Liver Cancer 101 Causes, Treatments, Innovations & Access
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CCSN was joined by Dr. Mamatha Bhat (Hepatologist at University Health Network in Toronto), Dr. Amol Mujoomder (Interventional Radiologist at London Health Sciences Centre) and Dr. Gregory Powell (HCC patient & founder of Shock Trauma Air Rescue Services Foundation) for a webinar surrounding Hepatocellular Carcinoma (HCC), the most common form of primary liver cancer. Our presenters defined what HCC is, discussed the current landscape for treatments and prognosis as well as new/innovative treatments, and insights from a liver cancer patient. The webinar also addressed concerns regarding lack of access and funding for life-saving treatments for liver cancer. This webinar was moderated by CCSN, and included an interactive question and answer session.
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Liver Cancer 101 Causes, Treatments, Innovations & Access
- 1. Liver Cancer 101: Causes, Treatments, Innovations & Access Presenters: Dr. Mamatha Bhat, UHN Dr. Amol Mujoomder, LHSC Dr. Gregory Powell, STARS
- 2. CCSN’s Liver Cancer Awareness Campaign • An information portal on our website, survivornet.ca • A dedicated Twitter account (@LiverCancerCa) • An advisory council for individuals affected by primary liver cancer • A new report based on a survey provided to Canadian liver cancer patients & caregivers • A free educational webinar about Liver Cancer • Legislative Reception at Queen’s Park in early spring
- 8. Farazi et al, 2006, Nat. Rev. Cancer
- 9. • 5th most common tumor worldwide • Rising incidence in US & Europe (HCV, EtOH, NASH), alongside Improved survival of patients with cirrhosis
- 12. Llovet, J. M. et al, 2016, Nat. Rev. Dis primers https://www.hopkinsmedicine.org/liver_tumor_center/conditions/
- 13. Llovet, J. M. et al, 2018, Nat. Rev. Clin. Oncol.
- 14. Zhu et al, Lancet June 2018Khoueiry et al, Lancet 2017;
- 17. Interventional Radiology Therapies for Liver Cancer Dr. Amol Mujoomdar, MD FRCPC Associate Professor of Radiology and Oncology Western University CCSN Liver Cancer Webinar
- 18. • I have received speaker honorarium from Medtronic and BTG in the last five years • I have proctored other physicians for LivaNova Inc. in the last year Disclosures IR Therapies for Liver Cancer
- 19. • What is the role of the diagnostic and interventional radiologist on the liver cancer team? • What are the different IR therapies for HCC? • Ablation • Embolization therapies (bland, chemoembolization and Y90) • What is the patient experience? • Risks, side effects? Objectives: IR Therapies for Liver Cancer
- 20. • Physician who interprets diagnostic imaging (US, CT, MRI) • Diagnostic radiologist • Physician who performs “image-guided” procedures with US, CT or live x- rays (fluoroscopy) • Interventional Radiologist • Interventional Radiologists form an integral part of the liver team (hepatologists, transplant surgeons, medical oncologists, radiation oncologists) Role of Radiologist IR Therapies for Liver Cancer
- 21. • Image-guided biopsies (liver biopsy, etc) with ultrasound or CT guidance • Thermal ablation of liver tumours (RFA, microwave) • Transarterial therapies for liver metastases • Chemoembo, bland embo or Y90 • Typically procedures performed with IR doc, nurse and technologist (MRT) What kinds of liver procedures are performed in IR? IR Therapies for Liver Cancer
- 22. Victoria Hospital IR Team: IR physicians, Medical Radiation Technologists, IR Nurses, Receptionists and IR Facilitator IR Therapies for Liver Cancer It takes a village!!!
