Latest / Meaningful Medicine with Novant Health / Destroying Liver Tumors Without Surgery

Transcript

Destroying Liver Tumors Without Surgery · Meaningful Medicine with Novant Health

• 0:03
  Carl Maronich (Host): Welcome to Meaningful Medicine, a podcast by
• 0:05
  Novant Health, where doctors address questions they wish you would ask.
• 0:09
  I'm Carl Maronich, and today joining me is Dr.
• 0:11
  David Sindram, a hepatobiliary and pancreas surgeon from Novant.
• 0:16
  And today we're gonna be talking about liver cancer, its implications and
• 0:19
  the advancements in treatment that really are shaping the future of care.
• 0:23
  Doctor, welcome to the podcast.
• 0:25
  David Sindram, MD: thank you, Carl, and, I'm happy to be here.
• 0:27
  This is, gonna be a great opportunity to talk a little bit about,
• 0:29
  yeah, about a difficult topic, so
• 0:31
  looking forward to it.
• 0:32
  Carl Maronich (Host): Yes, absolutely.
• 0:33
  And maybe we can start, doctor, by, by asking-- I'll ask, what, what is--
• 0:36
  how common is liver cancer?
• 0:37
  I see.
• 0:38
  So for this conversation, can we use
• 0:39
  David Sindram, MD: It starts by, making a slight correction to your question
• 0:43
  because the question asked about liver cancer and, the location of a cancer
• 0:48
  is not always how we name a cancer.
• 0:50
  So there is such a thing as liver cancer.
• 0:52
  That would be cancer that starts in the liver.
• 0:55
  and then there are many cancers that maybe start elsewhere, like
• 0:59
  the colon or breast or pancreas, that then end up in the cancer.
• 1:03
  So to, clarify that nuance is kind of important because not
• 1:07
  every cancer that ends up in the liver is called liver cancer.
• 1:11
  and we as cancer doctors really try to differentiate between, the
• 1:15
  various cancers based on their site of origin, where it came from,
• 1:19
  rather than from where it went to.
• 1:21
  Carl Maronich (Host): the general term liver cancer, or is there
• 1:24
  a better way we can define that?
• 1:29
  David Sindram, MD: There's probably a better way to define it.
• 1:30
  It's, we talk about it as medical doctors and cancer doctors, it's probably best
• 1:34
  to actually continue to talk about the cancer site of origin, where it came
• 1:38
  from, and just then talk about, tumors that are either primarily starting in
• 1:43
  the liver or, secondarily, have ended up in the liver, and metastatic disease.
• 1:47
  So we talk about it as primary liver cancer and metastatic
• 1:52
  disease that ended up in the liver.
• 1:54
  That's probably the more accurate way.
• 1:56
  and that's because when people get in touch with their doctors, regarding
• 1:59
  their own problems or own cancers, that's kind of how we talk about it.
• 2:02
  And, it's an important distinction because not every cancer that ends up
• 2:06
  in the liver is treated the same way
• 2:09
  Carl Maronich (Host): I see.
• 2:10
  So let, me ask then, how, common is it for cancer to impact
• 2:15
  somebody's liver in that, system?
• 2:17
  David Sindram, MD: And that's, a key question.
• 2:18
  That's actually a really good question.
• 2:19
  It's incredibly common.
• 2:21
  It's a common pathway of almost all cancers to end up in the
• 2:26
  liver at some point as well.
• 2:28
  so for instance, if you have a colon cancer and the colon cancer started
• 2:31
  somewhere in the length of your entire colon, somewhere there's a
• 2:34
  tumor, oftentimes the next place where cancer then spreads to is the liver.
• 2:40
  It, it literally f- cancer cells flush into the blood flow out of
• 2:44
  the colon, and the first station that it comes to is the liver.
