Transplant team helps ensure liver disease not a death sentence
By David Theis
OCT. 22, 2007--When Galveston resident Julie Booth was told that her long-term liver disease—which began as hepatitis C “decades ago,” then morphed into cirrhosis—had finally degenerated into cancer, she thought, “Oh, my God. I’m dead.”
Until fairly recently, that would have been an accurate prognosis. Even though people with liver cancer lived varying amounts of time, the diagnosis was ultimately a death sentence.
According to Dr. Philip Thomas, assistant professor of surgery, that’s because patients such as Booth needed a liver transplant for long-term survival but conventionally transplantation was not possible for cancer patients.
“So with a diagnosed cancer there was no way you could be a transplant patient,” Thomas said. And since chronic liver disease predisposes the patient to cancer, “it was a race to see which would kill you first—the liver disease or the cancer.” Even if the cancerous part of the liver could be surgically removed, it would almost certainly return.
In the United States, transplants are approved and overseen by the United Network for Organ Sharing. In the past, UNOS was slow to approve transplants for patients with liver cancer, viewing long-term survival as unlikely. Meanwhile, in other countries, looser controls led to new treatments. In France, Germany and Italy sporadic long-term survival was seen following liver transplantation for cancers of the liver.
“Liver disease is endemic in Asia,” Thomas said, and a search for effective treatment led doctors there to go beyond previous limits regarding transplantation and cancer.
New protocols arise
Doctors in Europe were also able to operate in a more experimental manner. Discoveries there led to the formulation of the Milan protocol, a set of criteria developed in Milan which defined the size limits per nodule and the number of tumor nodules which a patient’s cancerous liver could contain and still have a reasonable chance at a cure through transplantation. More recently, the UCSF criteria (University of California, San Francisco) expanded on the Milan criteria “so that larger tumors can be accepted for transplantation,” Thomas said.
The success of the Milan protocol led UNOS to adopt the new standards in 2003. Physicians have become increasingly aggressive in applying the new thinking, to the point now that when a patient with cirrhosis develops a cancerous nodule in the liver “we always think in terms of transplant,” Thomas said.
In January, as Booth’s condition worsened, her doctor presented her at the Multi-Disciplinary Liver Conference, a group at UTMB that includes representatives from hepatology, interventional radiology, transplant surgery, liver disease surgery, oncology, hepatitis surgery and liver pathology. The meeting, which is conducted weekly, is chaired by transplant hepatologist Dr. Gagan Sood.
The group meets weekly in the Sealy Radiology Conference Room where members typically review the files of between five and 10 patients, and recommend treatments.
“Booth was a classic case of chronic liver disease,” Thomas said. She had developed cancerous tumors and was assigned laparoscopic surgery to remove tumors and placed on the liver transplant list.
UTMB’s interdisciplinary advantage
Here is where the interdisciplinary nature of much of UTMB’s work paid dividends. Because of the success of UTMB’s weight-loss surgery program, for which UTMB is a recognized center of excellence, laparoscopic surgeons are available for advanced minimally invasive surgery. Minimally invasive surgery naturally creates fewer traumas for the patient, who can often be out of the hospital after a week. Dr. Guillermo Gomez, the chief of Minimally Invasive Surgery, along with the transplant surgeons performs laparoscopic liver resection for patients who will require liver transplant in the future.
UTMB’s interdisciplinary approach pays other dividends as well. Traditional cancer centers, such as the University of Texas M.D. Anderson Cancer Center in Houston, don’t do transplants. They also don’t do weight-loss surgery, so they don’t have the opportunity for interdisciplinary collaboration with the entire spectrum of surgery from minimally invasive surgery to transplantation.
Booth is not UTMB’s most dramatic example of the new protocol. That designation probably belongs to an unnamed patient treated by Thomas and Gomez. A long-time drug abuser, the patient developed chronic liver disease and cancer. He was given six months to live and sent to a hospice. Once there, however, he lasted longer than his allotted time — long enough to be included in the new protocol. He came to UTMB where his liver tumor was successfully resected. He is alive today and may be a candidate for transplantation if he is compliant with drug rehabilitation.
Now at home, Booth is waiting to see when a liver will be available to her. She is grateful that the transplant door has opened for her, but somewhat pessimistic about how long the process will take. Here again, UTMB has an advantage. “Our waiting list is one of the shortest from placement to transplantation,” Thomas said.
Advantages of geography
When a transplant candidate actually receives a liver depends on the severity of the liver failure as well as geography. Severity is determined by a patient’s MELD score. The Model for End-Stage Liver Disease is a calculation based on liver function.
Greatly simplified, the amount of time spent waiting for a transplant is based on the severity of the condition on the 0-40-point MELD scale. When a patient moves from a lower to a higher MELD level, the time spent waiting at the lower level is ignored and the clock is reset to zero. How long a patient has been waiting for a liver is considered only in cases where patients have identical MELD scores.
Based on the regional variations in the population and number of patients waiting for transplants, some transplant centers provide liver transplants to patients with MELD scores in the 30s, people who are very ill. Most patients with liver cancer complicating their cirrhosis do not have high MELD scores. In the north, patients with lower MELD scores may have a long wait as patients with high MELD scores are ahead of them on the transplant list. However, the average MELD score at the time of liver transplant in Texas is in the 20s. A patient with cancer in Texas could stand a better chance of getting a liver transplant before the cancer spreads.
This bold new approach to liver disease is of the utmost importance for the future, Thomas said. “We have a hepatitis C epidemic in this country,” he says. “But now liver disease is not a death sentence. It is not a fixed course.”