Locoregional Therapies for Liver Tumors: 2021 Update

Transcript

• 00:00OK, welcome to the second episode of
• 00:05our yearly after my lecture series.
• 00:11Today we are going to have
• 00:16our cheaper international.
• 00:18An ideology, namely.
• 00:22Doctor Madoff, David Madoff, David Madoff.
• 00:28Did his Bachelor degree and Emory University,
• 00:31and then the MD and University speech book
• 00:35from there went to SUNY for the residency?
• 00:38It was Othello, and then a faculty
• 00:42member at MD Anderson.
• 00:44From MDN, Nasoni moved to we Cornell
• 00:47Presbyterian in New York City,
• 00:49where he became the section chief
• 00:53of Interventional Radiology there
• 00:56and join him in July 2019 is now.
• 00:59Professional radiology and
• 01:01medical oncology section,
• 01:02chief of interventional radiology and
• 01:04vice chair for visas in the Department
• 01:08or radiology and biomedical imaging.
• 01:11David is a great aspect in liver tumor
• 01:14treatment without correctional treatment,
• 01:15and if you look at his CV and
• 01:18his publication, he has been.
• 01:22One of the forces behind the
• 01:26great developments that.
• 01:28I've been brought by interventional
• 01:31radiology in the treatment of liver cancer,
• 01:35and he in particular is very interested
• 01:38in all the method to which we can increase
• 01:43liver regeneration before and after
• 01:46surgery on Echologics surgery to deliver.
• 01:50David.
• 01:53Is one of the members of our team
• 01:56are as as highlighted in this slide.
• 02:01The treatment of Reperta
• 02:03circus numbers very complex.
• 02:06We have Transformers, action ablation,
• 02:09radiation, systemic therapy.
• 02:11We need to mind also the liver
• 02:15disease that is present in all if not.
• 02:20Most if not all,
• 02:21the patient liver cancer,
• 02:23and so it really takes a village
• 02:25to be able to manage and treat this
• 02:28patient and it is very important
• 02:31concept that this patient should
• 02:33be treated in referral centers.
• 02:35Yeah, you can see some of our members.
• 02:38Actually there should be 2 times than
• 02:41the pictures that are shown here,
• 02:44but I don't want to take more time to our.
• 02:50Lecture tonight then,
• 02:51so I'll stop here and I like
• 02:53the baby in the beginning.
• 03:02Jay Silva I assume you can see my screen.
• 03:06Yep. OK, so thanks Mario for
• 03:10that really nice introduction.
• 03:12What we're going to talk about today is
• 03:15local regional therapies for liver tumors.
• 03:19A 2021 update. What I wanted to do
• 03:22is really go through a whirlwind tour
• 03:26of what IR or IO can actually offer.
• 03:30And not necessarily bore a lot of the
• 03:34audience with a lot of really hardcore data,
• 03:37which I definitely have, but I think to
• 03:39make it more interesting and palatable,
• 03:42I think that we're going to show
• 03:45a lot of cases and make this.
• 03:47I think, quite interesting.
• 03:50So these are my disclosures.
• 03:53Some of which I'm going to
• 03:55be speaking about today. So.
• 03:58As you all know.
• 04:01Interventional radiology is involved
• 04:03in numerous types of tumors, right?
• 04:06We treat both primary liver cancer
• 04:10and metastatic liver cancer for
• 04:13the purpose of this talk today
• 04:15to focus primarily on each CC,
• 04:18with the understanding that a
• 04:21lot of the local local regional
• 04:24therapies that we can offer.
• 04:28Actually can be translated
• 04:31into other disease types.
• 04:34So when talking about the goals of therapy,
• 04:36there are really 3.
• 04:38There is what you would call curative
• 04:40therapy and that could be, you know,
• 04:43transplantation resection and
• 04:45ablation for early stage disease.
• 04:47We also I guess you briefly mentioned my
• 04:50area of interest in liver regeneration.
• 04:53We can convert patients who are
• 04:55unresectable to resectable,
• 04:56and that can typically be done by portal,
• 05:00vein, embolization, radiation, lobectomy,
• 05:01and transarterial emblow therapy,
• 05:03which we'll get into later.
• 05:05And for those patients that are
• 05:08of intermediate and advanced age,
• 05:10we really can offer what's called palliation.
• 05:12Which is, you know,
• 05:14can be transarterial embolization
• 05:16and or ablation.
• 05:17So all of the different types of
• 05:20therapies that we offer really
• 05:22depends on patients tumor Histology,
• 05:24the number and location of the
• 05:26tumors within the liver,
• 05:28the extent of the underlying
• 05:30liver disease and of course,
• 05:32the presence or absence of
• 05:35extrahepatic disease.
• 05:36Now what I want to do first was
• 05:38getting to the whole idea of defining
• 05:41the different types of procedures.
• 05:43It turns out that a lot of practitioners,
• 05:46yet a lot of the time you get a
• 05:48lot of the types of procedures
• 05:51that we do kind of misinterpreted,
• 05:54meaning that the terminology is often
• 05:56used entertained interchangeably,
• 05:57and when you go to tumor boards or you
• 06:00listen to or you read your image Ng,
• 06:03even your image, even your image Ng.
• 06:06Reports.
• 06:08Taste, for example,
• 06:09is sometimes used in the place of
• 06:11taec or transarterial embolization,
• 06:13you know.
• 06:14See, taste is sometimes used
• 06:16for debt ace and vice versa.
• 06:18When we talk about microwave ablation
• 06:20as well as you'll hear later,
• 06:22it's always called RFA,
• 06:25even if it's not really.
• 06:27Medium embolization is sometimes
• 06:29referred to as radiation therapy,
• 06:31and in addition you know when
• 06:33I'm reading these reports.
• 06:34There's often times where will do an
• 06:37embolization where we're discussing,
• 06:39you know,
• 06:39an ablation cavity,
• 06:41and this really isn't the case
• 06:43and the reason why
• 06:44I'm saying this and the reason why it's
• 06:47so important is that it really has
• 06:50major implications for patient care.
• 06:52Medical record keeping and billing,
• 06:54so I see a lot of times where a patient may.
• 06:58Get a treatment for an image in finding and
• 07:01in fact it may actually not be necessary
• 07:04and I'll get into an example of that later.
• 07:08Of course, before we can even talk
• 07:11about treatment, I want to stress the
• 07:14importance of percutaneous biopsy.
• 07:16OK now, interventional radiologists often
• 07:19think of this as kind of a mundane procedure.
• 07:23It's kind of basic and.
• 07:26In my opinion, Proteinous biopsy is
• 07:28probably one of the most important
• 07:30and impactful procedures that we do.
• 07:33This is a case that I want to show
• 07:36which is a 64 year old female with
• 07:39squamous cell cancer of the tongue
• 07:41base who has a pet CT positive avid
• 07:44lesion in the left lobe of the liver
• 07:46and of course because of the location
• 07:49because of the disease,
• 07:51it's very important to get a diagnosis now.
• 07:54We would all agree that this lesion.
• 07:56It's probably very difficult to biopsy.
• 07:59OK, it's at the very edge of the
• 08:01liver is literally right under
• 08:03the pericardium and diaphragm,
• 08:05and there really is no correlation
• 08:07with imaging findings.
• 08:08But you know,
• 08:09we we were able to do the biopsy
• 08:12as you see here,
• 08:14and this is actually the bottom of the heart.
• 08:17OK,
• 08:18and in fact the patient did not have
• 08:20squamous cell carcinoma but actually
• 08:22had low grade B cell lymphoma,
• 08:25which completely changed the patients.
• 08:27Management.
• 08:27So the reason why I bring this up is that.
• 08:32These procedures that you see
• 08:33here can be very, very difficult.
• 08:35OK from a technical perspective,
• 08:37but I think that it would be very
• 08:40important for the referring physicians
• 08:42to actually reach out to one of us in IR
• 08:46to see if it's actually feasible or not.
• 08:48And in this case,
• 08:50I think it really helped the patients.
• 08:53No diagnosis and therefore prognosis.
• 08:56So just to talk about HCC a little bit,
• 09:00we're all aware of the Barcelona
• 09:03Clinic liver Cancer Staging system.
