This is Roswell. Rookie by Roswell Park Cancer Institute European opinion where your total options you're -- him -- Welcome back to rise moments and comprehensive look at all aspects of cancer care treatment diagnosis and research from a comprehensive source of Roswell park. I'm -- linger and that's where we are in today we are talking about liver cancer. Doctor Boris commission office in studio today -- rector of the liver and pancreas tumor center also an associate professor. Of oncology here at Roswell park doctors cushion thanks for being here thank you can appreciate halftime is always. And with you today you brought doctor renewed got a year associate professor of oncology as well and co director of that liver. And pancreas tumor program doctor a -- thanks. Thanks for having me and I think we all know what the liver is I don't think a lot of us know. What the -- does let's start with kind of like a one on 101 day if you will on and what the liver isn't what it does for everybody. On the live artists of -- -- or again and located just underneath your ribs and your -- dominion valley on the right side. And the job also -- is to purifying. He implied in Nestle also blind especially in the lower half of the bodies directing first going through deliver. And that explains why a lot of the tumors within the liver actually originates somewhere else 85% of them do. And metastasized. To the them. In addition to that the littler itself the actual sells those ever. Can develop cancers and those from the Kansas -- primarily wanted to focus on today's primary cancers of the live. You know we have two of the few things in there you know we've got the two kidneys and me you know other organs and we can live without. Certain things you can't live with out of -- and in this can be a -- this is a a serious disease to talk about very serious steps to do with me. And why you're absolutely right to have just one member of the -- thing about the rumors that you could actually live in just a part of you never. And TV generation is pretty common deliberate campaign generating enough for -- as long as it's a healthy liver and has the ability to do so. Aren't you mentioned the you know what we're primarily here to talk about today and that is tumors that that. Beginning in within the liver. So often the case is that someone has another cancer in it metastasized or spread through body. To you know a place like the liver. Is that fairly is -- -- is deliver a fairly common destination for or metastasized and. Very at all and I'm not sure that's the correct medical term but that is that is it is a very common fight off -- metastasis in fact one of the most common sites of my -- to see. An 85% of all the tumors located in the live -- actually originated somewhere else. OK so the litter it's real important. We need it it does a very important job and her body we've determined that. What do we need to know how would we. Doctor crucial enough to know. That there's some concern there that maybe something is wrong with -- Well Tim is not always so easy. The blood tests for example can pick up a liver tumor you might have your typical. Comprehensive metabolic panel that is that is gotten your yearly exam or if there's another indication that make a couple of a tumor in his liver enzymes might be elevated. I'm in more advanced disease she might have yellow jaundice if it's. More serious problem. Or there's a small tumor blocking the -- docs and so we know the liver makes the yellow viral. If there's a tumor this physically obstructing the ducks and you can you can -- on this. -- a lot of times a liver tumors are picked up incidentally. CT scans are used much more commonly now. When patients can go to the emergency room of acute onset of pain. You know nowadays it's not a common thing in CT scan in the CT scan me pick up a massive. With these days we we used to pick up liver tumors as a mass or swelling. Now most of these are actually picked up on imaging studies or in response to abnormal blood tests of course symptoms weight loss. You know that those will also pick up some some liver tumors but the vast majority nowadays are picked up. On scanning. People get scans for a lot of reasons these days so -- it's nothing that we really physically can -- ourselves and instantly you're gonna feel anything in your body. Was doctor -- mentioned his liver is situated under the ribs and so that you know the ribs being a phony. Compartment. Oftentimes will. Not allow you to feel -- swindle ever gets in large and it and it goes down below the rib cage and you can actually feel that typical ever. Will be a clue that you may have a tumor that's causing liver enlargement now there's a lot of things that cause and march on the liver but certainly. You know having a tumor or mass. Under the -- cage would be one clue that there could be -- problem. This would be a real good instance I'm sorry thinner in Europe -- -- some lingered about does. Let's say something doctor but. This is a great reason for someone to make sure that for anyone to see their position every year and I absolutely screened. Absolutely and sometimes what happens -- stations was about some abnormal liver functions. And often the primary care of the more common reason why the liver functions mainly -- almost because they have some gallstones of their own some cholesterol. Building medication that can cause this elevation in liver function as a side effect. But the key message here for patients who had such a problem is to ensure after stopping the medication on the appropriate intervention has been. Recommended