Eren Berber, MD, MBA, director of the surgical liver tumor ablation program at Cleveland Clinic talks about a new method for treating large malignant liver tumors.
What is a liver resection?
BERBER: Liver resection is cutting a portion of the liver, including the tumor, by leaving the patient enough liver tissue, liver substance and also incoming and outgoing liver vessels. You have to make sure that the amount of liver you leave behind is adequate in volume and function.
And this procedure can be done, you said open or minimally invasive, laparoscopic. Is that right?
BERBER: That’s right. For more complicated tumors, we like to do open liver surgery. For less complicated tumors, we do laparoscopic surgery through small incisions.
How common are liver tumors?
BERBER: In the United States, we are dealing mostly with what we call metastatic cancers. These are cancers that have spread from other sites. For instance, to give you an idea of the colorectal cancer patients, about one-fourth of the colorectal cancer patients, when they are diagnosed with their primary tumor, they can have a liver spread and then about another one-fourth can develop liver spread later on during their course.
For the patients who have colorectal cancer?
BERBER: About half of the patients with colorectal cancer can eventually have a liver spread. So it’s a very common problem in this patient population.
Are there other cases where there would be a liver tumor that would develop besides people who have colorectal cancer?
BERBER: Yes, there are other types of tumors, too. The ones that we’re seeing at Cleveland Clinic are what we call neuroendocrine tumors. These are different type of cancers that are more indolent, but can still spread to the liver. In addition, breast cancer, melanoma, sarcomas, they can also spread to the liver.
And are those tumors cancerous? Do they need to be removed right away?
BERBER: Yes, they would need to be removed. Obviously, it depends on the tumor type you are dealing with. You need a certain type of what we call multimodality or multidisciplinary management. So, for each type of cancer, the management is different. Systemic therapy, commonly known as chemotherapy, and other treatments are critically integrated with the surgical options. The role of different types of treatment options varies from patient to patient based on the exact tumor type. For some patients, nonsurgical options have a dominant role, whereas for others, surgical options, either by cutting the tumors out or burning them, have a more important role in management of the disease.
Who are the best candidates for the minimally invasive ablation?
BERBER: The benefit of ablation depends on the circumstance. Let’s say you have a patient who is maybe a little bit elderly, doesn’t have a lot of functional reserve and maybe has a lesion that is amenable to be cutting out with a liver resection. But the patient might not tolerate the procedure well because of his other medical problems. So, in those patients, ablation is the perfect option because it’s done through a couple of small incisions. Complications are very low, and the efficacy of these new technologies is very high. So, that patient would be a perfect candidate. Another appropriate patient is a patient who has a small tumor but would require a significant part of the liver removed. Those patients are also good candidates for this ablation therapy, so that we can preserve as much liver tissue as possible (parenchymal preservation) while providing them with an effective treatment. In the past, if you burned a tumor with ablation, the failure rate of that treatment was up to 40% for colorectal cancer. But now with these more advanced technologies like microwave, we are seeing that only 12 to 13% of those tumors fail where you treat them, which is a significant advancement for the treatment of these tumors.
So, in other words, the technology that you’re using treats it better or can you expand on what you just said?
BERBER: Yes, I would say that compared to the past, the results of ablation technologies, which are the treatment options that use heat to destroy the tumors, have much improved. In the past, 4 out of 10 tumors that you burned would have failed at the treatment site. And now, it’s only about 1 out of 10 tumors that fail at the treatment site, which is a significant breakthrough.
So, the technology has improved?
BERBER: Yes. And we’re also able to treat larger tumors more efficiently nowadays with these technologies. In the past, burning (ablation) was a good option for tumors less than three or four centimeters, which is roughly 1 -1.5 inches. And, if you had bigger tumors, then you would have a higher failure rate, almost up to like 50%, 60%. Nowadays, with these new powerful technologies, I anticipate that because we are able to apply higher power, reach higher temperatures and provide more efficient burning, our success rate is also going to improve, but we will need to see the results.
