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Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
Mcwilliams sir 2012
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Mcwilliams sir 2012

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  • Capecitabine = XelodaIFL = Bolus 5-FU + leucovorin + irinotecanFOLFIRI = Infusion 5-FU + leucovorin + irinotecanFOLFOX = Infusion 5-FU + leucovorin + oxaliplatinFOLFOXIRI = Infusion 5-FU + leucovorin + oxaliplatin + irinotecanXELOX = Capecitabine + oxaliplatinCetuximab = EGFR inhibitor, infusional
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    • 1. PATIENT CARE I: PRE- AND POST-PROCEDURE EVALUATIONPrimary and metastatic liver cancer Justin McWilliams, MD UCLA Interventional Radiology
    • 2. Initial office visit for liver cancerPre-procedure decision-making Post-procedure follow-up
    • 3. INTERVENTIONAL ONCOLOGY CLINICINITIAL OFFICE VISIT – GENERAL PRINCIPLES• Have a dedicated clinic day if possible• Set aside a full hour for new patients• Assume they have been told nothing (usually true)• Discuss all relevant treatment options, including non-IR treatments• Discuss prognosis with and without treatment (no one else has)• Explore patient’s goals and expectations• Level V consultation
    • 4. Initial office visit for liver cancerPre-procedure decision-making Post-procedure follow-up
    • 5. HEPATOCELLULAR CARCINOMA
    • 6. HEPATOCELLULAR CARCINOMA• What would you like to know? • Age • Performance status • Labs • Child class • Comorbidities
    • 7. HEPATOCELLULAR CARCINOMA• Age 63• Performance status normal• Normal labs except Plt 100• Child A• No major comorbidity• Imaging: • Cirrhosis, splenomegaly, no ascites • 4.7 cm HCC in right lobe (segment 6) • 1.5 cm HCC in left lobe (segment 3) • No vascular invasion, no extrahepatic disease• The patient is referred to IR for consideration of locoregional therapy.
    • 8. or Y90
    • 9. HEPATOCELLULAR CARCINOMAPRE-PROCEDURE DECISION-MAKING What would you like to do?• Age 63• Performance status normal DOWNSTAGE RESECTION OLT THEN OLT (+/- RFA)• Normal labs except Plt 100• Child A PVE THEN• No major comorbidity RESECTION RFA TACE (+/- RFA)• Wants treatment TACE TACE + Y-90 AND RFA NEXAVAR• 4.7 cm HCC in right lobe (seg 6)• 1.5 cm HCC in left lobe (seg 3) NEXAVAR SBRT NOTHING
    • 10. HEPATOCELLULAR CARCINOMA PRE-PROCEDURE DECISION-MAKING • You chose OLT. • This is the preferred treatment for cirrhotic patients with low volume disease • 75% 4-year survival if within Milan • But, the patient is beyond Milan criteria! • He has two HCCs and therefore both must be under 3 cm to qualify for exception points. • Modest expansion of the Milan criteria (UCSF) may increase eligibility without worsening outcomes, but this is not yet widely accepted LESSONS LEARNED • The patient has a MELD of 10 and dies on the list from Milan criteria: tumor progression • One HCC up to 5 cm • 2 or 3 HCC, each up to 3 cm • No vascular invasion • THE END START • No extrahepatic disease OVERMazzaferro V, Regalia E, Doci R, et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med 1996; 334: 693–99.Duffy JP, Vardanian A, Benjamin E, Watson M, Farmer DG, Ghobrial RM, Lipshutz G, Yersiz H, Lu DS, Lassman C, Tong MJ, Hiatt JR, Busuttil RW. Liver transplantation criteria forhepatocellular carcinoma should be expanded: a 22-year experience with 467 patients at UCLA. Ann Surg. 2007 Sep;246(3):502-9; discussion 509-11.
