Highly Targeted Liver Cancer Treatment with SIRT and Surgery
A young man in his late thirties came to the University of Maryland Marlene and Stewart Greenebaum Cancer Center (UMGCC) with upwards of two dozen cancerous lesions on his liver — so many that imaging scans to diagnose him “lit up like a Christmas tree.” But his seemingly hopeless situation — which years ago would have caused physicians to throw up their hands in defeat — was tackled with unique, targeted therapy that resulted in clean CT scans for the patient six months later.
Known as selective internal radiation therapy (SIRT), the non-surgical outpatient treatment uses radioactive microspheres called SIR-Spheres to deliver up to 40 times more radiation to liver tumors than would be possible using conventional radiotherapy. Cutting-edge procedures such as this — which the University of Maryland Medical Center currently performs more of than any other hospital in the nation — combined with a variety of innovative surgical tactics place UMGCC at the forefront of comprehensive approaches to challenge this traditionally devastating malignancy.
“We have many different options to present to our patients, and sometimes the physicians on the Liver Tumor Board combine techniques, going back and forth to create the best treatment, which doesn’t always happen elsewhere,” says Navesh Sharma, D.O., Ph.D., assistant professor of radiation oncology and associate director of the radiation oncology residency program. “I’ve actually had several patients who had been told to get their affairs in order, who were told they had a few months left but lived well beyond a year or more. We encourage patients to be proactive and research all available options.”
Liver Cancer Surgery leads to "lasting treatment effect"
To be sure, liver malignancies remain a formidable foe, with most presenting as metastases of colorectal cancer and a smaller percentage presenting as primary liver cancers. But surgical remissions or cures are possible for increasing numbers of patients seen annually at UMGCC whose tumors are resected. More patients are being attracted to the highly reputable program every year, says Srinevas K. Reddy, M.D., an assistant professor of surgery in the Division of General and Oncologic Surgery.
“Of those with metastatic cancer, about 20% or 30% are resectable, where we can take out all the cancer and leave them with enough liver to survive,” Dr. Reddy explains. “Another 10% to 20% are resectable after chemo to shrink their disease, and about 20% of those with primary liver cancer are initially resectable.
“With all of these diseases, despite improvements in chemo, the only chance for longer-term survival is surgery, and it’s one of the only ways to make a lasting treatment effect with patients with these cancers,” he adds. “Multi-modality is important because other therapies can stop or shrink disease enough to allow surgery to be possible.”
Ten-year data shows that newer chemotherapy agents and better surgical techniques have led to a dramatic improvement in survival, Reddy notes. About 60% of colorectal cancer patients with liver metastases are still alive five years after diagnosis, compared to about one in six a decade ago. “We’ve really made excellent strides,” he says.
One of those advances is the use of laparoscopic or other minimally invasive surgery to remove some liver tumors, which wasn’t done until relatively recently. Aside from a faster recovery and less pain — both huge benefits — this technique also allows patients to begin chemotherapy more quickly afterwards than open surgery generally allows. But it’s not for everyone: Patients undergoing minimally invasive surgery typically have smaller tumors located in the outer portion of the liver, Dr. Reddy says.
“We’re still committed to safety and getting the tumor out,” he adds, “and we won’t compromise to do that through minimally invasive techniques. Every patient’s case is presented at a multidisciplinary liver tumor conference to really study the images and customize our approach.”
Sir-spheres surpass conventional radiotherapy
For inoperable liver malignancies, a variety of radiotherapy treatment options may be appropriate depending on a patient’s individual needs. The use of SIR-Spheres — which will be implanted in about 150 patients this year — builds on UMGCC’s role as the first center in the nation, in 2000, to successfully perform liver-directed therapy with TheraSpheres, which delivered radiation to liver tumors with microscopic glass beads.
Millions of tiny radioactive SIR-Spheres are transported to the tumor site through the hepatic arteries, trapping them in the tumor’s vascular bed where they can destroy adjacent tumor cells. The outpatient procedure, typically administered in two treatments, minimizes damage to healthy liver tissue and leaves patients feeling and functioning more normally within weeks, Dr. Sharma says.
Since each patient’s blood supply is mapped out prior to the procedure, “each is customized, and that’s where our experience and the experience of our colleagues in interventional radiology really matters because we’re able to do things on a small, segmental level … and change things on the fly where blood vessels are a little different,” he adds.
Treatment with SIR-Spheres can improve patient outcome with low toxicity — and hence better quality of life — than repeated chemotherapy cycles. “It depends on what stage we’re treating patients,” he says, “but it’s shown that at every stage of treatment ... SIR-Spheres improve both progression-free survival and overall survival.”
Communication is key
Beyond cancer, UMMC physicians are routinely investigating other common liver conditions such as hepatitis, cirrhosis and fatty liver disease. In fact, about half of Dr. Reddy’s time is spent on clinical outcomes research on fatty liver disease — not only its surgical outcomes, but whether the condition exacerbates problems with other organs such as the heart.
“So many different diseases affect the liver, from cancers to diabetes,” he explains. “That’s what distinguishes us from other places that may have one surgeon who can only do liver cancer. We are so interested in clinical outcomes research, and we want to apply it to patient care as opposed to an institution that operates on patients all day.”
Managing these patients, he points out, is a multidisciplinary, team effort. UMMC physicians give special focus to communicating with patients’ primary care doctors to make sure they understand what procedures have been planned or undertaken so it’s never a surprise.
“I’m constantly on the phone with a patient’s doctor so that doctor and I have a firm plan of what’s going on,” Dr. Reddy says. “I think it’s also important because it shows patients and their local doctors that we’re not going to ‘steal’ their patient. We recognize that the local doctor is the key to managing that patient from both a local standpoint and a long-term standpoint.”
N. SHARMA’S, D.O., Ph.D., research focus is in the application of radiation therapy for gastrointestinal, gynecological and hematological malignancies as well as in the improvement of treatment delivery for highly targeted radiation modalities. To schedule an appointment, please call 1-866-408-6885.