Interventional Hepatology with David Madoff

Transcript

• 00:11Welcome back, this session is being recorded.
• 00:18Hello, welcome back.
• 00:20My name is Chen Liu from pathology.
• 00:23It is my pleasure to
• 00:25introduce the next speaker,
• 00:27doctor David Medoff and Doctor Medoff
• 00:29is a professor of radiology and he's
• 00:32also the vice Chair for clinical
• 00:35research and the section chief for
• 00:38interventional radiology of useful medicine.
• 00:41So today he's going to talk about
• 00:44is interventional hepatology.
• 00:46Welcome, David, now is yours.
• 00:54Can you see? Yes, we can see it.
• 00:59OK, so thanks Chen.
• 01:01I would like to thank Mike Mario
• 01:03and the Planning Committee for
• 01:05inviting me to speak today.
• 01:07I am truly honored to serve as faculty
• 01:09for Yale Liver Center's Diamond Jubilee,
• 01:11a major notable achievement.
• 01:13My role today is to introduce the
• 01:15topic of interventional hepatology
• 01:16and how it is incorporated into the
• 01:19algorithm for treating patients
• 01:20with hepatobiliary disease at Yale.
• 01:22I must admit that I was a little
• 01:24nervous to talk about this,
• 01:26given the title, as I wasn't planning
• 01:28to devise and discuss a paradigm.
• 01:30For an entirely new field
• 01:33of interventional medicine,
• 01:34fortunately I was asked to focus
• 01:36on how IR interacts with cells.
• 01:38Multidisciplinary,
• 01:38hepatobiliary care team,
• 01:40and manage many of the most complex,
• 01:43challenging and sickest patients
• 01:45we see here at Yale.
• 01:47Therefore,
• 01:48despite the considerable amount of
• 01:50basic and translational research that
• 01:53we're doing at Yale and in this field,
• 01:55I will focus today on its clinical
• 01:57aspects and highlight them by
• 01:59showing some interesting cases.
• 02:07So what is interventional hepatology?
• 02:10Although there has been 80 years
• 02:11of the battle, biliary imaging for
• 02:13both diagnosis and intervention,
• 02:15it has not been formally defined like it
• 02:17has been for interventional oncology to me,
• 02:20interventional hepatology is subspecialty
• 02:22of IR that utilizes minimally invasive
• 02:25image guided procedures to diagnose
• 02:27and treat patients with various
• 02:30forms of hepatobiliary disease.
• 02:32Clearly there is some overlap
• 02:34with interventional oncology,
• 02:36such as treating tumors like
• 02:38HCC and Colangelo carcinoma,
• 02:40but there are also areas that don't overlap,
• 02:42such as managing the sequelae of portal
• 02:45hypertension, benign biliary strictures,
• 02:47destroy malformations, and trauma.
• 02:51And in terms of training,
• 02:52many in the audience may not be
• 02:54aware that IR is now a formalized,
• 02:56a CGM accredited categorical residency,
• 02:58where medical students can now
• 03:00match directly into it.
• 03:02Residents have a one year clinical internship
• 03:04followed by five years of radiology,
• 03:06with the final two years dedicated
• 03:08to interventional radiology.
• 03:09Imaging, of course,
• 03:11is a critical component to training as
• 03:13our patient as the patients we treat
• 03:16and the procedures we offer require a
• 03:19deep understanding of how the images are.
• 03:22Gained, interpreted,
• 03:23and ultimately used interprocedural.
• 03:25Clearly you understanding of complex
• 03:28Physiology is also important.
• 03:30And yeah, it was part of their internship.
• 03:31Our residents rotate on the classifying
• 03:34service and IR residents as well as
• 03:37faculty take part in inpatient consults,
• 03:39outpatient clinics,
• 03:40liver tumor boards,
• 03:41and portal hypertension conferences.
• 03:43We also recently implemented the
• 03:46nation's first IR night float system
• 03:48so patients can be seen and evaluated
• 03:51rapidly even in the middle of the night.
• 03:54So at Yale,
• 03:55we have 17 clinical IR faculty
• 03:57who help in providing the most
• 03:59comprehensive care possible for
• 04:01patients with a paddle biliary disease.
• 04:03Here you can see a long list of
• 04:05procedures performed by our team,
• 04:06which ranged from pretentious
• 04:07or transcellular.
• 04:08Image guided biopsy, tumor therapy,
• 04:12palliative procedures,
• 04:13central venous access,
• 04:15and managing complications like
• 04:16those seen after transplant,
• 04:17their resection,
• 04:18or simply as a result of their
• 04:21underlying liver disease.
