Innovating Liver Cancer Treatment: Expert Q&A

Cancer that begins in the liver usually affects individuals who already have advanced liver disease or cirrhosis. This is usually as a result of hepatitis B or C, alcoholic liver disease, or fatty liver disease. Because patients are battling two competing diseases, advanced liver disease and liver cancer, care and treatment is complex, and requires an experienced team.

Hepatologist Dr. Anjana Pillai, radiologist Dr. Carla Harmath, and vascular and interventional radiologist Dr. Osman Ahmed will join us to discuss the liver tumor program at UChicago Medicine. They'll tell us how imaging and intervention can help improve survival rates for patients living with liver cancer. And they'll answer your questions coming up right now on At the Forefront Live.

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And we want to remind our viewers that today's program is not designed to take the place of a visit with your physician. Let's start off by having each of you introduce yourselves, and tell us a little bit about what you do here at UChicago Medicine. And Dr. Pillai, I'm going to start with you.

Thanks. So my name is Anjana Pillai. I am a transplant hepatologist here at the University of Chicago. I'm the medical director of our liver tumor program. And that's really where my subspecialty is, in addition to chronic liver diseases.

Dr. Harmath?

Hi. My name is Carla Harmath. I am an assistant professor of radiology, and my subspecialty is actually abdominal imaging. And I do have interest specific in liver imaging. And I work together with Dr. Pillai and the liver group to evaluate patients.

Fantastic. And we want to remind our viewers that we will take your questions live on the air, so just type them in the comments section, and we'll try to get to as many as possible over the next half hour. And we're going to start off kind of in broad, general terms. Dr. Pillai, I want to start with you. And just tell us a little bit about the symptoms of liver cancer or liver tumors.

Sure. I think this is what may be the most frustrating to patients, is that there is not just a key set of symptoms that people have with liver cancer. So if you don't already know that you have underlying chronic liver disease and you're not undergoing routine surveillance, which means getting imaging every so often to look for liver cancer, you may not be aware that you are at risk for it. So most patients have no symptoms at all until the cancer progresses. It may cause jaundice or yellowing of the eyes because it's obstructing the bile ducts. It may lead to fluid formation or ascites in the damaged liver. It can cause pain if the tumor is very large. But most patients that have a small liver cancer don't really have any symptoms.

Who's most likely to get liver cancer? I would imagine, like with many diseases, different populations have probably different propensities to be affected by this. But possibly I'm wrong on that. Tell us a little bit more about that.

Absolutely. So we do know who is most likely to get liver cancer. And like you said, it's patients with chronic liver disease. So patients that have cirrhosis, specifically, so either cirrhosis from viral hepatitis, like hepatitis B or C, fatty liver disease leading to cirrhosis, alcoholic liver disease leading to cirrhosis, or any number of genetic factors that can lead to cirrhosis. So patients at cirrhosis are definitely at increased risk. And we have surveillance guidelines that require us, or ask of us to get imaging studies every six months in a cirrhotic to look specifically for liver cancer. Others that may also have a risk for liver cancer without cirrhosis are those patients with chronic hepatitis B.

So can we talk a little bit about cirrhosis just for a moment? Because I think probably the general public assumes that cirrhosis means that's a disease of somebody who has abused alcohol. That's not necessarily the case, though, and I think that's a pretty important distinction to make.

And you bring up a great point in that. That's absolutely right. I think that whenever we even diagnose someone with cirrhosis, their first shock is, doctor, I don't drink alcohol. And that's exactly right. So liver disease and chronic liver disease can come from a myriad of different etiologies.

And the most common that we see in the United States and most of the Western world is either hepatitis C, which is actually decreasing because we have great new treatments, alcoholic liver disease, which unfortunately has been on the rise, especially with everything that's been happening with COVID, and we're seeing a lot more binge drinking, but also fatty liver disease is on the rise, and is going to be one of the main indicators for people needing liver transplant.

