Life is Meant to be Lived

One Man’s Story: A Daughter’s Perspective

About two years ago, when my father received a diagnosis of primary hepatocellular carcinoma (HCC), or a liver cancer test, he looked to me for help in identifying treatment options. The diagnosis of HCC, difficult for anyone to handle, was extremely devastating to my father, who had already battled numerous life-threatening conditions and diseases.

Through it all, my father has been a fighter. He has refused to feel sorry for himself, lose control or break down. He has faced every enemy head-on with a fierce determination to gain the upper hand. My father’s philosophy has always been that life is meant to be lived.

A Silent, Deadly Infection

Almost two years ago, someone informed my father that he had liver cancer. Ironically, the same surgery that had saved his life 30 years earlier likely also infected him with a deadly hepatitis virus. Silently working behind the scenes, the infection had finally taken its toll. My father had multiple liver tumours. He had about 6 months to live.

For the first time, I heard my father’s tired voice. He could only take so much. It wasn’t fair. As soon as he surmounted one obstacle, another appeared in its place. But, despite it all, he wanted to lick this one, too, so the hunt for a treatment began.

Then I spoke with Dr. Jack Wands, director of the Division of Gastroenterology and The Liver Research Center Rhode Island and Miriam Hospital(s). He listened attentively to my story. He asked if I had heard of Dr. Damian Dupuy at Rhode Island Hospital. Dr. Dupuy did incredible things with radiofrequency ablation (RFA) therapy, including treating liver cancer.

New Therapy Extends Quality of Life

As soon as I got off the phone, I fired off an e-mail to Dr. Dupuy. Within 24 hours, I received a reply – he would be happy to evaluate my father but cautioned that this treatment was not for everyone. Within a few weeks, my father underwent several liver cancer tests and was then on his way to Rhode Island for treatment. Dr Dupuy could ablate most of the tumour masses; two months later, my father returned to the golf course. That was eighteen months ago.

Since that time, my father has needed two more RFA treatments. With every treatment, my father has recovered more rapidly. He is currently leading an active life with my mother. Spending time with his grandkids and, of course, playing golf. We know that the cancer is not gone, but we will control it with ablation therapy for as long as possible.

This treatment has extended his life and allowed him to live it doing the things he most enjoys doing.

A Doctor’s Perspective

Damian Dupuy, M.D.

Associate Professor, Department of Diagnostic Imaging at Brown Medical School, and Director of Ultrasound at Rhode Island Hospital

In addition to completely eradicating tumours, physicians can use radiofrequency ablation (RFA) to control primary liver cancer in patients who have no alternative options due to factors such as tumour size, location, or associated medical conditions. The daughter of one patient who greatly benefited from the soothing effects of RFA has written an account of his story. With the patient’s permission, I would like to share his case from the physician’s perspective.

First Impressions

Mr. Pachuk presented to me with two large hepatocellular carcinomas (>7cm) in the right lobe of his liver approximately 18 months ago. Standard therapy for his disease would have been surgical removal of the right side of his liver. Mr. Pachuk’s normal left lobe was sufficiently healthy to carry the workload. Unfortunately, Mr. Pachuk had a history of congestive heart failure and chronic renal insufficiency, making him a very poor surgical candidate. Despite his medical problems, Mr Pachuk lives a full life enjoying travel and golf, and he is not ready to throw in the towel just yet.

His local physicians, as well as specialists at a major cancer centre, were unaware of the benefits of RFA as a minimally invasive treatment option in cases such as his, and they gave him no treatment as his only option. This left him with a typical median survival of 4-6 months. Fortunately, his daughter works in the field of hepatology, and her connections led her to me at Brown Medical School and Rhode Island Hospital, where I had been using RFA as a palliative treatment and test options in patients with large liver cancer tumours such as Mr Pachuk’s.

Overcoming Complications

The first ultrasound-guided RFA treatment went very well. But I knew upfront that complete tumour eradication was out of the question. Nonetheless, I did my best, and approximately 80-90% of the tumour was killed. Normally, I follow patients with contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI). However, in Mr. Pachuk’s case, his renal insufficiency precluded the use of intravenous CT contrast due to its toxic effects on the kidney. Compounding this management dilemma, Mr. Pachuk developed a cardiac arrhythmia requiring a permanent pacemaker. This prevented him from being followed with an MRI since the magnetic fields interfere with pacemaker function.

Fortunately, Mr Pachuk’s tumour made a protein, which approximately 50% of primary liver tumours make, called alpha-fetoprotein (AFP). Therefore, I have followed Mr. Pachuk’s disease status with the AFP blood test. He has had two additional RFA treatments using CT guidance. His tumour has been retreated to keep it from growing into the vital part of his liver. This area contains major blood vessels and bile ducts. Walking the fine line between killing enough tumours without hurting the overall health status of Mr Pachuk has been challenging. However, compounding the inability to see the areas of viable tumours has made it even more challenging.

A Physician’s Reward

Despite the complexities of his Liver Cancer disease test and overall health status, Mr Pachuk continues to live a normal life. He is probably more active than most people in their 80’s. This desire to live life to its fullest is most refreshing. Applying state-of-the-art technology in a clinical situation where no other hope exists is very rewarding as a physician.

I thank Mr. Pachuk and his family for their bravery and open-mindedness during his RFA treatment. I will do my best to maintain his quality and quantity of life, which is the main goal of therapy. Hopefully, those who hear this story will share this knowledge so that others in similar situations can benefit from this remarkable treatment option.

About Radiofrequency Ablation

For decades, doctors have been using direct injection of absolute ethanol to treat and test small primary liver cancers with successful rivalling surgery. Recently, they have replaced alcohol with radiofrequency ablation (RFA). RFA is a heat-mediated therapy. It is favoured because of its ability to treat larger lesions with fewer treatments.

The RFA technique involves emitting an alternating current in the frequency of radio waves from the tip of an electrode or needle placed directly into a tumour. The alternating current flowing back and forth through the tissue causes frictional heating and coagulation of the tumour.

For the treatment of primary liver cancer, RFA has achieved complete cell death in over 85-90% of cases in lesions smaller than 5 cm, with less than a 10% local recurrence rate. Unlike surgery and other treatments, RFA can be performed often on the same patient. This is very important in the hepatitis B population. The reason is that these patients are prone to develop tumours in more than one site in the liver over time.

Until modern medicine can prevent the formation or stop the growth of primary liver cancer at the gene level, focal ablative therapies such as RFA will be mainstays in the treatment of primary liver cancer. This is expected to persist for years to come.

Cathy Pachuk, Ph.D.

Associate Professor, The Jefferson Center, Thomas Jefferson University