• 09:05As you know,
• 09:06we see patients all the range from
• 09:09very early stage or stage zero to
• 09:11terminal stage or stage D and the
• 09:15treatments obviously fit into where
• 09:17patients fall on this staging system.
• 09:20So typically patients that are
• 09:22very early stage or early stage
• 09:24have very limited disease,
• 09:26are often considered.
• 09:27Or ablation resection or transplant
• 09:30and depending on where they fall into this,
• 09:33that will determine the outcome of what kind
• 09:36of procedures that you would actually do.
• 09:39Intermediate stage is what we typically
• 09:41do for local for regional therapy,
• 09:44or maybe chemoembolization
• 09:45or radio embolization,
• 09:47which will get into and then systemic therapy
• 09:50and basic supportive care are released.
• 09:53It reserved for the more advanced
• 09:55age is the reason why I put the.
• 09:59Question mark for survival.
• 10:01Is that we go through the gamut of.
• 10:04Procedures that we can offer
• 10:06and then at the end
• 10:08of the talk, we're actually going to fill in
• 10:11where the survival actually is at this time.
• 10:14So there are multiple treatment
• 10:16options for Liberty Mears for surgery.
• 10:18We obviously have transplant or
• 10:20hepat ectomy and we if the patient
• 10:22has two small liver remnants,
• 10:24we can optimize the future liver remnant
• 10:27or FLR with a PV or something else.
• 10:29Portal animalization we can talk
• 10:31about a blade of techniques which are
• 10:34divided into thermal and non thermal.
• 10:36And for those that are thermal,
• 10:38we can look at those that are heat
• 10:41based in those that are cold based.
• 10:43And then there's a whole host of
• 10:46transarterial therapies we can offer,
• 10:47including chemo,
• 10:48infusion embolization,
• 10:49chemoembolization,
• 10:49as well as radio embolization.
• 10:52So just to bring up local
• 10:55oblated therapies first.
• 10:57The goal here is to percutaneously eradicate
• 11:00all viable malignant cells while sparing
• 11:04as much normal liver tissue as possible.
• 11:07We can treat tumors with
• 11:10unfavorable locations or patterns,
• 11:12patterns of distribution for resection,
• 11:14or patients that have multiple comorbidities
• 11:17that probably cannot tolerate resection,
• 11:20but maybe have resectable disease.
• 11:23It's these are most often used
• 11:25in patients that have what we
• 11:27consider low volume disease.
• 11:29It can be used for debulking
• 11:31an nowadays in recent years.
• 11:33I guess we can also use it to incite
• 11:36antigen stimulation for immunotherapy,
• 11:38and these are typically done
• 11:40as outpatient and repeatable.
• 11:42So the way we can do tumor treatment with
• 11:45local oblated therapies is by cooking,
• 11:48and that's what we would consider
• 11:50radiofrequency ablation.
• 11:51We can boil them.
• 11:53Which would be microwave ablation?
• 11:55We can freeze them,
• 11:56which can obviously be cryo ablation
• 11:58or we can electrocute them and
• 12:00that would be called irreversible
• 12:02electroporation and will go into a
• 12:04little bit more detail in a second.
• 12:08So this is a case of radiofrequency ablation.
• 12:12This is a 61 year old female with
• 12:15colorectal cancer and an isolated
• 12:17metastatic tumor in segment 6.
• 12:19Here we see a 2.2 centimeter tumor.
• 12:23Here there is an axle,
• 12:25the avid lesion in segment six,
• 12:27we place the needle proteins ablation,
• 12:30and here is one year. Follow up OK.
• 12:35Each major frequency ablation works is
• 12:37that you have oscillating electrical
• 12:39currents via electrodes to tumor,
• 12:41which results in a resistive
• 12:43heating and tissue hyperthermia.
• 12:45The tissue nearest the electrode
• 12:46is heated most effectively,
• 12:48and the side of toxicity of course
• 12:50depends on the tissue impedance.
• 12:52Now one of the reasons why I
• 12:55bring this up in the setting of
• 12:57colorectal cancer is with the next
• 13:00therapy that I'm going to discuss.
• 13:02Radiofrequency ablation is
• 13:04becoming less and less performed.
• 13:06And in fact,
• 13:07I haven't performed a radiofrequency
• 13:09ablation since my days at MD Anderson,
• 13:12now more than 10 years ago in
• 13:14terms of microwave ablation,
• 13:16this is a patient 60 year old
• 13:18female with HPV induced cirrhosis
• 13:20and a 2 centimeter HCC in segment
• 13:23seven who was awaiting transplant.
• 13:26Here we see the lesion here,
• 13:28which was simply done with microwave
• 13:30ablation and a 2.7 year follow up.
• 13:33There's no residual tumor so the
• 13:36way microwave ablation works.
• 13:37Is that you can propagate microwave
• 13:40energy via an electromagnetic field,
• 13:42and this induces tissue
• 13:44hyperthermia via dielectric height,
• 13:45historist hysteresis with that also means
• 13:48is basically you dehydrogenated the tumor
• 13:51and actually cause it to rapidly shrink.
• 13:54This actually is done in a way where you
• 13:57get higher ablation efficiency because
• 13:59you can actually get higher tissue
• 14:02temperatures and therefore you can get
• 14:05larger ablation zones with shorter times.
• 14:07And with this kind of treatment,
• 14:10it readily penetrates through long
• 14:11or chart issue where RFA is limited
• 14:14and it's not influenced by heat sink
• 14:16effects in the same way RFA is.
• 14:18What that means is that if you
• 14:20have a tumor that's sitting on a
• 14:23portal vein or some kind of vessel
• 14:25that can draw heat away from it.
• 14:28With microwave ablation,
• 14:30it's actually less common.
• 14:33And this is just a study that just
• 14:35shows that there similar overall
• 14:38and recurrence free survival when
• 14:40you compare microwave ablation RFA.
• 14:42There was no difference in local
• 14:45tumor progression.
• 14:46The technical effectiveness as well
• 14:48as the major complication rates.
• 14:50So now that we know that RFA is all it
• 14:54can be used as a first line therapy.
• 14:57So can microwave ablation.
• 14:59In terms of cryoablation,
• 15:02the goal here is to achieve temperatures
• 15:05less than 190 degrees Celsius.
• 15:08It results in direct cellular injury,
• 15:11vascular injury,
• 15:12and even immunological injury.
• 15:14What's interesting here is that you
• 15:17can place multiple simultaneous probes.
• 15:19You actually get in a natural
• 15:22anesthetic effect from the ice,
• 15:24and as you can see from this example.
• 15:29Here we see the ice ball,
• 15:31which is easily seen,
• 15:32so you can actually sculpt the
• 15:34lesion that you want to treat.
• 15:37And because of this you actually can
• 15:40get very predictable and reproducible.
• 15:42The treatments in terms the
• 15:46disadvantages because there's so many.
• 15:49Needle probes are there that are used.
• 15:52You can have longer procedure times.
• 15:54There's a theoretical bleeding risk
• 15:56and you can actually crack the liver,
• 15:58and patients could actually result
• 16:00in cryo shock,
• 16:01which is a form of tumor lysis syndrome.
• 16:04Now this is 1 case that I got
• 16:06from a paper from 2007,
• 16:08and the reason why I'm showing
• 16:10this like that is that I've never
• 16:13used cryo ablation in the liver,
• 16:15so I just want to show you that
• 16:18the example that we can do it.
• 16:21It is being used in other
• 16:23institutions or be it rarely.
• 16:25And then the last one is
• 16:27irreversible electroporation,
• 16:28so irreversible electroporation is
• 16:30a way that you can alter membrane
• 16:33ionic potentials and therefore
• 16:35induce irreversible disruption
• 16:36of the cell membrane integrity.
• 16:39The thought here is that this
• 16:42is a non thermal ablation.
• 16:44However there are studies now.
• 16:47They have been published,
• 16:49which actually does show a
• 16:51mild thermal component to it.
• 16:53So here we see a patient with cirrhosis
• 16:56and had a very challenging tumor where
• 16:58you see it right here in segment 4B
• 17:02and it's sitting right on the bile
• 17:04duct and right near the portal vein so.
