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HCC/Liver resection with Stage 4 Cirrhosis
Dear all,
My 55 year old husband was diagnosed with Stage 4 Cirrhosis and Hep C in 2000. He completed a full year of Peg Interferon w/ Ribavarin in 2001, and has been clear of HCV since treatment.
He has been under the care of a liver transplant team and has been monitored every 6 months since 2003 (blood work, ultrasounds, upper & lower GI, etc.). He had level 4 esophageal varisces at one point, but his last endoscopy indicated that instead of the multiple esophageal varisces there is currently only 1 near his stomach.
He has always struggled with fatigue, sensitivity to heat and cold, and lack of appetite. He has been sober since 1999.
This past September (2013), they performed an CT scan instead of an ultrasound for his 6 month checkup.
On Monday, we received a call to inform us that he has HCC. I do not have any staging information right now other than knowing that there is at least 1 tumor under 1 cm in size. His doctor has referred us to a surgeon (in the liver transplant group) to discuss a liver resection to remove this tumor.
His liver is functioning, which is why I understand they are offering this option. He does not want to pursue a liver transplant due to personal beliefs, which I respect.
My question has to do with surgery given his cirrhosis. His doctor has already told him that he has a higher chance of bleeding complications from surgery, and I am also concerned about his lung function during surgery as the CT scan revealed bilateral Atelectasis (which I understand to be areas of lung which are not fully inflated).
Other family members of his died of liver disease, so we are familiar with the symptoms and challenges. He does not suffer from ascites yet, but does take Lactulose to prevent the mental confusion. His appetite has gotten worse over the past couple of months, but he makes it a point to try to eat something, even if he can't finish it. He sleeps through the night, but needs 2 naps a day.
We are meeting with the team on Monday, so I apologize for asking things that will most likely be answered at that time. If anyone has any suggestions for other questions to ask, please let me know. My list is long but I'm sure not as comprehensive as I would like it to be.
Thank you in advance for any guidance or input you can offer.
Regards,
AnnaB519
My 55 year old husband was diagnosed with Stage 4 Cirrhosis and Hep C in 2000. He completed a full year of Peg Interferon w/ Ribavarin in 2001, and has been clear of HCV since treatment.
He has been under the care of a liver transplant team and has been monitored every 6 months since 2003 (blood work, ultrasounds, upper & lower GI, etc.). He had level 4 esophageal varisces at one point, but his last endoscopy indicated that instead of the multiple esophageal varisces there is currently only 1 near his stomach.
He has always struggled with fatigue, sensitivity to heat and cold, and lack of appetite. He has been sober since 1999.
This past September (2013), they performed an CT scan instead of an ultrasound for his 6 month checkup.
On Monday, we received a call to inform us that he has HCC. I do not have any staging information right now other than knowing that there is at least 1 tumor under 1 cm in size. His doctor has referred us to a surgeon (in the liver transplant group) to discuss a liver resection to remove this tumor.
His liver is functioning, which is why I understand they are offering this option. He does not want to pursue a liver transplant due to personal beliefs, which I respect.
My question has to do with surgery given his cirrhosis. His doctor has already told him that he has a higher chance of bleeding complications from surgery, and I am also concerned about his lung function during surgery as the CT scan revealed bilateral Atelectasis (which I understand to be areas of lung which are not fully inflated).
Other family members of his died of liver disease, so we are familiar with the symptoms and challenges. He does not suffer from ascites yet, but does take Lactulose to prevent the mental confusion. His appetite has gotten worse over the past couple of months, but he makes it a point to try to eat something, even if he can't finish it. He sleeps through the night, but needs 2 naps a day.
We are meeting with the team on Monday, so I apologize for asking things that will most likely be answered at that time. If anyone has any suggestions for other questions to ask, please let me know. My list is long but I'm sure not as comprehensive as I would like it to be.
Thank you in advance for any guidance or input you can offer.
Regards,
AnnaB519
COMMUNITY LEADER
Thanks Mike!
Nurse32 -
The most appropriate treatment for HCC depends upon the tumor size, number and location, the involvement of blood vessels, and on the severity of the underlying liver disease.
"They are telling me and my family there is no options for us. "
Who is telling you this?