These patients classically can be obese, may have diabetes and other metabolic risk factors. And then there's a whole host of genetic diseases that can also predispose you to liver disease. So diseases of the bile ducts, disease of iron storage or copper storage, and autoimmune diseases.

And I want to get Dr. Harmath involved in our discussion. So to kind of set that up, let's talk a little bit about what a patient can expect to experience when they come to UChicago Medicine and get their treatment. And I know one of the things that we are really good at here, and your team is certainly really, really good in this area, is the multidisciplinary approach and that teamwork that goes into caring for each patient.

Yeah, I absolutely could not do my job without Dr. Harmath or Dr. Ahmed or many of our collaborators. So essentially, when a person is referred to our multidisciplinary liver tumor program, they do see multiple specialists at one time, including myself or one of my colleagues, a transplant or hepatobiliary surgeon, and an interventional radiologist.

And once we determine what the patient has in respect to the lesion that they're usually seeing us for, we then take this to the multidisciplinary tumor board, which happens weekly, which Dr. Harmath directs with me. And so that's where-- and this is really important, that it's not just one person making a decision or one eye on here. It's multiple specialists, all of whom are in this call, looking at the patient, listening to the history, and then looking at these lesions, as Dr. Harmath guides us to what she, in her knowledge, what she thinks the most likely diagnosis is.

And Dr. harmath, let's bring you into the conversation now. We're going to look at some actual images and have you describe what's going on there. Kind of describe your job first before we do that, though, as you work with these patients.

Sure, sure. So my job when we-- at the liver tumor board is to basically review all the exams for all the patients that are on our list. So Dr. Pillai and her group send me a list of patients, and every patient has different imaging modalities. So I look at them and I try to characterize the lesions that the patients have.

And in that characterization, it's my responsibility to let them know if I think this is a disease that's coming from the liver itself, if it is a liver cancer from the hepatic cells or from the biliary cells, or if it's a lesion that is benign, or a lesion that needs attention and follow-up that we are not sure what it is exactly. Sometimes, too, there are patients that come in with lesions that are not specifically from the liver, but are what we call metastasis. They're lesions that get into the liver from a cancer or a neoplasm in another organ. So it's my job to let them know about that.

Also, in addition to this is our surgeons and our interventional radiologists also get consulted for every lesion. And they have specific questions about what vessels are involved, is this something I can take out. Our oncologists also want to know how many lesions do we see, is this something that can be cured and treated, do we need to do chemotherapy, do we need to reduce the lesion. So that's part of my job, to expansively explain and demonstrate the imaging findings for every patient.

And you were nice enough to provide us with some of these images to take a look at. And let's go ahead and start showing those, John, if we can. And then Dr. Harmath, if you can kind of explain to us what we are seeing here.

Yes, definitely. So this case here is an ultrasound image. So on the left-hand side, we have a more normal liver. On the right-hand side, we have a liver that has some what we call spots or lesions. One of them is that brighter area, the whiter area in the center. And if you see a little bit in the back, there is an area that is not very well-defined, but is a little bit darker. So those are two lesions. And they can be very subtle. And they're different lesions.

With ultrasound alone sometimes, it's difficult to identify and say what the lesion specifically is. This is a CT exam. And the liver is that brighter organ on the left-hand side. And within this liver, there is a darker area. And this is also what we call liver lesion. And again, my job is to recognize what it is and classify as a liver lesion of hepatic etiology or a liver lesion of other etiology, benign or malignant.

This is another case of liver lesions. And this liver -- and again, it's the organ on your left-hand side-- has several different lesions. And for me, it's easy to identify them. I wish I could point it out. But there are three lesions in this liver. Two of them are benign, one of them is a malignant or a neoplasm. And again, my job is to know about all those lesions, and describe them and describe vascular involvement, and what we can do to help our patients.