• 17:08So we thought that thermal ablation
• 17:10with heat may be very difficult and
• 17:13may result in some kind of injury to
• 17:16the bile duct or the portal vein.
• 17:19So here we see the electroporation
• 17:21needles placed.
• 17:22Now these need to be very symmetrical
• 17:24with so that you get very good electrical
• 17:27potentials across and here we see the
• 17:30tumor well treated and then at seven
• 17:33months follow-up there's no tumor at all,
• 17:35and that's a great result that's exactly.
• 17:38What we wanted to happen.
• 17:40In terms of ablation versus surgery
• 17:42in these early stage patients,
• 17:44we can see that there's survival and
• 17:46recurrence recurrence free survival and
• 17:48overall survival are not statistically
• 17:50significant in terms of all comers.
• 17:52However, when looking at
• 17:54those tumors that are central,
• 17:55that means that if a patient was to
• 17:58have a reception of a central tumor,
• 18:01it would be a very large and
• 18:03difficult reception that rate
• 18:05that ablation actually is favored,
• 18:07and in fact,
• 18:08when you look at the major complication rate.
• 18:11The ablation group is statistically
• 18:13significantly better than the resection.
• 18:18And then.
• 18:23Free in terms of overall and disease,
• 18:25free survival, but it also looks
• 18:28at the overall quality of Life OK,
• 18:30So what they found is that there's
• 18:32really no difference in overall
• 18:34and disease free survival when
• 18:36comparing both ablation and surgery.
• 18:38However, there was a significant difference
• 18:40in the quality of life scores such that
• 18:43the surgery does get a little better,
• 18:46but never to the level of the ablation.
• 18:48So when we look at a lot of the
• 18:52interventional procedures that we do.
• 18:54We're always looking at quality
• 18:55of life initiatives and then of
• 18:57course in these particular patients,
• 18:59again with low volume disease,
• 19:01we're always looking to treat these
• 19:03patients as a bridge to transplant.
• 19:05So this just is a few studies that
• 19:08just shows how the results of
• 19:10keeping patients on the transplant
• 19:12list so they don't drop out.
• 19:16So in terms of transarterial therapies.
• 19:20The rationale is that most liver
• 19:22tumors receive blood supply
• 19:24largely from hepatic artery,
• 19:26that these liver tumors are often
• 19:28hypervascular, especially HCC,
• 19:29and that this new metastases are less
• 19:32common than in other epithelial neoplasms.
• 19:35This has been initiated over 40 years ago.
• 19:38Some of the techniques we still
• 19:40use today when I talk to patients
• 19:43about some of these therapies,
• 19:46I do tell them that some of this
• 19:49therapy has been done for decades.
• 19:51However, it still is not the same therapy
• 19:54and I'll get into that a little later.
• 19:56So the goal here is to selectively
• 19:59and locally deliver these.
• 20:00Intra arterial therapeutics to the tumor bed
• 20:03thereby effectively targeting the tumor,
• 20:06sparing the surrounding hepatic parenchyma
• 20:08and minimizing complications in toxicities.
• 20:10But again, as we discussed,
• 20:12we really need to understand
• 20:15what the term tases,
• 20:16because again,
• 20:17there's a lot of difficulty within the
• 20:20literature and within just our own tumor
• 20:24boards and reporting structures that
• 20:26that seem to use these terms interchangeably.
• 20:29Now, all utilized selective catheterization
• 20:31of the paddock artery branches, but.
• 20:34Once that's done,
• 20:35the procedures are actually very,
• 20:37very different.
• 20:39So what is bland embolization?
• 20:41Bland embolization is
• 20:43embolization without chemotherapy,
• 20:44only using the embolic agent.
• 20:46The goal here is to completely
• 20:49occlude the tumor feeding vessels,
• 20:51which then can cause ischaemia and process.
• 20:54Now, because of this,
• 20:56the paint the procedures can
• 20:58be sometimes quite painful.
• 21:00So because of the way that we do
• 21:03it with very small particles,
• 21:05that actually leads to this kind of pain,
• 21:08it may have very different effects
• 21:11on the vasculature.
• 21:12There's been a lot of extensive research,
• 21:14but the precise effect on the
• 21:17tumor cells largely remain unknown,
• 21:19and because this is done through a scheme,
• 21:22yeah,
• 21:22be hypoxic events may actually
• 21:24cause activation of several genes,
• 21:26including veg F,
• 21:27which can then lead to compens,
• 21:29atory, angiogenesis, and tumor growth so.
• 21:32Like I said,
• 21:33the most common techniques that are used
• 21:35are these very very small particles
• 21:36which get very distal into the tumor.
• 21:39They don't actually make
• 21:40it to the capillary level,
• 21:41which may be an issue,
• 21:43but the goal was always really
• 21:44to get to near stasis or stasis
• 21:47while preserving flow to the larger
• 21:49arterial branches.
• 21:50This is just a case of a 61 year
• 21:53old female with HCV cirrhosis who
• 21:55had a 4.8 centimeter HCC.
• 21:57The goal here was to embolize her
• 22:00to get her as a bridge to transplant
• 22:03because she was very close to being
• 22:05over the five centimeters that would
• 22:08keep her within the Milan criteria.
• 22:10We did this very quickly and we
• 22:13were able to treat this tumor.
• 22:15As you can see here.
• 22:18Totally included and then one month
• 22:21later totally necrotic and now is
• 22:23at 4 centimeters,
• 22:24so she ultimately underwent a
• 22:27transplant that few months after
• 22:29the embolization.
• 22:30This is a patient that in a
• 22:33different location,
• 22:34probably would have gotten oblated.
• 22:36So here we see a very small
• 22:39lesion in segment
• 22:418. That's a solitaire E lesion that's
• 22:43very close to a budding the heart.
• 22:46So I thought that this would be a
• 22:50very challenging lesion to a blade,
• 22:52and I opted for embolization.
• 22:55We see the Hypervascular
• 22:57territory within the artery here.
• 23:00At the end of the procedure,
• 23:01there's no more tumor blush,
• 23:03and now on the post embolization MRI,
• 23:05no contrast enhancement is seen.
• 23:07And this is another case where this
• 23:10was a patient that was going to
• 23:12have a combined bland embolization,
• 23:14followed by portal embolization in order
• 23:17to increase hypertrophy prior to resection.
• 23:19So here we see the tumor
• 23:21we have replaced right?
• 23:23Hepatic artery from the smam.
• 23:25The patient was embolized with
• 23:26100 Micron microspheres and
• 23:28then a tolling aquatic tumor.
• 23:30But in this case we actually saw
• 23:32significant regeneration to the
• 23:34point where the patient never
• 23:36actually needed to get there.
• 23:38Pve and and ultimately underwent
• 23:40a successful resection,
• 23:41and this is just some data that I
• 23:44wanted to to show where we see some,
• 23:48you know, 33% median survival.
• 23:5021 months, you know three years.
• 23:53We also see some patients that
• 23:55have very good response rates
• 23:57and reasonable survival rates.
• 23:59And then when you have post
• 24:02op recurrence meeting,
• 24:03survival can be as high as 46 months.
• 24:08So what is conventional taste or see taste?
• 24:11So conventional taste is an infusion
• 24:13of a mixture of chemotherapeutic
• 24:15agents with iodized oil followed
• 24:18by embolization with microparticles
• 24:20and what the oil does act as in
• 24:22emulsion that functions as a vector.
• 24:24To carry these cytotoxic toxic
• 24:26agents to the panic sinusoids
• 24:28where drugs gradually are released
• 24:30from this unstable mixture.
• 24:32So like I said,
• 24:34these procedures have been done now
• 24:36for like for more than four decades.
• 24:39But when I consent or consult patients.
• 24:42For these procedures,
• 24:43I tell him that it's not.
• 24:45You know,
• 24:46the same.
• 24:47We don't do it the same way as
• 24:50we did in 1977,
• 24:51and based on the global
• 24:53utilization of this technique,
• 24:55the Society of Interventional
• 24:56Radiology has called in the first line
• 24:59therapy for inoperable HCC patients
• 25:01with well preserved liver function.
