Adam Rojan, MD, Hematologist Oncologist at University of Cincinnati Cancer Center, and Cutler Quillin, MD, Transplant Surgeon at University of Cincinnati Health talk about treating liver disease..
Interview conducted by Ivanhoe Broadcast News in 2024.
Tell me about non alcoholic fatty liver disease.
Rojan: Non alcoholic fatty liver disease is a condition that causes liver damage, that is, as the title indicates, unrelated to alcohol use. It can be related to diabetes or high cholesterol or other metabolic conditions.
What causes it?
Rojan: I don’t think we know all of the causes of non alcoholic fatty liver disease. We know that there are probably influences from cholesterol and diet and other metabolic issues, but I think that there’s still work to be done to totally understand that.
Are the symptoms the same as fatty liver disease? Is that cirrhosis or is that different?
Rojan: It can encompass cirrhosis. So yes, some of the symptoms when it progresses that would be the same.
What are the symptoms of non alcoholic fatty liver disease?
Rojan: Before patients are cirrhotic, they would often not have many symptoms. This would be the thing that would be detected on, screening tests or from, visits to primary care doctors and things like that on blood work, primarily blood work, probably.
How do patients get to you, though if they don’t have any symptoms?
Rojan: So patients make it to me after they have been diagnosed with cancer. So a patient may present to their primary care doctor and have abnormal liver tests and then be diagnosed, they may have a CT scan or something like that and be diagnosed with cancer.
Is that where you met Brad Myers?
Rojan: Yeah.
Can you tell me a little bit about Brad?
Rojan: Mr. Myers is really a model patient. He was diagnosed with cancer and he came to CR team here. He he was under the care of some of my colleagues and then myself while we treated him for his liver cancer.
How was he treated with the liver test?
Rojan: He underwent multiple forms of therapy. He saw our specialist in radiation oncology and received radiation. He saw our specialist in interventional radiology and received additional internal radiation therapy. Then with me, he received intravenous cancer treatment with medications.
Is there a clinical trial going on now for this?
Rojan: Our cancer center has multiple trials related to liver cancer, yes.
Talk to me about the treatment that he had with you. What did that involve?
Rojan: We gave him two intravenous medications that were given every three weeks. One is a targeted drug that is the way that it works is by disrupting the blood supply to the cancer, and the other is a form of immunotherapy where basically we try to stimulate his immune system to fight his cancer.
How long did those therapies take and how long ago were they?
Rojan: So he received those treatments over a period of roughly 4-5 months, probably. That was it ended roughly two months prior to his liver transplant.
What is his prognosis now?
Rojan: We are watching him closely, but he’s doing great.
Is he cancer-free?
Rojan: Yes. Right now, we have not found cancer, and again, I think he’s doing great.
I know with some cancers, there’s more that comes back more often than other cancers. Is liver cancer like that or not?
Rojan: All cancers have the potential to recur. And so yes, this is something where we will have to watch him closely for the next several years to make sure he remains in remission but we’re optimistic about his chances.
Is liver cancer one of these cancers where the research is just moving very quickly, and there’s new clinical trials, new drugs, new immuno therapy?
Rojan: I would say that we have made a lot of progress in treating patients with liver cancer particularly in the past five years. There was a period of time where we really had not made many advances until probably 4-10 years ago when we really have come up with a lot of effective treatments, particularly in the last five years.
Are you working with liver cancer patients every day?
Rojan: Yes.
Does that give you a lot of closure knowing that things are progressing, there are some cancers where it just like things aren’t progressing as quickly?
Rojan: It’s an exciting time to be a physician treating patients with cancer in general and liver cancer in particular. Absolutely.
Anything that we should talk about?
Rojan: Not to my knowledge.
Can you tell me what is NASH?
Quillin: So NASH, it’s nonalcoholic steatohepatitis. So there are certain instances where an individual might develop a certain amount of excess fat in the liver. This excess fat that can develop in the liver, we call it fatty liver disease. Ultimately can lead to damage and inflammation, scar tissue formation, and potentially, even cirrhosis, where a significant amount of scar tissue develops in the liver and people develop, essentially in stage liver disease related to fatty liver.
I think a lot of people associate cirrhosis and fat liver disease with alcohol. But these are people like Brad, who never drink.
Quillin: No, that’s the huge stigma, obviously, that’s associated with liver disease that a lot of people think it’s related to alcohol or drugs. But this is something that can develop in and of itself, independent of alcohol, and a lot of it is diet related or certain risk factors that people have.
Are a lot of the symptoms the same?
Quillin: Of the end stage liver disease? Yeah. No different. Exactly.
So tell me a little bit about Brad. When did you get involved in his treatment?
Quillin: So I met Brad in, I think it was the spring of 2023. So Brad had fatty liver disease, and he was in this trial to help treat fatty liver disease and apparently at the end of the trial, one of the requirements is that you do some random liver biopsy. So he completed his treatment and they did this random liver biopsy. And sure enough, the biopsy showed cancer in the liver that they hadn’t seen anywhere at that point in time, hadn’t seen on his ultrasound, so on and so forth. So sernipously, they found it. He got imaging and he was found to have this hepatocellular carcinoma, which was a big cancer. And it was a cancer in the liver that also had tumor clot in the vein which is a big problem. And so there’s many different ways that we can treat this. Sometimes we can do surgery, sometimes we treat it with.