    • 11. HEPATOCELLULAR CARCINOMA PRE-PROCEDURE DECISION-MAKING • You chose DOWNSTAGE THEN OLT. • This is a reasonable option for patients initially beyond Milan criteria • Rate of successful downstage = 24-69% • 5-year survival if downstaged to OLT = 55-94% • The patient undergoes TACE of the dominant lesion and 6 weeks later, RFA of the smaller lesion LESSONS LEARNED UCSF downstage criteria: • He is successfully downstaged, receives MELD • 1 lesion 5-8 cm • 2 or 3 lesions, at least 1 being >3 exception points, and receives OLT 1 year later and <5 cm, total tumor diam <8 cm • 4 or 5 lesions, all <3 cm, total tumor diam <8 cm • THE END • 3 month waiting period after downstaging START • No vascular invasion, no extrahepatic disease OVERGordon-Weeks AN, Snaith A, Petrinic T, Friend PJ, Burls A, Silva MA. Systematic review of outcome of downstaging hepatocellular cancer before liver transplantation in patientsoutside the Milan criteria. Br J Surg. 2011 Sep;98(9):1201-8.
    • 12. HEPATOCELLULAR CARCINOMA PRE-PROCEDURE DECISION-MAKING • You chose RESECTION. • This is the preferred treatment in non-cirrhotics and carefully selected Child A cirrhotics • Normal bilirubin • No portal HTN (no splenomegaly, platelets >100) • 5-year survival up to 70% can be achieved in early, solitary HCC • Improved surgical techniques have reduced mortality for major liver resection to <5% LESSONS LEARNED Consider resection for selected • The patient undergoes R lobectomy and intra-op RFA of Child A cirrhotics with: the L lobe lesion. His liver remnant is 30% of liver volume. • Solitary HCC (5-year OS 50-70%) He goes into post-operative fulminant liver failure and dies. • Large HCC (5-year OS ~30%) • 2 or 3 HCC in same lobe (5-year OS 30-40%) • THE END • HCC with PV/HV invasion (5-year START OS 20-40%) OVERLlovet JM, Fuster J, Bruix J. Intention-to-treat analysis of surgical treatment for early hepatocellular carcinoma: resection versus transplantation.Hepatology 1999; 30: 1434–40.Kishi Y, Hasegawa K, Sugawara Y, Kokudo N. Hepatocellular carcinoma: current management and future development – improved outcomes withsurgical resection. Int J Hepatology 2011; Epub 2011 Jun 23.
    • 13. HEPATOCELLULAR CARCINOMAPRE-PROCEDURE DECISION-MAKING• You chose PVE THEN RESECTION. • Pre-operative PVE improves perioperative outcome for major hepatic resection • PVE can achieve about 50% hypertrophy of the future liver remnant (i.e. from 500 cc to 750 cc)• The patient undergoes right PVE with increase in FLR from 30% of liver volume to 45% of liver volume. He undergoes successful R lobectomy with intra-op RFA of the left lobe lesion, and is tumor-free 3 years later. LESSONS LEARNED Consider PVE if FLR is:• THE END • <40% in cirrhotic patients • <30% in post-chemo patients START • <20% in non-cirrhotics OVERPalavecino M, Chun YS, Madoff DC, Zorzi D, Kishi Y, Kaseb AO, Curley SA, Abdalla EK, Vauthey JN. Major hepatic resection for hepatocellular carcinoma with or withoutportal vein embolization: Perioperative outcome and survival. Surgery. 2009 Apr;145(4):399-405.
    • 14. HEPATOCELLULAR CARCINOMAPRE-PROCEDURE DECISION-MAKING• You chose RFA. • RFA is a potentially curative modality with excellent tumor control rates in small tumors • For tumors >3 cm, complete ablation rate with single treatment decreases • Tumor <3 cm = 91% • Tumor 3-5 cm = 74% • Tumor >5 cm = 36% LESSONS LEARNED• The patient undergoes RFA of both lesions. The left • RFA is treatment of choice in lobe lesion is completely ablated, but the right lobe non-operative candidates lesion recurs, and the patient dies 3 years later of with very early or early HCC tumor progression. • Tumor size up to 3 cm • No vascular invasion START • No extrahepatic spread• THE END • Child class A or B OVERPeng ZW, Zhang YJ, Chen MS, et al. Risk factors of survival after percutaneous radiofrequency ablation of hepatocellular carcinoma. Surg Oncol. 2008 Jul;17(1):23-31.Crocetti L, de Baere T, Lencioni R. Quality improvement guidelines for radiofrequency ablation of liver tumours. Cardiovasc Intervent Radiol (2010) 33:11-17.Guglielmi A, Ruzzenente A, Battocchia A, Tonon A, Fracastoro G, Cordiano C. Radiofrequency ablation of hepatocellular carcinoma in cirrhotic patients.Hepatogastroenterology. 2003 Mar-Apr;50(50):480-4.