that that you're function and goes back to normal. On the other group of patients that have liver cancers are folks who have risk factors such as soon Ross's. And chronic hepatitis. Viral hepatitis B or C. And often these patients know they have hepatitis they've had John Chancellor -- Gone in with abnormal liver functions this has been screened and detected and their -- trying to -- the justice following them. Because they're liver functions have not returned to normal and that is some small lesion and -- that there are watching and those are also some individuals. Who get diagnosed. -- screening. Are you mentioned risk factors sometimes cancer just happens you know I guess unfortunately. But there are risk factors there are are you know whether it's genetics or or anything else talked to me if you could both about what the risk factors are. For developing a cancer within -- Four and for different kinds of liver cancers are different risk factors and I think this is a good opportunity to explain. Briefly what the different kinds of liver cancers earlier in the program you mentioned. Days that metastatic tumors are certain types of cancers ago liver and can be treated. Even when they metastasized the -- for example colon cancer. Work personally tumors we have episode I'm personally tumors. Recently on those tumors can actually be removed from a liver or other treatments are gonna talk about applied. Now we're talking about primary liver tumors that start in the liver. The most common one is is what we call each CC or -- cellular carcinoma or happened homeless the other naming goes by. The majority of those tumors to occur in the setting of an abnormal liver. Doctor Meyer mentioned hepatitis B hepatitis C. Longstanding use of alcohol all of those cause damage to the liver. That can -- twos are roses and the development of liver cancers so we have a pretty well. Define explanation for about 80% 85% of the liver cancers that that are that derived from the liver cells. On the other 1520%. Happened just sporadically we don't know why they happen they happen with the normal liver. And that would make up the smaller group. Now there's another kind of cancer occurs in the liver that occurs in the wild ducks called -- and you carcinoma. So the liver has to mean cellular components there's the liver cells. That make that it process and detoxification. Make that make the mile and then you have the bio toxins or actually little channels stocks that carried the vial back in -- -- into your intestines. And your gallbladder is part of your ability -- bile duct system so within these -- with and the liver you can get cancers develop and those two types of cancers even though there in the liver. Look a little bit differently on cat scans they they look different to the pathologists under the microscope and his doctor Meyer mentioned when she talks a little bit about the different kinds of chemotherapy. Very very different treatment so a liver tumor. When you say liver tumor can be very different things that need to be sorted out in terms for us to develop a treatment plan. Tumors can be inside deliver outside deliver -- mean is is that what you're -- I mean it because these are tumors in the liver okay. But that tumors may actually be large enough for me for true out of there but they're fundamentally inside deliver. And that when we're talking about these guys are OK before we get to the treatment he mentioned the chemotherapy that -- carriers tennis it's because. When we suspect if if someone is under suspicion either -- either a medical. Professional their primary position and then gets to a point. -- -- -- you know by somewhere near Roswell what do you do how you how you diagnose and how do you find. Whether someone does actually have or is dealing with liver cancer. Kansas can be diagnosed three different -- they geologic criteria. Biochemical criteria meanings of the loan to value an animation of the tumor marker on -- phosphate to protein. And that could -- would be a biopsy. A mixture of all of these things will take police when the patient is being. Evaluated. Usually the first step would be pain or an abnormal liver function that -- The next step on the suspicion that this needs to be looked into or evaluated. Unless that cat -- was done for some other reason. And upon finding -- Manso occasion they didn't deliver. The next steps of the next. -- -- would involve drawing an alpha fetal protein in tumor Mark -- And also ordering a biopsies that alpha -- protein and the creation alone is not enough to tell us that this is a primary cancer of the liver. So these will be on the disagrees with the diagnosis as me. Sorry that diagnosis then is made what happens how do you make a determination. As to the treatment plan and we'll get into how you know the different aspects of treatment but how you make that determination. Absolutely so the critical thing for patience if someone hasn't been a cancer that they should know is that -- cancer liver cancer is very unique. Is the one thing that's very different about this cancer is the fact. At this stage matters as much as the liver function. So it's critically important for the patient to be evaluated. By a physician. Who knows all the available options and the safety. As well as the dollar and ability and effectiveness of that person's liver function. So for example someone with an early stage liver cancer are very small lesion. Mean not be a candidate for surgery or any of these live addicted to appease the causes liver function is ready for anything we did would be too toxic for him. And