• 04:22So let's start with understanding how we
• 04:23can help in the management of liver cancer.
• 04:25There are three key goals we
• 04:28are which are potential for cure
• 04:30conversion of unacceptability to
• 04:32resectability and for palliation.
• 04:34How we decide depends on the tumor Histology,
• 04:37the number and location of
• 04:39tumors within the liver,
• 04:40the extent of underlying liver disease,
• 04:42and the presence or absence
• 04:45of extrahepatic disease.
• 04:46So I wanted to start by discussing
• 04:48one method by which we can convert
• 04:50unresectable patients to resectable by
• 04:52simply manipulating the livers portal.
• 04:54Blood flow with the procedural
• 04:56portal vein embolization in patients
• 04:58whose surgery will leave them
• 04:59with an inadequate remnant liver,
• 05:01P VE redirects portal blood flow to the
• 05:03future liver remnant that by doing so,
• 05:05can initiate hypertrophy of
• 05:06the non embolized segments.
• 05:08PE has been shown to reduce perioperative
• 05:10complications and increase the number
• 05:12of potential surgical candidates who
• 05:14have what we call marginal anticipated.
• 05:16I feel our volumes,
• 05:18user PVE,
• 05:19has therefore been able to
• 05:21achieve similar survival rates to
• 05:22surgical patients who initially
• 05:24did not require PV E.
• 05:26Next we move to percutaneous ablation.
• 05:28The goals of ablation are to eradicate
• 05:30all viable malignant cells while
• 05:32sparing normal surrounding tissues.
• 05:33Additionally, we can treat tumors with
• 05:36unfavorable location or patterns of
• 05:38distribution for resection and those
• 05:39with multiple comorbidities that can,
• 05:41in fact, undergo surgery.
• 05:44Population is most often used in patients
• 05:46with low volume disease which could,
• 05:48which could include potential first
• 05:49line cure or as a bridge to transplant.
• 05:52These procedures are typically done in the
• 05:55outpatient setting and are repeatable.
• 05:56We have many types of ablation
• 05:58devices which different energy used
• 06:00and this is just a short list.
• 06:01We can radio frequency,
• 06:02use radio frequency to cook the tumors,
• 06:05microwave to boil them,
• 06:06fry oblation to freeze them and the
• 06:08new kid on the block is irreversible.
• 06:10Electroporation to electrocute them.
• 06:14We can also treat tumors as
• 06:16a transarterial approaches.
• 06:17Transarterial therapies were
• 06:18initiated over 4 decades ago.
• 06:20Since most liver tumors receive blood
• 06:21supply largely from the optic artery,
• 06:23and are often highly vascular.
• 06:25Using current state of the art
• 06:27catheter and imaging technology,
• 06:29we can selectively and locally deliver
• 06:31intraarterial therapeutics to the tumor bed.
• 06:33Thus,
• 06:34we can effectively target tumors while
• 06:36sparing surrounding hepatic parenchyma,
• 06:38thus minimizing systemic complications,
• 06:41and toxicities.
• 06:42Transarterial therapies are
• 06:43usually reserved for.
• 06:44Patients with higher tumor burdens
• 06:46in new adjuvant settings and in
• 06:48difficult or dangerous locations
• 06:50for resection or ablation.
• 06:52In terms of specifics,
• 06:53there was bland embolization in
• 06:55which embolization is performed
• 06:57without chemotherapy.
• 06:58The goal is to completely occlude
• 06:59the tumor feeding vessels,
• 07:00which result in a schema and rapid necrosis.
• 07:03Conventional taste is divided,
• 07:05is is defined as the infusion of
• 07:07a mixture of chemotherapeutic
• 07:09agents with or without iodized oil,
• 07:11followed by embolization with particles.
• 07:13This iodized oil, when used,
• 07:15is taken up selectively and retained
• 07:17by HCC and acts as both an embolic and
• 07:20drug delivery vehicle given some potential.
• 07:23Albeit rare systemic toxicities,
• 07:25the idea for drug eluting beads
• 07:27loaded with chemotherapy came about
• 07:28which would theoretically be more
• 07:30predictable in terms of drug washout,
• 07:32leading to a potentially
• 07:34better toxicity profile.
• 07:36And lastly,
• 07:37there's radioembolization in which glass or
• 07:40resin microspheres are tagged atrium 90.
• 07:42These microspheres permanently lodged
• 07:44within terminal arterials of tumors
• 07:46and deliver high dose beta radiation.
• 07:49They kill the tumor.