- 23. Ablative Therapies IR Therapies for Liver Cancer
- 24. Hong K, Georgiades C. J Vasc Interv Radiol 2010; 21:S179–S186. IR Therapies for Liver Cancer
- 25. • Minimally invasive • Kill all of the tumour! • Destroy tumour without damaging adjacent vital structures with surgical margins • Improve survival Goals of Ablation IR Therapies for Liver Cancer
- 26. Indications for Thermal Ablation • In liver cancer, typically perform liver ablation for: – small solitary liver cancer (<3cm) – 3 tumours less than 3cm – Poor surgical candidate – ?bridge to transplantation – ?combination with chemoembolization IR Therapies for Liver Cancer
- 27. What can I use? • RFA • Microwave • Cryoablation
- 28. IR Therapies for Liver Cancer BBQ Microwave Freeze
- 29. What is the patient experience? • IR clinic visit to discuss treatment, MDT discussion • Outpatient procedure • Moderate sedation (Versed and Fentanyl) and local freezing • Imaging guidance with US only, CT only or both • Everyone is sent home with analgesia, antiemetics and bowel care • F/U in 4-6 weeks with CT and IR clinic visit IR Therapies for Liver Cancer
- 30. Pre-Treatment Scan HCC IR Therapies for Liver Cancer
- 31. RFA IR Therapies for Liver Cancer
- 32. Follow-up IR Therapies for Liver Cancer Curative!!Pre-Ablation
- 33. • Bleeding • Infection • Collateral damage to vital structures in the liver • Thermal damage to other organs • Risk of major complications rare… What are the risks of ablation? IR Therapies for Liver Cancer
- 34. What are the different arterial therapies for HCC? IR Therapies for Liver Cancer TACE, bland embolization and Y90
- 35. • Liver has a double blood supply feeding it • Portal veins feed the liver • Liver arteries feed the tumours • Goals of care depends on the patient • Palliative stand-alone therapy or in combination with radiation or systemic medication • Downstage patients with large tumours to “transplant eligible” • Bridge patients who are on the transplant list to control the tumours • Usually non curative What is the goals and rationale of TACE? IR Therapies for Liver Cancer
- 36. IR Therapies for Liver Cancer
- 37. • Treatment that involves liver angiography, and direct injection of bland particles (plastic shavings) or chemotherapy into the liver arteries (and tumour arteries that feed the beast) • IR clinic visit to discuss, MDT discussion • Requires admission to hospital the day prior for IV hydration, premedication and preparation • Procedure performed in IR suite with live x-rays • Patients usually discharged the next day with antibiotics, pain and nausea medications • 4-6 week follow-up with imaging and IR clinic Patient experience IR Therapies for Liver Cancer
- 38. • Bland embolization works by starving the tumours of their blood supply (choking effect) • Chemoembolization works by direct toxic effect of chemotherapy to tumour cells and choking the blood supply (1-2 punch effect) • Which is better???? • Scientific literature has more proven studies with chemoembolization • Recent studies have questioned whether chemo is truly better How does that work on tumours? IR Therapies for Liver Cancer
- 39. What about Y90? IR Therapies for Liver Cancer
- 40. • Radiation is lethal to neoplastic tissues if sufficient dose • However, normal liver is sensitive to radiation and can be lethal • Y90 bearing microspheres (unlike external radiation) are millions of high dose point sources of radiation that preferentially localize in tumours, while sparing the normal liver • Therefore can deliver a high dose of radiation Rationale for Y90: IR Therapies for Liver Cancer
- 41. IR Therapies for Liver Cancer
- 42. IR Therapies for Liver Cancer Y90 is not currently funded in Ontario Many of us are working on it with CCO, but change takes time... However…
- 43. • Similar to bland or chemoembolization procedure • Outpatient procedures (no admission required) • Two or three parts to the Y90 treatment: 1. Planning liver angiogram • Liver angiogram and nuclear medicine lung-shunt study • Information from study used to calculate dose 2. Y90 administration (1-2 weeks after planning angio) • Liver angiogram and delivery of Y90 particles • Recover for 2-3 hours and go home! What is the patient experience? IR Therapies for Liver Cancer
- 44. • Similar to chemoembolization: • Access related (bleeding, damage to blood vessels) • Infection (lower with Y90) • GI ulcers (rare with good technique, but devastating) • Liver failure (rare in NET with good patient selection) • Radiation induced liver disease (nausea, vomiting and “hepatitis) What are the risks of both? IR Therapies for Liver Cancer
- 45. • Post embolization syndrome (mild flu like symptoms: fatigue, nausea, vomiting, low grade fever) • Most people feel fatigue • Pain is less common • There are some radiation related precautions (7 days): • Cannot sleep in the same bed as partner • Cannot sit next to someone for >2 hours • No close contact with children and pregnant women What are the side effects? IR Therapies for Liver Cancer
- 46. IR Therapies for Liver Cancer How do we determine who is a candidate for what therapy? Discussed at the HCC/Liver tumour board meeting…
- 47. IR Therapies for Liver Cancer R L Liver HCC Spleen CT Scan
- 48. IR Therapies for Liver Cancer Liver Angiogram HCC Liver artery Catheter in aorta
- 49. IR Therapies for Liver Cancer
- 50. Pre-Y90 2 months 4 months 10 months 17 months 24 months IR Therapies for Liver Cancer
- 51. • Work with CCO to advocate for provincial funding for ablation (including microwave), TACE and Y90 • Advocate at the local and provincial level to health care providers to improve awareness of the disease and promote importance of multidisciplinary care and consideration of liver transplantation Next steps? IR Therapies for Liver Cancer
- 52. • IR has an important role in the multidisciplinary management of liver cancer • Sometimes curative (ablation) or palliative treatments (TACE, Y90) • Can also be used to bridge or downstage patients for liver surgery or transplantation • Work needed to fund emerging technologies (microwave ablation, Y90) in Ontario and other provinces In conclusion IR Therapies for Liver Cancer
- 53. IR Therapies for Liver Cancer Thank you for your attention and the invitation!
- 56. Questions? Ask your questions to our presenters by typing them into the questions box of your GoToWebinar panel.
- 57. Canadian Cancer Survivor Network Contact Info 1750 Courtwood Crescent, Suite 210 Ottawa, ON K2C 2B5 Telephone / Téléphone : 613-898-1871 E-mail: jmanthorne@survivornet.ca or info@survivornet.ca Website: www.survivornet.ca Twitter: @survivornetca Facebook: www.facebook.com/CanadianSurvivorNet Instagram: @survivornet_ca Pinterest: http://pinterest.com/survivornetwork/