    • 15. HEPATOCELLULAR CARCINOMA PRE-PROCEDURE DECISION-MAKING • You chose TACE. • TACE reduces mortality in HCC compared to symptomatic treatment (OR 0.54) • But, it is non-curative • 3-year survival ~25-30% • DEB-TACE reduces liver toxicity and side effects compared to cTACE • The patient undergoes repeated TACE LESSONS LEARNED procedures with initial response but eventual tumor progression. He dies 2 years later. • TACE is first-line non-curative therapy for non-surgical patients with large or multifocal HCC who • THE END do not have vascular invasion or extrahepatic spread START OVERCamma C, et al. Transarterial chemoembolization for unresectable hepatocellular carcinoma: meta-analysis of randomized controlled trials. Radiology 2002.Lammer J, et al. Prospective randomized study of doxorubicin-eluting-bead embolization in the treatment of hepatocellular carcinoma: results of the PRECISION V study. CardiovascIntervent Radiol (2010) 33:41-52.
    • 16. HEPATOCELLULAR CARCINOMA PRE-PROCEDURE DECISION-MAKING • You chose TACE AND RFA. • Combination TACE/RFA has been shown to reduce local recurrence compared to RFA alone • 6% vs. 39% local progression rate for tumors 3.1-5.0 cm • The patient undergoes TACE of the dominant lesion, followed by RFA of both lesions, with complete response. He remains tumor-free at follow-up. • THE END START OVERMorimoto M, Numata K, Knodou M, Nozaki A, Morita S, Tanak K. Midterm outcomes in patients with intermediate sized hepatocellular carcinoma: a randomized controlled trial fordetermining the efficacy of radiofrequency ablation combined with transcatheter arterial chemoembolization. Cancer 2010;116(23):5452-5460.
    • 17. HEPATOCELLULAR CARCINOMA PRE-PROCEDURE DECISION-MAKING • You chose YTTRIUM-90 EMBOLIZATION. • No RCTs • Response rate and survival appear similar to TACE in cohort studies • Less side effects and hepatic toxicity • The patient undergoes mesenteric mapping LESSONS LEARNED followed by sequential lobar Y-90 treatment. He has initial tumor response but dies 2 • Low embolic effect and mild side effects may make Y-90 years later of tumor progression. a good option for elderly patients, patients with reduced performance • THE END status, and patients with START portal vein invasion OVERSangro B, Carpanese L, Cianni R, et al; European Network on Radioembolization with Yttrium-90 Resin Microspheres (ENRY). Survival after yttrium-90 resin microsphereradioembolization of hepatocellular carcinoma across Barcelona clinic liver cancer stages: a European evaluation. Hepatology. 2011 Sep 2;54(3):868-78.
    • 18. HEPATOCELLULAR CARCINOMA PRE-PROCEDURE DECISION-MAKING • You chose TACE + NEXAVAR. • These treatments have each shown survival improvement for patients with intermediate or advanced HCC. • The combination remains unproven • One RCT showed longer time to progression with addition of Nexavar to TACE; another RCT showed no benefit LESSONS LEARNED • The patient undergoes TACE followed by • TACE + Nexavar is Nexavar. He tolerates the treatment but promising but unproven for eventually recurs, and dies 3 years later. intermediate and advanced HCC • Results of several RCTs are START • THE END expected in next 2 years OVERSansonno D, Lauletta G, Russi S, Conteduca V, Sansonno L, Dammacco F. Transarterial chemoembolization plus sorafenib: a sequential therapeutic scheme for HCV-relatedintermediate-stage hepatocellular carcinoma: a randomized clinical trial. Oncologist. 2012 Feb 14.Kudo M, Imanaka K, Chida N, et al. Phase III study of sorafenib after transarterial chemoembolisation in Japanese and Korean patients with unresectable hepatocellular carcinoma.Eur J Cancer. 2011 Sep;47(14):2117-27.
