TheraSphere Offers Liver Cancer Patients More Precise Treatment

Even as the incidence of primary liver cancer continues to increase in the United States, so has the arsenal of therapies available to improve patients' quality of life and survival. At Froedtert & The Medical College of Wisconsin, one of the breakthrough treatments for inoperable liver cancer is TheraSphere, a technology available at only 19 medical centers across the country.

TheraSphere, according to its manufacturer, consists of millions of microscopic glass beads that are injected into the main artery of the liver through a small tube, or catheter. The radioactive beads are delivered directly into the tumor via the blood vessels that feed it. The radiation destroys tumor cells from within the tumor with minimal injury to the surrounding tissue. Most of the radioactivity disappears within 12 days.

"It's an elegant procedure," says interventional radiologist William S. Rilling, MD, FSIR, an Associate Professor of Radiology and Surgery at the Medical College and Director of Vascular and Interventional Radiology. "It's incredibly precise; no radiation goes where we don't want it to go. Recovery time is shorter than with other procedures, and the outcomes are shown to be at least as good as conventional therapy."

Limitations of Standard Chemotherapy and Radiation
Two therapies often used to treat cancer - systemic chemotherapy and radiation therapy - have had limited success in patients with certain types of liver cancer. Often, by the time the disease is diagnosed, patients are not candidates for surgery, either, because of the size of their tumor or the severity of their underlying liver disease.

Froedtert & The Medical College have been using TheraSphere since mid-2003. "We were selected because of the volume of patients we treat with image-guided therapies and our multi-disciplinary expertise," Dr. Rilling says. Among the other therapies he and his colleagues also use to treat inoperable liver cancer are chemoembolization, radio frequency ablation and cryoablation. Patients are awake but sedated during all these procedures.

During chemoembolization, a potent dose of chemotherapy is delivered directly into the artery supplying a specific tumor. The feeding blood vessels are then plugged, transforming it into a closed pocket of potent, cancer-killing agents, which also cuts off the tumor's blood supply.

Like TheraSphere, both radio frequency ablation and cryoablation are done as outpatient procedures. "We use ultrasound or CT to guide the probe into the tumor," Dr. Rilling says. With the radio frequency technique, he and his colleagues use probes to kill the tumor and its surrounding margins with heat; with cryoablation, the tumor cells are destroyed by freezing the tissue.

Since these treatments are minimally invasive, hospital stays and recovery times are short, preserving the patient's quality of life. Patients typically go home the same day the TheraSphere procedure is performed. With chemoembolization, patients are hospitalized overnight.

With TheraSphere and the ablation procedures, patients recover within a few days. After chemoembolization, recovery normally requires one to two weeks. TheraSphere, like the other therapies, is approved by Medicare for reimbursement and is also covered by some other private insurance plans.

Why Liver Cancer Is Increasing
Primary liver cancer was once fairly rare in the United States, although it is a significant health problem worldwide, Dr. Rilling says, and usually associated with chronic hepatitis infection. The current rate of increase is greater in the United States than in any other country. Some have predicted a 280% increase in the incidence of hepatocellular (primary liver) carcinoma between 1998 and 2008.

The majority of this increase is due to the population of patients with hepatitis C, who were exposed in the 1970s and '80s before the blood supply was screened for this virus.

During those years, a growing number of people contracted hepatitis C, usually from a blood transfusion or, in the case of intravenous drug users, from sharing needles. Twenty years after they were exposed to hepatitis C, these people are at risk for primary liver cancer due to the development of cirrhosis (permanent scarring of the liver).

"And we expect to see more cases over the next decade as this group matures," says Dr. Rilling, adding: "People who developed liver cirrhosis from alcohol abuse are also at risk, but their numbers have remained relatively stable." By the 1990s, the blood supply in the United States began to be carefully screened for the presence of hepatitis C, and new cases have sharply diminished.

The liver performs several vital functions. It processes and stores many of the nutrients absorbed from the intestine. It also makes some of the clotting factors needed to stop bleeding from a cut or injury. And it secretes bile into the intestine to help absorb nutrients. The liver also plays an important role in removing toxic wastes from the body.

Since liver cancer is unusual and its symptoms mimic many other conditions, there is often a delay in making the diagnosis while the cancer grows larger. Unfortunately, by the time the diagnosis is made, most patients have advanced disease.

Currently, TheraSphere has Food and Drug Administration approval only for treatment of primary liver cancer, but Dr. Rilling says the FDA is reviewing a trial to treat patients with metastatic liver cancer (cancer that has originated in another organ, but has traveled to the liver). Froedtert & The Medical College will be one of just four sites in the country to participate in this clinical trial. In the meantime, Dr. Rilling and his colleagues have used TheraSphere on patients whose liver cancer is metastatic, but only after receiving "compassionate use" approval from the FDA.

Multidisciplinary Approach
Despite these advances, primary liver cancer remains a deadly disease that often defies a cure. Nevertheless, the newer therapies have enabled patients to live longer and in greater comfort than ever before. Dr. Rilling recommends that patients diagnosed with liver cancers be treated at facilities like Froedtert & The Medical College Clinics.

"We take a multidisciplinary approach," he says. "We discuss the care of each patient at a team conference to ensure that the patient can be directed to the best specialists for a particular diagnosis. We have a lot more weapons to use in this fight, and our toolbox keeps getting bigger."

For the past three years, Dr. Rilling and his Medical College colleagues have conducted research into the efficacy of the newer treatments. "We're finding excellent results for the quality of life of our patients," he says.

Barbara Abel
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.