All About Liver Cancer

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Dr. Scott Steele: Hi again everyone, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today, we're very pleased to have Dr. Choon Hyuck David Kwon, who's the Director of our Minimally Invasive Liver Surgery Program. And David, you've been on here before on Butts and Guts in the past, so welcome back to Butts and Guts.

Dr. David Kwon: Well, thanks for the invitation, and thanks for having me here. It's a pleasure.

Dr. Scott Steele: Today we're going to talk a little bit about liver cancer. But before we get there, for those who haven't heard your back episode, please go back and listen to it. But, tell us a little bit about your background and what led you specifically to this specialty about being involved in liver surgery.

Dr. David Kwon: Well, I always found the liver to be a fascinating organ. It's the only organ in our body that regenerates. So I do a lot of living donors as well. So in living donors, let's say you take away 70 percent, and in just about a year or so that removed 70 percent just comes back, and just that's where you are, where you started. So I think that's a really fascinating aspect. And another thing that I liked about the liver is that it is a very technically challenging organ to deal with, and I always love to do surgery, so I think that's how I fell in love with this organ.

Dr. Scott Steele: Fantastic. And we're so glad that you're here. And so on this episode, we're going to discuss a little bit about liver cancer. So let's go really high level to start up. What is the disease and how can it affect someone's liver?

Dr. David Kwon: Well, the liver cancer can be in two big categories, divided into two big categories. One for primary liver cancer and the other one is secondary. The primary is something that the cancer originated from the liver, and that, again, can be divided into two, which is hepatocellular carcinoma, which is a cancer that originated from a liver cell within the liver. And you have the cholangiocarcinoma, which is a cancer that derives from a bile duct cell inside the liver. So you have basically two main primary cancers of the liver. Theoretically speaking, when you talk about liver cancer, these are the two cancers we talk about.

However, what we find more often are those that had a primary cancer somewhere else, such as colorectal cancer, and you have liver metastases. And a big part of my practice, and of the patients that I see that needs liver resection, falls into this category.

Dr. Scott Steele: I should have maybe even started a little higher level. There's a lot of people out there that listen to our podcast that they might not exactly know what the liver does. Can you tell us a little bit about what the liver does and how could you remove 70 percent of it and it still functions?

Dr. David Kwon: Well, you can actually remove up to 80 percent, but you can survive with just 20 percent of the liver function. So the liver has a lot of reserve in the backup because it is at the centerpiece of the whole metabolism of your body. So whatever food you eat, it first goes into the liver. After it gets absorbed by the intestines, it goes to the liver. And the first metabolic cycle goes in the liver. And the liver screens, okay, let's say, this glucose is too much to go to this bloodstream directly, so let's digest it, let's slip in the liver and then pass it slowly to your main system. So, we sometimes call it the factory of the body because it deals with the base of all metabolic function.

It also works with the immunology. An aspect that, let's say, you have colitis, then you probably have bacteria going into the system, and the liver screens that and doesn't let the bacteria go towards the whole system. And the last part is it produces a lot of coagulation factors that are essential for your blood clots to form. So, we often see that patients with terminal cirrhosis, with poor liver function, they tend to have a very high tendency of bleeding because they lack this liver function.

Dr. Scott Steele: So, we're here talking a little bit about liver cancer. So how would somebody know if they had liver cancer, what symptoms would they have?

Dr. David Kwon: Actually, liver cancer is something that doesn't have a symptom initially, because the liver itself does not have a lot of pain neurons around there. Therefore, if you come to the hospital because you have symptoms, they're usually in stage three or stage four or advanced. When they're in stage one or two, usually most of the patients don't have symptoms, we just know that they have it because of a screening through the ultrasound or CT.

But nevertheless, some patients do manifest some symptoms. And I would say the most frequent would be right upper quadrant discomfort, some anorexia, loss of appetite, not feeling that good. So, it's very general symptoms that you can have whenever, let's say, you have a gastritis or colitis. So sometimes they come to the hospital, they're thinking they have colitis, they go through the workup, and they find the liver cancer and they end up getting surgery for that.

Dr. Scott Steele: Are there risk factors for liver cancer? Are there conditions that may directly result in liver cancer? How does that work?