• 25:03So unfortunately,
• 25:04at this time conventional taste
• 25:05is kind of non standardized.
• 25:07The trend over the years has gone from
• 25:11whole liver to low bar to selective.
• 25:14And also from occlusive to not
• 25:17necessarily occlusive again,
• 25:18the hypoxic insult may lead to
• 25:22actually stimulation of growth
• 25:25factors that may lead to tumor.
• 25:28To more tumor growth,
• 25:30there's various chemotherapeutic
• 25:31regimens and actually in 2019
• 25:34in the Journal cardiovascular
• 25:35Interventional Radiology,
• 25:36there was a global survey which
• 25:39basically showed that there's lots
• 25:41of different ways you can do this,
• 25:44But the most common embolic agents that
• 25:47we use these days are again our LOPI,
• 25:50Dolores Idol, PVA gel foam,
• 25:53and some others.
• 25:55So this is one of the two landmark
• 26:00randomized control trials,
• 26:01first showing the benefit of.
• 26:05Embolization it's interesting
• 26:06that the procedure was performed
• 26:09for 25 years before we actually
• 26:11were able to show benefit.
• 26:13This was a study that was
• 26:15performed from the Barcelona
• 26:16Cancer Center and it showed largely that it
• 26:20was working in a select group of patients.
• 26:23112 out of 903 that had well encapsulated,
• 26:26smaller sized tumors in patients with good
• 26:28liver function and good performance status.
• 26:31So that was one way that we were
• 26:34able to justify the use of.
• 26:36Conventional taste and this was another study
• 26:39that was performed in an Asian population,
• 26:42mostly with HPV that also had
• 26:45taste on demand. I'm sorry.
• 26:47Taste monthly or every two months,
• 26:49so they had a scheduled time where they
• 26:52had it and as you can see there is a
• 26:57statistically significant difference
• 26:58in taste versus supportive care.
• 27:01So how does this work?
• 27:03Well, basically aside,
• 27:04all Orlopp Idol is a poppy seed oil and
• 27:08it acts as a drug carrier that seeks out
• 27:11the tumors and also acts as an embolic agent.
• 27:15And we know that we can do this with the
• 27:17understanding that there's very complex
• 27:20sinusoidal anatomy and such that the
• 27:23hepatic artery and the portal vein are
• 27:25actually connected in this time besides.
• 27:28And the reason why that's important is
• 27:31that you can get in paddock arterial
• 27:33and portal venous occlusion such that
• 27:36the oil ends up in the tumors crosses
• 27:38from the artery into the portal vein
• 27:41and then kind of sits there and then
• 27:43you block up with particles because the
• 27:46forward flow is the arterial pressure
• 27:48is still pushing the oil across into
• 27:51the portal vein so you block it up
• 27:54with particles to stop that flow.
• 27:56This is just a case of a.
• 27:5853 year old man with multifocal
• 28:00HCC with chronic HCV and elevated
• 28:03AFP who has multifocal disease.
• 28:05This large tumor in segments in savings
• 28:07for taking some eight and four a.
• 28:10Here we see it on the CAT scan.
• 28:13Here's the tumor.
• 28:14The Lipiodol has iodine in it so you
• 28:17actually can see it on an X Ray and
• 28:20here you can see after the procedure is
• 28:23over where the lipiodol is staining.
• 28:25The reason why I brought up in the beginning.
• 28:29About the fact that it's really important
• 28:32to know what that this is lipiodol
• 28:34is that I had a report recently of a
• 28:38patient that I treated with this that
• 28:40kind of called the Lipiodol Council
• 28:44vacations of uncertain etiology.
• 28:46A whole plethora of why you know
• 28:48what what's going on here.
• 28:50But when we simply just apply it all,
• 28:52so like I said,
• 28:54there's arterial portal communication
• 28:55is very important to understand,
• 28:57and the more you get into the portal
• 28:59vein that apply at all in motion,
• 29:02the better results you actually
• 29:03get is born out here.
• 29:05Now we do see in our tumor boards that
• 29:08sometimes patients do have some portal,
• 29:10vein, bland thrombus,
• 29:11and that may be a reason why their
• 29:14outcomes for at least their tumor.
• 29:16Is really well because you're actually
• 29:18doing an arterial importal embolization.
• 29:20So I want to show a few cases.
• 29:23This is a patient.
• 29:24You see the tumor up here
• 29:27in segment 8. And.
• 29:30Again, we see the tumor here.
• 29:32You see, the lipiodol staining the
• 29:34tumor on the single flora scopic image,
• 29:37and you can actually see the
• 29:39portal vein here next to the
• 29:41tumor as well as down here.
• 29:43So at the end of the at
• 29:45the end of the procedure,
• 29:47we can see that there is a complete filling
• 29:51of two of tumor with dilipbhai at all.
• 29:55And then this is the before.
• 29:58And then this is one month after.
• 30:01We see a basically a whole.
• 30:04And ultimately,
• 30:05the patient had complete necrosis,
• 30:07an now at nine months.
• 30:09Follow-up has no residual disease.
• 30:13So one of the things that I
• 30:15think is really important and
• 30:16we can discuss this in all the
• 30:18different types of embolization.
• 30:20But because of applied all being
• 30:22radiopaque we can see I'm using this
• 30:24opportunity to talk about advanced imaging,
• 30:27so it's very important to get high
• 30:29quality imaging during procedures,
• 30:30which I believe is critical to
• 30:32optimize tumor targeting and
• 30:34this can be done with the 3D
• 30:36angiography combing or cone beam CT,
• 30:38which is some of what I showed
• 30:40or combining a multidetector
• 30:42CT angiography system.
• 30:44In your interventional suite and we know
• 30:46that from studies as early as 2007,
• 30:49of which I was involved in one from
• 30:52MD Anderson that you do see a lot
• 30:54of information that is important.
• 30:57Over standard digital subtraction
• 30:58angiography and back then,
• 31:00when we had very poor cone beam CT,
• 31:03it showed that we were able to impact
• 31:06the procedure in 19% of the cases.
• 31:08There's also now new software that
• 31:10helps precisely identify tumor feeders,
• 31:12so we're not just relying on
• 31:15standard DSA alone.
• 31:16And then we also with the pie at all,
• 31:19which isn't the same as with
• 31:21the other kinds of therapies.
• 31:23We can actually use this to immediately
• 31:26look at post procedure imaging.
• 31:28To show the benefit of the of
• 31:30the tumor targeting as well as
• 31:32having confirmation that you
• 31:34effectively treated the tumor.
• 31:37So here you see a tumor in. I said,
• 31:41once you fast here, let me go back.
• 31:47So in this case we have two HCC's in
• 31:52segments for a in segment 7 and what
• 31:55I want to show is a tumor sitting.
• 31:59Here. And here OK.
• 32:01And when you do the angio it's very
• 32:03unclear where these tumor feeders are.
• 32:06So you have one.
• 32:07It's definitely in the right,
• 32:09but you have one here,
• 32:10which is unclear if it's
• 32:12coming from the left,
• 32:13so you can so you can do a cone beam
• 32:15CT from the left and see no tumor
• 32:18vascularity and then you do it from
• 32:20the right and we can see a tumor
• 32:22there and then the tumor there.
• 32:24And now we know that we're in the right lobe.
• 32:28So after the procedure is over,
• 32:30we can see on a plane image
• 32:33or a flora scopic image.
• 32:35One tumor treated here one tumor
• 32:37treated here an on cone beam CT.
• 32:39You can see tumor here.
• 32:42In tumor here.
• 32:43So now we know that it
• 32:44was effectively treated.
• 32:48So this is a case that I did just
• 32:50last week and I thought it would
• 32:52be interesting to show 74 year old
• 32:55patient with alcoholic cirrhosis
• 32:565.8 centimeter HCC in segment 7.
• 32:59This is the CT scan right here.
• 33:02This is a previous treatment area.
• 33:05We did the angiogram.
• 33:06We see the tumor up here.
• 33:11We then see I'm selective image here.
• 33:13So when we do the cone beam CT thinking
• 33:15that we may have had the whole thing,
• 33:17we're missing half the tumor.
• 33:20OK, so we treated the patient.
• 33:25And we see a basically a Half
• 33:27Moon where half of it's missing.
