1. Interventional Oncology Michael Kotton MD October 27, 2012

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

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

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

5. Liver Blood Supply

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

7. How Do We Decide Extent of Tumor 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 Health of Patient Condition of the Liver Condition of the Liver

8. Treatment Options Transplantation Milan Criteria (5/3 Rule) Milan Criteria (5/3 Rule) 70% survival at 5 Years 70% survival at 5 Years IR treatments as bridge to transplant IR treatments as bridge to transplantSurgery No Cirrhosis No Cirrhosis No Portal HTN No Portal HTN 30-60% 5 year survival 30-60% 5 year survival Interventional Radiology Chemotherapy Advanced cancer Advanced cancer Nexevar Nexevar

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

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

11. RFA Probe Needle Placement Stomach

12. Post Ablation

13. Post Treatment PrePost

14. Post Open RFA Liver

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

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

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

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

19. Chemoembolization

20. Chemoembolization

21. Case 2 69 year old male 69 year old male Hep B Hep B 9 cm tumor 9 cm tumor Normal Bilirubin Normal Bilirubin Mild PVH 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 Bleeding Liver Failure Liver Failure Infection Infection –Biliary-Enteric Anastomosis Post Embolization Syndrome Post Embolization Syndrome Fever, nausea, pain Fever, nausea, pain Ends after 7 days, infection usually presents later Ends after 7 days, infection usually presents later Inadvertent Embolization Inadvertent Embolization Gallbladder, bowl Gallbladder, bowl

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

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

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

35. 2 RESPONSE

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

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

38. Questions???