Interventional Oncology
Michael Kotton MD
October 27, 2012
Objective
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Understand role of thermal ablation in
treatment of HCC
Understand role of TACE in treatment
of HCC
Know patient selection criteria and
possible complications of TACE and
thermal ablation
Liver Cancer
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5th most common cancer
80% Hepatocellular Carcinoma (HCC)
18,910 deaths in USA 2010
Incidence increasing 4.3% per year
Underlying chronic liver
disease/cirrhosis
Hepatocellular Carcinoma
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Tends to stay localized to Liver
Can be cured by liver transplant
Prognosis depends on both cancer and
underlying liver disease
Liver has a dual blood supply
Tumor supplied by hepatic artery
Liver Blood Supply
Interventional Options
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Percutaneous
– Thermal ablation, Chemical ablation
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Transarterial
– Bland embolization
– Radioembolization
– Chemoembolization
– Drug Eluding Beads
How Do We Decide
Extent of Tumor
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Milan Criteria (5/3 Rule)
One tumor less then 5 cm
Up to 3 tumors less then 3cm
No vascular invasion
Health of Patient
Condition of the Liver
Treatment Options
Transplantation
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Milan Criteria (5/3
Rule)
70% survival at 5
Years
IR treatments as
bridge to transplant
Interventional
Radiology
Surgery
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No Cirrhosis
No Portal HTN
30-60% 5 year survival
Chemotherapy
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Advanced cancer
Nexevar
Thermal Ablation
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Curative Intent
– Recurrence at 5 years 60-70%
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Size <5cm
Solitary
Safe location
Not surgical candidate
Case 1
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58 year old female
2.2 cm tumor
Hep B
HTN
Normal Bilirubin
Mild PVH
Needle Placement
RFA Probe
Stomach
Post Ablation
Post Treatment
Pre
Post
Post Open RFA Liver
Complications
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Bleeding
Infection
Tumor Seeding 2-10%
– Subcapsular location
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Inadvertent Ablation
– Bowl, Gallbladder, Diaphragm
– Central Biliary Tree
Outcome
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<1% Mortality
Complications 5%
30-55% five year survival
Local Recurrence 2-10%
– Can be treated again
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Recurrence at 5 years same as
resection
Chemoembolization
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Large or multifocal tumors
Can Liver Tolerate Treatment
Patient benefit
Size and number of tumors
Patient Selection
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Bilirubin < 3
Albumin >3
PLT >90
No encephalopathy
No vascular Invasion
No Biliary Dilation
Tumor Less then 50% liver
Chemoembolization
Chemoembolization
Case 2
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69 year old male
Hep B
9 cm tumor
Normal Bilirubin
Mild PVH
RESPONSE
Post Treatment
Chung W et al. AJR 2012;199:349-359
Mannelli L et al. AJR 2009;193:1044-1052
Complications
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Bleeding
Liver Failure
Infection
– Biliary-Enteric Anastomosis
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Post Embolization Syndrome
Fever, nausea, pain
 Ends after 7 days, infection usually presents
later
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Inadvertent Embolization
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Gallbladder, bowl
Does It Work
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Survival Benefit in select patients
Hong Kong trial
– 2 Year Survival 31% versus 11%
– 3 Year Survival 26% versus 3%
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Barcelona trial
– 2 Year Survival 63% versus 27%
Summary
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Remember the 5/3 rule
Transplantation is best treatment in
eligible patients
Ablation for small tumors and
resection for non cirrhotic livers
Chemoembolization for non surgical
tumors who can tolerate the procedure
Case 3
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68 year old female
Hep C
Multifocal tumors (5.2cm,3cm,2cm)
Good liver function
RESPONSE
2
Case 4
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79 male
Hep C Cirrhosis
3.7 cm solitary
tumor
Multiple medical
problems
Case 5
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62 year old female
Hep C
Cirrhosis
2.4 cm tumor
Otherwise healthy
Questions???