Which leads us to the next question. Could you describe the new technology surgeons are using on large liver tumors?
BERBER: So, the efficacy of the treatment, i.e., how best you can burn a tumor, depends on the power you’re applying with your treatment option. Nowadays, microwave ablation has replaced radiofrequency ablation as the modality for burning these liver tumors. And the systems we have had so far could provide up to 100 watts of power through a single needle. Recently, a new device, which allows us to deliver 150 watts of power has received an FDA approval. And this has caused a significant improvement of the ablation procedure. First of all, you’re able to burn the tumor much more efficiently by delivering more energy. Secondly, with a single needle stick, you can create a burn up to six, seven centimeters, which is about two to three inches compared to 4 cm (1 1/2 inches) before. So, because of this, we will be able to treat larger tumors with burning (ablation) that would have otherwise been only treated by a liver resection (cutting out). However, if the patient were not a good candidate for a liver resection due to their additional medical problems, you would run out of treatment options.
And it’s also easier on the patient’s recovery.
BERBER: Yes. It also provides more treatment options for the patient. In the past, if you had a patient with a big liver tumor who might not be a good candidate for a liver resection, that large tumor could not be burned with the old technology. And, some other technologies might not be as effective as surgical options. The patient and their healthcare team would be left with a tough decision on treatment. Nowadays, if you have large tumors that are amenable to this technology, the patient can go home the next day and will be back to their baseline in about one to two weeks. A liver resection requires a longer recovery.
I think we started covering this question, but can you walk us through the steps of the surgery.
BERBER: So a patient comes to the hospital and before they have surgery, they are put to sleep with anesthesia so they don’t feel any pain. Then, we make two small cuts, about half an inch on the right side and then insert our special instruments that we call trocars. We insert a special stick camera through which we can look inside. We also insert a special ultrasound stick that we can place right on top of the liver and look for tumors with it and determine how extensive the cancer is in and outside the liver. Using this special ultrasound stick, which is more sensitive than any other imaging that we can do before the surgery (including MRI or PET scans), we examine the liver and figure out the extent of the disease. Then, through a very small incision, only a couple of millimeters, we introduce our ablation needle. Under the ultrasound guidance, basically, we see what we are doing. Then, we burn the tumor. With the ultrasound, you monitor the procedure. So, if we feel that a part of the tumor is not covered with the burn, then you can treat that spot with a separate stick. The procedure takes anywhere from 40 minutes to 2-3 hours depending on how many spots the patient has. Once the procedure is completed, the patient goes in a hospital room to recover. We start their diet right away. The next morning, they can usually go home. Most patients don’t need any narcotics for pain relief. We see them at the office about two weeks after the procedure for a follow-up appointment. We get another scan to see how the tumor has been treated. We follow these patients life-long. We get their scans every three to six months. I see them in person in the office for follow-up together with the oncologist.
So, and you also answered this question, how long does the procedure take?
BERBER: It depends on the size and number of spots that we are treating. It could take anywhere from 40 minutes to 2-3 hours.
And the recovery time, what is it like? And maybe if you can compare it to just a little bit with, you know, an open resection just so that the person understands the difference between the two.
BERBER: Sure. The open-resection patient would stay in a hospital five to seven days and then their recovery would be about probably four to six weeks. If they have a laparoscopic operation, then they initially stay in the hospital for 1-3 days, and their recovery would take 2-4 weeks. If they have an ablation, they will stay in the hospital overnight and will be back to their baseline in about a week or two.
And when you say baseline, you mean like their normal state?
BERBER: Yes, back to daily basic activities. No matter what operation you do, you need to wait about four to six weeks before you can go back to strenuous activities such as going to the gym and lifting weight more than 20 lbs.
How important are these new advances in terms of patient survival and recovery?