• 2:47
  as a point of distinction to kind of set, the stage, if a cancer were to
• 2:51
  start, for instance, in breast tissue, then the cancer starts in the breast
• 2:55
  tissue, makes it into the bloodstream as a way of spreading, has to travel
• 3:01
  through your entire body, but can eventually also end up in the liver.
• 3:05
  those two cancers have very different ways of approaching them because one is the,
• 3:10
  it's the first station where the cancer might nestle as a, uh, form of spreading.
• 3:15
  And the second cancer that I gave as an example, that cancer, may have traveled
• 3:19
  to various other places before it landed in the liver, and as such, the
• 3:23
  disease might be far more progressed and far more advanced, which would
• 3:26
  limit our, ability to treat the cancer effectively once it ends up in the liver.
• 3:32
  Carl Maronich (Host): see.
• 3:33
  So those, individuals that cancer is now impacting the liver, what
• 3:38
  would some of the typical symptoms be and, how is that diagnosed?
• 3:42
  David Sindram, MD: the scary part, Carl.
• 3:43
  This is the scary part, where the liver doesn't really
• 3:46
  have any sort of pain fibers.
• 3:49
  So it's not like you can feel it.
• 3:51
  It's not like a tumor in the liver would give you an obvious pain an obvious ache.
• 3:56
  And it's often very late in the process, of, a patient's cancer journey that
• 4:01
  a cancer gets discovered in the liver because the only real way to find a lot
• 4:04
  of the cancers is by means of scans.
• 4:06
  It's, it, you have to discover them as part of routine follow-up that,
• 4:11
  most of us cancer doctors do, when we follow patients on their cancer journey.
• 4:16
  so the only other time maybe that, people will recognize, a
• 4:19
  symptom is when the bile ducts.
• 4:23
  Those are, important structures within the liver that carry some of
• 4:26
  the waste products that the liver produces back into the intestine.
• 4:30
  If some of those bile ducts get blocked off by a tumor, somebody can
• 4:34
  turn, jaundiced, can turn yellow.
• 4:37
  Having said that, that's often a very, very late sign, a, not a good thing.
• 4:41
  So, the scary part of, cancer that, uh, found in the liver is that you don't know
• 4:46
  until it's oftentimes quite advanced.
• 4:49
  Carl Maronich (Host): is scary, as you said with the start of that.
• 4:52
  how has cancer that gets to this region been treated historically?
• 4:57
  David Sindram, MD: Up until the mid-'80s, we had very, very...
• 5:01
  1980s, we had very, very little options.
• 5:03
  we treated patients with fairly rudimentary chemotherapy agents,
• 5:07
  treatments that would affect the whole body and by extension also the liver.
• 5:11
  That was pretty much all that we could since the 1980s, s- surgeons have become
• 5:18
  more adventurous and, technically a little bit more adapt based on new technology
• 5:22
  and new abilities and, if I can say so, also some d- very daring individuals
• 5:27
  that, that stepped into that void.
• 5:29
  They started exploring whether surgery on the liver could help
• 5:33
  people live longer and better.
• 5:35
  And it's on the shoulders of those giants, those few individuals, and most
• 5:38
  surgeons know those guys by name, that we started exploring if maybe doing
• 5:43
  surgical procedures to the liver could help people live longer and better.
• 5:47
  And, in some cancers, like for instance colon cancer, or primary liver cancer,
• 5:52
  cancer that started in the liver, we started recognizing based on those
• 5:56
  early daring, adventures that we could impact patients' lives very dramatically
• 6:02
  for the better and that we could make people live longer and better,
• 6:05
  by, exploring those kind of options.
• 6:08
  The problem was that liver surgery was still in its infancy and patients
• 6:12
  were, required to undergo and endure very, very drastic operations,
• 6:16
  very big surgical incisions.
• 6:19
  we gave them names such as Mercedes-Benz or Chevron incisions that resembled
• 6:24
  the shape of the car symbols for sh- Mercedes-Benz and Chevron.