really benefit from my liver transplant his survival may -- our. -- then someone who has a stage thirty or forty liver cancer. So I think knowing that you are going to a center that specializes in treating this type of two mark and is completely aware of the safety. And eligibility and his -- and -- before you -- to -- and in your liver function is very important. Really kind of goes against the grain of other cancers are to -- we -- stage 1234. When we talk about. You know other cancers in the body whether it's breast cancer colon cancer. I'm so that really is something that's unique with with liver cancers that you can have a stage one. And it could be maybe someone you know more serious than someone with a three year before the staging system is similar in that the the size of the tumor the invasive ness of the tumor of the multiple tumors will have a higher stage but we also act -- that the the whether or not that has cirrhosis or fibrosis that's also critical element in the decision making. -- you are listening to Roswell this today that is doctor Boris cushion off director of the liver and pancreas tumor center here at Roswell park. And also doctor in new guy here is here she is the co director. Of that same center. That I just mentioned both associate professors of oncology here. At Roswell park and we're talking specifically about liver cancer in specifically as you both distressed about liver cancer that develops. With in the liver and the outcomes of dealing with liver cancer use. Widely differential whether it's something that developed within the liver or whether it's something that metastasized to deliver my correct. Me. There it there are most cancers and fortunately the spread -- -- with the exception of a few. Mom is -- that would be stage four and those would by and large be treated with chemotherapy. There are some exceptions to that -- a very important exceptions for example with colon cancer that metastasized of liver. If it's in a part of the liver and can be removed. You can actually do surgery on those patients with pretty good outcomes over half of those patients. Will be alive five years and to say that for patients with metastatic cancer to the liver and say that you could remove the tumor -- -- and they have a chance of cure. That's staying alive and that together with some of the -- More effective chemotherapy agents for colon cancer is essentially revolutionized the care colon cancer. Almost to the point of making in some cases a chronic disease that you just live way. But. You know you can you know do surgery because of delivers very own unique regenerative capacity can remove. Two thirds of the liver and other third emblem for will grow -- -- But there are these are very you know you have to be very careful about. Sort of extrapolating this to everything you really have to look carefully at the number of tumors location. The patient's overall health. And and in it doesn't work for example for pancreas cancer. If Pincus cancer metastasized colon for eyes a surgeon would not have a role there. But if it's colon cancer that metastasized colon -- very critical world in the in the care. That patient Terry we're gonna get into options now and in and how -- you is is medical professionals and oncologists make decisions on how to how to treat liver cancer. But I think there but you know one of the big takeaways here is you know liver has this reputation out there in society. That it it is a real important organ within our body and if you hear liver cancer I think you think. While you know is there any option. And I think the real message I'm hearing today is there are a lot of options if if someone has cancer that starts in the liver. That you have some. Tremendous options to to deal with these patients so let's let's get there right now what are the different options to deal with -- liver cancers. And again stressing that these are cancers in developed within the liver and as you mentioned doctor Christian -- Are many different kinds of liver cancers so I'm sure the answer is multifaceted. I think I'll start with this one cents. There's a surgeon I I get involved pretty early and where there's an actor's a sort of an algorithm or pathway that we we follow when we're looking at situations like this and the first thing would be. Looking at the this size of the tumor in the liver of a number of tumors. The underlying. Health of the liver. If if that tumors are localized to part of the -- than the gold standard would be to remove the tumor you can actually surgically remove the tumor either using laparoscopic minimally invasive techniques or open techniques. If the tumors larger or there's this underlying cirrhosis and we always have to consider liver transplant. I won't talk too much about liver transplant but it is there is an indication from liver transplant for patients who have. Primary liver tumors if the tumors are relatively small. And and and localized for advanced tumors and obviously liver transplant wouldn't be so first thing we look at this is surgery. To either remove or transplant. Benefit tumors we look at -- distribution if we're dealing with one tumor or multiple tumors if we're dealing with a small number of tumors and we might do. He if surgeries not feasible we might incorporate microwave inflation. Microwave inflation is essentially. Using using the same kind of microwave everybody's familiar with. But the microwave is in it is in a needle and you can actually put this in the solar probe into the tumor and actually microwave for heating kill the tumor. Radio frequency inflation