Hepatocellular carcinoma—role of interventional radiologist Dr. Muhammad Bin Zulfiqar
Interventional Treatment for Hepatocellular Carcinoma
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Transcript of Interventional Treatment for Hepatocellular Carcinoma
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Interventional Treatment for Interventional Treatment for Hepatocellular CarcinomaHepatocellular Carcinoma
Sheng-Long Ye, MD, PhD
Liver Cancer Institute
Zhongshan Hospital
Fudan University
Shanghai, China
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China—High Incidence of Liver Cancer
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New Cases of Liver Cancer (2008)
748
x103
402
48.2%
6
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Deaths of Liver Cancer (2008)
694
x103
372
48.4%
6
3
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The Second Cancer Killer in ChinaThe Second Cancer Killer in China
0
5
10
15
20
25
30
35
Nati onwi de Urban Rural
1973-19751990-19922004-20052006
PLC Mortality (per 10PLC Mortality (per 1055 people) people)
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Problem in HCCProblem in HCC
Severe Severe cirrhosiscirrhosis Intrahepatic Intrahepatic spread spread and and
distant distant metastasismetastasisLowLow resectabilityresectabilityHigh postoperative High postoperative
recurrencerecurrence
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HCC
PS 0~2 PS 3~4
Child-Pugh A/B Child-Pugh C
ECOG
Liver Function
Metastasis No Yes
Vascular Invasion
Number
Tumor size
No Yes
≤3cm >3cm
≥42~3
•Supportive care
•Supportive care
•Transplant (UCSF)
•TACE
•Radiotherapy
•Molecular targeted
•Systemic chemotherapy
•TACE
•Resection
•+ablation
•Resection
•TACE
+Ablation
•Transplant (UCSF)
•Resection
•Ablation (≤3cm)
•Transplant
Optimal treatment
•TACE
•Resection
•Radiotherapy
•Targeted
•Systemic chemotherapy
Single
HCC Treatment Algorithm
≤5cm > 5cm
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Non-surgical TreatmentNon-surgical Treatment Interventional treatment –
TACE, Intratumor injection, RFA, MWCT, Laser, HIFU, Cryotherapy
Radiotherapy Chemotherapy Biotherapy Molecular targeted therapy Traditional Chinese medicine
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Interventional Treatment is a main modality for HCC
1995
Murakami
Microwave
1976GoldsteinTAE
1979Nakakuma Lipiodol TACE
1986LivraghiPEI 1986
OnikCryoablation
1992MastersLaser
1993Rossi RFA
1994OhnishiPAI
TIPS, stent in IVC, biliary tract, portal vein……
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Key Pathologic Features of HNS: Vascular Supply
Normal PV
Arterial supply
Portal supply
RN low-DN high-DN EHCC wd-HCC md/pd-HCC
ClassicNormal HA
Abnormal HA
Loss of visualization of portal tracts and development of new arterial vessels
Significant overlap
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Llovet JM, et al. Hepatology. 2003;37:429-442.
Arterial Embolization for HCCMeta-analysis of 6 RCTs (2-Yr Survival)
Random Effects Model,OR (95% CI)
Author, Journal Yr Patients,
n
Lin, Gastroenterology 1988 63
GETCH, NEJM 1995 96
Bruix, Hepatology 1998 80
Pelletier, J Hepatol 1998 73
Lo, Hepatology 2002 79
Llovet, Lancet 2002 112
Overall 503
Median survival: ~ 20 mos
0.01 0.1 0.5 1 2 10 100
Z = -2.3P = .017
Favors Treatment
Favors Control
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HCC
PS 0~2 PS 3~4
Invasion
Child-Pugh C
No Yes
ECOG
Liver Function
Metastasis
Child-Pugh A/B
No Yes
Tumor Number
·TACE·Radiotherapy·Sorafenib·Chemotherapy
·TACE·Resection·Radiotherapy·Sorafenib·Chemotherapy
One 2~3 ≥4
Tumor Size
≤3cm > 3cm
Treatment ·TACE·Resection·+Ablation•Transplant
·Resection·TACE+RFA·Transplant
< 5cm ≥5m
Application of TACE for HCCApplication of TACE for HCC
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Improvement of TACE H.A.-P.V. combined embolization Super selective segmental
chemoembolization TACE with temporary occlusion of H.V. Hot lipiodol embolization Segmental ethanol-lipiodol infusion Stent in P.V. with I125 intra-radiation Radioembolization (Y90 microsphere) Drug-Eluting Bead embolization
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Personalization of TACEPersonalization of TACE
Super-selective embolizationSuper-selective embolization Prolongation of treatment intervalProlongation of treatment interval Tumor down-staging resectionTumor down-staging resection Adjuvant TACEAdjuvant TACE Thrombus in P.V. and I.V.C.Thrombus in P.V. and I.V.C. Combination treatmentCombination treatment Avoiding over-treatment Avoiding over-treatment !!
