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???