscopic donation for all pediatric liver donor liver transplants in 2009.

Our program routinely achieves excellent outcomes for donors and recipients. Our recipients have 97.1 percent one-year survival after transplantation and a three-year survival of 93.3 percent. Additionally, nearly all donors are very satisfied or satisfied with the experience of donating a portion of their liver. After surgery, we also offer specialized nursing, nutritional support, smoking cessation, weight loss and pain management.

Columbia's Jean C. Emond, MD, was a member of the team that pioneered living donor liver transplantation, now considered one of the most important advances in the treatment of severe liver disease. Approximately 15 to 20 percent of the center's transplant patients currently receive a liver from a living donor. Dr. Benjamin Samstein has led the program since 2008, introducing laparoscopy.

Columbia is also one of only a few centers in the country which offers liver transplantation for selected patients with bile duct cancers. For patients who are unresectable, this procedure can offer an unprecedented chance for cure.

Resection: For patients who do not have significant underlying liver damage, often our surgeons can remove the tumor surgically without a transplant. This is called resection. Dr. Tomoaki Kato has pioneered a technology called “ex vivo” resection which allows removal of tumors which have been considered traditionally unresectable, again offering a chance for cure

Local Therapies

There are several types of local therapies, including ablation, chemoembolization, radioablation, and targeted radiation therapy. Columbia Presbyterian has the best interventional radiology team in the region, led by Joshua Weintraub.

Radiofrequency or Microwave Ablation The tumor is destroyed with highly targeted radiowave or microwave energy. This can sometime cure patients with very small tumors.

Chemo-embolization In this approach, usually beads which are labelled with chemotherapy are introduced into an artery which supplies the tumor, blocking off its blood supply while also delivering the chemotherapy directly into the tumor.

Radio arterial embolization Tiny spheres of a radioactive substance (yttrium-90) are delivered to the tumor site via the hepatic arterial system. The radioactive substance then kills cancer cells at the tumor site.

Radiation We have cutting edge protocols looking at new ways to use focal radiation (SBRT) to try to treat locally aggressive cancers. In particular, we have seen exciting results using this approach to treat hepatocellular carcinomas which have begun to invade the portal vein.

Management of Bile Duct Obstruction Blockage of the bile duct is a potential complication of liver tumors, liver surgery, and bile duct cancer. Our interventional endoscopists utilize endoscopic retrograde cholangiopancreatography (ERCP) to relieve bile duct obstructions. During this procedure, a physician inserts a stent into the duct to relieve the obstruction and allow drainage to proceed into the intestine, sparing the patient from having to wear an external bag on the abdomen to drain fluids. This approach improves the patient’s quality of life and relieves symptoms associated with jaundice. Our endoscopists also have pioneered novel treatments for biliary cancers which use photodynamic therapy and local ablative techniques.

More information can be found here.

Chemotherapy

Chemotherapy (systemic therapy) is often offered to patients who are not appropriate candidates for surgery. Because hepatocellular carcinomas are particularly vascular tumors, shutting down the blood supply of the tumors with different targeted therapies has been the most effective treatment option to date. Sorafenib is a pill which was developed to block signaling pathways which cause blood vessels to grow, and is currently the only approved FDA-approved therapy for HCC. We participated in the pivotal trial leading to its approval, and have been at the forefront of developing new drugs in this class and with other mechanisms to move the field forward.

For biliary cancers (including intrahepatic, extrahepatic, and gallbladder cancers) chemotherapy has become the primary treatment modality for those with unresectable disease. The combination of gemcitabine and cisplatin is typically considered a standard of care for these diseases for the first line setting, but large trials have not yet been reported examining adjuvant therapy (after surgery) or second line treatment options.

Dr. Abby Siegel is a member of the National Cancer Institute’s Hepatobiliary Task Force, which develops the agenda for novel trials throughout the United States and internationally. She is also the co-chair of the Hepatobiliary Subcommittee for SWOG, the largest NCI-sponsored clinical trials network in the country. She has spearheaded several pivotal trials in hepatobiliary disease. For instance, she was the lead author of a trial examining a potentially less toxic drug, called bevacizumab, in patients with HCC. She also completed the first multicenter trial looking at sorafenib dosing in subjects after liver transplantation to establish the correct dose, and to ultimately prevent recurrences in high-risk patients. Dr. Siegel is developing several proposals using new drugs targeting novel pathways in HCC and biliary cancers through the NCI and different pharmaceutical companies, and has several ongoing trials using the most promising new drugs in these diseases. In biliary cancers, she is helping to develop the first national adjuvant trial for resected biliary cancers, a new first-line trial using a drug to help make platinum drugs work more effectively, and second line therapies using drugs which block stem cell pathways.

More information can be found here.

Radiation Therapy

With advanced radiation therapy techniques doctors can better target tumors while reducing the radiation to nearby healthy tissues. Here at HICCC our radiation oncology experts have the ability to provide “state of the art” treatments for liver disease.

Your radiation oncologist will design the optimal treatment plan for you with you that will provide you the best optimal results. Treatment delivery can be daily, weekly, every other day, and or single fraction.

If radiation treatment is recommended, a radiation oncologist will work with our radiation oncology team to create a course of treatment. At Columbia University Irving Medical Center treatment modalities available and most commonly used for this cancer are External Beam Radiation Therapy, 3D Conformal Radiotherapy, Intensity Modulated Radiation Therapy (IMRT), Image Guided Radiation Therapy, Stereotactic Body Radiation (SBRT) and Yttrium 90.