Dr. David Kwon: Yeah. I said about hepatocellular carcinoma and cholangiocarcinoma. In those two, the risk factors are very similar. The most frequent risk factors I would say is the alcohol. We all know the alcohol is very heavy on the liver. And I would say the second in this day and age is obesity. And obesity causes a disease called NASH, which is an abbreviation of nonalcoholic steatohepatitis. So what happens if fat accumulates in your liver, the liver starts to get inflamed, it starts to have inflammation, and that in turn injures the liver cells around it and that becomes a source of the cancer.

And thirdly, although nowadays, it is a lot better because we have very good treatment for that, is the hepatitis C virus. The hepatitis C virus can be eradicated with just two months of medication with very little side effects, so anyone who has hepatitis C, please go and see your hepatologist or any GI doctors and get treated, because the earlier you get treated, the more you're able to prevent. And for cholangiocarcinoma has specifically the PSC, primary sclerosing cholangitis, is one of the risk factors for cholangiocarcinoma.

Dr. Scott Steele: So, truth or myth: liver cancer is most often diagnosed between the ages of 55 and 64? Truth or myth?

Dr. David Kwon: Truth. But this is also a moving target. Previously, it used to be in the 50s, was the peak. Now it's going a little bit more to towards the 60s because let's say patients who go for hepatitis C treatment, the cancer appears later because the inflammation that was caused by the virus is delayed, and, therefore, the cancer appears later.

Dr. Scott Steele: So you mentioned before about some of the symptoms that can occur, but eventually how is liver cancer diagnosed?

Dr. David Kwon: So usually, I would say, the majority of the cases get diagnosed with an ultrasound or CT and majority of the cases before we think about doing any kind of treatment, we also do an MRI specifically designed for the liver because an MRI tends to be a little bit more specific. We understand a little bit better of the tumor character, whether it's true cancer or it's a benign lesion that looks like a cancer, and so on. Other than those image studies, the alpha-fetoprotein is known to be a very relatively good surrogate marker for hepatocellular carcinoma. And the CA 19-9, which is also a tumor marker, is usually used to detect cholangiocarcinoma.

Dr. Scott Steele: What treatment options are available for someone who has been diagnosed with liver cancer? Obviously, we're here to talk a little bit about surgery, so I'm guessing that's one of them, but can you walk me through that?

Dr. David Kwon: Yeah, so actually liver cancer is one of the diseases that a multidisciplinary approach is essential because even though I'm a surgeon, I love doing surgery, surgery cannot be everything. There are a lot of liver tumors that actually do a lot better in treatments other than surgical treatment. And so, from just looking at surgery, we have liver resection that can be also divided into minimally invasive, like laparoscopic, robotic, or open liver resection. And we also have liver transplant as the surgical option.

Other than that, we have ablation, which is you stick a needle in the tumor and you burn it and you also have a trans-arterial embolization, and depending on what kind of agent you use, it can be classified as chemoembolization where you put chemotherapeutic agents and you have radioembolization where you put beads that contain radioactive particles.

Fourthly, you have external beam radiotherapy. And in the past, this SBRT was really not used that much for liver cancers, but recently the SBRT is used a lot more frequently because a lot of the technology behind the radiation has improved and can target the tumor a lot better than previously.

And lastly, but not least, comes the chemotherapy. So depending on how many tumors you have, depending whether its spread throughout the liver, if it's localized in one place, depending on how big the tumor is, you have all these different options that can be applied. And this does essentially need a teamwork approach in order to have the best treatment option.

Dr. Scott Steele: So, can you talk a little bit about if surgery is needed, the minimally invasive approaches, how does that all work?

Dr. David Kwon: Well, the minimally invasive approach has been around for quite some time, but the more we do, we understand that, I would say, around 40 percent of all liver cancers are very, very good candidates of minimally invasive approach. Traditional laparoscopic approach has been used a lot more widely. Recently, robotic approach is getting more traction, but it all depends on how comfortable the surgeon is. Sometimes laparoscopic is better, sometimes the robotic is better. There are cases that minimally invasive is not the best option, especially those who are in very complicated surgeries. In those cases, even though I love doing laparoscopic surgery, those are better to be done open because of the complexity of the surgery. And at end of the day, it's about treating the cancer, and it's not only about the surgical approach that you do that is more important for the patient.

Dr. Scott Steele: So, a lot of people out there want to say, "I don't want liver cancer." So are there ways that they can do to lower their chances of getting liver cancer?

