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Interventional Oncology

Interventional Oncology. Michael Kotton MD October 27, 2012. 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. Liver Cancer.

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Interventional Oncology

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  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

  22. RESPONSE

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

  24. 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

  25. 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%

  26. 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

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

  28. RESPONSE 2

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

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

  31. Questions???

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