• 33:29So we even got into the other branch.
• 33:33C. Feeling of the tumor.
• 33:35And at the end we can see that
• 33:38the tumor is completely treated
• 33:40and then on final cone beam CT.
• 33:44There is complete embolization with lipiodol
• 33:46so you can see this is very important.
• 33:50And I just wanted to show that we have
• 33:52also imaging software that we can use
• 33:55to track these tumors very nicely.
• 33:57I don't want to get all details,
• 33:59but you can see that we have a
• 34:01road map simply goes straight to
• 34:03the tumor and that I think results
• 34:05in a much more effective therapy.
• 34:07And we published on this back in a 2019.
• 34:11When we look at treating
• 34:15with chemoembolization.
• 34:16We can see that you get much better
• 34:19local tumor progression and overall
• 34:22survival when combing CT is used.
• 34:25And then we look at adverse events.
• 34:28We always tell patients that this
• 34:30is a liver directed therapy.
• 34:32However,
• 34:33their study that came out of Johns
• 34:35Hopkins back in 2008 showed that you
• 34:38can get systemic effects from the
• 34:41chemoembolization or conventional tastes,
• 34:43and this is what led to the institution
• 34:46or development of drug eluting be tastes.
• 34:49So the idea here?
• 34:51Is that the chemotherapy is then
• 34:53loaded into beads and added to
• 34:56water soluble contrast and can act
• 34:58as a vector for drug delivery and
• 35:01embolic agent to block arterial
• 35:03blood flow or supply to the tumor?
• 35:06As we discussed.
• 35:09The actually just you're aware
• 35:10that Luppino has some limitations
• 35:12where their attention is variable,
• 35:14and it could wash out quite rapidly
• 35:17if we don't use those particles.
• 35:19And then, like I just showed,
• 35:21there could be some systemic toxicity.
• 35:24So with drug alluding beads you can
• 35:26get predictable retention and this can
• 35:29lead to overall less systemic toxicity,
• 35:31and this is just a case that I did awhile
• 35:34back showing a force .6 centimeter tumor,
• 35:37which we did with drug eluting beads.
• 35:40However,
• 35:40you can't see at the end of the
• 35:43procedure that the tumor was treated,
• 35:45because there is no iodine in
• 35:46these particles and then this is
• 35:48what it looks like afterwards.
• 35:50So this is just a couple of.
• 35:52I have a couple of studies
• 35:54which show the benefit of.
• 35:56Of drug eluting beads.
• 35:57I don't want to get into all the details,
• 36:00but just show that there
• 36:02are promising results,
• 36:03but in my personal opinion I am much
• 36:05more a fan of using conventional
• 36:07rather than dip tastes and then
• 36:10this is just a recent study
• 36:12published in radiology which is a
• 36:14prospective single arm study which
• 36:15also shows the benefit of idarubicin
• 36:18alluding beads for the treatment of
• 36:20patients with unreflectively CC.
• 36:22So there's been a lot of
• 36:24interest in recent years
• 36:25in radio embolization.
• 36:27Here we have an implanted radiation
• 36:29source that's directly sent to
• 36:31the tumors via the attic artery.
• 36:33Use Yttrium 90 as the source,
• 36:36which is a beta emitter which penetrates
• 36:39only 2.5 millimeters in the tissue.
• 36:41There are glass and resin
• 36:43microspheres available.
• 36:44These are thera spheres or Sir spheres,
• 36:46but I just wanted to make sure you're all
• 36:49aware that these are not interchangeable.
• 36:52They're very different products
• 36:55and they have very different.
• 36:58Characteristics the main idea, I guess,
• 37:00is that the glass beads are have
• 37:03a much smaller number of spheres,
• 37:05so each year themselves is much hotter.
• 37:08So if you want to treat a much larger area,
• 37:12you may need to use something
• 37:14which is much more embolic than
• 37:16than than these very small ones.
• 37:19But again,
• 37:19these have much less activity per sphere,
• 37:22but here you get a much more minimal embolic,
• 37:26which is much more like
• 37:28real radiation therapy.
• 37:29Whereas the Sir spheres are
• 37:32more like embolization.
• 37:34So this is just a case of a 92
• 37:36year old female with multifocal HCC
• 37:38who actually had a tumor rupture.
• 37:41Um, here in in segment 8 with the
• 37:44satellite tumor as well,
• 37:45and as we know,
• 37:47when patients have tumor rupture,
• 37:48they have a very dismal prognosis.
• 37:50So like I said,
• 37:51this is a 92 year old female an because
• 37:54I did this with with therasphere for
• 37:57example it was a micro embolic Ann.
• 38:00I treated her as an outpatient.
• 38:02OK, so here is the tumor.
• 38:04We do a mapping study,
• 38:06so this is the difference.
• 38:08When you do the other
• 38:09kinds of chemoembolization,
• 38:10you basically take the product off the shelf.
• 38:13At the time of the procedure,
• 38:15however,
• 38:16with 190,
• 38:16you really have to map out the patients
• 38:19to make sure that you're not getting
• 38:22nontarget embolization to other
• 38:23areas which include extra product sites,
• 38:26and you also have to calculate
• 38:28a lunch on fraction,
• 38:29which is how much of the material
• 38:32gets to the lungs because there exist
• 38:35you heard earlier there are very.
• 38:38Small communication between artery and veins,
• 38:40and therefore if you give too high a dose,
• 38:43you can actually get pulmonary fibrosis.
• 38:45So in this patient we were able
• 38:47to see that the radiation went
• 38:50exactly to where we wanted to tumor.
• 38:52Here we see the patient for years later,
• 38:55so this patient lived to 98 years
• 38:57old and this again is the fact that
• 39:00I treated a 92 year old patient
• 39:02with an outpatient therapy.
• 39:04I kind of thought was pretty amazed.
• 39:07These are the toxicities that can
• 39:09occur by doing very good cone beam CT.
• 39:12This actually highlights the
• 39:14reason for it that we can reduce
• 39:16the toxicities by doing all these
• 39:19advanced imaging techniques.
• 39:20This was just the case.
• 39:22I want to show it with the utilization
• 39:25of cone beam CT where on cone beam
• 39:28CT we see in this patient a retro
• 39:31portal artery that on mapping study
• 39:34we can see some technetium 99 M.
• 39:37Maa actually getting into the duodenum.
• 39:40So if you were not care if you
• 39:42were if you were not careful,
• 39:45you would actually send radioactivity down
• 39:47there and that would result in an ulcer.
• 39:50So what I want to also highlight here.
• 39:53Is that? Now a recent article came
• 39:56out talking about recommendations.
• 39:59A standardized recommend.
• 40:00Nations 4Y-90, in this case,
• 40:03resin microspheres and what they say
• 40:06is that if you do not use cone beam,
• 40:09CT or advanced imaging techniques that
• 40:12that companies or vendors that are
• 40:15supporting clinical trials won't actually
• 40:18want them as part of one of their sites.
• 40:21OK, this just shows some data from Europe
• 40:25on those patients that are all within
• 40:28all across all the PC else stages.
• 40:31I'm in this particular study.
• 40:33You can see the median overall
• 40:36Survival's in a PCL CAB&C.
• 40:39Residents, although common,
• 40:40are fatigue, nausea, vomiting and fever.
• 40:44There's the GI ulcers are very uncommon
• 40:48and as well as grade three biliary.
• 40:52Issues.
• 40:54And you know one of the most
• 40:57prolific users of Y-90.
• 40:59This is North data from
• 41:01Northwestern University,
• 41:02where they looked at their first
• 41:041000 patients over a 15 year period,
• 41:08and you can see all the
• 41:10classification systems, child,
• 41:12child, Pugh,
• 41:12AB&C where you see BCLCAB&C,
• 41:15and they've even treated patients
• 41:17with PC LCD and then with those
• 41:20patients that had child Pugh A&B.
• 41:23These are the overall survival rates.
• 41:26And you can see they have
• 41:29very low adverse events.
• 41:30So based on their experience
• 41:32with 1000 patients over 15 years,
• 41:35they use radio embolization as
• 41:37their primary treatment option
• 41:39and then this just shows.
