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Joey Wahler: For those with liver cancer, receiving a transplant can be a life-saving, but also a very daunting process. So, we're discussing liver cancer and liver transplantation. Welcome to MD CAST by Tampa General Hospital, a go-to listening location for specialized physician-to-physician content, and a valuable learning tool for world-class healthcare. Thanks for listening. I am Joey Wahler. Our guest, Dr. Vijay Subramanian, a transplant hepatobiliary and pancreas surgeon at Tampa General Hospital and assistant professor for the Department of Surgery at University of South Florida, Morsani College of Medicine. Dr. Subramanian, thanks for joining us.

Vijay Subramanian, MD: Thank you, Julie. I'm happy to be here.

Joey Wahler: Happy to have you. So, first, in a nutshell, what are the different types of liver cancers?

Vijay Subramanian, MD: So, liver cancers can broadly be divided into cancers that start in the liver or what we call as primary liver cancers, and those that start elsewhere and then spread to the liver. Those are usually called metastatic liver cancers. Among the primary liver cancers, the most common type is hepatocellular carcinoma. And among the secondary liver cancers or the cancers that come to the liver, the most common type is colorectal cancer that spreads to the liver.

Joey Wahler: And so, what liver cancer treatments are typically offered prior to one seeking a transplant?

Vijay Subramanian, MD: Liver cancer treatments are usually directed towards based on what type of cancer it is, and they can be divided into what we call local therapy, that is treatments that are derived for just treating the cancer in the liver and systemic therapy or treatments that are to treat the cancer elsewhere in the body as well. And these treatments also depend on what the stage or what the quality of the liver is, that is whether your liver is healthy or whether your liver has any other problems including fatty liver or cirrhosis, which is a scarred liver. So, the commonest treatments would be either surgery to cut the cancer out. So, that would be called a liver resection or what we call local therapy, which involves either burning the cancer cells itself or giving some sort of therapy to cut off the blood supply to the cancer and prevent it to stop growing.

Joey Wahler: Gotcha. And so to be clear before we go any further, which liver cancers are eligible for a transplant if needed?

Vijay Subramanian, MD: In the current setting, what we call standard acceptance criteria for transplant, the most commonest would be hepatocellular carcinoma or HCC, which is the commonest liver cancer that would be eligible for transplant. Another cancer which may be eligible for transplant in certain specialized circumstances is cholangiocarcinoma, which is another type of cancer that starts in the liver, in particular hilar cholangiocarcinoma that can be considered for liver transplantation.

Joey Wahler: In the patients you see, doctor, generally speaking, what percentage would you say are usually eligible for a transplant?

Vijay Subramanian, MD: Among patients with liver cancer, and in particular hepatocellular carcinoma, if they have underlying cirrhosis or scarring of their liver, then most patients would be eligible for transplant provided they meet certain criteria called the Milan criteria for transplantation. So, that's about 70 to 80%.

Joey Wahler: Wow. Okay. So, you led me beautifully into my next question. In determining transplant eligibility, there are certain scores, eligibility factors, please explain to people what those are.

Vijay Subramanian, MD: Yeah. So, in determining transplant eligibility, we first determine who needs a transplant based on something called a MELD score, which stands for Model for End-Stage Liver Disease, which is basically a score that predicts how bad your liver or how good your liver function is. This is a score that's calculated by lab values that includes your bilirubin, your creatinine, your INR and the sodium level is also added sometimes. Now, this score will help us determine whether someone needs a transplant or can get away with not needing a transplant and getting any other treatment for liver cancer. Now, especially patients whose MELD score is usually about 15, then these are patients that we would normally consider for transplant. But if their score is below 15, and depending on the type of tumor, they could still be considered for liver transplant. And when I say the criteria for the tumor itself, this is called the Milan criteria, where they can have either a single cancer in their liver that's less than five centimeters or about a couple of inches or if they have up to three tumors, all of which are less than three centimeters.

Joey Wahler: So once it starts, what basically is the process of seeking a liver transplant?

Vijay Subramanian, MD: So once it starts, we first make sure that your cancer fits those criteria that we mentioned, or if they need any other treatments to make sure that they meet that criteria. Following that, there's a detailed physical, social, psychological evaluation that's done by multiple members of the team. That includes not only a liver surgeon, it includes a hepatologist, which is a doctor who specializes in liver disease. And then, the pharmacist, a social worker, a dietician. And they also undergo financial counseling because this can be quite an extensive process. In addition, we also check to make sure that their heart and lungs are functioning well. And particularly, patients who have liver cancer, we do additional tests to make sure that the cancer has not spread outside of the liver. Because if it is spread outside of the liver, then they are not eligible for liver transplant.

