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In 2020, Cleveland Clinic was the first hospital in the world to use a recently FDA-approved ablation technology that can destroy large liver tumors. Eren Berber, MD, Director of Cleveland Clinic's Surgical Liver Tumor Ablation Program, joins Butts & Guts to discuss liver tumors, treatment options, and this innovative ablation procedure.

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Liver Tumors and Innovative Ablation Technology

Podcast Transcript

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

Hi again everybody, and welcome to another episode of Butts & 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 talk on the topic of liver tumors and then an innovative approach, which is ablation technology for these tumors. And I'm very, very pleased to have Dr. Eren Berber, who's the Director of Cleveland Clinic's Surgical Liver Tumor Ablation Program. Dr. Berber, thanks so much for joining us on Butts & Guts.

Dr. Eren Berber: Thank you, Scott. I'm happy to be here.

Dr. Scott Steele: So for our listeners who don't know you as well, can you give us a little bit of background about yourself? Where are you from where'd you train and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Eren Berber: Sure. Thank you. I'm a Turkish American. I was born in Turkey and did my initial medical school and actually did general training there. And then 1999, I came to the United States and did my training at UCSF and Cleveland Clinic and have been on staff since 2005, for general surgery and endocrine surgery. My career interests include minimally invasive treatment of liver tumors, as well as a lot of other different general surgical patients.

Dr. Scott Steele: Yeah, you do have a very unique practice, I would say that. So let's start very high level for our listeners. So how common are liver tumors and what are some of the causes of these tumors, that we're going to talk about these ablative techniques on?

Dr. Eren Berber: So in the United States, the most common type of tumors that we're treating are actually colorectal. Liver metastasis is a colorectal cancer that has spread to the liver. Just to give you some statistics, in 2021, about 150,000 new cases of colorectal cancer was diagnosed. And we know that one out of four of those patients present with, already spread to the liver and another one-fourth will spread to the liver during their lifetime. So about half of the patients with colorectal cancer will have liver tumors at some point in their treatment cycle. And we also know some other tumors that are also increasing in frequency, such as these liver cancers associated with obesity pandemic, both in the world and in the United States. We know that these patients also address of developing this primary liver tumors, that we call hepatocellular cancer. So they're pretty common in our practice.

Dr. Scott Steele: So are most of these just picked up incidentally, you mentioned about tumors and they get CAT scans, or what are the different symptoms that people can be on the lookout for?

Dr. Eren Berber: So obviously, any patient with any type cancer, when they're being followed in surveillance, they get some kind of imaging to look at their liver, either with CAT scans or MRIs, so this could be picked up without the patients having symptoms. Or in rare cases, the patient could develop pressure symptoms, related to a stretch of liver capsule, or rarely, blackish of the biliary duct, the bile channel inside the liver, which can cause jaundice. And then, by those mechanisms, these tumors can become apparent.

Dr. Scott Steele: So, what are the different surgical options for removing these tumors? And then if you would, just tell us a little bit about more in depth, this innovative ablation procedure, that you, here at the Cleveland Clinic, are using to destroy these larger tumors?

Dr. Eren Berber: So, whenever we have a patient that I know with a liver tumor, the first option, we always consider whether we can cut it out or not? Some patients are not candidates for this treatment because either, they are not so fit to undergo a big operation, or they might have maybe too extensive disease in the liver, or sometimes, an interesting scenario arises, where the tumor is very small, but the amount of liver you have to remove is very big. So for these patients, we have some alternative options and one of these options is burning them with ablation technologies.

We initially started with radio frequency ablation in the 2000s, and then over the last 10 years, microwave ablation has risen as a better and more effective technology. And for patients who are not candidates for burning them or ablating them, then we have embolization options by radiology, as well as these, what we call stereotactic or focused radiation treatments done by radiation oncology.

Dr. Scott Steele: And so when is this type of operation recommended instead of a liver resection? You spoke a little bit about this, but in general, is it size, is it location to the vessels, is it just personal preference? I know you said the primary way is to cut it out, but is there anything else that you take into consideration when looking at these types of lesions?

Dr. Eren Berber: So, the patients who are going to be better candidates for an ablation versus a resection, are going to be those patients first of all, who are not fit to undergo a big operation. Most of the time the liver is actually, we're doing them through open surgery. We also developed a laparoscopic program, where you can make these operations with a small incision, but still, most of the procedures are done through a big, open operation, not every patient can tolerate it. So those patients are definitely candidates for burning them.

Then the other group of patients, are those patients in whom we need to follow the principle, of what we call parenchymal preservation, which translates into trying to preserve as much liver tissue as possible. Ordinarily, we would cut out about 50% of the liver, but in that case, you may want to burn it with these technologies because these technologies are more powerful nowadays. And that the failure rate, where we treat the tumor, is going down every time this technology progresses. So you can burn these tumors laparoscopic, needing a couple of small incision. The patient goes home and there's about a 90% chance that the patient doesn't need any treatments for that tumor and then you preserve the patient's liver. So that's another group of patients or candidates.

And the last group of patients, are patients who have a more extensive disease, where you can do both cutting them out, so a liver resection and also ablation together. And then by doing this, you're able to treat all of the lesions, all of the tumors that the patients have in their livers.

