Liver cancer management requires a comprehensive team approach due to the complexities of the various therapeutic options, as well as the fact that the majority of liver cancers occur in the setting of chronic liver disease. The prevalence of hepatocellular carcinoma (HCC) is increasing dramatically in the United States, due primarily to the hepatitis C epidemic. In addition, liver cancer patients span a wide spectrum of tumor stages and degree of liver insufficiency, making therapeutic decisions difficult. One of the services provided through the Liver Transplantation Program at Northwestern Memorial Hospital is the weekly Comprehensive Liver Cancer Clinic. The purpose of this clinic is to provide liver cancer patients with the opportunity to be evaluated in a clinic focused exclusively on their illness, thus allowing for individual care plans tailored specifically to a liver cancer diagnosis.
The clinic is complemented by a multi-disciplinary liver cancer tumor board, which includes surgeons, hepatologists, medical oncologists and both diagnostic and interventional radiologists. Every Friday this board meets specifically to discuss the care plans of clinic patients and to review the cases of referred patients who will subsequently be seen in the clinic in order to determine the best avenue for treatment. On Friday afternoons clinic nurses call patients and referring physicians to inform them of management decisions. This oncology team is an important part of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University, a National Cancer Institute-designated Comprehensive Cancer Center.
The clinic's multi-disciplinary team approach to the diagnosis and treatment of liver cancer ensures that every facet of each patient's condition is fully addressed. The clinic's diagnostic and treatment algorithms incorporate healthcare professionals from various disciplines including surgery, medical oncology, hepatology, diagnostic and interventional radiology, pathology, nursing and social work. For each patient the team focuses on understanding the underlying status of the liver, including the presence or absence of cirrhosis, in the context of the tumor stage. Thus, the team's approach to staging has two levels of complexity - staging the degree of chronic liver disease and assessing the tumor stage in order to make the right therapeutic decisions. Through discussions at the weekly tumor board meetings the diagnostic and treatment algorithms are updated to keep pace with evolving technologies and advancements in the field.
Every Monday afternoon patients are seen in the clinic, where they have the opportunity to interact with members of the multi-disciplinary team. The team evaluates the extent of any chronic liver disease and the extent of liver cancer. The team then defines a management/treatment plan. In order to better stage the disease, patients may be asked to undergo further testing, which can include detailed imaging of the liver by MRI and CT-scan, metastatic surveys of the bones and chest or possibly a direct measurement of the portal pressure gradient. A biopsy also may be recommended.
Based on the results of these tests the team and the patient will come to a joint decision about appropriate treatment. Treatment options offered through the clinic include surgical resection (open or laparoscopic), loco-regional ablative therapies such as radio frequency ablation (RFA), trans-arterial chemo-embolization (TACE), and intra-arterial radio-therapy (IRT). The newest treatment modality, IRT, involves the injection of radioactive microspheres directly into the vascular bed of the liver cancer, which results in emission of internal radioactivity. Under certain circumstances, these liver-directed ablative therapies are combined. With larger lesions, for example, TACE may be followed within seven to 10 days by RFA in order to maximize the tumor "kill." RFA is offered either percutaneously or laparoscopically depending on whether the percutaneous route is technically achievable.
Liver transplantation may be offered to patients who meet certain staging criteria, which include having single tumors less than five centimeters in diameter; having multiple tumors (three or fewer lesions with the largest lesion being no larger than three centimeters); and having no vascular invasion. Depending on specific circumstances transplantation from either living or deceased donors may be offered.
Not all patients seen in the Liver Cancer Clinic have HCC. Patients with other malignant liver tumors are also evaluated and managed by the multi-disciplinary team. These patients may have cholangio-carcinoma or a metastatic liver cancer such as colo-rectal cancer or another cancer. In addition, patients with benign liver tumors also are assessed at the clinic, although these patients are evaluated and seen only by the surgeons.
Contact
Galter Pavilion
675 N. St. Clair St, Suite 21-200
(312) 695-0870