    • 19. HEPATOCELLULAR CARCINOMA PRE-PROCEDURE DECISION-MAKING • You chose NEXAVAR. • Oral multikinase inhibitor • Extends survival from 7.9 to 10.7 months in advanced HCC • Diarrhea, weight loss, hand-foot syndrome are common side effects LESSONS LEARNED • The patient does not have advanced HCC. SHARP inclusion criteria: He progresses on Nexavar and dies 18 • Not candidate for locoregional therapy months later. • ECOG 0-2 • Child A START • Vascular invasion and • THE END OVER extrahepatic spread OKLlovet JM, Ricci S, Mazzaferro V, et al. SHARP Investigators Study Group. Sorafenib in advanced hepatocellular carcinoma. N Engl J Med. 2008 Jul 24;359(4):378-90.
    • 20. HEPATOCELLULAR CARCINOMA PRE-PROCEDURE DECISION-MAKING • You chose SBRT. • Stereotactic body radiotherapy is noninvasive and shows efficacy against small-medium HCC • 73% response rate (usually partial) • 60% 2-year survival • Not yet enough data to recommend as part of the HCC treatment paradigm LESSONS LEARNED • The patient undergoes SBRT with partial • SBRT is a promising response of the tumors. They eventually recur noninvasive treatment for and he dies 3 years later. small HCC that is ineligible for locoregional treatment • THE END START OVERPrice TR, Perkins SM, Sandrasegaran K, Henderson MA, Maluccio MA, Zook JE, Tector AJ, Vianna RM, Johnstone PA, Cardenes HR. Evaluation of response after stereotactic bodyradiotherapy for hepatocellular carcinoma. Cancer. 2011 Oct 24.
    • 21. HEPATOCELLULAR CARCINOMA PRE-PROCEDURE DECISION-MAKING • You chose NOTHING. • Patients always have the right to refuse treatment • Survival is dismal (3-17% at 3 years) • The patient receives only supportive care, and dies 1 year later. • THE END START OVERCamma C, et al. Transarterial chemoembolization for unresectable hepatocellular carcinoma: meta-analysis of randomized controlled trials. Radiology 2002.
    • 22. HEPATOCELLULAR CARCINOMAPRE-PROCEDURE DECISION-MAKING What would you like to do?• Age 63• Performance status normal DOWNSTAGE RESECTION OLT THEN OLT (+/- RFA)• Normal labs except Plt 100• Child A PVE THEN• No major comorbidity RESECTION RFA TACE (+/- RFA)• Wants treatment TACE TACE + Y-90 AND RFA NEXAVAR• 4.7 cm HCC in right lobe (seg 6)• 1.5 cm HCC in left lobe (seg 3) NEXAVAR SBRT NOTHING
    • 23. HEPATOCELLULAR CARCINOMAPRE-PROCEDURE DECISION-MAKING What would you like to do?• Age 63• Performance status normal DOWNSTAGE RESECTION OLT THEN OLT (+/- RFA)• Normal labs except Plt 100• Child A PVE THEN• No major comorbidity RESECTION RFA TACE (+/- RFA)• Wants treatment TACE TACE + Y-90 AND RFA NEXAVAR• 4.7 cm HCC in right lobe (seg 6)• 1.5 cm HCC in left lobe (seg 3) NEXAVAR SBRT NOTHING
    • 24. HEPATOCELLULAR CARCINOMAPRE-PROCEDURE DECISION-MAKING What would you like to do?• Age 83• Not able to work, but up and about DOWNSTAGE RESECTION OLT THEN OLT (+/- RFA) >50% of waking hours (ECOG 2)• Normal labs except Plt 100 PVE THEN• Child A RESECTION RFA TACE (+/- RFA)• No major comorbidity• Wants treatment TACE TACE + Y-90 AND RFA NEXAVAR• 4.7 cm HCC in right lobe (seg 6)• 1.5 cm HCC in left lobe (seg 3) NEXAVAR SBRT NOTHING
    • 25. HEPATOCELLULAR CARCINOMAPRE-PROCEDURE DECISION-MAKING What would you like to do?• Age 83• Not able to work, but up and about DOWNSTAGE RESECTION OLT THEN OLT (+/- RFA) >50% of waking hours (ECOG 2)• Normal labs except Plt 100 PVE THEN• Child A RESECTION RFA TACE (+/- RFA)• No major comorbidity• Wants treatment TACE TACE + Y-90 AND RFA NEXAVAR• 4.7 cm HCC in right lobe (seg 6)• 1.5 cm HCC in left lobe (seg 3) NEXAVAR SBRT NOTHING