Another case here, these are both CT exams, and the liver is, again, the larger organ that we see. And you can see that both of them, they're different patients and they're different appearances of the liver. One has a background liver disease with steatosis, basically the fatty liver, which is the one on your right-hand side. The other one does not have that fatty liver, but both of them have a lot of little different spots or different lesions. This is usually how metastases look in the liver, like cancers that came from another organ and deposited in the liver.

And this is basically -- you get a lot of these questions about patients, why sometimes I get three scans at the same time, or four scans at the same time. This is what we call multiphasic CT exam. And basically, this is what helps me be able to characterize the lesion. And we get an image without contrast. We get an image after they give you the contrast or the IV dye. And that's the first one there.

Then we get a little bit later, so I can see the veins, as well as not only the arteries, and then even later to evaluate how lesions behave after I wait a little bit and see how the liver is enhancing or getting the contrast, and how the vessels are getting the contrast. So it's imperative for us identifying liver lesions and characterizing them sometimes to have several different what we call phases of imaging on a CT scan. And same thing for the MRI. They are different exams, but both require quite a few phases for us to be able to characterize lesions.

So can you tell just by looking at the imaging what is likely a benign tumor versus one that isn't?

Yes. Yes. It takes practice. That's why radiologists go through intensive training. But yes, there are some lesions that are obviously benign. And those lesions do not need to be followed. Like cysts, for example, they're very benign-looking. There are other lesions that are vascular in origin, but happen in the liver. They are called hemangiomas. And those are usually benign, as well, so we don't need to follow them.

There are lesions, though, that are indeterminate or non-specific that sometimes need to be followed, like adenomas. There are other lesions, like focal nodular hyperplasias, that are also benign. And then we have the malignant lesions which are of liver origin, mostly hepatocellular carcinomas and cholangiocarcinomas, and mixed cholangio hepatocellular carcinomas, which have certain specific characteristics that we look for.

Interesting. So we are getting some questions from viewers. And Dr. Pillai, I'm going to give this one to you. What are the autoimmune diseases that predispose one to liver cancer, and also, what do you do about someone that has been told they have-- and I believe it's hemangioma, and not necessarily a tumor. If you can answer that one, that'd be great.

Sure, of course. I just want to, before I answer, just again highlight the importance of Dr. Harmath and exactly what she said about deciphering what's benign and what's malignant, because we see so many patients that have had scans over year after year with all the scan anxiety for a cyst, or let me take the hemangioma, which is actually a benign collection of blood vessels that grows into what looks like a lesion. And that can be scary. And when you see it on a CT scan, people may think that it could even be cancer. But in fact, it's completely benign. And unless it's very large, which very few hemangiomas are, you really don't need any intervention or any follow-up.

If they're very, very large and they cause symptoms-- sometimes these lesions can grow significantly, and they can hit the liver capsule, grow into the liver capsule and cause pain in the abdomen, or they can grow in such a way that they're sitting on your inferior vena cava, one of the main blood vessels in your body, and cause lower extremity swelling, or sometimes they can abut the stomach and cause a feeling of early satiety-- that's when we would think of doing something for hemangioma. But those lesions are completely benign, and really do not have to be, once we confirm that's what it is, have to be followed, unless the patient has symptoms. So I think that's really important for the patient's well-being, as well, when we have these benign lesions.

Now to go back to the second question about autoimmune disorders, so when we characterize autoimmune disorder that could affect the liver specifically and cause advanced liver disease, I am talking about autoimmune hepatitis in the liver, primary biliary cholangitis, primary sclerosing cholangitis. So they have an autoimmune origin. And so those specific diseases are often progressive, not all, and can eventually lead to cirrhosis of the liver. And that's where the liver cancer risk comes in. Not just because you have these autoimmune diseases, but specifically because the liver disease has progressed to cirrhosis of the liver.

Interesting. So do benign tumors actually cause symptoms?