is another technique where you actually heat burn the tumor in place. Nano knife is an even newer technology where you actually send electrical current through tumors all of these what we call of police have technologies basically. Kill the tumor in place. Without you having to actually cut part of the liver -- so for certain patients that's that's the way to go. If the tumors are multiple. Then we do that we we would approach it with what we call regional therapy. Where we would take. Little beats little microscopic -- impregnated with chemotherapy. All called drug -- beads and these little deeds are put in just like a heart catheters nation you actually go into the artery. And you distribute diesel -- into the liver and the bees go to where the tumor is and the chemotherapy actually kills a tumor from these -- There's also radioactive beads that is what we call -- -- ninety's or the search fears which are a little microscopic pieces have. Radiation. C built into it. It's a it's a very at this radiation and only goes a very very short distance of these -- actually go into the tumor. And essentially radiate the tumor from the inside. So that people around the patient -- aren't affected only the tumors affected so if you think about it as local localized in one part of the liberty could remove. Or do some microwave population or they're multiple tumors. Then you can do these these either drug -- deeds or words or them microwave now. If it's not amenable to any of those therapies then doctor iron gets involved and I'll let her take it from there. He's also features an act in all vulnerable. Not candidates for so -- residents because of the location and size of their tumor or their liver function or their agent -- one dvds. As well as the patients are not amenable to a local or regional canopy that is an outpatient on an overnight stay kind of procedure. That would give them prolonged benefit not necessarily curative. Then they look into options that would be chemotherapy. Or targeted -- of the options. The other under the law to monitor liver cancer biology kind of a cancers of color and that same idea that we've been mentioning again and again. Going in cutting off the blood supply inducing delivers blood supply to tumors blood supply as a source of delivering human therapeutic agents. That same idea has been used. In targeting. The patient's cancer. So now we have the drug -- an afternoon which is an oral inhibitor of blood vessel growth. As a signaling in cancer cells that is now approved and it has only become available to us in the last five years for the treatment of liver cancer. Couldn't you do have clinical trials trying to mix craftsmen work better be less toxic and the decent -- on an NCC and ground. Just to study and new drug like sort -- -- collective goals -- man and that's studies likely to open in the next two months hitter Russell park. Once spacious progress the meaning their chances of become a little resistant there's still growing despite two targeting their blood vessels. We have a number of new agents that target other signaling mechanisms within the cancer and chemotherapy agents either on trial. Or off trial available to patients. To be used to treat their disease and systemically and all -- all global basis. Can get the truth because. Go ahead and I wanted to mention something doctor iron just reminded me of a recent patients or might be a good example of howl howl we worked together so we we have a patient who had a liver tumor that was a very large and he couldn't be removed. So doctor higher put her on chemotherapy. And she shrunk the tumor. About half its previous size. So when we looked at the CT scans now that tumor that was not removable. Was small enough that I thought I could remove it so we ended up taking that patient to surgery and we took out the right blow to the liver. We we used and and a knife to help us to make sure that our margins were clear. And we got the path report -- she did -- she she went home recently and when we got the -- report back. Smaller margins were clear and the tumor had a lot of dad -- and -- so. With that told us is that the chemotherapy was able to shrink the tumor and make something that wasn't enough operable. Operable so that was kind of an example of one of our success stories where we're integrating the care actually really allowed us to do something that we can't otherwise guess what such -- -- in -- where you know it's either surgery or it's going to be chemotherapy you can work together. Shrink tumors and then hopefully you know remove it when I wanted to ask about outcomes is is there a it is her way for the two -- you characterize outcomes I mean is someone who is able to have surgery for. A liver cancer. You know likely to have a better outcome or is someone who goes to chemotherapy likely to have -- better outcome or is there really kind of a great answer that question in its defense. The patients who don't best of the ones who are amenable to science and the RB I believe is potentially curative option one of those choices that doctor cushion -- talked about flew back to push enough can do something to help handles of the folks that will do the best. The other thing that works in the favor of those individuals is the fact that they have a little bit of a lead -- -- they have come a little bit earlier in the game if you will -- terms of when he presented in terms of their diagnosis. Often the patients that I am seeing are the ones who have. A more advanced stage one extensive disease won't -- more babies. Generally speaking people who are only