• 6:28
  La- li- ri- large star-shaped incis- incisions to expose the abdomen properly
• 6:34
  and then very difficult procedures were then, entertained and done to
• 6:40
  cut out large portions of the liver.
• 6:42
  Those were the first adventures, and that's not very long ago.
• 6:45
  I mean, considering that I started my medical school and surgical journey
• 6:49
  in the '90s, remember those days.
• 6:51
  I remember studying these kind of operations and participating in them.
• 6:55
  And it's not since sort of the early 2000s that people started thinking, "Okay, if
• 6:58
  we can exert an effect by doing these big operations, by cutting out, tumors, can we
• 7:03
  maybe do this, slightly less invasively?
• 7:06
  Are there other ways to accomplish the same, but maybe not damage patients, much
• 7:12
  as we, are with these big operations?"
• 7:15
  And that set off an 10, 15, now almost 20-year trajectory where,
• 7:21
  technological advancements, very clever, device development and,
• 7:27
  various interventional techniques have become, currently mainstay.
• 7:32
  and we live in a fantastic time right now where we're at the end of that road, and
• 7:37
  now we're able to even treat liver tumors, remove them without incisions whatsoever.
• 7:43
  So it's an incredible journey, and f- I feel incredibly privileged to have
• 7:48
  been, part of that and, have been able to facilitate a lot of those new technologies
• 7:52
  over time, including laparoscopic liver surgery, microwave ablation, itrem nine-
• 7:58
  90 radioactive microscopically small spheres, microspheres that were injected
• 8:03
  into the bloodstream of the liver.
• 8:05
  and now even, a new technologies that we call histotripsy, which is
• 8:10
  a technology that doesn't even use incisions whatsoever anymore, and
• 8:12
  it's just an incredibly, brilliant use of, converging ultrasound beams that
• 8:18
  we aim straight at a tumor to affect the tumor and effectively destroy it.
• 8:22
  I think it's a glorious time for us liver surgeons.
• 8:25
  It's also a little scary from a professional perspective because
• 8:28
  as we've miniaturized all of our technologies, then maybe, just maybe
• 8:32
  I, put myself out of a job eventually.
• 8:34
  but as most cancer doctors will say that if, we can put ourselves out of a
• 8:37
  job, that's actually a really good thing because it means that we are really
• 8:40
  helping patients live longer and better, and that our help is no longer needed.
• 8:44
  Carl Maronich (Host): Doctor, let's talk a little bit about the
• 8:45
  histotripsy that you mentioned.
• 8:47
  I mean, that's new age treatment.
• 8:49
  So talk a little bit more about if, an individual were need to have that,
• 8:53
  what would their journey look like?
• 8:55
  Soundfont
• 8:55
  David Sindram, MD: so I think the reason why I try to put it in perspective of the
• 8:59
  historic sort of journey of-- historical journey of how we arrived at this point
• 9:04
  is to kind of demystify it to some degree.
• 9:06
  Histotripsy is not a, magical solution to liver cancer or cancer in the liver.
• 9:12
  it's the next iteration of trying to miniaturize or minimize the damage that
• 9:16
  we do while still trying to achieve the same goals, which is for-- as a liver
• 9:20
  surgeon, the goal is to destroy a liver tumor, to get it out of the liver.
• 9:24
  so it's not a technology that now suddenly treats the cancer
• 9:28
  in the rest of your body.
• 9:29
  a device.
• 9:29
  It's based on physics.
• 9:30
  It's based on very, very smart, use of, some of the basic principles of, sound
• 9:36
  technology, where we use very loud bad noise, uh, high frequency, high-pitched,
• 9:46
  noise sounds that we cannot hear.
• 9:49
  but if you were to synchronize those sound waves very precisely and, let
• 9:54
  the sound from about a hundred and twenty-eight precisely synchronized
• 9:58
  ultrasound elements aim at the same point in sync, then you get something
• 10:04
  that's, called amplitude amplification.