They can if they grow. They can if they grow. So most people, we find these incidentally. We're scanning just-- I feel like we scan everyone so readily. They come to the ER, they have something, we scan them. And then as Dr. Harmath showed in one of her last pictures, there's one lesion that was actually significant, but there were several others that were benign. So most of these are found incidentally. But if they do grow over time-- it may take years to grow-- they can potentially cause symptoms based on some of those organs and blood vessels that I was talking about that they could impinge.

And the final question before we get into our break and get into the second half of the show, does liver cancer spread quickly?

It really depends on-- I feel like I'm giving a lot of if/maybe answers--

But it's true. But it really depends on the biology of the cancer itself. And so it is a very what we call heterogeneous cancer, that it does not behave equally in everyone. So some people have very slow-growing liver cancers, primary liver cancers that take years to grow, and some people have pretty aggressive liver cancers that can show up with metastasis on presentation. And so it's hard to make a determination just by seeing it, but we do look at whether it's a single lesion or multiple lesions, how large it is, if it invades the blood vessel already. And also, we look at some tumor markers and see how aggressive it is that way.

So it's not just one picture that can answer that question. And then there's also how the patient responds to treatment, which I know we're going to talk about, as well as their functional status and liver function. So all of that is kind of important in treating a liver cancer because they can be so variable in how they present and how they grow and respond to therapy.

Well, you all certainly do some wonderful work. And Dr. Harmath, thank you for being on this section of the show. We are going to show a patient's story that's just fantastic. It really shows, I think, the scope of the work that your team does, and the great work done by our liver team. And then when we come back, Dr. Ahmed is going to join us, along with Dr. Pillai again. Let's go ahead and roll that story, and we'll talk about that as we come out.

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That is just such a neat story. Again, it just shows the wonderful work that you all do. And it's really quite touching. And Dr. Osman Ahmed joins us now for this portion of the show. And Dr. Ahmed, or as we call you, the real Dr. Os, here, if you could introduce yourself and tell us a little bit about what you do here at UChicago Medicine, and then we'll get into the questions.

Awesome. Thanks, Tim, for the introduction. And yeah, my name is Osman Ahmed, or most people call me Os. So I go by Dr. Os. I'm a vascular and interventional radiologist, as you mentioned, integral member of the liver tumor program, as well, with Dr. Pillai, Dr. Harmath, and other colleagues, as well. I have a particular interest in minimally invasive procedures for treating cancer. So that's where my passion kind of has led me towards teaming up with the rest of the folks here on the call today.

Great. And I don't know, either one of you can take this question, but let's start off just why it's so important for early detection of liver cancer.

You want me to take?

Yeah, go ahead.

Yeah, why don't you?

So just to step back a little bit, one, that video, I did not have any hand in that surgery. So that was all Dr. Baker. I know that they performed. So I want to give Dr. Baker all the credit for performing that successful surgery. But the most important thing about when we see a patient, we evaluate if that patient's lesion or cancer is cured. That's the first thing we always ask. So that's why it's so important how early we see it, and whether or not we can offer a curative option. And if we can, we look at the patient's performance status, meaning how functional are they, we look at the patient's underlying liver, is it very healthy, and then we look at the location of the tumor and number, as I mentioned just previously.

And that determines if Dr. Ahmed can perform a curative procedure, if Dr. Baker can perform a curative resection, or does that patient require liver transplant. And if we're not able to do curative options, then we think about how can we best give this person other options to treat their cancer, but also really focus on their quality and longevity of life.

So Dr. Ahmed, I've got kind of a two-parter for you. So the first part is, why is liver cancer so difficult to treat? And then the second part would be, what are some of the newer treatments that are offered here at UChicago Medicine?

Yeah, Tim, that's a great question. So I think one of the things that makes liver cancer particularly difficult to treat, as Dr. Pillai kind of mentioned, is there's a vast range of disease severity. And tumors can be very tiny and very slow-growing, at which point they're going to be more likely to be cured, or they can present with very advanced-- what we call metastatic disease, where the disease has spread outside of the liver.