Before you go there doctor, finding that through that biopsy, it’s like you’re finding a needle in a haystack, right?
Quillin: It’s dumb luck, really. And a stroke of that luck is really why Brad’s here today because otherwise it may have been diagnosed when the cat was out of the bag, so to speak, and when the liver- when the cancer potentially would have spread. So yeah, it was really fortunate for Brad that they were able to find it under those circumstances.
Let’s go on the treatment then.
Quillin: So there’s all different treatments that we can offer. The really gold standard treatment for someone that has this liver cancer is transplant. But his cancer was so advanced, so large, and given the involvement of tumor in the vein, that at that point in time, he wasn’t a candidate for transplant unless we could downstage or shrink the cancer and basically killed the tumor that was in the portal vein. And so, he saw a bunch of different physicians and ultimately was treated by Dr. [inaudible 00:03:52], who treated him on another clinical trial. And this clinical trial really compared proton beam external radiation versus photon therapy, and Brad had an amazing response to the proton therapy. The proton therapy is a unique treatment option that we offer here at UC and it’s really offered nowhere else in the region. So Brad had a great treatment response. And unfortunately, after his initial treatment, about six months later, he developed a recurrence. So the cancer had come back in the liver. And our team basically put together, what is the next step? What is the next treatment that we have for Brad? And Brad received another type of radiation therapy, but this was a radiation therapy that the interventional radiologists used to treat the cancer in the liver. So they went up through a catheter, went and basically, treated the cancer and blasted it for lack of a better word with radiation labeled beads, essentially. And at that point in time, Brad also got started on a special type of chemotherapy called immunotherapy, which essentially hijacks your body’s immune system to fight cancer cells. This is the point in time where we meet Brad, and we’re trying to determine if Brad’s a transplant candidate because we know if he continues to have a good response to this treatment, and if we can knock the cancer back again, then we can do the transplant. So we meet Brad in the spring of 2023. We evaluate him for transplant, and we want to watch his progress over the next six months or so to ensure that the cancer has a favorable response and it hasn’t spread. The issue with Brad though, is because the cancer is out of criteria, he doesn’t have access to transplant. So we give priority to patients in this country for transplant based on how sick they are from their liver disease. Brad really wasn’t sick from his liver disease, but he was sick from the cancer in his liver that was going to kill him. And he didn’t meet the necessary criteria in order to get these bonus points that would give him extra priority. So we worked long and hard in how to figure out how to get Brad a liver. We consider living donor. Brad has this huge family. They’re from Miamisburg, Ohio. He worked in the school system there at the high school. His brother works there as well. They’re both actively involved in the football program. They’re a huge football family. One of his sons is the center at the Green Bay Packers, the other son played football, I think on the line, I don’t know, but at UK. And everyone came forward. Two brothers came- two sons came forward. His brother, Brian came forward, and we evaluated everybody, and it just didn’t work out. There was an issue here, there was an issue there, and none of the living donors worked out. And we even were contacted from the Green Bay Packers physician, can his son who’s a professional football player be considered as a donor as well? And this is something I’m going to remember for a long time. So Brad comes into the office. It’s in September, September 18, and he knows that we’ve just ruled out his brother, who’s like the last glimmer of hope as a potential donor for his transplant. And he knows this, but we’re meeting him in the office to explain this to him. And I sit down with them and I tell them that your brother is not a candidate for donation. And at that point in time, he just thought that he had lost all hope that there was no possibility for transplant, and I said, ”No, we got you man. It’s okay. We’re going to find you a liver.” And we activated them for transplant that day. And eight days later, we had a transplant for- we had an organ available for Brad. We did another clinical trial where we preserve the liver outside of the body on a hyperthermic machine perfusion pump. So this is a device that pumps preservation solution through the liver that helps preserve it and minimizes some of the injury that happens when the liver is outside of the body. We did the transplant and four days later, Brad’s home and the rest of this history. He’s doing great.
Have you had anyone like Brad recover so quickly?
Quillin: The average length of stay in the hospital is about eight or nine days after liver transplant. The quickest you go home typically is five days, so to go home at four days is an exception.
Are the clinical trials national trials, do you know?
Quillin: The initial trial, the proton therapy trial, that’s a UC specific trial is my understanding, but don’t quote me on that. In regards to the machine perfusion trial, this is a continued access trial that is a national study. It’s currently being- this device is currently being used at three centers, here, Rutgers in Newark University Hospital in Newark, and then Northwestern in Chicago. And this is a continued access to this device while the device is getting final FDA approval. So in this continued access arm of the study, we’ve transplanted about 65 -70 livers with it, and total, there’s been about 120, 130 livers transplanted. So we’ve done the lion’s share of the transplant using this device and really has increased our options to provide life saving organs for patients.
END OF INTERVIEW
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