interventional oncology michael kotton md october 27, 2012
TRANSCRIPT
Interventional Interventional OncologyOncology
Michael Kotton MDMichael Kotton MD
October 27, 2012October 27, 2012
ObjectiveObjective
Understand role of thermal Understand role of thermal ablation in treatment of HCCablation in treatment of HCC
Understand role of TACE in Understand role of TACE in treatment of HCCtreatment of HCC
Know patient selection criteria Know patient selection criteria and possible complications of and possible complications of TACE and thermal ablationTACE and thermal ablation
Liver CancerLiver Cancer
55thth most common cancer most common cancer 80% Hepatocellular Carcinoma 80% Hepatocellular Carcinoma
(HCC)(HCC) 18,910 deaths in USA 201018,910 deaths in USA 2010 Incidence increasing 4.3% per yearIncidence increasing 4.3% per year Underlying chronic liver Underlying chronic liver
disease/cirrhosisdisease/cirrhosis
Hepatocellular Hepatocellular CarcinomaCarcinoma Tends to stay localized to LiverTends to stay localized to Liver Can be cured by liver transplantCan be cured by liver transplant Prognosis depends on both Prognosis depends on both
cancer and underlying liver cancer and underlying liver diseasedisease
Liver has a dual blood supplyLiver has a dual blood supply Tumor supplied by hepatic arteryTumor supplied by hepatic artery
Liver Blood SupplyLiver Blood Supply
Interventional OptionsInterventional Options
PercutaneousPercutaneous– Thermal ablation, Chemical ablationThermal ablation, Chemical ablation
TransarterialTransarterial– Bland embolizationBland embolization– RadioembolizationRadioembolization– ChemoembolizationChemoembolization– Drug Eluding BeadsDrug Eluding Beads
How Do We DecideHow Do We Decide
Extent of TumorExtent of Tumor– Milan Criteria (5/3 Rule)Milan Criteria (5/3 Rule)– One tumor less then 5 cmOne tumor less then 5 cm– Up to 3 tumors less then 3cmUp to 3 tumors less then 3cm– No vascular invasionNo vascular invasion
Health of PatientHealth of Patient Condition of the LiverCondition of the Liver
Treatment OptionsTreatment OptionsTransplantationTransplantation Milan Criteria (5/3 Milan Criteria (5/3
Rule)Rule) 70% survival at 5 70% survival at 5
YearsYears IR treatments as IR treatments as
bridge to bridge to transplanttransplant
SurgerySurgery No CirrhosisNo Cirrhosis No Portal HTNNo Portal HTN 30-60% 5 year 30-60% 5 year survivalsurvival
Interventional Interventional RadiologyRadiology
ChemotherapyChemotherapy Advanced cancerAdvanced cancer NexevarNexevar
Thermal AblationThermal Ablation
Curative IntentCurative Intent– Recurrence at 5 years 60-70%Recurrence at 5 years 60-70%
Size <5cmSize <5cm SolitarySolitary Safe locationSafe location Not surgical candidateNot surgical candidate
Case 1Case 1
58 year old 58 year old femalefemale
2.2 cm tumor2.2 cm tumor Hep BHep B HTNHTN Normal BilirubinNormal Bilirubin Mild PVHMild PVH
RFA Probe
Needle PlacementNeedle Placement
Stomach
Post AblationPost Ablation
Post TreatmentPost Treatment
Pre Post
Post Open RFA LiverPost Open RFA Liver
ComplicationsComplications
BleedingBleeding InfectionInfection Tumor Seeding 2-10%Tumor Seeding 2-10%
– Subcapsular locationSubcapsular location Inadvertent AblationInadvertent Ablation
– Bowl, Gallbladder, DiaphragmBowl, Gallbladder, Diaphragm– Central Biliary TreeCentral Biliary Tree
OutcomeOutcome
<1% Mortality<1% Mortality Complications 5%Complications 5% 30-55% five year survival30-55% five year survival Local Recurrence 2-10%Local Recurrence 2-10%
– Can be treated againCan be treated again Recurrence at 5 years same as Recurrence at 5 years same as
resectionresection
ChemoembolizationChemoembolization
Large or multifocal tumorsLarge or multifocal tumors Can Liver Tolerate TreatmentCan Liver Tolerate Treatment Patient benefitPatient benefit Size and number of tumorsSize and number of tumors
Patient SelectionPatient Selection
Bilirubin < 3Bilirubin < 3 Albumin >3Albumin >3 PLT >90PLT >90 No encephalopathyNo encephalopathy No vascular InvasionNo vascular Invasion No Biliary DilationNo Biliary Dilation Tumor Less then 50% liverTumor Less then 50% liver
ChemoembolizationChemoembolization
ChemoembolizationChemoembolization
Case 2Case 2
69 year old male69 year old male Hep BHep B 9 cm tumor9 cm tumor Normal BilirubinNormal Bilirubin Mild PVHMild PVH
RESPONSERESPONSE
Post TreatmentPost Treatment
Chung W et al. AJR 2012;199:349-359
Mannelli L et al. AJR 2009;193:1044-1052
ComplicationsComplications
BleedingBleeding Liver FailureLiver Failure InfectionInfection
– Biliary-Enteric AnastomosisBiliary-Enteric Anastomosis Post Embolization SyndromePost Embolization Syndrome
Fever, nausea, pain Fever, nausea, pain Ends after 7 days, infection usually presents Ends after 7 days, infection usually presents
laterlater Inadvertent EmbolizationInadvertent Embolization
Gallbladder, bowlGallbladder, bowl
Does It WorkDoes It Work
Survival Benefit in select patientsSurvival Benefit in select patients Hong Kong trialHong Kong trial
– 2 Year Survival 31% versus 11%2 Year Survival 31% versus 11%– 3 Year Survival 26% versus 3%3 Year Survival 26% versus 3%
Barcelona trialBarcelona trial– 2 Year Survival 63% versus 27%2 Year Survival 63% versus 27%
SummarySummary
Remember the 5/3 ruleRemember the 5/3 rule Transplantation is best treatment Transplantation is best treatment
in eligible patientsin eligible patients Ablation for small tumors and Ablation for small tumors and
resection for non cirrhotic liversresection for non cirrhotic livers Chemoembolization for non Chemoembolization for non
surgical tumors who can tolerate surgical tumors who can tolerate the procedurethe procedure
Case 3Case 3
68 year old female68 year old female Hep CHep C Multifocal tumors Multifocal tumors
(5.2cm,3cm,2cm)(5.2cm,3cm,2cm) Good liver functionGood liver function
2
RESPONSE
Case 4Case 4
79 male79 male Hep C CirrhosisHep C Cirrhosis 3.7 cm solitary 3.7 cm solitary
tumortumor Multiple medical Multiple medical
problemsproblems
Case 5Case 5
62 year old 62 year old femalefemale
Hep CHep C CirrhosisCirrhosis 2.4 cm tumor2.4 cm tumor Otherwise Otherwise
healthyhealthy
Questions???Questions???