• 07:51So this is the recently updated
• 07:54Barcelona Liver Clinton Barcelona
• 07:56Clinic liver cancer staging for HCC
• 07:58which is now much more comprehensive
• 08:01than previous iterations.
• 08:03So where does interventional
• 08:05hepatology fit in this paradigm?
• 08:08Of course,
• 08:09transplanted hepatitis and resection
• 08:11are key curative treatment options,
• 08:14but defining resectability can be difficult.
• 08:16Resectability is not just based
• 08:17on tumor size and location,
• 08:19but also on the size,
• 08:20quality and function of the underlying liver.
• 08:22Therefore,
• 08:22even those with early stages of disease,
• 08:25many patients may not be deemed
• 08:27safe for resection.
• 08:28Therefore,
• 08:29when discussing management
• 08:30of unresectable HCC,
• 08:32there are many ways to cure
• 08:33patients without surgery and
• 08:34some patients who may be unresectable
• 08:36due to an insufficient future live.
• 08:38Pregnant or or may require downstage,
• 08:41and that can be converted to respectability
• 08:43and successfully undergo surgery.
• 08:45To that end, those that are within
• 08:48Milan criteria that is early HCC and
• 08:50deemed unresectable due to various
• 08:52comorbidities or patient preference.
• 08:54Ablation is a great option for those in
• 08:57early stage when resection transplant
• 08:59and ablation options are not feasible.
• 09:01Fans arterial therapies can be offered.
• 09:03In fact, Radioembolization for the
• 09:05first time has made it into the BCLC,
• 09:07but only for single lesions
• 09:09larger than 8 centimeters.
• 09:11Further transfer trial therapy for
• 09:12years has been the standard of care for
• 09:15patients with intermediate HCC and lastly,
• 09:17for diffusely infiltrative disease by
• 09:19low bar disease or advanced disease.
• 09:22There are numerous systemic therapeutics
• 09:24that can be used that can be used
• 09:27either alone or in combination
• 09:28with local regional therapies and
• 09:30clinical trials are ongoing.
• 09:32So how about for intrahepatic
• 09:34cholangio carcinoma?
• 09:35At present,
• 09:35there are no formalized guidelines
• 09:37for the local regional management
• 09:38of intermatic landrew carcinoma
• 09:40with unclear and limited evidence,
• 09:42supported chiefs local ablation may
• 09:44be used for patients with early stage
• 09:46disease or ineligible for surgery,
• 09:48and regional therapies typically reserved
• 09:49for those with disease that's more advanced,
• 09:52and even the NCCN guidelines and a
• 09:54recent paper from Nature Reviews
• 09:55gastroenterology and Hepatology do not
• 09:58explicitly mention ablation in the paradigm,
• 10:00although they do mention
• 10:01local regional therapy.
• 10:02Unresectable liver dominant disease.
• 10:05So I wanted to show a case of how
• 10:08interventional hepatology can be used to
• 10:10treat a typical patient with liver cancer.
• 10:13So this is a 48 year old female
• 10:16with biopsy proven multifocal
• 10:17intrahepatic Andrew carcinoma having
• 10:19a 4.5 centimeter mass in segment 7
• 10:22and a 7.7 centimeter infiltrative
• 10:24mass and segments four and five.
• 10:26She had lymphadenopathy in the
• 10:28gallbladder and Porta Hepatus.
• 10:30There were no masses seen in
• 10:31the left lateral liver and there
• 10:33were no peritoneal implants.
• 10:34She was considered for an
• 10:35extended right up protecting me,
• 10:37but the FLRW was deemed
• 10:38insufficient for safe resection.
• 10:40Therefore P VE was requested to have
• 10:42purchase. The floor preoperatively.
• 10:44Here you see a right PV E with extension
• 10:47to the segment 4 Portal vein branches.
• 10:50There is occlusion of portal flow
• 10:52to the entire liver to be resected
• 10:54with complete diversion of flow
• 10:56to the left lateral liver.
• 10:57One month later,
• 10:58enough FLR hypertrophy occurred
• 11:00to proceed with resection.
• 11:02So an extended by Hepatectomy,
• 11:04cholecystectomy and regional Lymphadenectomy
• 11:05was performed with pathology showing.
• 11:07You basically had no carcinoma of
• 11:09intrahepatic bile ducts with multiple
• 11:11positive regional lymph nodes.