• 41:40And this is something that I
• 41:43think we basically treat probably
• 41:45less than I think we should.
• 41:47We start tumor board is patients
• 41:49that have portal vein tumor thrombus.
• 41:52This just shows the overall benefit
• 41:54of those patients that with Y-90.
• 41:57And I also believe conventional
• 41:59tastes do a good job,
• 42:01at least getting into the tumor vasculature
• 42:04of these portal vein tumor thrombus.
• 42:07They're having some advanced
• 42:09radio with embolization concepts.
• 42:10When we first started
• 42:12doing radio embolization,
• 42:13patients got whole liver infusions.
• 42:16However,
• 42:16overtime with patients getting
• 42:18going into liver failure and
• 42:20having really severe fatigue,
• 42:22it's turned into a originally low bar.
• 42:25Infusions OK,
• 42:25which you so from here to
• 42:28here and then overtime.
• 42:30The idea was that we can maybe get
• 42:33segmental infusions and then ultimately
• 42:35get the infusion directly into the.
• 42:38Into the tumor,
• 42:39provided that there is a single
• 42:42or maybe two feeding arteries.
• 42:45So here we talk about radio radiation,
• 42:48lobectomy OK,
• 42:49and this is a way that we can
• 42:51hypertrophied the liver prior
• 42:53to resection while still keeping
• 42:56control of the tumor.
• 42:57So the idea here is that we can
• 43:00generate future liver remnant
• 43:02hypertrophie that permit resection,
• 43:04allowing for a biological test of time.
• 43:07And as you may have seen from
• 43:09the previous patient,
• 43:11the previous slide we can permit
• 43:13patients with portal vein tumor
• 43:15thrombus to maybe be converted to even.
• 43:18Being resectable the pathophysiology
• 43:20of this is that you are getting
• 43:23some scarring and fibrosis of the
• 43:25liver in the side that was treated,
• 43:28and therefore you're getting compared to
• 43:30Tori hypertrophy of the untreated low.
• 43:33That being said, the treatment changes
• 43:36are comparable to portal vein EMBO.
• 43:38I'll beat it. Invite at a slightly lower,
• 43:41slower way, but it does have
• 43:43the benefit of tumor control,
• 43:45which portal embolization doesn't,
• 43:46and then we can talk about
• 43:48radiation segmentectomy,
• 43:49which is directly getting which is
• 43:51supposed to be a curative treatment,
• 43:54similar to ablation,
• 43:55where you treat up to two panic
• 43:57segments with a low bardo.
• 43:59So you're basically taking this large
• 44:01dose that you do for the whole lobe,
• 44:04and putting it into one or two segments.
• 44:08OK, you get much higher.
• 44:13Active activity to each of those areas
• 44:15and in some cases it's been adopted
• 44:18as first line transarterial therapy.
• 44:19So the idea here that is that it
• 44:22really needs to. In my opinion,
• 44:24it really needs to be more validated,
• 44:26but you can see from this case that you're
• 44:29placing the catheter right up to the tumor.
• 44:32The tumor here is completely hot
• 44:34and then after six weeks later you
• 44:37see complete necrosis of the tumor.
• 44:39So I also wanted to focus on
• 44:42portal vein embolization.
• 44:43This is a transvenous therapy supportively,
• 44:45and embolization is is that it's a way
• 44:48of redirecting portal blood flow to the
• 44:50future liver remnant and by doing so
• 44:53could initiate hypertrophy of the non
• 44:55embolize segments and by doing that
• 44:57can reduce perioperative complications
• 44:59such that we can increase the number
• 45:01of potential surgical candidates who
• 45:03have what we call marginal anticipated
• 45:05future liver remnant volumes.
• 45:07We can also achieve looks like similar.
• 45:09Survival rates surgical
• 45:10patients not requiring PV.
• 45:11Now Kevin Billingslea spoke
• 45:13about this a month ago,
• 45:14so I didn't want to focus too much on it.
• 45:17But this is just a case of a patient
• 45:19with HTC 10 centimeter solitaire E mass.
• 45:22But you can see here we perform volumetry
• 45:25in patients that have cirrhosis,
• 45:27but normal underlying liver function.
• 45:29We need about 40% of the remaining liver
• 45:32after surgery, so this patient had 33%.
• 45:34I don't want to get into all the
• 45:37like how you measure it exactly.
• 45:39It's kind of beyond the scope here,
• 45:42but basically this patient did
• 45:44not have sufficient liver.
• 45:45A sufficient anticipated future
• 45:47liver remnant.
• 45:47So this patient was considered
• 45:49a candidate for right Pve.
• 45:51We do write PVE,
• 45:53we do Pve.
• 45:54Cricket Aneus Lee where you
• 45:55puncture into the right portal
• 45:57vein and ipsilateral approach.
• 45:59We infuse particles and coils and we
• 46:01can see that there's complete diversion
• 46:03of flow from the right into the left.
• 46:06We do the volumes and this
• 46:08patient increased their size,
• 46:10their liver and 18% so this patient was
• 46:13considered a candidate for right hip.
• 46:15Protect me and this is how the
• 46:17liberal looks intra,
• 46:18procedurally or interactions
• 46:20intraoperatively where you see a
• 46:22very atrophic right lobe and a very.
• 46:24Hypertrophic very pinkish.
• 46:28Left lobe so this patient underwent
• 46:31a very uneventful hospital course
• 46:33after surgery,
• 46:34but developed recurrence at five years,
• 46:37but then underwent
• 46:39successful transplantation.
• 46:41A little bit of data on this.
• 46:45This is the only prospective
• 46:47clinical trial looking at PVE and
• 46:49in the setting of injured liver.
• 46:51It's the only clinical trial that
• 46:54will be done because there's those.
• 46:57Surgeons and interventional radiologist
• 46:59who believe that it's unethical to submit
• 47:02to subjective patient to a procedure
• 47:04that they think or I should say,
• 47:06not subject to patients to a procedure that
• 47:08those surgeons and radiologists think work.
• 47:11And then if a patient dies because
• 47:13they went into liver failure,
• 47:15that will be a problem.
• 47:17So this just shows how using
• 47:20Portal vein embolization.
• 47:21Actually improves patients
• 47:23postoperative course.
• 47:23This was a study that we did at MD
• 47:27Anderson where we see that all of
• 47:30the deaths occur in those patients
• 47:32that did not have Pve and then
• 47:36in terms of survival outcomes.
• 47:38We have,
• 47:39you can see that there are pretty
• 47:42similar those patients to those patients
• 47:44that have deviated to those that didn't.
• 47:46Now what we need to understand
• 47:48is that those patients that did
• 47:51not I should say that received
• 47:52portal vein embolization.
• 47:54Those patients typically would
• 47:55not have been a certain would not
• 47:58have been a surgical candidate,
• 48:00would have probably undergone
• 48:01a transarterial therapy,
• 48:02and the numbers show that those
• 48:05patients would probably have a 20
• 48:07to 30% three year overall survival.
• 48:09So just by doing the Pve and
• 48:11getting the patient to surgery,
• 48:13the patient had a much better outcome.
• 48:15So when we look at the staging
• 48:17system which I discussed in the very
• 48:19beginning and by understanding all
• 48:20the different procedures that we can
• 48:22offer at all the different stages,
• 48:24we now see that those patients
• 48:26that have very early or early
• 48:28stage disease can result in.
• 48:33Major stage be can have a greater
• 48:36than 2.5 year survival and then those.
• 48:39Of course that have advanced in terminal
• 48:41stages obviously don't do as well,
• 48:43but this just shows a recent.
• 48:46This is from a recent Journal of Hepatology
• 48:49Clinical Practice guidelines from Easel
• 48:50that there is really the newest thing.
• 48:53So I just wanted to pretty much finish
• 48:56up by some things that we're doing now.
• 48:59Some new therapeutic approaches and I want to
• 49:02discuss immunotherapy and interventional on.
• 49:04And how it interacts with interventional
• 49:07oncology so we all know that
• 49:10immunotherapy plays an important
• 49:12role in malignant tumor treatment.
• 49:15In particular.
• 49:16Immune checkpoint inhibitors have
• 49:18promising clinical applications and we
• 49:21also understand that monotherapy only
• 49:23benefits a small portion of the patients.