    • 26. HEPATOCELLULAR CARCINOMAPRE-PROCEDURE DECISION-MAKING What would you like to do?• Age 63• ECOG 0 DOWNSTAGE RESECTION OLT THEN OLT (+/- RFA)• Plt 50, T bili 2.5• Child B PVE THEN• No major comorbidity RESECTION RFA TACE (+/- RFA)• Wants treatment TACE TACE + Y-90 AND RFA NEXAVAR• 4.7 cm HCC in right lobe (seg 6)• 1.5 cm HCC in left lobe (seg 3) NEXAVAR SBRT NOTHING
    • 27. HEPATOCELLULAR CARCINOMAPRE-PROCEDURE DECISION-MAKING What would you like to do?• Age 63• ECOG 0 DOWNSTAGE RESECTION OLT THEN OLT (+/- RFA)• Plt 50, T bili 2.5• Child B PVE THEN• No major comorbidity RESECTION RFA TACE (+/- RFA)• Wants treatment TACE TACE + Y-90 AND RFA NEXAVAR• 4.7 cm HCC in right lobe (seg 6)• 1.5 cm HCC in left lobe (seg 3) NEXAVAR SBRT NOTHING
    • 28. METASTATICCOLON CANCER
    • 29. METASTATIC COLON CANCER• What would you like to know? • Age • Performance status • Labs • Comorbidities • Chemo regimens
    • 30. METASTATIC COLON CANCER• Age 55• Performance status normal• Normal labs except CEA 200• No major comorbidity• Status post L colectomy and FOLFOX + Avastin, then 2nd line Irinotecan with partial response• 3 tumors now growing 6 months after last chemo• Imaging: • Three lesions in the right lobe (2 cm, 2 cm, 1 cm); PET positive • No extrahepatic disease• The patient is referred to IR for consideration of locoregional therapy.
    • 31. METASTATIC COLON CANCERPRE-PROCEDURE DECISION-MAKING What would you like to do?• Age 55• Performance status normal SYSTEMIC RESECTION CHEMO• Normal labs except CEA 200• No major comorbidity RFA DEB-TACE• Status post L colectomy, FOLFOX + Avastin, Irinotecan Y-90 HAI• 1 cm lesion segment 5• 2 x 2 cm lesions segment 8 SBRT NOTHING
    • 32. METASTATIC COLON CANCER PRE-PROCEDURE DECISION-MAKING • You chose RESECTION. • Surgery is the standard treatment approach for resectable mCRC • 5-year survival 30-50% following hepatic resection with curative intent • Wedge vs anatomic resection is equivalent as long as tumor-free margin achieved • Need 30% residual liver post-chemo LESSONS LEARNED • The patient undergoes curative R lobectomy Risk factors for poor outcome with 30% FLR, and slowly recovers. He remains with resection of mCRC: disease-free for 4 years. • >3 tumors • Tumor size >5 cm • CEA > 200 ng/mL • THE END START OVERAlberts S. Update on the optimal management of patients with colorectal liver metastases. Crit Rev Oncol/Hematol (2012), doi:10.1016/j.critrevonc.2012.02.007.
    • 33. METASTATIC COLON CANCER PRE-PROCEDURE DECISION-MAKING 25 • You chose SYSTEMIC 20 Median OS (months) CHEMOTHERAPY. 15 • Chemotherapy prolongs survival for patients with mCRC 10 5 • Median survival 18-21 months 0 • Once 1st and 2nd line chemo has failed, 3rd line chemo yields response rates <20% and survival ~9 months • The patient is placed on cetuximab and LESSONS LEARNED irinotecan. He progresses after 6 months Once first and second line and dies several months later. chemotherapy has failed, third line chemotherapy rarely yields START objective response. • THE END OVERChong G, Dickson JL, Cunningham D, et al. Capecitabine and mitomycin C as third-line therapy for patients with metastatic colorectal cancer resistant to fluorouracil and irinotecan. BrJ Cancer. 2005 Sep 5;93(5):510-4.Vincenzi B, Santini D, Rabitti C, et al. Cetuximab and irinotecan as third-line therapy in advanced colorectal cancer patients: a single centre phase II trial. Br J Cancer. 2006 Mar27;94(6):792-7.
