Dansk Dansk PancreasPancreas Cancer Cancer

Gruppe (DPCG)Gruppe (DPCG)

Session IV: Levertumor Gruppen Session IV: Levertumor Gruppen (DLGCG) (DLGCG)

ArterialArterial and Portal and Portal VeinVeinEmbolizationEmbolization

Poul Erik Andersen, MD, Poul Erik Andersen, MD, PhDPhD

DeptDept. . RadiologyRadiology, , InterventionalInterventional SectionSection

Odense Odense UniversityUniversity HospitalHospital

anders1@dadlnet.dkanders1@dadlnet.dk

InterventionalInterventional RadiologicalRadiological treatmenttreatment

options options ((MinimallyMinimally invasiveinvasive procedures)procedures)

neoneo--adjuvantadjuvant therapytherapy

�� TransarterialTransarterial�� HepaticHepatic arterialarterial infusion infusion therapytherapy (HAI)(HAI)

�� EmbolizationEmbolization

�� TranscatheterTranscatheter arterialarterial chemoembolizationchemoembolization(TACE)(TACE)

�� Radioembolization/brachytherapyRadioembolization/brachytherapy, , internalinternal radiation radiation (Y(Y9090glass glass microspheresmicrospheres ((TheraSphereTheraSphere),), 188Re 188Re HSAHSA--microspheresmicrospheres))

�� PercutaneousPercutaneous�� Portal Portal veinvein embolizationembolization

�� RadioFrequencyRadioFrequency ablationablation (RFA), (RFA), cryoablationcryoablation ((cookcook, , boilboil and and

freezefreeze))

HAIHAI

�� Infusion of Infusion of chemotherapychemotherapy directlydirectly intointo the the liver(tumorliver(tumor) ) –– regional regional chemotherapychemotherapy

�� TargetingTargeting the site of the tumor the site of the tumor whilewhileminimizingminimizing systemicsystemic exposureexposure and and resultant side resultant side effectseffects

�� AllowsAllows a a greatergreater concentrationconcentration of the drug of the drug to to reachreach the tumorthe tumor

�� ReduceReduce tumor tumor burdenburden to to allowallow for RFA for RFA ororsurgerysurgery

HAIHAI

�� AdministeredAdministered alonealone oror in in combinationcombination withwithsystemicsystemic chemotherapychemotherapy

�� OxaliplatinOxaliplatin everyevery 22’’nd nd weekweek and and systemicsystemicgemcitabinegemcitabine and and capecitabincapecitabin

�� ImproveImprove survivalsurvival rates and rates and decreasedecreaserecurrencerecurrence of liver of liver diseasedisease at at twotwo yearsyearscomparcompar. . withwith pttptt. . treatedtreated onlyonly withwithstandard standard systemicsystemic chemotherapychemotherapy. . SignificantlySignificantly betterbetter outcomeoutcome

�� Not in Not in extensiveextensive liver liver involvementinvolvement (> 75%) (> 75%) and portal and portal veinvein occlusionocclusion

HAI # 1HAI # 1

�� 46 46 yearyear oldold femalefemale

�� Mamma c. 1996Mamma c. 1996

�� OvarianOvarian c. c. stst T1 2005 T1 2005 –– nono recurrencerecurrence

HAI # 2HAI # 2

�� 57 57 yearyear oldold womanwoman

�� Mamma cancerMamma cancer

EmbolizationEmbolization

�� NonNon--surgicalsurgical, , minimallyminimally invasiveinvasive

procedureprocedure

�� SelectiveSelective occlusionocclusion of of bloodblood vesselsvessels by by

introducingintroducing emboliemboli

�� IschaemiaIschaemia, , necrosisnecrosis

–– ReduceReduce the the sizesize of of tumourtumour

HaemangiomaHaemangioma

�� 43 43 yearyear oldold femalefemale

TranscatheterTranscatheter arterialarterial

chemoembolizationchemoembolization (TACE)(TACE)

�� WellWell toleratedtolerated, , minimallyminimally invasiveinvasive procedure to procedure to deliver deliver chemoterapeuticchemoterapeutic drug and drug and restrictrestrict the the tumourtumour’’ss bloodblood supplysupply –– controlledcontrolled targetedtargetedchemoembolizationchemoembolization –– regional regional chemotherapychemotherapy

