Procedure aims to battle cancers that spread to liver

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. For people with colorectal or bile duct cancer that has spread to the liver, a new treatment option may improve survival and life expectancy. Dr. Mashaal Dhir is here to tell us about hepatic artery infusion therapy. He's an associate professor of surgery at Upstate and section chief of hepatobiliary and pancreatic surgery. Welcome to "The Informed Patient," Dr. Dhir.

[00:00:38] Mashaal Dhir, MD: Thank you for having me.

[00:00:40] Host Amber Smith: First of all, do colorectal and bile duct cancers typically spread to the liver?

[00:00:46] Mashaal Dhir, MD: Yes, the colorectal cancers, they typically arise in the colon and rectum part, which is connected to the liver, through a big vein called portal vein. So liver becomes the next step for many of these cancers. And in general, 50 percent of the patients with colorectal cancer will have spread of the disease to the liver during their lifetime.

The bile duct cancers which are particularly relevant to this type of therapy are the ones which start within the liver. The medical term we use for these are intrahepatic. That means the ones which are arising within the liver. Those are the ones which are treated by this type of treatment.

[00:01:32] Host Amber Smith: And how's this traditionally been treated when you have a colorectal or bile duct cancer that has spread to the liver? In the past, how's it been treated?

[00:01:42] Mashaal Dhir, MD: For colorectal cancer, surgery has been the forefront of treatment in addition to chemotherapy. There are other treatment options for some of the patients as well. For example, radiation or injection of radioactive particles into the liver. And hepatic artery chemotherapy has been around for some time, but just not at our institution.

Similarly, for the bile duct cancers arising within the liver, it's a combination of surgery with chemotherapy. And for patients who are not candidates for surgery, it's typically chemotherapy alone, in conjunction with radiation for some patients.

[00:02:26] Host Amber Smith: So tell us about what is hepatic artery infusion therapy? How does it work?

[00:02:31] Mashaal Dhir, MD: One of the unique things for these colorectal liver metastases, as well as the bile duct cancers arising in the liver, is that they derive their blood supply from the hepatic artery, which is the liver artery. And liver in itself has two blood supplies, the artery and the vein. So the principle of this therapy is to deliver the high dose of chemotherapy directly into the artery, which supplies these tumors and in a way could be 400 times more effective than infusing the same chemotherapy in the IV form.

[00:03:12] Host Amber Smith: So that it goes just to the liver, as opposed to the whole body?

[00:03:17] Mashaal Dhir, MD: Yes. Yes. And 95% of this chemotherapy is cleared by the liver within 10 minutes, and a very small amount of the chemo goes into the circulation. So a lot of it is effective locally with very small amount of side effects which patients experience, so that's the main strength of this treatment.

[00:03:41] Host Amber Smith: That's good to know. Now, what are the risks of this procedure, because to get this to be done you have to insert a pump, right?

[00:03:52] Mashaal Dhir, MD: That's true. That's true. That traditionally has been one of the drawbacks of this therapy that you have to undergo procedure to implant a pump which sits underneath the skin and put the catheter in the liver artery. But more and more data suggests that it really prolongs life, and patients do bounce back quickly from the procedure itself.

And over the last few years we are also doing this procedure robotic. We haven't started doing it robotic here at Upstate, but that's something I trained in and I have written about it in the past. However, we started our program as offering it open to our patients and making it readily available to them.

[00:04:39] Host Amber Smith: How long does the infusion therapy last once the pump is implanted?

[00:04:45] Mashaal Dhir, MD: It really depends on what the intent of the treatment is. In a way, if we are doing the treatment for -- it can be done in two ways, I should clarify that -- one for patients where we cannot remove their disease, where the disease is un resectable. That's the term we would use. For those patients, either it can be for as long as they can tolerate, or if the tumors become resectable, we can take them to surgery down the road and stop treatment at that time, or if some side effects of the treatment start showing up.

So it can vary from patient to patient, how they tolerate, at what point do they develop any side effects, and if their disease becomes amenable to surgery down the road.

[00:05:36] Host Amber Smith: So if all goes well, does the pump get removed at the end of the chemotherapy?

[00:05:44] Mashaal Dhir, MD: That's an excellent question. It is possible to remove the pump. The procedure to remove the pump is actually much simpler, where you just make an incision and remove the pump. We leave the catheter in the artery as such and it doesn't pose any threats or side effects. But there are other medications which can be put into this pump which keep it open, and those medications can be replaced every three months or so to make the life of the patients easier.