• 11:13She underwent adjuvant chemotherapy with
• 11:15gemcitabine and cisplatin for six months
• 11:17but nine months later there were two
• 11:19new small tumors in the remnant liver,
• 11:21one in segment 2 and the other in
• 11:24the junction of segments 2 and three,
• 11:26and there was also increased size
• 11:29of retroviral lymphadenopathy.
• 11:31Both tumors were successfully treated
• 11:33with microwave ablation as shown here.
• 11:36Subsequently,
• 11:36adjuvant chemotherapy with
• 11:37Zolota was given for three months
• 11:40with several new hepatic tumors were found,
• 11:42as well as increased size of
• 11:44the retroviral lymphadenopathy.
• 11:45This is also very nicely shown
• 11:47with the pet CT shown here.
• 11:49Radio embolization was performed,
• 11:51but in a staged approach to avoid
• 11:53treatment of the entire liver.
• 11:55In one session,
• 11:56that can ultimately lead to liver failure.
• 11:59Subsequently,
• 12:00there was good treatment response
• 12:02with decreased FDG avidity and nine
• 12:05months after radioembolization,
• 12:07she developed a severe, intractable,
• 12:11bandlike pain around the upper abdomen and
• 12:13several FDG avid hepatic segment 3 masses.
• 12:16One was increased in size
• 12:18from the prior study,
• 12:19and there were two new tumors.
• 12:20She also had stable FDG avidity in in
• 12:24the pulmonary nodules and retroviral
• 12:27and retroperitoneal lymphadenopathy.
• 12:28So bland embolization was
• 12:30performed for pain control,
• 12:31as the anterior most tumor which you see
• 12:34here was stretching the liver capsule,
• 12:36causing the pain.
• 12:37Fortunately,
• 12:38the treatment resulted in complete
• 12:40tumor necrosis and she had
• 12:42immediate and sustained pain relief.
• 12:44Unfortunately,
• 12:44she died from disease progression,
• 12:46but lived three years after initial
• 12:48diagnosis with this multimodality
• 12:49therapy and with nearly the entire
• 12:51gamut of local regional strategies,
• 12:53we have to offer playing a major role in
• 12:56her much lower than expected survival.
• 12:58I just wanted to say a few words
• 13:00about combining immunotherapy
• 13:01and interventional hepatology.
• 13:03Interestingly, local regional therapies,
• 13:04such as ablation and transarterial
• 13:07envelope therapy,
• 13:07do elicit immune responses.
• 13:10Therefore,
• 13:10there could be synergies between
• 13:12local regional therapy and immune
• 13:14checkpoint inhibitors for better
• 13:16outcomes and numerous clinical
• 13:18trials are currently underway,
• 13:20such as this one.
• 13:21We are now enrolling 4 at Yale in this study.
• 13:24LEAP 012 patients will receive
• 13:26taste with or without.
• 13:28Embolism AB and levatino.
• 13:33So let's now move to management of portal,
• 13:34vein tumor thrombus, and entity.
• 13:36I personally believe is
• 13:37under treated in the West.
• 13:39Here we have a 54 year old man
• 13:42with HCC and HBV cirrhosis.
• 13:45He has scanned showing. By low bar.
• 13:50HCC with extensive infiltrative
• 13:52tumor in the left lateral liver.
• 13:56There's portal vein tumor
• 13:57thrombus within the right, left,
• 13:59and mid main portal veins extending
• 14:01to the sphenoid portal confluence,
• 14:03and there are numerous enhancing
• 14:05vessels throughout the tumor.
• 14:06Thrombus with arterial portal shunting?
• 14:08I am sure most practitioners in
• 14:10the audience would have just placed
• 14:12this patient on a TI and his
• 14:14life expectancy would have been
• 14:15dismal just a few months at best.
• 14:17As often happens,
• 14:18we hear very compelling stories such as
• 14:21having a wife and two young children.
• 14:23So against all odds we try to do what we can.
• 14:27So in this case, taste was offered,
• 14:30but knowing the challenges he was
• 14:32scheduled for four monthly taste sessions.
• 14:34Here we used a novel doable and
• 14:36occlusion catheter and see the tumor
• 14:38supplied by the writer padick artery
• 14:39with rapid shunting into the portal vein.
• 14:41And this is an angiogram with only the
• 14:44distal balloon inflated on the right.
• 14:46The comb beam CT fluoroscopic scopic
• 14:48images with both balloons inflated
• 14:51nicely shows the portal vein tumoral
• 14:53blood supply one year after initial taste,
• 14:56the portal vein tumor thrombus.
• 14:57Detracted from the spinal portal.
• 14:58Confluence and there was increased
• 15:00portal flow.
