Goodbye to Hy

One of my favorite patients died this month.  I first met him in January, 2008 when he was diagnosed with liver cancer. He was a 60-year-old martial arts and music instructor, a seriously cool dude who always showed up in rimless sunglasses with his grey hair tied back in a neat queue. 

At diagnosis he had segmental right portal vein invasion and an AFP of 27,000, so was not considered for transplantation. Had he been so unfortunate as to live in Barcelona, he would have been classified BCLC-C and not offered liver-directed therapy, with a prognosis of 6 months. After a single chemoembolization he had complete tumor necrosis and his AFP returned to normal.

Nine months later he still had a complete imaging and biochemical response, and we tried to re-list him for transplantation. At one year he developed a new HCC nodule with a normal AFP, indicating that this was a new clone rather than a recurrence of his original tumor. I ablated it successfully.

At 18 months from diagnosis he came into clinic with an unusual request. He had a much younger wife who wanted a child “to remember him by”, and wanted to know if this was safe after having been chemoembolized the year before. We had a long discussion about prognosis in HCC, that successful eradication of a tumor was not the same as curing the disease, and that he would most likely die of recurrent liver cancer within five years. I firmly believe that the patient is the customer, and I try hard to respect patient autonomy and not to insert myself into their decision-making. The proposal to create a young widow with a fatherless child was a rare exception. Patients don't always follow your advice. Within a year he had a second recurrent HCC nodule successfully ablated, and a baby boy. 

Three years from initial presentation he developed multifocal recurrence in his liver, again with a normal AFP. He underwent bilobar chemoembolization, with complete necrosis by imaging criteria. Given the acceleration of the pace of his disease, I offered sorafenib, but he was very reluctant because he was afraid that hand-foot skin reaction would keep him from being able to play music.

Four months later he again had multifocal recurrence. Since chemoembolization was not durable, we switched to Y-90 radioembolization. He again declined sorafenib. When I last saw him two months ago, he had stable disease almost a year after radioembolization. He died from complications of a variceal bleed, 4.5 years after diagnosis with invasive liver cancer, with his malignancy under control. He was a wonderful man with a wonderful family. Thanks to Interventional Oncology, they enjoyed almost a half-decade of life together.

Bittersweet as it is, this is one of the success stories in image-guided therapy of liver cancer. IO offers hope to patients who have none otherwise. Do you have a great success story to share from your practice? Post it in response to this column or in a Discussion Group on IO Central, and help spread the word of the value of IO.

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