Interventional Oncology

1. Interventional Oncology Michael Kotton MD October 27, 2012

2. Objective • Understand role of thermal ablation in treatment of HCC • Understand role of TACE in treatment of HCC • Know patient selection criteria and possible complications of TACE and thermal ablation

3. Liver Cancer • 5th most common cancer • 80% Hepatocellular Carcinoma (HCC) • 18,910 deaths in USA 2010 • Incidence increasing 4.3% per year • Underlying chronic liver disease/cirrhosis

4. Hepatocellular Carcinoma • Tends to stay localized to Liver • Can be cured by liver transplant • Prognosis depends on both cancer and underlying liver disease • Liver has a dual blood supply • Tumor supplied by hepatic artery

5. Liver Blood Supply

6. Interventional Options • Percutaneous • Thermal ablation, Chemical ablation • Transarterial • Bland embolization • Radioembolization • Chemoembolization • Drug Eluding Beads

7. How Do We Decide • Extent of Tumor • Milan Criteria (5/3 Rule) • One tumor less then 5 cm • Up to 3 tumors less then 3cm • No vascular invasion • Health of Patient • Condition of the Liver

8. Treatment Options

9. Thermal Ablation • Curative Intent • Recurrence at 5 years 60-70% • Size <5cm • Solitary • Safe location • Not surgical candidate

10. Case 1 • 58 year old female • 2.2 cm tumor • Hep B • HTN • Normal Bilirubin • Mild PVH

11. Needle Placement RFA Probe Stomach

12. Post Ablation

13. Post Treatment Pre Post

14. Post Open RFA Liver

15. Complications • Bleeding • Infection • Tumor Seeding 2-10% • Subcapsular location • Inadvertent Ablation • Bowl, Gallbladder, Diaphragm • Central Biliary Tree

16. Outcome • <1% Mortality • Complications 5% • 30-55% five year survival • Local Recurrence 2-10% • Can be treated again • Recurrence at 5 years same as resection

17. Chemoembolization • Large or multifocal tumors • Can Liver Tolerate Treatment • Patient benefit • Size and number of tumors

18. Patient Selection • Bilirubin < 3 • Albumin >3 • PLT >90 • No encephalopathy • No vascular Invasion • No Biliary Dilation • Tumor Less then 50% liver

19. Chemoembolization

20. Chemoembolization

21. Case 2 • 69 year old male • Hep B • 9 cm tumor • Normal Bilirubin • Mild PVH

26. RESPONSE

27. Post Treatment Chung W et al. AJR 2012;199:349-359 Mannelli L et al. AJR 2009;193:1044-1052

28. Complications • Bleeding • Liver Failure • Infection • Biliary-Enteric Anastomosis • Post Embolization Syndrome • Fever, nausea, pain • Ends after 7 days, infection usually presents later • Inadvertent Embolization • Gallbladder, bowl

29. Does It Work • Survival Benefit in select patients • Hong Kong trial • 2 Year Survival 31% versus 11% • 3 Year Survival 26% versus 3% • Barcelona trial • 2 Year Survival 63% versus 27%

30. Summary • Remember the 5/3 rule • Transplantation is best treatment in eligible patients • Ablation for small tumors and resection for non cirrhotic livers • Chemoembolization for non surgical tumors who can tolerate the procedure

31. Case 3 • 68 year old female • Hep C • Multifocal tumors (5.2cm,3cm,2cm) • Good liver function

35. RESPONSE 2

36. Case 4 • 79 male • Hep C Cirrhosis • 3.7 cm solitary tumor • Multiple medical problems

37. Case 5 • 62 year old female • Hep C • Cirrhosis • 2.4 cm tumor • Otherwise healthy

38. Questions???