[00:06:19] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with surgeon Mashaal Dhir, who's the section chief of hepatobiliary and pancreatic surgery at Upstate, and we're talking about a new hepatic artery infusion pump that can help some patients with certain cancers that have spread to the liver.

Now, who would be a candidate for hepatic artery infusion, and is there anything that would disqualify someone?

[00:06:46] Mashaal Dhir, MD: The two particular diseases for which we use this therapy are the colorectal liver metastases. So in general, it is recommended for those patients who have unresectable disease. That means disease which cannot be removed, which typically involves both sides of the liver. And, such patients also should not have disease outside the liver as well, for example, to their lungs or bones, because we are delivering this therapy to one organ only.

And same for unresectable bile duct cancers, the intrahepatic cholangiol, like we discussed before. These are the bile duct cancers arising within the small bile ducts within the liver. So, unresectable disease is one clear-cut indication, but in some patients where we resect the disease, but they have lots of lesions in the liver, pump can still be implanted to prevent recurrence down the road or to treat the recurrence if they were to develop one down the road.

[00:07:51] Host Amber Smith: How soon do you know whether the therapy is working?

[00:07:57] Mashaal Dhir, MD: This is similar to as we do for most patients who undergo chemotherapy. Usually we check a scan after two to three months of treatment. If patient has elevated blood tumor markers, which are elevated in some patients with bile duct cancers and colon cancers, we can also check those in their blood levels. But usually we check a scan in about two to three months after the treatment.

[00:08:24] Host Amber Smith: So far, how does the effectiveness with the hepatic artery infusion compare with traditional chemotherapy?

[00:08:32] Mashaal Dhir, MD: Over the last few years, there have been several studies. More recent data suggests that, actually, if we use both, rather than one versus other, it can enhance the effectiveness.

And in patients who have unresectable disease, if we add this therapy to their chemotherapy regimen, it can actually double their survival. So, it depends on the intent. And for unresectable patients, if it is added to chemotherapy, over 30 to 40 percent of those patients can become resectable down the road. So the data is very, very encouraging, especially when we combine this with modern chemotherapy regimens.

[00:09:20] Host Amber Smith: It does sound encouraging. There are other types of cancer that travel to the liver. Would an infusion pump work for those cancers too?

[00:09:31] Mashaal Dhir, MD: In general, this therapy is not recommended for those types of cancers, just because the mode of spread is different, and they progress at different times, and it's a more systemic disease when we think of those types of cancers. I would say intrahepatic cholangio as well as the colorectal liver metastases are the two major indications for hepatic artery infusion chemotherapy.

[00:10:04] Host Amber Smith: Well, I understand you recently published a paper about the global trends in primary liver cancer. Can you share the highlights?

[00:10:12] Mashaal Dhir, MD: Thank you for bringing that up.

So I think it was interesting that traditionally there has been increase in the incidence of the primary liver cancers, but what we saw when we studied the Global Can (Global Cancer Observatory) database was that the numbers are starting to plateau.

And I think some of it may have to do with some vaccinations in endemic areas, for example, hepatitis B and so forth. But I think these things may change in future as well as we see obesity and other diseases which can impact liver health increase. They may impact the numbers going forward, but so far compared to 2012 and 2020, based on the database, the numbers seem to be plateauing, which is good news in general.

[00:11:02] Host Amber Smith: Which regions are historically endemic for liver cancer?

[00:11:06] Mashaal Dhir, MD: The eastern region, including China, would be one. But then there are certain parts of Africa and the different regions. WHO (World Health Organization) divides world into six major regions. So I would say there are several endemic regions, but Eastern Asia has been one of the major endemic.

[00:11:34] Host Amber Smith: Well, it's encouraging. If the incidence is going down, that's going in the right direction, I suppose.

[00:11:39] Mashaal Dhir, MD: Yes.

[00:11:40] Host Amber Smith: Well, Dr. Dhir, thank you so much for making time for this interview. I appreciate it.

[00:11:45] Mashaal Dhir, MD: Well, thank you for having me.

[00:11:47] Host Amber Smith: My guest has been Dr. Mashaal Dhir, an associate professor of surgery at Upstate and section chief of hepatobiliary and pancreatic surgery. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at glenviewelectric.com/informed. If you enjoyed this episode, please tell a friend to listen too. And you can rate and review "The Informed Patient" podcast on Spotify, Apple, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.