BERBER: They’re very important because obviously, while we prefer a less invasive option for a patient, we don’t want to compromise from what we call oncologic outcomes. At the end of the day, we are doing the treatment to treat the cancer. We don’t want the cancer to come back where it has been treated. And, we want the patient to enjoy a long survival. So, it’s very important. Initially in early 2000s, when we had the earliest ablation (burning) technologies, the failure rate was high. So, I think we have to achieve a good balance between how well patients recover and also how well the cancer is treated. That’s why we need very effective, minimally invasive cancer options.
And you explained also to us that initially, that ablation technology, when it first started, it was not burning as well. That it was not destroying the tumor as well initially, but now the technology that has improved now is able to destroy the tumor. Is that right?
BERBER: Yes, that’s right. And we’re also seeing in the scientific literature that with these newer technologies, the control rate of the cancer is much higher compared to the old technologies.
The success rate?
BERBER: The success rate is higher, yes.
Is there anything that we haven’t asked you that you think it would be important for someone who has a large liver tumor and they are considering what the best treatment options are for them to, you know, have their liver tumor removed? Anything that you want to add?
BERBER: I want to emphasize that patients should be managed by a multidisciplinary team that involves the oncologists, the surgeons, radiologists, interventional radiologists and radiation oncologists. The patient should be frequently assessed to see what treatment option is best at a given stage in the course of the cancer. Sometimes, an ablation may not really be the best option for the patient. Maybe systemic therapy or a liver resection is a better option for the patient at that point in time. And, subsequently, with a recurrence of an isolated area in the liver, the patient may become a better candidate, let’s say, for an ablation. Therefore, I believe the healthcare team has to be very dynamic in assessing the patient and figuring out what treatment modality might be best for the patient at different stages of the disease. So, we cannot consider a disease management such as, ‘OK, I have one treatment that will be best for the patient during their lifetime,’ to be true anymore. So, you have to have a multidisciplinary team. At Cleveland Clinic, we have multiple multidisciplinary teams for different cancers. And, every week, we have tumor boards during which cancer treatment options are very dynamically assessed. I think you need a very dynamic multidisciplinary team to best treat patients.
And in the end, for the patient to understand the different options for treatment and what is the best treatment for that specific patient with that specific tumor.
BERBER: Exactly. We should not consider that, ‘OK, for every patient who comes in through the door, I’m going to do an ablation.’ That’s not true. So, you have to have a multidisciplinary mentality and a multidisciplinary team to best care for patients.
So, what is the traditional or the gold standard treatment for patients with liver tumors? Right now, what is the traditional standard treatment for patients with liver cancer?
BERBER: So, the gold standard treatment for patients with liver cancer is always liver resection. So, when a patient comes to our office, we always ask this question: “Is the patient a candidate for a liver resection either open or laparoscopic?” That’s always the first question we ask to determine if the patient is a candidate for a liver resection because that is the gold standard that gives the patient the best chance for a cure. Some patients, though, and I will say the majority of the patients, are not really candidates for a liver resection because of their comorbidities or the extent of their disease. They may not have strong hearts to go through a big operation or they may have lung problems. Maybe they have spots in multiple segments in the liver, and you can’t hardly cut them all out. So, for those patients then, we go down the list of treatment options and the next in efficacy is ablation, which uses heat to destroy these tumors. And, historically, that had been done with radio frequency ablation. Nowadays, most recently, microwave is getting more popular. Lower down the list, we also have other liver-directed therapies like external radiation treatments known as SBRT or embolization options by interventional radiology, depending on the type of tumor that we are treating. In summary, for every patient, we try to decide what treatment option would be best, based on the tumor type, extent of disease, and patient’s characteristics.
And you said that if there are multiple liver tumors on the liver, you need to leave a certain amount of the liver in your body so you cannot remove all the tumors. I think that was an important point that you need to leave enough of the liver inside, right?
BERBER: Exactly. First, the patient needs to be fit to go through a liver resection safely. Second, an adequate volume of liver needs to remain in place after a liver resection for the patient to have adequate liver function after the surgery.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Caroline Auger
216.636.5874
Sign up for a free weekly e-mail on Medical Breakthroughs called First to Know by clicking here