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Local Ablation therapy
Clinical departments involving in ablation therapy
---- Surgical, Medical, Interventional, Radiology,
Radiotherapy, Ultrasonography…)
Imaging-guided targeting
cancer location, resulting in
direct coagulation, necrosis
and killing of cancer tissues
by physical and chemical
approaches with minimal
invasion
Safe, minimal-invasion,
simplified , repeatable
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Local AblationLocal Ablation PEI, RFA, MWCT, Laser thermal therapy, HIFU, PEI, RFA, MWCT, Laser thermal therapy, HIFU,
(Argon-Helium)-Cryotherapy.(Argon-Helium)-Cryotherapy. All tumors amenable to ablation (enough margin of All tumors amenable to ablation (enough margin of
normal tissues).normal tissues). Tumors in a location accessible for ablation.Tumors in a location accessible for ablation. Tumors ≤ 3cm --- optimally treated with ablation . Tumors ≤ 3cm --- optimally treated with ablation . Tumor 3-5cm --- combination of embolization and Tumor 3-5cm --- combination of embolization and
ablation. ablation. Unresectable/inoperable lesions (Unresectable/inoperable lesions ( >> 5cm) -– arterial 5cm) -– arterial
embolization approaches.embolization approaches. Caution --- ablating lesions near major vessels, Caution --- ablating lesions near major vessels,
major bile ducts and other intra-abdominal organs.major bile ducts and other intra-abdominal organs.
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Ablation area should include at least 5 cm of surrounding tissues for “safe margin”
Ablation area needs to be extended for liver cancer with infiltrative type or metastatic type if the surrounding tissues and structure are available
Personalization of treatment strategy is important for liver cancers near heart, diagram, stomach, intestine, gallbladder and other organs
Blood-supply vessels of hypervascular cancer may be blocked before ablation
Principles of Ablation therapy
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RFA for Small HCCRFA for Small HCC
Jiang XC
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Wang ZS
RFA for Small HCCRFA for Small HCC
Wang ZS
Mao YY
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RFARFA - CEUS- CEUS
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Small HCC: RFASmall HCC: RFA vs Surgeryvs Surgery
RecurrenceRecurrence% 1-y 2-y 3-y% 1-y 2-y 3-y
Resection 65 10.7 18.4 24.6Resection 65 10.7 18.4 24.6
RFA 47 8.5 19.1 23.4RFA 47 8.5 19.1 23.4
SurvivalSurvival% 1-y 2-y 3-y 4-y 5-y% 1-y 2-y 3-y 4-y 5-y
Resection 90 93.9 89.1 80.0 67.4 48.6Resection 90 93.9 89.1 80.0 67.4 48.6
RFA 71 90.7 83.3 74.9 57.0 47.2 RFA 71 90.7 83.3 74.9 57.0 47.2
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HCC(≤4cm): RFAHCC(≤4cm): RFA vs Surgeryvs Surgery
RecurrenceRecurrence% 1-y 2-y 3-y% 1-y 2-y 3-y
Resection 84 Resection 84 8.3 20.2 32.1 8.3 20.2 32.1
RFA 84 11.9 27.4 41.7RFA 84 11.9 27.4 41.7
SurvivalSurvival% 1-y 2-y 3-y% 1-y 2-y 3-y
Resection 84 96.0 87.6 74.8Resection 84 96.0 87.6 74.8
RFA 84 93.1 83.2 67.6 RFA 84 93.1 83.2 67.6
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HCC
PS 0~2 PS 3~4
Vessel Invasion
Child-Pugh C
No Yes
ECOG
Liver Function
Metastasis
Child-Pugh A/B
No Yes
Tumor Number One 2~3 ≥4
Tumor Size
≤3cm > 3cm
Treatment ·TACE·Resection·+Ablation•Transplant
·Resection·Ablation≤3cm·Transplant
·Resection·TACE+Ablation·Transplant
< 5cm ≥5m
Application of Ablation for HCC
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Combination of TACE and ablation prolongs
survival of cancer patients with multiple
nodules
Wang, et al. Liver International 2010Wang, et al. Liver International 2010
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05
1015
2025303540
455-y10-y
TACE PEI
Outcome of Non-Surgical PLC (1995-2009)
25.3%
37.9%
44.6%
41.0%
32.8%
44.7%
RF RF+TACE TACE+PEI RF+PEI RF+PEI+TACE
37.7%
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Evidence Levels in the Treatment of HCC according to the strength of study design
and of end-points
Treatments assessed Benefit Evidence level
Surgical treatments Surgical resection Increased survival 3iiA Adjuvant therapies Controversial 1A-D Liver transplantation Increased survival 3iiA Neo-adjuvant therapies Treatment response
3Diii
Loco-regional treatments Percutaneous treatments Increased survival 3iiA Radiofrequency ablation Better local control 1iiD Chemoembolization Increased survival 1iiA Lipiodolization Treatment response 3iiDiii
Internal radiation (I131, Y90) Treatment response 3iiDiii
Systemic treatments Sorafenib Increased survival 1iA Tamoxifen No survival benefit 1iA Systemic chemotherapy No survival benefit 1iiA Immunotherapy No survival benefit 1iiA
Llovet & Bruix: J Hepatol, 2008; 48: S20-S37
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5-Year PlanNew Building for Liver Cancer CenterNew Building for Liver Cancer Center