In 2018, Jarrett Singer, a fit 18-year-old hockey player, had his whole life in front of him.
He started his first year of university in September, taking classes to become a nutritionist. In November of that year, his appetite suddenly disappeared and he constantly felt lethargic, sleeping in until 3:00 pm. Gradually, severe abdominal pain set in.
"It got to the point that I contemplated going to the hospital instead of my final exam," he recalls.
In December, still in extreme pain, Jarrett saw his family physician in Whitby, Ont., who immediately ordered an ultrasound. The results stunned everyone. They showed a 12-centimetre mass on his liver, which was a fibrolamellar hepatocellular carcinoma, a rare form of liver cancer that kills between 32 per and 66 per cent of those diagnosed within five years.
Jarrett reeled from the news, having just started a new chapter of his life.
"I was shocked," he says. "You never think it's something that can happen to you."
Jarrett was referred to UHN's Ajmera Transplant Centre, where he was placed under the care of Dr. Gonzalo Sapisochin, transplant surgeon at the centre and part of UHN's Sprott Department of Surgery, who was confident he could help him.
Dr. Gonzalo and his team initially thought they could just remove the cancerous part of his liver when they performed exploratory surgery in early 2019. Then they saw the tumour had wrapped itself around the blood vessels going into the liver, including the bile duct, a thin tube that carries bile, a liquid that helps digest fats in food, from the liver and gallbladder into the small intestine.
Jarrett's only hope was a liver transplant, which historically has been a non-starter, since implanting a new organ into someone who has cancer carries the risk that the disease will end up attacking that new tissue. The Ajmera Transplant Centre, however, is world-renowned for this type of procedure. It performs 40 per cent of the cancer-related transplants in Canada.
Cancer-fighting transplants
One of the challenges of doing oncology-related transplants is that recipients have to take medications that suppress their immune systems so they won't reject the organ. But these medications also reduce the body's ability to fight off cancer cells.
Ajmera Transplant Centre researchers, however, have discovered ways to adjust medications and use chemotherapy in advance of a transplant to ensure operations are successful.
"In the last decade, the outcomes of these transplants have really improved," says Dr. Sapisochin.
It's helped that the Ajmera Transplant Centre is a pioneer in living donor transplants, which is when clinicians use an organ – such as a liver or a kidney – from someone who is living versus someone who is deceased.
Living donor transplants dramatically increase the availability of organs, which means more cancer-related procedures can get done. The centre conducts about 70 transplants involving living donors every year, with about 30 per cent to 40 per cent of them in liver cancer patients.
"We are one of the largest programs in the world doing this," notes Dr. Sapisochin.
Instilling hope
It was a living donor who ultimately saved Jarrett's life. When it became clear he required a transplant, his firefighter father put out the word in his workplace that his son needed a liver donor.
Nadine Young, a 38-year-old firefighter who worked in the same fire hall as Jarrett's father but barely knew him, answered the call. She offered up a piece of her liver, in part because, as a parent to a two-year-old girl, she could understand Jarrett's family's pain.
Fortunately, Nadine was a blood and tissue match. She was scared but excited to be selected as a donor. While she was in perfect health, she was also aware of the possible complications: a blood clot or, in extremely rare cases, death.
Nadine underwent blood work and psychological testing to determine her readiness, and MRIs and CT scans to assess the health of her liver. When she met Jarrett, though, she knew she was making the right decision.
"I would do it all again in a heartbeat," she says.
Jarrett, who had undergone chemotherapy to shrink the tumour ahead of surgery, was incredibly grateful.
"It was a special day to see the person who was going to save my life," he says.
The surgery took more than eight hours and involved removing the right lobe of Nadine's liver, which was used to replace Jarrett's diseased liver. Nadine, who was left with a small scar, says her liver regrew after a month and she was back to work after three months.
As for Jarrett, he's had a smooth recovery and his new liver has been accepted by his body. Best of all? He's now cancer-free.
New opportunities
While stories like Jarrett's are becoming more common, clinicians and researchers are looking at other opportunities in transplant oncology. Dr. Marcelo Cypel, Surgical Director of the Ajmera Transplant Centre, is currently exploring how transplantation can help patients with lung cancers.
Physicians have traditionally done these kinds of procedures on those with early-stage lung cancers, but Dr. Cypel and his team are exploring whether lung transplants can help patients with end-stage lung disease and lung cancer, too.
"We are doing this more for patients with lung cancer in the context of other lung diseases, like emphysema," says Dr. Cypel, who is also part of the Sprott Department of Surgery, adding that those with lung disease typically can't have surgery because of a high risk of post-operative complications.
"A transplant, though, can prolong a patient's survival dramatically, says Dr. Cypel.
"Most of these patients wouldn't survive a year if left untreated," he explains. "If you get a transplant, you have a 65 per cent chance of being alive in five years."
Colon cancer that has metastasized to the liver and bile duct cancer are two other malignancies for which surgeons are testing out transplantation. While most of these procedures are currently being done in clinical trials, there have been three colon cancer procedures and one bile duct cancer transplant at UHN, says Dr. Ian McGilvray, abdominal transplant surgeon and scientist in the Ajmera Transplant Centre and Head of Liver and Pancreas Surgery in the Sprott Department of Surgery.
"Some colorectal cancer patients with liver tumours go on to have lengthy survival times," notes Dr. McGilvray.
"There are patients who are alive 10 years after colorectal metastasis," adds Dr. Sapisochin.
There's still much work to be done before these transplants become part of standard care. UHN's immunologists and medical oncologists are trying to determine more ways to modulate immunosuppressive drugs to ensure they don't suppress the immune system too much, which could then cause cancer cells to grow, explains Dr. McGilvray.
Researchers are also exploring ways of preparing the immune system prior to transplantation to attack cancerous tumours and leave the new organ intact.
It won't be long, though, before doctors treat different types of cancer with transplantation. That's good news for people like Jarrett, who initially worried about how his cancer would be treated.
He is now 21 and back in school, receiving scans every six months to confirm his cancer hasn't come back. To date, all is well, but even if his liver cancer recurs, Dr. Sapisochin says surgeons will likely be able to go in and surgically remove any tumours.
Jarrett encourages people to consider becoming living organ donors.
"We have a shortage of deceased donors," he notes. "If you're willing to do it, you can be a true hero for someone else."
As for Nadine, she treasures a necklace Jarrett gave her just before the transplant operation. On it is inscribed, "We needed a miracle. Instead, we got an angel."
"I never take it off," she says.