    • 34. METASTATIC COLON CANCER PRE-PROCEDURE DECISION-MAKING • You chose RFA. • This is a safe, well tolerated procedure with survival benefit in nonresectable mCRC • 5-year survival 25-40% • Meta-analysis shows that RFA is inferior to resection for resectable mCRC, mostly due to higher local recurrence rate LESSONS LEARNED • The patient undergoes RFA of all 3 lesions. He is Size is most important predictor disease free for 3 years but then develops recurrence of survival for RFA of mCRC and dies 1 year later. • Median survival 41 months if largest met < 3 cm • Median survival 22 months • THE END START if largest met > 3 cm OVERVan Tilborg AA, Meijerink MR, Sietses C, et al. Long-term results of radiofrequency ablation for unresectable colorectal liver metastases: a potentially curative intervention. Br J Radiol.2011 Jun;84(1002):556-65.Veltri A, Guarnieri T, Gazzera C, et al. Long-term outcome of radiofrequency thermal ablation (RFA) of liver metastases from colorectal cancer (CRC): size as the leading prognosticfactor for survival. Radiol Med. 2012 Mar 19.
    • 35. METASTATIC COLON CANCER PRE-PROCEDURE DECISION-MAKING • You chose DEB-TACE. • Irinotecan mounted on drug-eluting beads • Only retrospective data available • After failure of systemic chemo • Response rate 75% at 12 months (including 15% complete response) • Overall median survival 19 months LESSONS LEARNED • The patient undergoes 2 sessions of irinotecan DEB- DEB-TACE is a promising TACE with partial response; he dies 18 months later therapy for chemoresistant patients who are not surgical or ablation candidates, but no • THE END RCT are yet available. START OVERMartin RC, Joshi J, Robbins K, et al. Hepatic intra-arterial injection of drug-eluting bead, irinotecan (DEBIRI) in unresectable colorectal liver metastases refractory to systemicchemotherapy: results of multi-institutional study. Ann Surg Oncol. 2011 Jan;18(1):192-8.
    • 36. METASTATIC COLON CANCER PRE-PROCEDURE DECISION-MAKING • You chose Y-90. • No RCT • Retrospective data shows favorable response in chemo-refractory patients • Overall survival 12-17 months • Low toxicity • Prospective data supporting Y-90 use in 1 st or 2nd line setting is accumulating LESSONS LEARNED Selection criteria for Y-90 in mCRC • Unresectable • The patient has mesenteric mapping followed by right • ECOG 0-2 lobe infusion of resin microspheres. He has a partial response and dies 18 months later. • Life expectancy >12 weeks • Albumin >3, bili <2, no ascites • No GI shunt, <30 Gy lung • THE END exposure START OVERColdwell D, Sangro B, Wasan H, Salem R, Kennedy A. General selection criteria of patients for radioembolization of liver tumors: an international working group report. Am J ClinOncol. 2011 Jun;34(3):337-41.Cosimelli M, Golfieri R, Cagol PP, et al; Italian Society of Locoregional Therapies in Oncology (SITILO). Multi-centre phase II clinical trial of yttrium-90 resin microspheres alone inunresectable, chemotherapy refractory colorectal liver metastases. Br J Cancer. 2010 Jul 27;103(3):324-31.
    • 37. METASTATIC COLON CANCER PRE-PROCEDURE DECISION-MAKING • You chose HEPATIC ARTERY INFUSION. • Direct infusion of FUDR (similar to 5-FU) • Meta-analysis showed better response rate but no survival benefit compared to systemic chemo • Problems: hepatic toxicity (biliary sclerosis), catheter displacement, catheter occlusion LESSONS LEARNED The role of HAI, if any, is unclear. Existing data used • The patient undergoes pump insertion and HAI outdated chemotherapeutics therapy with FUDR; he dies 1 year later. and had high incidence of toxicity and catheter problems. START Further study is needed. • THE END OVERBouchahda M, Lévi F, Adam R, Rougier P. Modern insights into hepatic arterial infusion for liver metastases from colorectal cancer. Eur J Cancer. 2011 Dec;47(18):2681-90.