The other thing that makes liver cancer particularly difficult to treat is it often arises in the setting of cirrhosis, again, as Dr. Pillai mentioned, which is essentially end-stage liver disease of the normal liver. So you have a cancer that's arising from a diseased organ. So for us, particularly interventional radiology, one of the things that we really need to take into account when we evaluate patients for our treatment, as well as for surgery, is how healthy is their underlying liver, and will they be able to tolerate a treatment that will hopefully either shrink or kill their tumor entirely, but also not damage their underlying liver such that they may go into total or complete liver failure. So those are all the kind of complex things that we have [AUDIO OUT].

And with respect to some of the new innovative treatments, I think Dr. Pillai can definitely speak to some of the new chemotherapies that we have that have kind of come out recently, which have really, I think, expanded options for patients with advanced cancers that can't undergo surgery. But within our realm, we have some really exciting minimally invasive treatments that we do do and offer. And so what our role in interventional radiology is, it's sort of two parts.

One is for patients that have, quote unquote, curable disease, sometimes our procedures that we do can actually be similar to surgery in effectiveness, but have less complications and be more minimally invasive and allow patients to get home sooner. And those procedures are typically called percutaneous ablations, where essentially we take a needle, we stick it through the skin into the tumor, using either a CT scan or ultrasound that Dr. Harmath kind of showed us earlier, and then we can burn tumors [AUDIO OUT].

Additionally, for patients who may be waiting to undergo surgery or waiting to undergo a transplant, we can act as like middlemen. And what we can do is try to either keep the tumor at bay or shrink it such that the patient becomes eligible for surgery. And we call that bridging therapy or top-down patient therapy. So we treat a lot of those patients, as well, again, acting as middlemen to try to get the patient to their final destination, which would be, hopefully, a cure.

Great.

Sorry for the long-winded response.

No, no, that's good. And Dr. Pillai, do you want to take kind of that second portion of that, as far as, from your standpoint, some of the new and interesting treatments that are available?

Sure, yeah. And just to backtrack just a little bit, so when we look at patients, we look at, like we talked about, the underlying liver function, the patient's functional status, and then the size and number of lesions. So and we kind of in our heads, we group those patients based on that. So if it's very early, the things that Dr. Ahmed talked about doing, a microwave ablation or cooking the tumor, essentially, or resection, which is removing the tumor, or transplant are all great options.

And then as the disease is maybe more advanced, we can do still those interventional radiology techniques, but using, let's say, chemoembolization beads or radiation beads, which we do. But when it gets to the point that it's even more advanced, we think about different chemotherapies. And I'm not an oncologist, but we do work with our oncologist Dr. Liao very closely.

And all of us have clinic together on the same exact day. And there's several medications that have been approved in the last several years for liver cancer. And most notably, just this past year in 2020 was the first combination therapy of two different types of medications that target liver cancer two different places that was approved, and was the first really significant big change in liver cancer therapy in the first-line setting since 2007. But we also have a myriad of other medications and trials that are going on.

So not to go into the specifics of each medication, but I think the bigger picture that we're able to offer is that combination of hepatologic management, making sure that your liver stays well, making sure that we check for ascites, we check for varicose veins in your feeding pipe that we can treat that, making sure that you are eligible, if needed, for advanced treatments like chemotherapies or trials for chemotherapies, as well as giving you the ability to have surgery, which is either a resection or transplant, and then this myriad of interventional radiology procedures.

And many times, they do all overlap, and the patients may progress in their cancer, and some of these treatments work, and then they regress in their staging to better stages. So the idea is, as long as we can, if we can truly offer a cure now, try to get patients to a curative option. And if we still can't do that, try to treat them and give them long duration of life, but keeping in mind the health of their body and their quality of life, as well as the health of their liver.

One of the things that I do want to stress-- and you talked about this in the first part of the show-- is really this team approach or this multidisciplinary approach to fighting these situations and using the tumor board. It's just a group effort, and it's a lot of different minds and really smart people working on a problem, which I think is part of the strength. And it's part of what we do here at UChicago Medicine. We're an academic medical center. And all of that combined, I think, makes for a really positive patient experience.