Her hepatologist at the transplant center?
Why is there no options? Is her liver disease to advanced? Does she have intrahepatic or extrahepatic spread?
If you don't mind... which liver transplant center is this?
Treatment of HCC depends upon the severity of liver disease. For example compensated cirrhotics with Childs-Pugh score of class A can be treated with TACE, ablation, etc. A patient with class B or C usually can not have their HCC treated with standard HCC treatments.
Is this why the transplant center says your mom has no options?
Tumors of 4 and 8 cm can usually be treated and downsized while the patient waits for enough MELD points to get a transplant. This is the purpose of TACE, Ablation (RFA) (PEI), This is why HCC treatment is called “bridge to transplant”. They are not curative treatments. Only transplant can cure HCC unless the cancer is caught very early (before cirrhosis) and resection can be used.
Chemotherapy:
Sorafenib is recommended as first line option in patients, who can not benefit from resection, transplantation, ablation or transarterial chemoembolization,and still have preserved liver function.
So without knowing the details of your mother’s condition I can’t say why they are saying there are no options. Even myself who had untreatable HCC was able to get a life saving transplant because I volunteered to undergo an experimental treatment and the transplant center didn't give up on me despite the odds and then was lucky enough that the treatment worked for me. Of course I had HCC that had not metastasized and enough liver function remaining to do and fail 7 different HCC treatments before being successful with the 8th and last Cyberknife radiation treatment.
If you can provide more information I might be able to be more helpful.
Don’t give up hope!!! There may still be a way your mother can get a transplant like I did at age 61 on November 16th 2013, just 2 weeks ago after being taking off the waiting list for most of 2013
Hang in there! .
-`ღ´-
Hector
Nurse32 -
The most appropriate treatment for HCC depends upon the tumor size, number and location, the involvement of blood vessels, and on the severity of the underlying liver disease.
"They are telling me and my family there is no options for us. "
Who is telling you this?
Her hepatologist at the transplant center?
Why is there no options? Is her liver disease to advanced? Does she have intrahepatic or extrahepatic spread?
If you don't mind... which liver transplant center is this?
Treatment of HCC depends upon the severity of liver disease. For example compensated cirrhotics with Childs-Pugh score of class A can be treated with TACE, ablation, etc. A patient with class B or C usually can not have their HCC treated with standard HCC treatments.
Is this why the transplant center says your mom has no options?
Tumors of 4 and 8 cm can usually be treated and downsized while the patient waits for enough MELD points to get a transplant. This is the purpose of TACE, Ablation (RFA) (PEI), This is why HCC treatment is called “bridge to transplant”. They are not curative treatments. Only transplant can cure HCC unless the cancer is caught very early (before cirrhosis) and resection can be used.
Chemotherapy:
Sorafenib is recommended as first line option in patients, who can not benefit from resection, transplantation, ablation or transarterial chemoembolization,and still have preserved liver function.
So without knowing the details of your mother’s condition I can’t say why they are saying there are no options. Even myself who had untreatable HCC was able to get a life saving transplant because I volunteered to undergo an experimental treatment and the transplant center didn't give up on me despite the odds and then was lucky enough that the treatment worked for me. Of course I had HCC that had not metastasized and enough liver function remaining to do and fail 7 different HCC treatments before being successful with the 8th and last Cyberknife radiation treatment.
If you can provide more information I might be able to be more helpful.
Don’t give up hope!!! There may still be a way your mother can get a transplant like I did at age 61 on November 16th 2013, just 2 weeks ago after being taking off the waiting list for most of 2013
Hang in there! .
-`ღ´-
Hector
Many transplant centers follow the Milan Criteria.
According to the Milan guidelines in order for a patient with HCC to qualify for a liver transplant there must be no more than 1 tumor not greater than 5 cm or no more than 3 tumors none of which are greater than 3 cm. Some centers have adopted an expanded Milan Criteria which goes beyond those parameters. UCSF has studied this;
"....Yao studied consecutive transplant recipients over a 12-year period and formulated a modest expansion of the Milan criteria: solitary HCC ≤6.5 cm, or ≤3 nodules with the largest lesion ≤4.5 cm and a total tumor diameter ≤8 cm. With this new set of criteria, a 5-year survival rate of 75% was achieved...."