    • 38. METASTATIC COLON CANCER PRE-PROCEDURE DECISION-MAKING • You chose SBRT. • Limited data suggest efficacy against oligometastatic disease • 2-year local control 74% • 2-year overall survival 83% • Noninvasive LESSONS LEARNED • The patient undergoes SBRT of all 3 lesions The role of SBRT in mCRC is without event. He dies of tumor progression unclear. It may have a role for 3 years later. patients with oligometastatic disease who are not surgical or RFA candidates. • THE END START OVERvan der Pool AE, Méndez Romero A, Wunderink W, Heijmen BJ, Levendag PC, Verhoef C, Ijzermans JN. Stereotactic body radiation therapy for colorectal liver metastases. Br J Surg.2010 Mar;97(3):377-82.
    • 39. METASTATIC COLON CANCER PRE-PROCEDURE DECISION-MAKING • You chose NOTHING. • Survival with supportive care alone after failure of first and second-line chemotherapy is dismal (3-4 months) • The patient receives supportive care, and dies 4 months later of progressive disease. • THE END START OVERSeidensticker R, Denecke T, Kraus P, et al. Matched-Pair Comparison of Radioembolization Plus Best Supportive Care Versus Best Supportive Care Alone for ChemotherapyRefractory Liver-Dominant Colorectal Metastases. Cardiovasc Intervent Radiol. 2011 Jul 29.
    • 40. METASTATIC COLON CANCERPRE-PROCEDURE DECISION-MAKING What would you like to do?• Age 55• Performance status normal SYSTEMIC RESECTION CHEMO• Normal labs except CEA 200• No major comorbidity RFA DEB-TACE• Status post L colectomy, FOLFOX + Avastin, Irinotecan Y-90 HAI• 1 cm lesion segment 5• 2 x 2 cm lesions segment 8 SBRT NOTHING
    • 41. METASTATIC COLON CANCERPRE-PROCEDURE DECISION-MAKING What would you like to do?• Age 55• Performance status normal SYSTEMIC RESECTION CHEMO• Normal labs except CEA 200• No major comorbidity RFA DEB-TACE• Status post L colectomy, FOLFOX + Avastin, Irinotecan Y-90 HAI• 1 cm lesion segment 5• 2 x 2 cm lesions segment 8 SBRT NOTHING
    • 42. METASTATIC COLON CANCERPRE-PROCEDURE DECISION-MAKING What would you like to do?• Age 55• Performance status normal SYSTEMIC RESECTION CHEMO• Normal labs except T Bili 2.1• No major comorbidity RFA DEB-TACE• Status post L colectomy, FOLFOX + Avastin, Irinotecan Y-90 HAI• 1 cm lesion segment 5• 2 x 2 cm lesions segment 8 SBRT NOTHING
    • 43. METASTATIC COLON CANCERPRE-PROCEDURE DECISION-MAKING What would you like to do?• Age 55• Performance status normal SYSTEMIC RESECTION CHEMO• Normal labs except T Bili 2.1• No major comorbidity RFA DEB-TACE• Status post L colectomy, FOLFOX + Avastin, Irinotecan Y-90 HAI• 1 cm lesion segment 5• 2 x 2 cm lesions segment 8 SBRT NOTHING
    • 44. Initial office visit for liver cancerPre-procedure decision-making Post-procedure follow-up
    • 45. LIVER CANCERPOST-PROCEDURE FOLLOW-UP – IN-HOSPITAL• Post-RFA • Post-TACE (overnight • Contrast CT on the table admission) • Recovery area for 2-3 hours • PCA • MRI liver once awake enough • Zofran prn • Discharge home with Vicodin • IVF and Cipro • Dexamethasone (if non- diabetic)• Post-Y90 • [Cipro] • Recovery area for 2-6 hours • AM labs: CBC, BMP, LFTs • PPI + carafate • D/c Foley in AM • [Medrol Dose-Pak] • Switch to PO Vicodin, ambulate and d/c home