Joey Wahler: Now, with a liver transplant, I know this might be kind of an open-ended question for you, but considering a waiting list, et cetera, what kind of a timetable can patients usually expect from start to finish?

Vijay Subramanian, MD: So, usually, what I tell patients is that the transplant itself is based on what their MELD score is, and that's the priority on the national list that they get. So, the lower the MELD score, the longer is the wait time. Now, the average score or what we call the median score at which most patients get a liver transplant at Tampa General is around the score of 29. And the higher the score, obviously the faster they will get a liver transplant.

Now, a lot of patients, like I mentioned before, who have liver cancer, sometimes their MELD score is not that high. So in order to make sure that these patients are eligible to get a liver transplant, after about a six-month period of waiting, once they're on the list, they get something called an exception MELD score. So what that means is that it doesn't matter what their lab values are and what their actual MELD score is, but on the national wait list, they get a score that's about three points below what the average MELD score is for transplant at that time. So for example, if someone were to get an exception score today, and based on what I told you about our median MELD score being 29, then that person's MELD score will be 26. And what that does is that it opens up their opportunity and it puts them at about 80th percentile or higher on the list, so that opens up the opportunity for them to get a transplant.

So usually for patients, particularly patients who have liver cancer, who get on the list for a transplant, these patients, suppose they get on the list today, they end up waiting the six-month period. And the reason we wait for the six months is to make sure that during those six months, that the cancer doesn't spread anywhere else. And if the cancer remains inside the liver and remains within those criteria, then six months from now they'll get an exception MELD score of three points below the median MELD.

Usually, once they get that exception MELD score, then most patients will get a transplant within two to three months of that. So in reality, going back to what you said about the timeline, from the time that you're on the list, you're really looking at about nine to 10 months before you're transplanted.

Joey Wahler: Interesting. So basically, some of that waiting time is purposely built in for sort of prep purposes. Couple of other things before we let you go. So, how would you describe to people the outcomes and benefits of liver transplants? What can people look forward to once they get to the other end?

Vijay Subramanian, MD: So, what I like to tell patients is that the goal of transplant is to get them to what we call a normal quality of life. So, we inquire to figure out what these patients are doing before, what they enjoy doing, and our goal at the end of transplant is to get them to that livelihood. So, I would say, liver transplant is curative of liver cancers with really good survival rates compared to other type of cancers. If the cancer remains under check, then these patients have close to 95 plus percent one-year survival, close to 75% to 80% of five-year survival. So, these are otherwise patients who have definitely would not have made it five years without a transplant. So when we tell them that there's at least a 75% to 80% chance that you're going to live another five years, I think overall this is a very positive outcome and certainly better than survival for a lot of other cancers that we treat. And usually after about two to three months after their surgery, most patients, so majority of patients will get back to a normal routine life. They're driving, able to do whatever they want and go on with their life and are independent most of the time.

Joey Wahler: So, recovery is a few months. And finally, what risks are involved?

Vijay Subramanian, MD: So, the biggest risks are long-term risks of you are on medicines that are actively preventing your body from rejecting or destroying someone else's organ. So, these immunosuppression medicines have long-term risks for the patient themselves in terms of they have long-term risk for infections. These medicines can cause long-term risk of developing cancers, particularly skin cancers. We live in Florida, so we encourage patients to make sure they have a dermatologist and apply lots of sunscreen when they go outside to the beach. Something that normally you won't do, but certainly for transplant patients, we highly encourage to do that.

And then, there's certainly other risks of developing new-onset diabetes or heart problems. So, these are things that we monitor on patients long-term. This is a big operation. A liver transplant is a complicated and big operation. We quote to patients that there's a 20 to 30% chance of having complications from surgery itself that are usually not lifelong, but at least in the short run, immediately after surgery. And like I mentioned, the one-year survival is about 95%. So, there's about 5% of patients who can die from the transplant itself or around the time after transplant. So, those are the big risks of a transplant itself. And that's the reason for us to make sure these patients are as fit as they can be before they undergo such a big procedure such as this.

Joey Wahler: Well, doc, as you just said, indeed, a very complicated process, but certainly great to hear us walk you through some of the basic steps. Folks, we trust that indeed you're now more familiar with liver cancer and liver transplantation. Dr. Vijay Subramanian, thanks so much again.

Vijay Subramanian, MD: Thank you so much, Joey. It was nice talking to you.

Joey Wahler: You too. And thank you for listening to MD CAST by Tampa General Hospital, available on all major streaming services for free. To collect your CME, please click on the link in the description. For other CME opportunities, including live webinars, on-demand videos, and local events offered by Tampa General Hospital. Please visit cme.tgh.org. Again, cme.tgh.org. Hoping your health is good health. I'm Joey Wahler.