(See: http://www.thehbsn.org/article/view/1342/1849)
Even under that expanded criteria it appears as if your mother would not qualify.
I hope that Hector sees your question because he knows much more than I do about approaches to HCC.
I wish that I could offer more hope and more information. I feel very badly that you're going through something this heart wrenching.
Mike
According to the Milan guidelines in order for a patient with HCC to qualify for a liver transplant there must be no more than 1 tumor not greater than 5 cm or no more than 3 tumors none of which are greater than 3 cm. Some centers have adopted an expanded Milan Criteria which goes beyond those parameters. UCSF has studied this;
"....Yao studied consecutive transplant recipients over a 12-year period and formulated a modest expansion of the Milan criteria: solitary HCC ≤6.5 cm, or ≤3 nodules with the largest lesion ≤4.5 cm and a total tumor diameter ≤8 cm. With this new set of criteria, a 5-year survival rate of 75% was achieved...."
(See: http://www.thehbsn.org/article/view/1342/1849)
Even under that expanded criteria it appears as if your mother would not qualify.
I hope that Hector sees your question because he knows much more than I do about approaches to HCC.
I wish that I could offer more hope and more information. I feel very badly that you're going through something this heart wrenching.
Mike
Hello Can someone please give me any information possible. My mother 60 years old is in the hospital with end stage cirrhosis as well as HCC. Her MELD score right now is 27 and she has two tumors one 8cm the other 4cm. They are telling me and my family there is no options for us. I cant just watch my mother die without trying something. If anybody has any info or insight please help. Thank you
COMMUNITY LEADER
Best of luck with the doctor's visit!
Cheers!
Hector
(HCV and stage 4 liver disease since 2007. Diagnosed with HCC 28 months ago. 4 TACE cancer treatments, 3 Ethanol Injection cancer treatments. Currently undergoing CyberKnife radiation treatment of my remaining HCC. MELD score 36).
Cheers!
Hector
(HCV and stage 4 liver disease since 2007. Diagnosed with HCC 28 months ago. 4 TACE cancer treatments, 3 Ethanol Injection cancer treatments. Currently undergoing CyberKnife radiation treatment of my remaining HCC. MELD score 36).
Thank you, Hector.
I found that information online as well - I guess I was hoping to hear this in regular English and you helped me with that.
After reading all of this, I am just a little surprised that they are offering surgery as an option. I will find out on Monday, I suppose.
Thank you again for your answer!!
I found that information online as well - I guess I was hoping to hear this in regular English and you helped me with that.
After reading all of this, I am just a little surprised that they are offering surgery as an option. I will find out on Monday, I suppose.
Thank you again for your answer!!
COMMUNITY LEADER
Resection is usually not an option for a patient with cirrhosis. Particularly one with portal hypertension (varices) and a low platelet count.
Unfortunately HCC is an incurable cancer. The only cure is a liver transplant. All of the standard HCC treatments such as TACE, RFA, PEI are used to keep the patient alive long enough to get a liver transplant. They are not cures.
"Surgical Resection
This is the treatment of choice for HCC in non-cirrhotic patients, who account for just 5% of the cases in Western countries, and for about 40% in Asia. These patients will tolerate major resections with low
morbidity, but in cirrhosis candidates for resection have to be carefully selected to diminish the risk of postoperative liver failure with increased risk of death. Right hepatectomy in cirrhotic patients has a higher
risk of inducing decompensation than left hepatectomy.