�� HigherHigher dosedose to the to the tissuetissue and and reducesreduces systemicsystemicexposureexposure –– likelike in HAIin HAI

�� ChemotherapeuticChemotherapeutic drug not drug not washedwashed out from the out from the tumor bed tumor bed afterafter embolizationembolization

�� SafeSafe and and effectiveeffective in in achievingachieving locallocal tumor tumor controlcontrol in HCC, in HCC, prolongingprolonging survivalsurvival

�� Stable Stable diseasedisease oror downstagingdownstaging, , combinationcombinationwithwith ablation/surgeryablation/surgery

TACETACE

�� TACE TACE superiorsuperior to to systemicsystemic therapytherapy re. re.

median median survivalsurvival, tumor , tumor responseresponse and and

time to time to hepatichepatic progression in liver progression in liver

metastases from metastases from colorectcolorect. and mamma . and mamma

c.c.

�� More More effectiveeffective thanthan bland bland embolizationembolization

oror HAIHAI

�� More More effectiveeffective in the right liver in the right liver lobelobe

thanthan the the leftleft

TACETACE

�� DoxorubicinDoxorubicin oror irinotecanirinotecan--elutingeluting beadsbeadsDcBeads/HepaSphereDcBeads/HepaSphere

�� Cisplatin/lipiodolCisplatin/lipiodol, , EmboCeptEmboCept

�� MitomycinMitomycin (+(+gemcitabinegemcitabine), ), irinotecanirinotecan + + mitomycinmitomycin+ + embolizationembolization ((lipiodollipiodol, , emboceptembocept))

�� AnthracyclinAnthracyclin idarubicinidarubicin--TACETACE

�� EpirubicinEpirubicin--loadedloaded beadsbeads

�� Not in Not in extensiveextensive liver liver involvementinvolvement (> 75%) (> 75%) and portal and portal veinvein occlusionocclusion

TACE # 1TACE # 1

�� 69 69 yearyear oldold malemale

�� NeuroendocrineNeuroendocrine gastricgastric carcinomacarcinoma

TACE # 2TACE # 2

�� 68 68 yearyear oldold malemale

�� HCC HCC JulyJuly 20102010

Future developments ?

Delcath is dedicated to...

Concentrating the Power of Chemotherapyby chemosaturation of the liver. The idea is to manage

liver metastases through isolation of the organ,

saturation with ultra-high doses of chemotherapeutic

agent, and filtration of the blood to minimize systemic

toxicity before returning it to the patient.

Because chemosaturation is intended to be a minimally

invasive, repeatable way to deliver high-dose chemo-

therapy to the liver, it may have the potential to comple-

ment existing systemic treatments for a patient’s primary

disease.

PreoperativePreoperative portal portal veinvein

embolizationembolization (PVE)(PVE)

�� IncreaseIncrease in future in future remnantremnant liver liver functionfunction to to allowallow safesafe resectionresection

�� Future Future remnantremnant liver liver functionfunction increasesincreasessignificantlysignificantly more more thanthan future future remnantremnant liver liver volumevolume

�� NecessaryNecessary waitingwaiting time time untiluntil resectionresection maymaybebe shortershorter thanthan indicatedindicated by by volumetricvolumetricparametersparameters

�� BrBr J J SurgSurg 2011;98:8252011;98:825--834834

PVEPVE

�� ImprovesImproves resectabilityresectability and and maymay improveimprove

diseasedisease--freefree survivalsurvival for patients for patients withwith HCC HCC

requiringrequiring right right hepatectomyhepatectomy

�� J J SurgSurg OncolOncol 2011;104:6412011;104:641--646646

PVE # 1PVE # 1

�� 52 52 yearyear oldold malemale

�� PrimaryPrimary rectumrectum cancer T3 N1 V0/M0cancer T3 N1 V0/M0

MinimallyMinimally invasiveinvasive interventionalinterventional

radiologicalradiological treatmentstreatments

�� MakesMakes sensesense to give the drug to give the drug targetedtargeted to to

increaseincrease the the tumourtumour dosis and dosis and avoidavoid

general side general side effectseffects –– betterbetter QOLQOL

�� The The effecteffect onon tumourtumour sizesize and median and median

survivalsurvival is is evidenceevidence basedbased

�� SelectedSelected patients patients –– enterenter protocolsprotocols

�� FurtherFurther studies/investigationsstudies/investigations necessarynecessary