• 10:06
  and as a result of that amplitude amplification, sort of exaggerated,
• 10:10
  waveform that then happens, sort of akin to, standing in front of a bunch of
• 10:16
  converging loudspeakers at a rock concert.
• 10:19
  You can feel the air moving in your stomach, and if you were to, make it
• 10:23
  louder than you can imagine, then you actually end up creating, vacuum pulses
• 10:29
  in the space, where that sound is aiming.
• 10:32
  And that vacuum is then, filled with col-collapsing gas that
• 10:37
  tries to fill those gaps.
• 10:40
  we call that the bubble cloud, or cavitation.
• 10:42
  And that process of cavitation is so violent, but it happens at such a
• 10:46
  microscopic level because of the very high frequency of the sound that the
• 10:50
  cavi- that this cavitation disrupts the cells entirely and busts them up
• 10:55
  basically and turns them protein juice.
• 10:57
  so it's, a really remarkable, way of using basic physics, and it's a really
• 11:03
  remarkable way of, affecting cancer without causing any sort of damage to
• 11:09
  the surrounding structures because only the cells that are in the crosshairs
• 11:13
  of that sound beam are being destroyed.
• 11:17
  Anything sturdier than a cell or, tissues that don't contain cells, like the
• 11:21
  connective tissues in your body, they don't get destroyed by the sound wave.
• 11:25
  and if I were to, point out one of the most important, and critical features
• 11:30
  of this new technology is that not just that it can destroy, but also that it
• 11:33
  can keep intact some of these sturdier structures so that we can treat over
• 11:38
  those structures and not hurt them.
• 11:41
  And I mentioned earlier that, uh, liver has bile ducts, for instance, where
• 11:44
  bile, a waste product of the liver collects and is transported to the liver.
• 11:49
  Those are extremely critical structures, and if we were to erase them or create
• 11:53
  holes in them, or burn them shut, which is often what we had to do
• 11:57
  with previous technologies, you would throw the baby out with the bathwater.
• 12:01
  you help somebody, but you hurt them in such a degree that that people
• 12:04
  don't enjoy life anymore and are, made very sick by the procedure.
• 12:07
  Histotripsy seems to have the amazing capabilities of not destroying some
• 12:11
  of those sturdier structures, and you can treat a cancer that has enveloped
• 12:15
  around a bile duct, for instance, and erase them without incisions and leave
• 12:20
  those critical structures intact, to allow patients to continue to live
• 12:24
  their lives, in a helpful, healthy way.
• 12:27
  So it's an advance in so many different ways.
• 12:30
  and the reason why a lot of liver surgeons, including myself, are
• 12:33
  extremely excited about this new option is exactly because of that.
• 12:36
  It allows us to treat cancers in places where we couldn't before, which then
• 12:40
  allows application of all of the other technologies that, we had available to
• 12:45
  ourselves, including surgery, minimally invasive, robotic, all the things that
• 12:49
  we had available up to this point, to potentially be even more effective
• 12:52
  in conjunction with histotripsy.
• 12:54
  So it's not magic.
• 12:56
  It's physics.
• 12:57
  it's an incredible leap forward, but it is an iteration of multiple leaps
• 13:02
  that we've made forward, and as a result, we can now treat patients that
• 13:05
  we were never able to treat before.
• 13:07
  Carl Maronich (Host): Yeah, amazing.
• 13:08
  I'll just say, doctor, when I was in school, physics seemed like
• 13:10
  magic to me, but that's another
• 13:12
  story.
• 13:12
  David Sindram, MD: of like magic, yeah
• 13:14
  Carl Maronich (Host): Let me ask, doctor, who qualifies for histotripsy?
• 13:18
  And what percentage of patients that have cancer, affecting their
• 13:21
  liver would qualify for this?
• 13:23
  David Sindram, MD: I think, that's, a crucial question.