So another question from a viewer. This one's interesting. It is, is the liver tumor program currently accepting patients that have started treatment at other facilities? I don't know how that actually works.

Absolutely. We always welcome second opinions. We encourage our patients to get second opinions if they're not-- if they would like. So I think second opinions are really important if someone wants them. So absolutely we do. We try our best to communicate with the patient and any other provider, and we ask that-- sometimes patients come just because they want to start, in a sense, over. Sometimes, it's just to confirm what their doctors have already told them. And so either of those things we do accept in our program.

Perfect. And John put the phone number up on the screen as you were talking, too, so people can easily reach out and make that appointment if they need to. So talk to us a little bit about the treatment experience for the patient. What happens as they go through the different phases of treatment at UChicago Medicine, kind of from the starting point, if you will?

It's a great question. So one of our strengths is that it's truly multidisciplinary and multi-formatted, so meaning when a patient comes in, they truly do see more than one discipline. So they don't have to wait for their second appointment, their third appointment.

So we really encourage them, before COVID, at least, to bring their family members so they have a second ear, and because they're going to see multiple specialists. Sometimes we see them in the same setting, depending on our schedules. And in a way, that's easier for the patient when we can all be together and tell them this is what each of us will do for you.

The most important person, I would argue, is our nurse navigator, Elizabeth Houlihan, who really does a lot of this work so the patient does not fall through the cracks of having different specialists and different interventions. And I think she's one of the-- and having a navigator nurse like that is one of the main strengths of our program, specifically, the fact that, yes, you do see multiple disciplines, and yes, you do have multiple therapies possibly that you will have to do and keep track of.

But she will also keep track of those for you, and she also communicates with the other nurses. So she will communicate with the nurse in oncology, with the nurses for interventional radiology and the nurse practitioners. So our team is well-- over time has really gelled and figured out how to do this together, trying to make it as less anxiety-provoking for a patient who is coming in with a life-changing, life-altering diagnosis.

That's great. And we're basically out of time right now, unfortunately. This one went by very quickly. But Dr. Ahmed, I want to give you one more kind of opportunity to speak with our viewers. And you know, I think oftentimes when people get a diagnosis like this, first of all, they're scared. And that's certainly understandable. And oftentimes, they may lose hope. But there is hope, and there are a lot of treatment options. And can you just kind of take us out with maybe a comment about that, and what people should keep in mind?

Yeah, absolutely, Tim. I think that's a great question because, because of the complexity of the disease and all the kind of variables that we discussed, and again, just building on what Dr. Pillai said was, you know, I think the benefit of the true multidisciplinary format, where all three of us or four of us, oftentimes, are seeing a patient all together at once is we discuss that patient's case, we discuss all the treatment options.

And then on top of it, again, Tim, as you alluded to, kind of being at a university academic center, we are very blessed and fortunate to have a lot of sharp minds, but also a lot of technology available to us, such that we really do try to think outside of the box, especially if we are giving second opinions or seeing patients who, quote unquote, are not offered any hope, per se.

So I think, from an interventional perspective specifically, we do a lot of procedures. We treat a lot of [AUDIO OUT] again, as mentioned, from very early, curative type disease to all the way to late-stage. So I think the take-home message is that seeing a program or seeing physicians like us, there's no harm in getting a second opinion, and there's no harm in kind of seeing approached the way that we do, I think.

Fantastic. We are out of time. And you all were fantastic. Shared a lot of really important information with our audience. So I thank you for taking your time. I know you're very busy. And thank you to our viewers for your questions.

Please remember to check out our Facebook page for a schedule of programs that are coming up in the future. And to make an appointment, go online at UChicagoMedicine.org. Or you can call 773-702-4500. Thanks again for being with us today. I hope you have a great week.

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