...in Europe and the United States, selection of optimal candidates for resection is usually based on the assessment of the presence of portal
hypertension, as assessed clinically or by hepatic vein catheterization. Studies have shown that a normal bilirubin concentration, and the absence of clinically significant portal hypertension measured by hepatic
vein catheterization (hepatic vein pressure gradient <10 mmHg) are the best predictors of excellent outcomes after surgery, with almost no risk for postoperative liver failure. Such patients will not decompensate after resection and may achieve a 5-year survival of better than 70%. In contrast, the majority of patients with significant portal hypertension
will develop postoperative decompensation (mostly ascites), with a 5-year survival of less than 50%. Finally, the survival of those subjects with both adverse predictors (portal hypertension and elevated bilirubin) and/
or multifocal disease is less than 30% at 5 years, regardless of their Child–Pugh stage. Therefore, measurement of portal pressure is a key step in the evaluation of candidates for resection. Obviously, if
upper endoscopy shows varices or if diuretic treatment is needed to control ascites, portal hypertension is already severe and catheterization is not necessary. Clinically significant portal hypertension may also be suspected when the platelet count is below 100,000/mm3
associated with significant splenomegaly. The usefulness portal pressure measurement to predict the outcome of patients and define optimal candidates for resection has been validated in Japan.This study
confirms that resection should remain the first option for patients who have the optimal profile, as defined by the BCLC staging system. Thus, although resection can be performed in some of these patients with
advanced liver disease, the mortality is higher and these patients might be better served by liver transplantation or thermal ablation."
16. Local ablation is safe and effective therapy for patients who cannot undergo resection, or as a bridge to transplantation (level II).
17. Alcohol injection and radiofrequency are equally effective for tumors <2 cm. However, the necrotic effect of radiofrequency ablation is more predictable in all tumor sizes and in addition, its efficacy is clearly superior to that of alcohol injection in larger tumors (level I).
18. TACE is recommended as first line non-curative therapy for non-surgical patients with large/ multifocal HCC who do not have vascular invasion or extrahepatic spread (level I).
19. Sorafenib is recommended as first line option in patients who can not benefit from resection, transplantation, ablation or transarterial chemoembolization, and still have preserved liver function
(level I).
20.Tamoxifen, anti-androgens, octreotide or hepatic artery ligation/embolization are not recommended (level I).
21. Radioembolization with Yttrium90-labeled glass beads has been shown to induce extensive tumour necrosis with acceptable safety profile. However, there no studies demonstrating an impact on survival and hence, its value in the clinical setting has not been established and cannot be recommended as standard therapy for advanced HCC outside
clinical trials (level II).
22. Systemic or selective intra-arterial chemotherapy is not recommended and should not be used as standard of care (level II)."
General questions about liver cancer...
What is my diagnosis? What is the exact type of liver cancer? HCC?
What is the size of the tumor? Is there only one tumor?
Can the tumor be removed surgically? What does this mean?
Can you explain my pathology report (laboratory test results) to me?
Do I have cirrhosis of the liver? What does this mean? How does it affect my cancer treatment?
What are my treatment options?
What treatment plan do you recommend? Why?
What is the goal of each treatment? Is it to eliminate the cancer, help me feel better, or both?
What are the chances for success with the planned treatment?
Do I need treatment right away?
Who will be part of my health care team, and what does each member do?
Who will be coordinating my overall treatment and follow-up care?
What are the possible side effects of this treatment, both in the short term and the long term?
How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?
If I’m worried about managing the costs related to my cancer care, who can help me with these concerns?
What support services are available to me? To my family?
Whom should I call for questions or problems?
Good luck.
Hector
Unfortunately HCC is an incurable cancer. The only cure is a liver transplant. All of the standard HCC treatments such as TACE, RFA, PEI are used to keep the patient alive long enough to get a liver transplant. They are not cures.
"Surgical Resection
This is the treatment of choice for HCC in non-cirrhotic patients, who account for just 5% of the cases in Western countries, and for about 40% in Asia. These patients will tolerate major resections with low
morbidity, but in cirrhosis candidates for resection have to be carefully selected to diminish the risk of postoperative liver failure with increased risk of death. Right hepatectomy in cirrhotic patients has a higher
risk of inducing decompensation than left hepatectomy.