• 13:25
  I think that histotripsy in and of itself is, perhaps not something to
• 13:29
  qualify for, but something that would need to fit within the treatment
• 13:33
  strategy that we come up with as a team.
• 13:36
  I firmly believe that the multidisciplinary approach, the, sitting
• 13:40
  together in a room with all the doctors that can do all the different things that
• 13:44
  we do for cancers, and look at somebody's cancer needs, along their cancer
• 13:49
  journey, and that may change over time.
• 13:51
  and we try to apply the best possible method of, care depending on the
• 13:55
  situation that a patient is in.
• 13:57
  So I can go as, make it as straightforward and, saying, "Well, everybody's a
• 14:01
  candidate," but that's not exactly true.
• 14:04
  It's not like you have, we, can just aim this beam of sound on every
• 14:09
  tumor and, it, would help patients.
• 14:12
  it's still a very, complex and comprehensive, discussion that,
• 14:17
  patients should have with their cancer treatment team about whether histotripsy
• 14:21
  would be something that would fit and, can be part of their treatment
• 14:25
  treatment journey, I guess, is the term that I like to use for that.
• 14:27
  I think that important to know because I know that, histotripsy has gained a lot
• 14:31
  of attention, and there's, a lot of, hope particularly that emerged from patients
• 14:36
  that are, and family members that, deal with cancer, and they understand
• 14:39
  cancer is very scary threatening.
• 14:42
  And for those patients, histotripsy seems so magical.
• 14:46
  That's why I perhaps use those terms.
• 14:49
  but we still need to make sure that it's right for them, and,
• 14:52
  the pursuit of histotripsy in and of itself is not sufficient.
• 14:54
  It has to be seen in conjunction with other technologies.
• 14:57
  But it does offer, opportunities where there weren't any before, and we are
• 15:03
  at an infliction point there that a lot of the treating physicians don't know
• 15:07
  exactly about histotripsy themselves.
• 15:09
  It's still fairly new.
• 15:10
  only been at this point about 4,000 patients that have been treated.
• 15:14
  So, I would encourage patients that wonder about histotripsy as part of
• 15:19
  their journey to discuss that with their, treating physicians and ask them
• 15:22
  to read up on it or maybe connect with people like me or others that have been
• 15:29
  on the early adopting sort of side of new technology to see if histotripsy
• 15:35
  is something that can fit in their doctor's treatment strategy for them.
• 15:40
  Carl Maronich (Host): very good.
• 15:41
  Well, Dr.
• 15:41
  David Sindram, a lot of great information about some really amazing technology
• 15:46
  that's now available, to cancer patients.
• 15:48
  we appreciate your time today.
• 15:50
  David Sindram, MD: Thank you, Carl.
• 15:50
  really hope that you never have to see me again.
• 15:53
  that's usually not a good thing as a liver surgeon in cancer.
• 15:56
  It's a serious topic and, like I said, we unfortunately still don't have the
• 16:00
  magic cure for cancer as much as I'm excited about being able to help, people
• 16:04
  live longer and better with the help of these kind of technologies, I sincerely
• 16:08
  hope you and, all the people you love never have to deal with this themselves.
• 16:12
  Carl Maronich (Host): Well, the, rewarding thing is if we should need you, you're
• 16:15
  here and you, have this technology and these skills, so we're grateful for that.
• 16:20
  David Sindram, MD: Thank you, sir.
• 16:20
  I appreciate your time with me today.
• 16:22
  Carl Maronich (Host): For more information or to find a
• 16:24
  physician, visit novanthealth.org.
• 16:26
  For additional health and wellness information from our experts,
• 16:29
  visit healthyheadlines.org.
• 16:32
  If you enjoyed this podcast, please share it on your social channels
• 16:35
  and explore our entire podcast library for topics of interest.
• 16:39
  I'm Carl Maronich, and this has been Meaningful Medicine.
• 16:42
  Thanks for listening