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Personal Stories: Life is Meant to be Lived

Published in the Hepatitis B Foundation newsletter B Informed Spring 2003 

Pachuk

One Man's Story

A Daughter's Perspective
Cathy Pachuk, Ph.D.
Associate Professor, The Jefferson Center, Thomas Jefferson University

When my father was diagnosed with primary hepatocellular carcinoma (HCC), or liver cancer, about two years ago 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.

No Stepping Back from Set Backs
In February 1970, during a routine physical, a massive thoracic/abdominal aneurysm was found on my father's aorta. The odds of surviving surgery were very low and the odds of surviving without serious complications, such as paralysis, were even lower. The only surgeon willing to perform the surgery was the one who pioneered the development of this type of surgery, Dr. Michael DeBakey, of Methodist Hospital in Houston, TX. My father was one of the first patients to undergo this type of surgical procedure. The 12-hour operation was a success. Within three months, my father was back on the golf course.

Due to complications from the aneurysm, however, one of my father's kidneys atrophied, leaving only one functional kidney. In addition, my father developed adult onset diabetes, congestive heart failure and an irregular heart beat that required insertion of a pacemaker. In 1992, my father was diagnosed with prostate cancer and treated successfully. Nine years later, the seemingly impossible happened: the cancer had metastasized and was now in his bones and spinal column. Currently, the cancer is being managed by hormone therapy.

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
Then one day, almost two years ago, my father was informed that he had liver cancer. Ironically, the same surgery that had saved his life 30 years earlier likely also resulted in his being infected with a deadly hepatitis virus. Silently working behind the scenes, the infection had finally taken its toll. My father had multiple liver tumors. He had about 6 months to live.

For the first time, I heard the tiredness in my father's 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, and so the hunt for a treatment began.

Hunt for a Treatment
I spent the next few days speaking with hepatologists and scouring the internet for therapies, treatments and clinical trials. Unfortunately, I was learning that my father was ineligible for many standard treatments, including chemoembolization and surgery, due to his many health problems. His options were growing scarce and time was running out.

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 and asked if I had heard of Dr. Damian Dupuy at Rhode Island Hospital, who was doing 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 tests and was then on his way to Rhode Island for treatment. Dr. Dupuy was able to ablate most of the tumor masses and two months later, my father was back on 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 is 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 not only extended his life; it has allowed him to live it doing the things he most enjoys doing.

Editor's Note: The Hepatitis B Foundation sincerely thanks the Pachuk family for graciously sharing their story so that other families can learn from their experience. It is vital that individuals and families be aware that liver cancer can occur in those chronically infected with hepatitis B. Please feel free to email the Hepatitis B Foundation at info@hepb.org or call 215-489-4900 for more information about hepatitis B and liver cancer.


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 complete tumor eradication, radiofrequency ablation (RFA) can be used to control primary liver cancer in patients with no alternative options due to tumor size, tumor location or associated medical conditions. The daughter of one such patient who greatly benefited from the palliative effects of RFA has written her 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 enough to carry the work load. 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 center were not aware of the benefits of RFA as a minimally invasive treatment option in cases such as his and he was given 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 option in patients with large liver tumors such as Mr. Pachuk's.

Overcoming Medical Complications
The first ultrasound-guided RFA treatment went very well, but I knew upfront that complete tumor eradication was out of the question; nonetheless, I did my best and approximately 80-90% of the tumor was killed. Normally, I follow patients with contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI), but in Mr. Pachuk's case his renal insufficiency precluded 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 now prevented him from being followed with MRI since the magnetic fields interfere with pacemaker function. 

Fortunately, Mr. Pachuk's tumor made a protein, which approximately 50% of primary liver tumors make, called alpha fetoprotein (AFP). Therefore, I have been following Mr. Pachuk's disease status with the AFP blood test. He has had two additional RFA treatments using CT guidance, whereby his tumor has been retreated to keep it from growing into the vital part of his liver where the major blood vessels and bile ducts are located. Walking the fine line between killing enough tumor without hurting the overall health status of Mr. Pachuk has been challenging enough, but compounding the inability to clearly see the areas of viable tumor has made it even more challenging. 

A Physician's Reward
Despite the complexities of his disease and overall health status, Mr. Pachuk continues to live a normal life probably more active than most people in their 80's. This desire to live life to its fullest is most refreshing and as a physician, I find it very rewarding to be able to apply state-of-the-art technology in a clinical situation where no other hope exists.

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

About Radiofrequency Ablation     
For decades, direct injection of absolute ethanol had been used to treat small primary liver cancers with success rivaling surgery. Recently, radiofrequency ablation (RFA) a heat-mediated therapy has replaced alcohol due to its ability to treat larger lesions with fewer treatments.
 
RFA is a technique whereby an alternating current in the frequency of radio waves is emitted from the tip of an electrode or needle placed directly into a tumor. The alternating current flowing back and forth through the tissue causes frictional heating and coagulation of tumor.

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 many other treatments, RFA can be performed many times in the same patient. This is very important in the hepatitis B population because these patients are prone to develop tumors in more than one site in the liver over time.
 
The RFA procedure is a very safe and non-toxic treatment. The procedure is almost exclusively performed on an outpatient basis with the administration of intravenous medication to alleviate pain during the procedure. After the procedure, patients are given a small bandage and sent home with narcotics for a few days to reduce discomfort at the treatment site.

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 for years to come.

Please feel free to email the Hepatitis B Foundation at info@hepb.org or call 215-489-4900 for more information about hepatitis B and liver cancer. 


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