...in Europe and the United States, selection of optimal candidates for resection is usually based on the assessment of the presence of portal
hypertension, as assessed clinically or by hepatic vein catheterization. Studies have shown that a normal bilirubin concentration, and the absence of clinically significant portal hypertension measured by hepatic
vein catheterization (hepatic vein pressure gradient <10 mmHg) are the best predictors of excellent outcomes after surgery, with almost no risk for postoperative liver failure. Such patients will not decompensate after resection and may achieve a 5-year survival of better than 70%. In contrast, the majority of patients with significant portal hypertension
will develop postoperative decompensation (mostly ascites), with a 5-year survival of less than 50%. Finally, the survival of those subjects with both adverse predictors (portal hypertension and elevated bilirubin) and/
or multifocal disease is less than 30% at 5 years, regardless of their Child–Pugh stage. Therefore, measurement of portal pressure is a key step in the evaluation of candidates for resection. Obviously, if
upper endoscopy shows varices or if diuretic treatment is needed to control ascites, portal hypertension is already severe and catheterization is not necessary. Clinically significant portal hypertension may also be suspected when the platelet count is below 100,000/mm3
associated with significant splenomegaly. The usefulness portal pressure measurement to predict the outcome of patients and define optimal candidates for resection has been validated in Japan.This study
confirms that resection should remain the first option for patients who have the optimal profile, as defined by the BCLC staging system. Thus, although resection can be performed in some of these patients with
advanced liver disease, the mortality is higher and these patients might be better served by liver transplantation or thermal ablation."
16. Local ablation is safe and effective therapy for patients who cannot undergo resection, or as a bridge to transplantation (level II).
17. Alcohol injection and radiofrequency are equally effective for tumors <2 cm. However, the necrotic effect of radiofrequency ablation is more predictable in all tumor sizes and in addition, its efficacy is clearly superior to that of alcohol injection in larger tumors (level I).
18. TACE is recommended as first line non-curative therapy for non-surgical patients with large/ multifocal HCC who do not have vascular invasion or extrahepatic spread (level I).
19. Sorafenib is recommended as first line option in patients who can not benefit from resection, transplantation, ablation or transarterial chemoembolization, and still have preserved liver function
(level I).
20.Tamoxifen, anti-androgens, octreotide or hepatic artery ligation/embolization are not recommended (level I).
21. Radioembolization with Yttrium90-labeled glass beads has been shown to induce extensive tumour necrosis with acceptable safety profile. However, there no studies demonstrating an impact on survival and hence, its value in the clinical setting has not been established and cannot be recommended as standard therapy for advanced HCC outside
clinical trials (level II).
22. Systemic or selective intra-arterial chemotherapy is not recommended and should not be used as standard of care (level II)."
General questions about liver cancer...
What is my diagnosis? What is the exact type of liver cancer? HCC?
What is the size of the tumor? Is there only one tumor?
Can the tumor be removed surgically? What does this mean?
Can you explain my pathology report (laboratory test results) to me?
Do I have cirrhosis of the liver? What does this mean? How does it affect my cancer treatment?
What are my treatment options?
What treatment plan do you recommend? Why?
What is the goal of each treatment? Is it to eliminate the cancer, help me feel better, or both?
What are the chances for success with the planned treatment?
Do I need treatment right away?
Who will be part of my health care team, and what does each member do?
Who will be coordinating my overall treatment and follow-up care?
What are the possible side effects of this treatment, both in the short term and the long term?
How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?
If I’m worried about managing the costs related to my cancer care, who can help me with these concerns?
What support services are available to me? To my family?
Whom should I call for questions or problems?
Good luck.
Hector
I wanted to add my apologies up front, as well -- I stated that my husband does not wish to pursue a liver transplant for personal reasons which is true; his meld score is still under 10 but we stopped keeping score of it anyway a few years ago since he does not want to do this. I know that this is a very personal choice that everyone approaches differently, and I hope I have not offended anyone by stating his choice the way that I did. He has made peace with many facets of his illness and the choices that he will have to make in the future. My reason for rejoining this board is for my own benefit to try to learn what I can about this new part of the journey that we are on.
Many thanks to all of you - you have been so helpful to so many and I am grateful that you are so willing to share your knowledge and experiences.
Many thanks to all of you - you have been so helpful to so many and I am grateful that you are so willing to share your knowledge and experiences.
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I did not initially respond to your question because I simply cannot answer it. However Dr. Schiano on the Liver Transplant forum should be able to help you. He answers questions about HCC unrelated to transplant as well.
http://www.medhelp.org/forums/Liver-Transplant/show/274
I had a tumor that was 3.0 and was treated with TACE. It killed the tumor and for now I am cancer free. They were considering resection for me too but decided against it and I am not sure why, possibly because I am cirrhotic.
Please keep us posted on how things go and if I do find any helpful information, I will send it on to you.
I wish you both all the best.