Dr. David Kwon: Yeah, of course. As I said, if you look at the risk factors, you can extrapolate from there what could be prevented. So first, you have alcohol, so don't drink too much. I would say if you really cannot live without alcohol, well, have one day of rest for your liver, for the liver to regenerate, to catch up with digesting your alcohol that you took the day before.

The second risk factor was NASH, you know, obesity. So watch your weight. And if your BMI is above 30 or 35, you really have to actively work on trying to get below 30, which is a lot healthier for the liver.

And thirdly, I haven't mentioned about hepatitis B, but hepatitis B has the vaccine option. So, in case you did not get the vaccines, get the hepatitis B vaccines. And hepatitis C is mostly transmitted through IV drug use. So, just don't do drugs.

Dr. Scott Steele: Fantastic. And so I have had the wonderful opportunity of seeing firsthand and had the privilege of watching you operate, but are there any advancements on the horizon for the liver cancer diagnosis or treatment, especially here at the Cleveland Clinic?

Dr. David Kwon: Well, recently immunotherapy has been a big traction, although we don't have enough evidence, but we do see every now and then, patients that are really, really responsive to immunotherapy. So, I think that should be something that you should always ask your oncologist whether you're a candidate for immunotherapy.

We also have some newer chemotherapeutic agents that are targeted chemotherapy. Also, it's not the most effective, but it does help, so also ask your oncologist about that aspect. And as I said, the external beam radiation has not been a stronghold in their liver cancer traditionally, but I think I see more and more cases where, let's say traditionally you cannot do surgery on, but you can downstage the cases with the external beam radiation or chemoembolization or radioembolization and the patients can reach the point where they can get surgery.

Looking at just the surgical side, a lot of surgical techniques have improved. So nowadays, a lot of cases we do what we call liver venous deprivation. So, this is an interventional radiology technique in which you can hypertrophy. You know, you can increase the size of your future liver remnant for, let's say, you get a right hepatectomy, but your left lobe seems to be a little too small. Then if you do this embolization procedure before, it improves the regeneration capacity of the remaining liver and, therefore, the surgery can be done in a safer way.

Dr. Scott Steele: So, now it's time for our quick hitters where we get to know you a little bit better. So first of all, what's your favorite sport either to play or to watch?

Dr. David Kwon: To watch, I would say baseball and football would be what I watch. But recently, I haven't been watching a lot. I was busy with my kids and the clinical work.

To play, I just like biking a lot. So I think Cleveland is great. During winter is not the best, but spring, summer and fall is a great place to bike.

Dr. Scott Steele: Yeah, absolutely. What's your favorite meal?

Dr. David Kwon: Favorite meal? A good, well-done Korean dish. Any Korean dish is good, my favorite meal.

Dr. Scott Steele: Fantastic. What was your first car?

Dr. David Kwon: My first car was almost not secondhand, almost like a fourth-hand Tayo car. It is the one my mom bought for me, a replacement for a motorcycle that I had been begging her to buy. And she said, "No, I'll just buy you a car."

Dr. Scott Steele: That's fantastic. And so you've been all in the world, but is there something still on your bucket list of a trip that, a place that you'd still like to go?

Dr. David Kwon: Iceland is on my bucket list. I also would like to go to Patagonia if I have the chance. Antarctica would not be bad.

Dr. Scott Steele: Just went to Iceland last summer and it was a very wonderful place to visit. So how about a final take home message for our listeners about liver cancer or minimally invasive surgery as it pertains to this?

Dr. David Kwon: So, as I said, liver cancer, it's a team approach that you need. So, it's very important that you raise questions about having a second opinion with some other disciplines so that you're not stuck with just one option and you have the approach by a group of experts that can treat you right.

I see so many cases that they've been treated by one or two physicians when they had other surgical options or they had other radiological options and those were not taken and they come to me late, of course. Some of them I can treat them, but if they had come to me earlier, they would've had a lot better prognosis. So, I know it's not easy to navigate around the medical field, but if you are diagnosed with liver cancer, please be diligent in doing research and trying to find teams that afford you a very good team approach or treatment.

Dr. Scott Steele: Well, that is fantastic advice. And so, to learn more about the liver cancer program here at the Cleveland Clinic, please visit clevelandclinic.org/livercancer. That's clevelandclinic.org/livercancer. You can also call us at (216)-445-8389. That's (216)-445-8389. David, thanks so much for joining us here on Butts and Guts.

Dr. David Kwon: No, it is my pleasure. Thank you.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.