• 15:01There was no evidence of new
• 15:03or residual hepatic tumor,
• 15:04but his liver function did worsen
• 15:06some now being child BQ.
• 15:08Child Pugh, B7 and mild of 11.
• 15:12He died 16 months after the first
• 15:14case which was much longer than
• 15:17expected with systemic therapy.
• 15:19Next list,
• 15:19discuss the management of the
• 15:21sequel of Portal Hypertension.
• 15:22Although there are numerous
• 15:23reasons for performing a tips,
• 15:25the most common indications are variceal
• 15:27bleeding and refractory ascites.
• 15:29Both indications have exceedingly
• 15:30complex Physiology and the benefits
• 15:32of percutaneous approaches to manage
• 15:34these have been well documented.
• 15:36For now more than 25 years,
• 15:38so this is a 62 year old woman
• 15:40with HCV cirrhosis,
• 15:41recurrent ascites and hepatic
• 15:43hydrothorax in two small HCS.
• 15:46She was getting Thoreson,
• 15:47TCS and Paris and TCS.
• 15:48Every two days and had a miserable
• 15:51quality of life over the three
• 15:52years prior she had variceal,
• 15:54bleeding, and esophageal banding,
• 15:55and when I saw her,
• 15:57she was child's C at a meld score of 12
• 15:59and was undergoing transplant evaluation.
• 16:02Intraprocedural and a one month follow up.
• 16:04See T we effectively we see that we
• 16:07effectively treated the tumor with
• 16:09conventional taste and therefore
• 16:11proceeded to tips after tips placement.
• 16:14Her new comparison TCS and Thoracentesis
• 16:16immediately diminished and there
• 16:18was no evidence of viable tumor
• 16:19on any of the subsequent scans.
• 16:21And to the best of my knowledge,
• 16:22she was awaiting liver transplantation.
• 16:24Sorry,
• 16:25sorry they made a full interruption.
• 16:27We have to wrap it up in a minute.
• 16:30OK, all right.
• 16:32I guess I'll just discuss this case.
• 16:35So here's another case
• 16:36of portal hypertension.
• 16:37A 67 year old woman with cirrhosis
• 16:38and HCC who transferred from
• 16:40outside hospital for management
• 16:42of massive variceal bleeding.
• 16:43Originally I was consulted for the tips
• 16:45but as you can see from this portal vein,
• 16:47very tiny portal vein,
• 16:48she was not a candidate for because
• 16:50the students are actually much
• 16:52larger than this so we ended up
• 16:54performing of what's called the RTO.
• 16:56And here we see that we're able
• 16:58to use a splenorenal shunt.
• 17:00You have two catheters.
• 17:01Into the into the variceal complex
• 17:03coil with one of the catheters and
• 17:06then infused foam directly beyond
• 17:07it and therefore we were able to
• 17:10successfully treat the bleeding.
• 17:12But unfortunately this patient had a died,
• 17:15so I will skip this.
• 17:17And then we'll just go to the conclusion,
• 17:20which is as I hope I have shown,
• 17:22and I know I did,
• 17:23mostly on a tumor therapy.
• 17:25Interventional Hepatology plays an
• 17:27important role in the management of
• 17:29numerous complex compatible biliary diseases.
• 17:32Interventional radiology,
• 17:33as I discussed,
• 17:34is now in a CGM accredited 6 year
• 17:37categorical residency and I think this
• 17:39is very important as understanding
• 17:40imaging and Physiology is really the
• 17:43critical differentiator among proceduralists.
• 17:45I think that it yell we
• 17:47have a very collaborative,
• 17:48excellent.
• 17:48Environments we have liver tumor boards,
• 17:50portal hypertension,
• 17:51conferences and our trainees get to
• 17:53rotate on the class and service,
• 17:56and I think that from my perspective
• 17:58the future of interventional
• 18:00hepatology is extremely bright.
• 18:02There are novel technologies
• 18:03which are listed here,
• 18:05as well as a lot of promising
• 18:08combination therapies,
• 18:08so with that I will stop here and
• 18:10thank you for your attention.
• 18:13Thank you David. So we will have
• 18:15to skip the question and answer
• 18:17session so we now you know please,
• 18:20everybody goes straight to the 3:30
• 18:23session to imaging based hepatology.
• 18:25Thank you all.
• 18:32Thank you everyone due to the timing,
• 18:34we will be skipping this 315 session
• 18:36if you have a question for a speaker,
• 18:38please send it in to the speaker
• 18:39directly through the attendee hub.
• 18:41Please join us at 3:30 for
• 18:42the next session. Thank you.