Abdominal imaging treatment of inoperable hcc p kwok
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Transcript of Abdominal imaging treatment of inoperable hcc p kwok
Traitement du CHC inopérable : le scenario de Hong Kong
Treatment of Inoperable Hepatocellular Carcinoma:
the Hong Kong Scenario
Philip CH KWOK Queen Elizabeth Hospital Hong Kong SAR, CHINA
HCC in Hong Kong
• Worldwide 750000 new cases HCC diagnosed in 2008
• High prevalence in HK : chronic hepa;;s B infec;on
• Worldwide: 6th most prevalent cancer, 3rd cause of cancer death
• 3rd leading cause of cancer death in HK – 4th commonest cancer in men – 7th commonest cancer in women
Cura;ve treatment for HCC
• HK has high standard and advanced skill of surgical resec;on
• Play a leading role in HCC research • Include: – Surgical resec;on – Transplanta;on – Local abla;on with various means
Treatment for Inoperable HCC
• HCC is a combina;on of 2 diseases : cancer + liver cirrhosis (mostly)
• Successful cura;ve treatment 1. remove the tumor + some surrounding
noncancerous ;ssue 2. + Enough and func;oning residual liver ;ssue to
sustain life
Treatment for Inoperable HCC
• Inoperability due to: – Too much tumor ;ssue, either in one lobes, or in both lobes, or outside the liver
– Inadequate func;oning liver ;ssue leT behind aTer tumor resec;on/ abla;on
Tools for inoperable HCC
• Transarterial chemoemboliza;on (TACE) • Transarterial radioemboliza;on (TARE or RE) • External radiotherapy • Target therapy (Sorafenib)
Tools for Unresectable HCC • Unresectable ≠ Inoperable
• Tools for unresectable tumors: – Radiofrequency abla;on (RFA)
– Microwave abla;on (MWA)
– Percutaneous alcohol injec;on (PEI)
– Cryoabla;on
More Aggressive way: RFA, ar;ficial ascites
More Aggressive way: RFA, transpleural with ar;ficial pneumothorax
More Aggressive way: RFA, transpleural with ar;ficial pneumothorax
More Aggressive way: RFA, blood flow control, percutaneous or open
Pringle manoeuvre
Percutaneous Alcohol Injec;on (PEI)
PEI: S'll has a role for tumors near cri'cal loca'ons or vital structures , where thermal abla'on is dangerous or ineffec've
Do we have a Guideline to follow?
• Currently no local consensus, we will have one very soon
• Commonly quoted : – Barcelona Clinic Liver Cancer (BCLC) staging system and management
– Asian Pacific Associa;on for the Study of the Liver (APASL)
BCLC staging
BCLC staging
• There are more treatment modali;es available than men;oned in the “guideline”
• Not up-‐to-‐date
APASL Guidelines for HCC Management
APASL guideline
• More closely reflect the local prac;ce
China An;-‐cancer Society
China An;-‐cancer Society
• In 2009
J-‐HCC Guidelines
J-‐HCC Guidelines
• Different prac;ce in Japan
Hong Kong Guideline on Treatment of HCC
• Consensus Mee;ng in 2013 • Will come out soon • A group of local specialists led by Prof Ronnie TP POON – Surgeons – Oncologists – Interven;onal Radiologists – Hepatologists
Treatment aim
• For inoperable HCC, the treatment aim is mainly pallia;ve
• Pallia;ve – Transarterial chemoemboliza;on (TACE) • lipiodol + chemotherapeu;c agent(s) • Drug elu;ng beads
– Transarterial radioemboliza;on (TARE) • Ymrium-‐90
HCC Treatment
• The commonest treatment for inoperable HCC in Hong Kong
• About 500 TACE per year in a single ins;tute • The standard treatment in most centers for inoperable HCC
• Emulsion of lipiodol + single/ mul;ple chemotherapeu;c agents
• Oily emulsion can reach 500 um • Effect proven by mul;ple studies and 2 RCT (Llovet, Lo)
Conven;onal TACE
Conven;onal TACE
• TACE given once every 2 months or 3 months • Usually through the hepa;c artery • Also possible through other extrahepa;c arteries
• Assess the response aTer every TACE
TACE
Defect of lipiodol reten.on
TACE, inferior phrenic artery
TACE
Conven;onal TACE
• Stop TACE – when the tumor(s) do not respond, either there is inadequate uptake, or the tumor(s) enlarge
– When the liver func;on gets worse aTer TACE – When the supplying artery is occluded – When there are other complica;ons of TACE, e.g. biliary necrosis
TACE – induced biliary Injury
• ATer 6 sessions of TACE
Conven;onal TACE
• TACE can be cura;ve, though it is oTen considered a pallia;ve treatment
• So, stop TACE also when – THE DISEASE IS CURED!
• This is oTen the situa;on when – TACE is performed superselec;vely – TACE is performed for a small lesion inapproachable by other local abla;ve treatment e.g. RFA for a lesion near another organ (gall bladder)
• Variants: – Superselec;ve TACE with microcatheter • Overflow of emulsion to portal venules
– (Balloon occluded TACE ) • Not yet available locally
Conven;onal TACE
• Matsui O. • Superselec;ve TACE with microcatheter • Lipiodol flows to the portal venules through peribiliary plexus
• Enhances treatment effect
Superselec;ve TACE with overflow to portal venules
Superselec;ve TACE with overflow to portal venules
• The 3-‐year local recurrence rate for grade 0, 1, 2: 74%, 42%, 19%
Balloon-‐occluded TACE
B-‐TACE
• 3Fr microballoon catheter
• Reduce the arterial stump pressure
• Increase lipiodol emulsion accumula;on inside the tumor
• Side effects are common • Related to early systemic release of chemo agents – Nausea, vomi;ng, alopecia, renal impairment, marrow suppression, etc.
