Liver Transplants
Liver transplantation began in the late 1960s, and liver cancer was a main reason people received liver transplants. Until the 1980s, there was no reliable way to prevent rejection of transplants, so few were performed and results were poor. With the discovery of the drug cyclosporine -- the first truly effective anti-rejection medicine -- the success rate rose dramatically. The number of liver transplants performed began to rise rapidly, as well.
Before long, it became clear that most people transplanted for liver cancer did poorly because the cancer returned. As a result, most transplant programs stopped transplanting patients with cancer. Over the past ten years, however, a greater understanding of the behavior of liver cancer and the development of better tests to determine its extent have enabled us to identify some people with liver cancer for whom a liver transplant is indeed the best treatment.
Whom with Cancer is a Candidate for Liver Transplantation?
A liver transplant is about as major an operation as you can undergo. In order to make it through, you have to be in good general condition. Your doctors will do an evaluation to ensure that your heart, lungs, and kidneys are in good shape. There is no absolute age limit, but most people past 70 are not ideal transplant candidates.
If your cancer originated in the liver (primary liver cancer), a transplant may be appropriate. Let's look at a few different scenarios.
- The easiest scenario is if you have advanced cirrhosis, and you just happen to have a small HCC (less than 5 cm) or up to 3 small HCC, the largest of which is 3 cm. In a person with advanced cirrhosis, it is very risky to try to remove the part of the liver that contains a cancer. Small HCC's almost never come back after transplant. A transplant will cure both the cirrhosis and the cancer, and should be done as soon as possible.
- Let's say that you have a small HCC and you have cirrhosis, but your liver is still working pretty well and (apart from the tumor) you really don't need a transplant. The only reliable way to cure HCC is to take it out. We can do this either by removing the part of the liver that contains the cancer (this is called liver resection), or by removing the entire liver and putting a new one -- or part of one -- in its place (transplant).
- There are a few other types of primary liver tumors for which a liver transplant might be considered. Cancer can develop from your bile ducts, the passages that collect the bile from within the liver. This type of cancer is variously called cholangiocarcinoma, bile duct carcinoma, or Klatskin tumor. Bile duct cancer spreads in a totally different way from HCC -- it finds its way into lymphatic channels and along the course of nerves running alongside the bile ducts at an early stage, and often has already traveled a distance away from the main tumor by the time it is discovered. If you have cholangiocarcinoma, most transplant centers do not consider you a transplant candidate. A few hospitals have begun experimental programs using combined radiation and chemotherapy followed by transplantation in carefully selected cases with good early results, but the jury is still out on this approach.
If you have metastatic cancer, the experience over the years has been that when liver transplants have been tried for metastatic cancer, the cancer has nearly always come back. However, there are some exceptions. Let's look at a few scenarios.
- A 'neuroendocrine tumor' usually arises in the pancreas, the intestine, or the lung. The liver is the most common site to which they spread, because the liver is such a good place for tumors to grow. In some cases, despite a careful search, the primary site cannot even be identified (there may be some cases in which neuroendocrine tumors arise within the liver, but this is quite rare). Neuroendocrine tumors are, as a group, quite slow-growing. The tumor cells often produce hormones or other substances that can cause you a variety of problems including diarrhea, stomach ulcers, low blood sugar, and flushing that can be more troublesome than the mere presence of the tumor masses. Because a liver transplant is so risky, we believe that other treatments, mainly chemoembolization, should be used first. Most likely, you will be able to live a fairly normal life for a long time with periodic chemoembolization. If the time comes when the tumors in the liver grow or are producing hormones so that you are having bad symptoms that don't respond to chemoembolization, a transplant will give you a number of years with good quality of life.
- What if your HCC has already grown past the 5 centimeter limit, or if you have more that three tumors, or if there are other signs that your tumor is already more advanced? If there is evidence that the tumor has spread out of the liver to lymph nodes or other organs, or if it has grown into the veins that bring blood into the liver (portal vein) or drain its blood out (hepatic veins) then a transplant has no chance of curing you. More importantly, it would be a mistake. We know that the more advanced your HCC is before transplant, the greater the chances of your HCC coming back after transplant -- even if we cannot detect spread preoperatively. The process of tumor metastasis begins microscopically, and may not become evident until a year or two after your transplant.
- What if you are one of the 10% of people with HCC who do not have cirrhosis? Liver surgeons have become very good at removing tumors from otherwise normal livers, even when they are very large. If you have an HCC in an otherwise normal liver and an expert liver surgeon cannot remove it, chances are that your tumor is too advanced to be cured by a transplant. You should be evaluated carefully because decisions have to be made on a case by case basis.
- Epithelioid hemangioendothelioma is a rare type of cancer that often appears to originate in the liver, though it is actually a blood vessel tumor that may also begin in the bone marrow or the spleen. If you've been given this diagnosis, take a deep breath, slow down, and relax -- don't rush into anything. There's a lot we don't understand about this tumor, but one thing we do know is that is slow growing, often very slow-growing. The best thing to do if you have epithelioid hemangioendothelioma is to wait. If the tumors progress in your liver to the point where they are causing trouble, a transplant may solve that trouble and prolong your life, even though it will probably not cure you.
About Liver Transplants
On the surface, a liver transplant seems like a great choice if you have cirrhosis and a small HCC. It will almost certainly cure the cancer, and will get rid of the cirrhosis at the same time. Transplants are risky, though -- much riskier than resections. There's about a 10-15% chance that if you have a transplant you won't make it through the first year, due to complications of the transplant. That's much higher than for resection. After a transplant, you will have to take a number of very potent drugs for the rest of your life to block your immune system and prevent rejection, and these medicines have significant side effects.
The biggest problem with transplants these days, however, is finding a donor! If a transplant center decides that you need liver transplant, you will be placed on the national waiting list. The way the system is set up in the United States, patients are graded as to how sick they are according to rules made up by the United Network for Organ Sharing (UNOS), and the sickest patients get the most priority.
If you have a single HCC less than 5 centimeters in diameter (about 2 inches), or two or three HCC's none of which is more than 3 centimeters in diameter, you can qualify for a higher number of points on the UNOS MELD scoring system -- independent of liver disease. Thus your waiting time is decreased and you can have a transplant before the tumor grows and spreads.
In order to try to prevent your HCC from growing while you are waiting for a transplant, we usually decide to treat the tumor. The three most commonly used treatments are
- injection of the tumor with 95% alcohol
- injection of chemotherapy and microscopic plastic beads into the artery bringing blood to the tumor to cut off its blood supply (chemoembolization)
- heating of the tumor using an electrical device (radiofrequency ablation)
No one method applies to all cases, and the choice of which one to use depends a lot on how expert your doctor is at the various techniques. In some cases, these treatments will completely destroy an HCC, but they are not reliable enough to count on. Almost everyone agrees, however, that they are useful to buy some time.