• 49:26So for that reason,
• 49:28combination of different immune
• 49:31checkpoint inhibitors with
• 49:32different mechanism of action.
• 49:34Have been utilized.
• 49:36However,
• 49:36despite this there's been a
• 49:39increase in the incidence of immune
• 49:42related severe adverse events,
• 49:44so in some cases a lot of patients
• 49:48may not be really amenable to this.
• 49:52We know that our interventional oncology
• 49:56therapies do elicit systemic immune response.
• 50:00However,
• 50:01these responses may be too weak to prevent
• 50:03local recurrence in distant metastases,
• 50:05and it's really unclear how we
• 50:07can regulate the immune system
• 50:09through these different mechanisms,
• 50:11and this is a you know from a paper
• 50:14from current oncology reports in 2020,
• 50:16which shows a very complex.
• 50:20I used paradigm in how we know therapy can
• 50:23be used in the setting of chemoembolization,
• 50:26radioembolization, inflation etc.
• 50:28So there is an opportunity for
• 50:30potential synergy with these
• 50:32checkpoint inhibitors with some of
• 50:34the therapies that we can offer.
• 50:36And this just shows how taste and
• 50:39ablation and even breakey therapy,
• 50:41really can result in both
• 50:43immunostimulation an immune suppression.
• 50:45I don't want to get into
• 50:47all the details of this,
• 50:50but basically it's something where we
• 50:52can utilize the intervention oncology
• 50:54therapies in order to really delve
• 50:56into how we can treat patients much
• 51:00more effectively with immunotherapy.
• 51:02And then this just shows that
• 51:04there are numerous ongoing studies.
• 51:07Looking at the combination of immune
• 51:10therapy with locoregional therapy and
• 51:13this is a study I just wanted to show
• 51:16one that just got activated two days ago.
• 51:19At Yale Cancer Center,
• 51:21which probably need to discuss soon.
• 51:23If Mario allows me to at our upcoming
• 51:26one of our upcoming tumor boards,
• 51:29which is the Merkley 012 clinical trial,
• 51:32which is basically taste is the backbone,
• 51:35with or without, you know,
• 51:37therapy,
• 51:37which in this case is is pen bro
• 51:40plus at multi kinase inhibitor
• 51:42which is live at and if so each
• 51:46patient will get taste and then they
• 51:48may or may not be randomized.
• 51:51Those they get the systemic
• 51:53therapy and those that don't,
• 51:54but we can go into that another time.
• 51:57And Lastly,
• 51:58I just wanted to show that
• 52:00we do treat other patients.
• 52:02I just have a couple of cases to
• 52:04show that this is a patient with
• 52:07colorectal cancer that followed.
• 52:09They failed multiple
• 52:10chemotherapeutic Regimen's who was,
• 52:11as you can see,
• 52:13has innumerable tumors with with this
• 52:15colorectal cancer did have normal
• 52:17underlying liver function and we
• 52:19treated this patient with white 90
• 52:21and you can see that there's a clear
• 52:24impact on the tumor response and I
• 52:26don't want to go into all the surf locks,
• 52:29data and all that,
• 52:31but just be aware that.
• 52:33We can do it for this.
• 52:35This is a patient that was referred to me.
• 52:37Well,
• 52:38it was a Cornell from a radiation oncologist.
• 52:40Actually with chair who had breast cancer,
• 52:42liver,
• 52:43Mets.
• 52:43And as you can see it's really
• 52:45really overtaking the liver.
• 52:47I was asked to see if we can really
• 52:50do anything for this patient and we
• 52:52did why 90 the page and then this
• 52:56was a situation where the patient
• 52:58was able to see even though she
• 53:00did succumb not within a year,
• 53:03she was able to see her son's
• 53:05wedding and also spend their her
• 53:07last Thanksgiving with family.
• 53:09So again,
• 53:09this is where the palliative nature comes in.
• 53:12And then Lastly,
• 53:13this is a patient with pancreatic cancer,
• 53:16who we were able to.
• 53:18Treat with conventional tastes in
• 53:19a term that I call like just like
• 53:22radiation segmentectomy something I
• 53:24call now chemoembolization segmentectomy,
• 53:26where we can actually you know,
• 53:28in pancreatic cancer,
• 53:30we know these patients have very hypo
• 53:32vascular tumors in a very dismal
• 53:35plastic fibrotic tumor structure
• 53:37where if we can treat the entire segment,
• 53:39the tumors cannot live, so that's
• 53:42something that we're also looking at,
• 53:44so I wanted to make it clear that you
• 53:48know HCC is not the only thing we do.
• 53:51If you do have patients that have
• 53:54other types of tumors, we're actually
• 53:56able to really treat those as well,
• 53:58and we're happy to speak to you about them.
• 54:02So in conclusion, I hope I demonstrated
• 54:04their local regional therapies do play
• 54:07an important role in the management of
• 54:09both primary and metastatic liver cancer.
• 54:12They often provide benefit for survival,
• 54:14local tumor control,
• 54:15and improve quality of life compared
• 54:18to and in some cases, you know,
• 54:20compared to resection and compared
• 54:22to some systemic therapies,
• 54:24it may result in cure.
• 54:26In some patients,
• 54:27such as those that have solitaire E
• 54:30small HCC's and can enable patients
• 54:32to be bridge or down stage 2.
• 54:35Transplant or surgery?
• 54:38There's various sublative
• 54:39entrance arterial therapies,
• 54:40and they have very different
• 54:42mechanism of of actions,
• 54:43but I think when looking at
• 54:46these kinds of therapies,
• 54:47it's important to really understand
• 54:49the real true nuances of the therapies
• 54:52that you're either performing or
• 54:54requesting is a refer so that you
• 54:57really understand what we're talking
• 54:59about and how to read reports when
• 55:02they come out saying ablation
• 55:04or a key mobilization.
• 55:06I've also hope to have shown advanced
• 55:08that both advanced imaging an
• 55:10catheter based technology has been
• 55:12very helpful in treatment decisions.
• 55:15By providing intraprocedural guidance
• 55:16and therapeutic confirmation that we
• 55:19were able to effectively treat the tumors,
• 55:21and we're also now on the precipice
• 55:23of looking at combination therapies
• 55:25which appear promising,
• 55:27such as those found in immuno oncology.
• 55:30So with that I think I'll stop here.
• 55:36Think I was on time, but you know I'm
• 55:38sure we have some time for questions.
• 55:42Thank you very
• 55:43much, Sir David. For anybody has a
• 55:47question and type type it please in
• 55:50the chat and then we will respond.
• 55:52In the end I mean by what
• 55:55people may be thinking.
• 55:57I want to thank you for the these.
• 56:00Are this great review of all the possible.
• 56:06Approach is there.
• 56:08Interventional radiology can can
• 56:10provide for the treatment of primary,
• 56:12secondary liver tumor.
• 56:13I mean from my own point of view, I,
• 56:16I think you really showed the complexity of
• 56:19the dictation making that is behind this.
• 56:22It's you know, as you said at the beginning,
• 56:25we think in a very simplified way.
• 56:28Yeah, let's sub later if aid is.
• 56:31But in reality, you really do.
• 56:35Send the patient to centers that have
• 56:39all these possibilities, Anan abilities,
• 56:41and they can really tailor.
• 56:44The treatment of the patient to the.
• 56:49To amend personalized treatment
• 56:51to the patient, and. Great.
• 56:55So we have a question from even a
• 56:58rukundo great informative presentation.
• 57:01My questions and terminology,
• 57:03embolus therapy versus embolization.
• 57:05Is there any difference?
• 57:09Well, that's actually a very
• 57:11interesting question because I like
• 57:13to always call things emblow therapy.
• 57:16Now clearly there's really not
• 57:18a major difference between.
• 57:19Well, I guess the term embolization
• 57:22implies that similar to like,
• 57:24what a pulmonary embolism uses
• 57:26that you're taking a catheter,
• 57:28and your iatrogenic Lee moving one
• 57:31particle or or structure to another area.
• 57:33Now that could be with one particle, right?
• 57:37But that doesn't have to be with.