• Liver parenchymal damage – Liver func;on impairment, liver failure, liver abscess, biliary duct injury and biloma
Conven;onal TACE
Drug elu;ng beads-‐TACE/DEB-‐TACE
• Replace lipiodol with microspheres (100-‐300um)
• Slow release of drugs • Enhances local therapeu;c efficacy
• Less systemic side effects
– Two randomized controlled trials showed bemer control of disease progression but
– no sta;s;cal significant in survival rate due to short follow-‐up period and small sample size
DEB-‐TACE
– PRECISION V study recruited 217 pa;ent showed that DEB had a disease control rate of 63.4% and conven;onal TACE had a disease control rate of 51.9% (P=0.11).
– Pa;ent with Child-‐Pugh B, ECOG 1, bilobar disease, and recurrent disease showed a significant increase in objec;ve response (P=0.038) compared to cTACE.
– DC Bead was associated with improved tolerability, with a significant reduc;on in serious liver toxicity (P=0.001) and a significant lower rate of doxorubicin-‐related side effects (P=0.0001).
DEB-‐TACE
• Malagari K, et al. (CVIR 2012) • 173 pa;ents, Child A, B • Mean lesion diameter 7.6 +/-‐ 2.1cm • Mean overall survival was 43.8 months (range 1.2–64.8)
• Overall survival at 1, 2, 3, 4, and 5 years was 93.6, 83.8, 62, 41.04, and 22.5 %,
DEB 5-‐yr survival
Malagari K, et al CVIR 2012
DEB-‐TACE
• Used more frequently in private hospitals than public hospitals due to the high costs
TARE
• Transarterial Radioemboliza;on
• Ymrium-‐90 is beta emitng
• On resin or glass beads (20-‐60um)
• 2mm range bachytherapy
• Half life 64 hours • Usually perform once
TARE
• Can be performed in 3 public hospitals and 2 private hospitals in Hong Kong – Exper;se required – Great demand on several special;es working together as a team
– Currently Hospital Authority only approved and reimbursed its use in HCC > 8cm diameter, or there is portal vein invasion
TARE
• In Western countries, TARE is used mainly for liver dominant colorectal metastases
• Not in HK public hospitals
• large-‐scale phase II studies show, when compared with cTACE, – less side effects, bemer tolerance, – bemer response rate and longer ;me to disease progression
• No definite survival benefit when compared with cTACE
• Maybe related to its use in moderate to advanced disease
TARE
TARE • Benefit in HCC with portal vein invasion
• Kulik LM, et al. (Hepatology 2008)
• PR: 42.2% (WHO); 70% (EASL)
TARE
Salem and Lewandowski. Clin Gastroenterol and Hepatol 2013
TACE + RFA
• In HB cirrhosis, there may be lots of nodules • HCC focus seen in CT or MR, but not seen under ultrasound
• Perform TACE once, then RFA under CT guidance
TACE + RFA
S7 lesion seen in MR Selec;ve TACE to RHA once
TACE + RFA
CT guided RFA with mul;planar recon CT post RFA 1 month
• cTACE + RFA has bemer response rate, bemer 1-‐year and 3-‐year survival than either monotherapy
• Metaanalysis of 6 papers – Ni JY et al. (J Cancer Res Clin Oncol 2013)
LR therapies + others
cTACE + RFA • TACE plus PRFA had
significantly bemer effec;veness on 1-‐ and 3-‐year overall survival rate – odds ra;o [OR] 1-‐year = 4.61,
95 % confidence interval [95 % CI] 2.26–9.42, P < 0.0001
– OR 3-‐year = 2.79, 95 % CI 1.69–4.61, P < 0.0001
• and 3-‐year recurrence-‐free survival rate – [OR] 3-‐year = 3.00, [95 % CI]
1.75–5.13, P < 0.0001 • 1-‐year recurrence-‐free survival
rate: no significant difference
• cTACE or DEB-‐TACE + Sorafenib (kinases inhibitor) – Inves;ga;onal – Timing and dose of Sorafenib needed to be determined with clinical studies
Locoregional therapies + Sorafenib
• Previously overlooked because of fatal liver toxicity at doses lower than therapeu;c doses
• Recently, precise delivery of focused high-‐dose on targeted volume of the liver – 3D conformal RT – Intensity modulated RT (IMRT) – Stereotac;c body RT (SBRT) – Image guided RT (IGRT) – Proton therapy
Image guided Radiotherapy for HCC
IGRT and BCLC stages • Stage A: nonsurgical
cura;ve therapy. • Stage B: can be
combined with other treatments such as TACE.
• Stage C: prolong the survival ;me in selected pa;ents with locally advanced HCC associated with portal vein invasion but not distant metastasis.
• Stage D: pallia;on.
Lee IJ et al. Gut Liver 2012
Thanks