    • 46. LIVER CANCERIN-HOSPITAL PROBLEMS• Pain • Just keep on PCA until controlled • For chest pain after anesthesia have high index of suspicion for MI• Hypotension • Evaluate groin (if arterial access) • IVF • Orthostatic? Oversedated? • Consider stat CT • Consider H&H, type and cross• Transaminitis • No action if not too high, and patient doing well • If AST/ALT > 300 or TB increases by >1 point, consider keeping until LFTs begin to recover
    • 47. LIVER CANCERPOST-DISCHARGE PROBLEMS• Pain • Occasionally lasts weeks after RFA or TACE • Motrin (anti-inflammatory), Vicodin • Dual-phase CT if severe • Endoscopy for pain >1 week after Y90• Fever • Usually just PES • Tylenol for fever <101.5 • High fevers, especially >1 week after intervention, may require CT to evaluate for biloma or abscess (requires percutaneous drainage)
    • 48. LIVER CANCERPOST-PROCEDURE FOLLOW-UP – CLINIC• Post-RFA, TACE or Y90 • 1 month follow-up with Eovist MRI • Clinic visit on same day as MRI • CBC, BMP, LFTs, INR, AFP/ CEA • Discuss results, treatment plan • If no residual disease, MRI and clinic visit q3 months
    • 49. THE ENDJUMCWILLIAMS@MEDNET.UCLA.EDU
    • 50. INTERVENTIONAL ONCOLOGY CLINICINITIAL OFFICE VISIT – HISTORY1. HPI: • Liver disease • Severity of cirrhosis (Child class) • Ascites, encephalopathy, varices • Liver tumor • Tumor symptoms • Prior treatments • Activity level
    • 51. INTERVENTIONAL ONCOLOGY CLINICINITIAL OFFICE VISIT – HISTORY1. HPI:2. PMH: • Diabetes? • CAD/CHF? • Renal disease? • Other malignancy?
    • 52. INTERVENTIONAL ONCOLOGY CLINICINITIAL OFFICE VISIT – HISTORY1. HPI:2. PMH:3. PSH: • Prior liver surgery? • Hepatoenteric anastomosis? • Orthopedic hardware?
    • 53. INTERVENTIONAL ONCOLOGY CLINICINITIAL OFFICE VISIT – HISTORY1. HPI:2. PMH:3. PSH:4. Meds: • Nexavar? • Diuretics? • Lactulose?
    • 54. INTERVENTIONAL ONCOLOGY CLINICINITIAL OFFICE VISIT – HISTORY1. HPI:2. PMH:3. PSH:4. Meds:5. Allergies: • Iodinated contrast? • Gadolinium? • Antibiotics?
    • 55. INTERVENTIONAL ONCOLOGY CLINICINITIAL OFFICE VISIT – HISTORY1. HPI:2. PMH:3. PSH:4. Meds:5. Allergies:6. FH: • Usually noncontributory • Vertical transmission of Hep B? • Hemochromatosis? • Autoimmune disease?
    • 56. INTERVENTIONAL ONCOLOGY CLINICINITIAL OFFICE VISIT – HISTORY1. HPI:2. PMH:3. PSH:4. Meds:5. Allergies:6. FH:7. SH: • Alcohol/drug use? • Quantity and duration • Support system?
    • 57. INTERVENTIONAL ONCOLOGY CLINICINITIAL OFFICE VISIT – REVIEW OF SYSTEMS• How have you been feeling, in general?• Fatigue or weight loss• Chest pain• Dyspnea• Hematemesis, hematochezia• Diarrhea or constipation• Nausea or vomiting• Urinary retention• Anxiety or depression• Rash/pruritis
    • 58. INTERVENTIONAL ONCOLOGY CLINICINITIAL OFFICE VISIT – PHYSICAL EXAM1. Vitals2. General appearance – well or sick?3. Icterus, fetor hepaticus4. Heart rate/rhythm5. Breath sounds6. Abdominal exam for tenderness, palpable mass, ascites, caput medusa7. Peripheral pulses, edema, clubbing8. Clarity of thought, asterixis9. Spider angiomas, palmar erythema

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