This document discusses local therapies for liver metastases resulting from uveal melanoma, emphasizing the importance of liver-directed therapy. It outlines various treatment modalities such as percutaneous ablation and catheter-directed therapy, highlighting their roles and success rates. The document concludes that while more research is needed, liver-directed therapies may enhance survival for selected patients.

1. Local Therapies for UvealLocal Therapies for Uveal
Melanoma Liver MetastasesMelanoma Liver Metastases
Interventional Radiology and
Image-guided Medicine
Emory University Hospital, Emory University Hospital Midtown,
Emory St. Joseph’s Hospital, Children’s at Egleston, Grady
Memorial Hospital
WINSHIP CANCER INSTITUTE
Darren Kies, MD
Assistant Professor of Radiology
Division of Interventional Radiology &
Image-Guided Medicine
Director of Interventional Radiology
Services at Emory University Hospital

2. No Disclosures

3. Objectives
• Understand the concept of liver directed therapy
• Understand the difference between percutaneous
ablation and catheter directed liver therapy
• Discuss the role of percutaneous ablation in uveal
melanoma
• Discuss the role of catheter-directed liver therapy in
uveal melanoma

4. What is Liver Directed
Therapy?
• Oncologic treatment targeted
solely at liver metastases
– Minimally invasive
– Tolerable side effects
– Fast recovery
– Relatively low risk

5. Why is Liver Directed Therapy
Helpful?
• Liver is a vital organ
• Liver metastases will ultimately
lead to liver failure
• Systemic therapies are limited in
uveal melanoma
• Controlling liver metastases can
improve survival in certain
cancers, particularly uveal
melanoma

6. Who Should Get Liver
Directed Therapy?
• Patients with liver dominant metastatic disease
– Primary tumor is known to respond to liver directed
therapy
– Primary is removed or is under control
– Low burden or no metastatic disease outside the liver
– Liver involvement < 70% with metastatic disease

7. CurativeCurative PalliativePalliative

8. Percutaneous Ablation
• Minimally invasive method of killing focal tumors in the
liver with either heat or cold
– Size matters
– Location matters
– Extent of disease matters – limited role in uveal
melanoma
• Heat vs. Cold
– Operator experience is key
• Success Rate
– Local control: 85-95%

9. Case Example

12. Catheter Directed Therapy

13. Catheter Directed Therapy
• Transarterial Chemoembolization (TACE)
– Chemotherapy + embolic particles
– Chemotherapy in the embolic particle
• Transarterial Radioembolization (TARE) – Yttrium 90
(Y90) – Selective Internal Radiation Therapy (SIRT)
– Resin Microspheres
– Glass Microspheres
• Immunoembolization
– GM-CSF Embolization

14. TACE
• First performed in the early 1980’s
• Targeted intra-arterial delivery of
chemotherapy followed by an embolic
agent
• Drugs: No standard
– BCNU
– Cisplatin
– Mitomycin C
• Embolic agent
– Prevents drug washout
– Induce ischemic necrosis
+ Lipiodol
PVAGelfoam
hydrogel
PVA Embospheres

15. TACE Outcomes
Semin Intervent Radiol. 2013 Mar; 30(1): 39–48.

16. Radioembolization/Y90

17. Case Example

18. Case Example

19. Case Example

20. • Retrospective study
• 13 patients treated with resin-based yttirum-90
• PR or SD in 77%
• OS 7 months
• Retrospective study
• 32 patients treated with resin-
based yttirum-90
• OS 10 month
• PFS Liver 4.7 months
• Less tumor burden = better
survival

21. Immunoembolization
• Infusion of immunologic stimulant into liver followed by
embolization
• Granulocyte-macrophage colony-stimulating factor (GM-
CSF)
– Protein secreted by immune cells that stimulates
immune activity

22. • Immunoembolization w/ GM-CSF vs. Bland Embolization
• OS: 21.5 vs. 17.2 months
– Pt with greater tumor burden had better response
• Pro-inflammatory cytokine production was greater with
IE

23. Conclusions
• Much more work is needed
• Liver-directed therapy may improve survival
• Liver-directed therapy may be the only reasonable
treatment option for selected patients

24. How Do I Access Liver
Directed Therapy?
• Talk to your oncologist
– NCI Designated Cancer Centers
– Tumor Board with Multiple Specialists
• Seek out an Interventional Oncologist
– http://doctor-finder.sirweb.org