• 57:40The whole thing, so I guess emblow
• 57:43therapy is actually defined.
• 57:44Should be defined as the
• 57:47treatment of patients with.
• 57:49You know, using these transcatheter
• 57:51transarterial methods,
• 57:52but I guess embolization doesn't
• 57:55necessarily have to be therapeutic.
• 57:57So that's actually a great I
• 57:59think about that all the time.
• 58:01And you know when we talk about in reports,
• 58:04for example, embolization of that,
• 58:06would you know?
• 58:08And I think that's the actual.
• 58:10That's the actual difference.
• 58:14I come. Baby, do you have?
• 58:19Can you expand a little bit of
• 58:22the possible adverse effect of
• 58:25combination therapy with the. They
• 58:28send the email uncle immunotherapy.
• 58:33Well, basically we don't know
• 58:34that yet, right? I mean,
• 58:36that's why we're doing these.
• 58:38That's why we're doing these studies.
• 58:40I mean basically.
• 58:43We also we also don't know if you
• 58:47should do the if you should do the.
• 58:51There are which therapy used to 1st right?
• 58:54Like should you do the should you start
• 58:57with taste and and then follow it with
• 59:00immunotherapy or should you start with
• 59:02your therapy and then do the taste right?
• 59:05You know each. I guess trial is
• 59:08very different, right? And each.
• 59:12I guess therapy has its own company,
• 59:15has its own adverse events.
• 59:18The thought is that you would
• 59:22do the immunotherapy. You know,
• 59:24after the at least two weeks you would
• 59:27do the therapy immunotherapy after the taste.
• 59:30That by then the tastes adverse events
• 59:32should already be taken out of the equation.
• 59:35Because in the time that you're
• 59:38getting the immunotherapy,
• 59:39those patients would already
• 59:40be beyond that time.
• 59:42So in terms of the actual combination
• 59:44is kind of hard to understand. I mean,
• 59:47particularly in the Merck study where.
• 59:50Pizza getting taste first.
• 59:52So you know, we still don't know.
• 59:55I mean,
• 59:55we're still very early in in all of these,
• 59:58you know, in all of these studies.
• 60:00So I.
• 01:00:00I don't have a very good answer yet.
• 01:00:04Switch an ATC and different
• 01:00:07histopathology dash subtypes
• 01:00:09with different molecular bases.
• 01:00:12Do you predict?
• 01:00:15If there is a possibility that the
• 01:00:17different subtype of ACC can be
• 01:00:20treated differently by locoregional
• 01:00:21therapies and they, I would have
• 01:00:24to say the answer is yes.
• 01:00:26The reason why I think that is that
• 01:00:28there's a very big difference is as
• 01:00:31you know in colon cancer and right
• 01:00:34sided versus left sided colon cancer
• 01:00:36and actuality when there's been studies
• 01:00:39out there that with colon cancer
• 01:00:41that there's when patients get why
• 01:00:4390 to deliver in patients that have.
• 01:00:46Different types of colon cancer.
• 01:00:48They actually get different.
• 01:00:51Response rates.
• 01:00:53So that way you would actually be able
• 01:00:57to tailor it so I do believe that in time.
• 01:01:01You know, as I said,
• 01:01:03I mean right now we're only like 40
• 01:01:05years into really treating patients with
• 01:01:07these kinds of therapies for liver cancer.
• 01:01:10So which means to me that in 100 years
• 01:01:12we're going to be so far advanced that
• 01:01:15I don't see how you wouldn't have,
• 01:01:18you know, genetics involved into a
• 01:01:20personalized treatment algorithm
• 01:01:21for these kinds of therapies,
• 01:01:22so that's what we're here to do.
• 01:01:25That's why we're doing the research here,
• 01:01:27so I think that that's a great question,
• 01:01:30and I think that.
• 01:01:31Like I said,
• 01:01:32we're in the we're in the infancy.
• 01:01:34So the agency is acquisitively
• 01:01:37rather sensitive. How do you
• 01:01:39decide between taste and why? 90?
• 01:01:42Because in certain institution actually
• 01:01:44went 90 is preferably with days.
• 01:01:47Can you comment? So I thought
• 01:01:50I had a slide and an and where it went,
• 01:01:55which was a meta analysis of. And actually,
• 01:01:59the slide said how to decide now?
• 01:02:01Maybe I went through.
• 01:02:02Maybe I clicked the button too fast,
• 01:02:04but at the end of the the taste.
• 01:02:08Question I thought I had a meta analysis
• 01:02:11lie which basically shows that there's very
• 01:02:15similar outcomes in both taste and MY90,
• 01:02:18so you know the way that we've
• 01:02:22used to think about it is that.
• 01:02:25In in, in patients that were older patients
• 01:02:28that you know we want to do it as outpatient.
• 01:02:32You know, back then,
• 01:02:33those were all considered.
• 01:02:34You know why 90 patients?
• 01:02:36OK? Now we do taste all the
• 01:02:40time as outpatient as well.
• 01:02:42So when I'm looking at it I'm looking at,
• 01:02:45I guess the.
• 01:02:47The I guess you need to look at the patient.
• 01:02:50In general the performance status you need
• 01:02:53to look at is it low bar or BI lo bar.
• 01:02:56You have to look at how you're going to like.
• 01:03:00If tumors are all in different locations
• 01:03:02where you have to cherry pick each each one.
• 01:03:05Sometimes you opt for.
• 01:03:07Radioembolization or the other
• 01:03:09one so so basically.
• 01:03:11If you have if you have
• 01:03:15multiple tumors in in a lobe.
• 01:03:18And you're doing radio embolization.
• 01:03:21You either have to treat the whole lobe.
• 01:03:26OK,
• 01:03:26which is a very big low bar taste or
• 01:03:29you have to do all of this difficulty
• 01:03:32which is changing out catheters,
• 01:03:35splitting doses.
• 01:03:36You know it's very complex
• 01:03:38the way the anatomy is OK,
• 01:03:40so the other thing I said is that
• 01:03:43sometimes you have patients where
• 01:03:45you don't know what you want to do
• 01:03:48and chemoembolization or the other
• 01:03:50embolization is besides why 90.
• 01:03:53Are ones where you can get them.
• 01:03:56You can get the product off the shelf.
• 01:03:59OK,
• 01:04:00so instead of having to order it and
• 01:04:03and waiting and all that kind of
• 01:04:05stuff so you know there's a lot of
• 01:04:09different opportunities for treatment.
• 01:04:11Unfortunately, and this is where.
• 01:04:15You know, institutional.
• 01:04:16I guess expertise comes in
• 01:04:19is that there is no answer.
• 01:04:22OK, there really isn't, and you know,
• 01:04:25I, as we've discussed in the past,
• 01:04:27I personally believe taste is a great
• 01:04:30option for portal vein tumor thrombus,
• 01:04:33because you know,
• 01:04:34if you look at a lot of the
• 01:04:37Asian publications,
• 01:04:38you can see the actual apidel
• 01:04:40sitting in the portal vein codian.
• 01:04:43OK, where it's very difficult
• 01:04:45to see that with Y-90.
• 01:04:48So I know that why 90 right now
• 01:04:51seems to be the hot option.
• 01:04:54Technically I used in figuratively
• 01:04:56for portal vein tumor thrombus,
• 01:04:58but it's a very very delicate situation,
• 01:05:01I mean.
• 01:05:03I I don't really get too much
• 01:05:05into the expensive at all,
• 01:05:06which we haven't even discussed at all,
• 01:05:09but.
• 01:05:10A lot of it is just
• 01:05:12institutional northwestern.
• 01:05:13I guess you would most likely
• 01:05:14get away 90 even though I do
• 01:05:17know they do taste so you know
• 01:05:19it's very difficult to choose.
• 01:05:22Alright, so if there are no no other
• 01:05:25questions, I think we need we.
• 01:05:28We need to thank David Matter for this.
• 01:05:31Very nice, informative in broad
• 01:05:34lecture an and keep that in mind
• 01:05:38when we have a patient with the.
• 01:05:42Metastatic of primary liver cancer.
• 01:05:44Thank you very much to all
• 01:05:46and have a good evening.
• 01:05:48Thanks Mary for the invitation.