Dr. Scott Steele: So Truth or Myth: recovery time from this procedure, the ablation procedure, is comparable to liver resection surgery.

Dr. Eren Berber: That's true. And I would say, it's even better when the patients undergo this process. They're able to go home the next day and they're back to their baseline by one to two weeks. We know that if you do an open liver resection, where we give the patients an open incision, then the patients stay about four to six days in the hospital and their recovery is about four to six weeks. If you do a laparoscopic resection, where you do the operation for a small incision and cut it out, the patients stay about three days in the hospital and their recovery is about two to three weeks. So definitely, there's a better recovery after an ablation procedure, if the patient is a candidate for it.

Dr. Scott Steele: Truth or Myth: Liver tumors can start off benign and then become malignant.

Dr. Eren Berber: It applies to actually, a small minority of the tumors we're talking about. There's a tumor type, which is special, it's called an adenoma. It's normally a benign growth that occurs in the liver but over time, as the nodule gets bigger and it reaches a certain size, it can turn into a primary liver cancer. For a small minority of the tumors, it is possible.

Dr. Scott Steele: So what's on the horizon, when it comes to the future use of liver ablation therapy? And how are we going about optimizing this technique?

Dr. Eren Berber: So basically now, what we have is, we have much better technology, in terms of what does it mean when we have better technology? So when we burn the tumors, the way you create the heat and how you can disperse it around the tumor is very important. When we start with something called radiofrequency ablation, we are not able to create the heat very evenly around the tumor and it was leading to a lot of failures, about one out of three tumors was failing.

Nowadays, there are microwave options, then the heat is produced very rapidly and it is spread around the tumor very evenly and this decreases the chance of the cancer coming back. And then in fact, we are seeing that only one out of ten tumors treated for colorectal cancer, they come back where you treated. So what's in the horizon now is, look, how are we going to incorporate this data into our current patient treatment algorithm? So does it mean we're going to be able to treat patients who are resection candidates with this treatment? That's actually possible but we need evidence.

And in Europe, there are actually, big studies on the way to randomize patients, to either ablation or cutting out for colorectal cancer. And I think that study will generate us data, to know exactly how this treatment will fit into the patient's treatment algorithm. So basically on the horizon, is going to be data coming out from good studies to really appreciate the role of this treatment, in the patient's disease process.

Dr. Scott Steele: So we always like to get to know our guests a little bit better. So we're going to transition to some quick hitters about you, Dr. Berber. So first of all, what is your favorite food?

Dr. Eren Berber: My favorite food, I'm a Turkish American, so a lot of Mediterranean cuisine and obviously, kebabs and baklava-

Dr. Scott Steele: Yeah, I had some of the best kebabs-

Dr. Eren Berber: ... and calorie intake is not good.

Dr. Scott Steele: ... yeah. I have to say, I had some of the best kebabs when I went to Turkey. Just unbelievable food there. So very, very good. And what is your favorite sport?

Dr. Eren Berber: My favorite sport is soccer. I used to play a lot of soccer in high school. And I guess, if I were not to become a physician, I would have probably become a soccer player. So soccer is my favorite sport.

Dr. Scott Steele: And what is the last nonmedical book that you've read?

Dr. Eren Berber: The last nonmedical book? I'm a little bit into physics and I read a book on how astrophysics and the quantum physics really affect our life. It's just the count of time, history of time and it was interesting to see how physics really affects our life and how much we can learn from physics in our life.

Dr. Scott Steele: And you been and lived around the world, so what is it, something that you like about here in Northeast Ohio and Cleveland?

Dr. Eren Berber: I like the cardinals, for sure. I mean, it really gives you a moment of joy in your life, when you see these red birds around, or when you wake up in the morning. And the nature is so beautiful in Northeast Ohio, just seeing all the nature, is something that you cannot really find in a lot of places.

Dr. Scott Steele: That's fantastic stuff. And so why don't you give us a final take home message regarding liver ablation for our listeners?

Dr. Eren Berber: I would say, that it's a technology that works on patients with good indications. It's not a miracle therapy, but it's very promising and encouraging to see that technology advancing and that it helps us treat the patients more effectively.

Dr. Scott Steele: Well, that's great stuff. And so for more information on Cleveland Clinic's Liver Cancer Program, and to download a free treatment guide, please visit clevelandclinic.org/livercancer. That's clevelandclinic.org/livercancer, you can also call 216.445.8389, that's 216.445.8389.

And again, please remember, that it's extremely important for you and your family to continue to receive medical care, receive regular checkups, as well as screenings. And be rest assured, here at the Cleveland Clinic, we're taking all of the necessary precautions to sterilize our facilities and protect our patients and our caregivers. Dr. Berber, thanks for joining me on Butts & Guts.

Dr. Eren Berber: Thank you. My pleasure.

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

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Butts & Guts

A Cleveland Clinic podcast exploring your digestive and surgical health from end to end. You’ll learn how to have the best digestive health possible from your gall bladder to your liver and more from our host, Colorectal Surgery Chairman Scott Steele, MD.
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