candidates for chemotherapy. -- little limited in their options and then survival outcomes are likely to be a little bit lesser. Then what we would expect with this energy options funding to mention is that -- order that gets cancer of the liver. Is -- sick and other which is kind of cancer in the first place. So even when you have treated 121 of them over the remainder of the -- is still at risk to develop a new toolbar. -- are also the recurrence or spread from the first Umar. So we still have not come home with Ruiz for a second any prevention we have not yet completed all the clinical trials and gain data to know want to know when you've already had one potentially curative therapy. To make sure you are now and in the situation again to need another treatment. But thankfully those patients are followed -- surveillance and they're not out of our site. So we're watching we find the next to my if it does appear early enough that often he can go back into another obligation. You both I have worked hard to come together and in joined forces to. To found this and now in direct the liver and pancreas tumor center what is what does it mean. To Roswell park to have a centered like that -- liver and pancreas tumors that are. Well through a very calm thoughtful. Donation from one of -- grateful patients we were able to start this endeavor. That what it's allowed us to do is have a -- coordinated program we have for example a liver. Tumor coordinator who's a who's a nurse who helps us coordinate all of the care. When you have patients -- two in three different doctors sometimes it gets a little disjointed. -- Roswell it's nice because they're all under one roof that even within Roswell having a coordinator and navigators as you will is very helpful we all. Tom we've taken that and and together with our. How multi disciplinary. Conference we have every Tuesday morning. The fact that the patients can common -- on the same day so basically we've taken this center concept. And tried to make it in a in a fashion that really helps the patients. Get through a very complex problem because these patients have to deal with nutrition issues with pain issues with social services issues. Not to mention -- you know dealing with seeing multiple. You know specialists at the same time so we try to try as best we can to. Haven't as this when we -- center we just mean a the place where you can get a lot of this -- and one physical location for for one. But also in the in the virtual sense in terms of coordination of care we try to give ourselves an identity. So that we can get resources specific to these patients with liver paying. There's and I think so important to point out is is it the you know somebody times as we do here on this show. A team of people that are focused on one thing one aspect of cancer or you know one -- one area of cancer care what you think. You know that focus in and of itself I think proves beneficial to be -- we learn so much from each other I think -- Tuesday morning conference to. I can't tell you all the things that doctor Myers taught me about managing these these patients and to be able to just walk across all and say -- I had a tough. Problem here you know I need your help and and you know so that I think that. Sort of cross fertilization and they and they and -- sort of teaching each other has really really. I think benefited patients and all she wants from you is to learn to play tennis. Pray pray pray that we don't have a lot of time to get into clinical trials here perhaps we can save it for another day. But. You know ending on on a -- looking forward do you both see. Tremendous amount of advances dealing with liver cancer has there. You know in the immediate past been a tremendous amount of change -- how you do this disease or do you see that coming. It's already here that I technologies available left -- that I never heard often dreamed it would ever be possible national alliance. I never heard of this before we now have all of these available options and we continue to refine there you see. And take better care of patients in terms of their supportive care providing new resources. And getting them through the entire experience of dealing with this cancer -- getting better at it every day. And I would add that now doctor hires a wallow in the forefront of of research. She's -- working on developing drugs that workers are specific for this kind of cancer. And and that's going to be a -- home run it's it's going to be through efforts in her lab and and developing these targeted therapies that are just. You know precise for an -- tiny cancer and that patient I mean I think that's where you know down the road making deaths were really -- it. Doctor cushion -- thank you so much appreciate the time. Thank you that is doctor Boris -- should not fees a director of the liver and pancreas tumor center and associate professor of oncology Europe Roswell park. Doctor renewed prior thank you very much for being here appreciate it my pleasure and our -- is a doctor you're an associate professor of oncology as well and co director of that liver. And pancreas tumor program here at Roswell park. If you have any questions that we may have raised questions in general you can call Roswell any time at 877 ask our PCI. That is 8772757724. You can hear this show many more just like it different subject matter at Roswell park dot org. -- Listen to roster bonus Sunday mornings at 630 young WB yeah. -- by Roswell Park Cancer Institute your team opinion for your total options on line at Roswell this god of war. Me. And hanging do you. Then.