Recurrent Hepatocellular Carcinoma (Multifocal) | Radioembolization | 65 | Male
Recurrent Hepatocellular Carcinoma (Multifocal) | Radioembolization | 65 | Male
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So my case is kind of reiterate some of the same points. So the first case is a 65 old male, HCV cirrhosis, newly diagnosed HCC potential liver transplant candidate. It's not working? So a look at the liver status as well as

the performance status, get the lab, look at the CT, so he's beyond milan, there is 4.5 centimeter segment five LIRADS five lesion, and a 2.6 centimeter segment five lesion as well.

So then I see the patient in clinic and I have a discussion with them of kind of like what Mike was saying, of between what the options are and what the benefits and risks are of each one of them, and so there is no good randomized control trial comparing

these. So I go over some of the retrospective trials that are out there. So I talk to them how there's no difference in the survival. [BLANK_AUDIO] I talk about how there's no difference in the survival with the patients and then if there are a transplant candidate I talk about how a retrospective

study showed that the downstaging rate from t3 to t2, was better with Y90 that TACE. Time to response also shown to be better with Y90. Time to progression better with Y90. Looking at pathologic response and explants, two separate papers but at the same institution show that Y90 was a little better.

Toxicity profile also has shown again retrospectively Y90 a little bit better. >> Not really. >> So looking at TACE, I talked to them about why TACE and it's kinda of what Mike was saying that you can get them to treatment faster, potentially.

It depends where you are so at North Western we could, see them in clinic one week and the next week treat. Not only do the full study and treat them the same day. At Jefferson I can't do that. That was one of the biggest shocks when I first got there.

I have to wait about two weeks to get insurance approval then I have to do the full study. I'm not allowed to be the authorized user so I have to wait for Radhoc/g to figure out the dosing. It takes another two weeks to get the dose. So it takes a month till I can treat the patient versus TACE I can

do the next day. So I talk about that with my patients and TACE shorter time to evaluation results, so it's embolic and on imaging we look at enhancement. So TACE, one month out you can tell whether you need to go back in or not Y90. Sometimes you can tell,

and I'll show an example of that, but generally I usually get an imaging at one month and then another one in three to four months, and it's that second imaging that I go off of whether I needed the treatment more. And then I also talk about micro-embolic versus macro-embolic so it's all theoretical but I feel like if I do Y90 first I may still

preserve the vasculature to be able to do more TACE later. Do you guys have any comments on any of that? >> Well just that I mean the whole the idea of who goes first is, a little bit of a myth in that some people say why should you do Y90 first coz with chemoembolization shall

block the vessels. Well, if you do chemoembolization first the tumor grows, then there's obviously there's arteries to treat and the Y90 will get in there and we actually went and looked retrospectively the bunch of patients we treated with Y90 who either had or did not have prior chembolization. There is absolutely no difference in dose delivery

between the two groups and no difference in tumor response between the two groups. So you really can't go on either order, and you're not comprising anything. >> So I went with Y90 in the patient, after discussion agreed.

So just a little about how I do it. So I give some peri-procedure medications. Before treatment they're on protonix a week before and then four weeks after, and I send them home with zofran and oxycodone. So in terms of catheters that I use, I use different catheters

for planning versus treatment. For guiding catheters there is a lot of different things you can use, I generally use a Simmons one. For planning treatments, I want something short and higher flow so that I can get good contrast delivery and see things well,

so I tend to use the 110 2.8 F Progreat. When training I did the Renegrade Hi-Flow but if I wanna coil I don't wanna use the 2.8 F microcatheter so I use the 2.4 F catheter if I can predict that I'm gonna coil something. And then for treatment I want something that's longer with a smaller

diameter so that I don't just rush in Y90, it might just be theoretic but to decrease the risk of reflex I tend to use a 130 Maestro for that. Do you guys put things in that order or is that just my OCD? [LAUGH]

>> OCD >> OCD [LAUGH] It's also the North Western way. [LAUGH] So this is that treatment, you can see that the lesion, I didn't

see the smaller lesion, this is the planning arteriogram but the bigger lesion was treated, was supplied by both mainly the posterior branch but a little bit of the anterior branch. And I do a lot of cone beam CT,

I'm a cone beam CT junkie, I do it in my pre-planning and on my treatment days. So I got in and decided I need treat both, line spred function was 6.15. And so on the same day I treated both with two separate vials, and

I like to use extended shelf life in my mind it's still less embolic than SIR-Spheres but you get better coverage within the tumor especially if it's something that's very hypervascular. And so based on the volumes I did 18 Gigabecquerel vials, that's a relatively large amount of beads to segment six, seven and then a smaller one to the other

one, but that was based on volume, not based on how much the tumor is getting covered. >> So then one month out, no viability in the tumor and it's 4.1 centimeters.

So we started the transplant evaluation. And then nine moths out, they started, the tumor got smaller but then there started being some LIRADS three lesions. >> They developed the ascites. >> And they developed ascites, yes. Which you don't know whether it's the Y90 or whether it's the natural

progression of the cirrhosis, could be a combination. But unfortunately at 12 months, multifocal bilobar HCC and distant mets so, this kinda shows for down staging why some people think that there needs to be a waiting period. Because something that's bigger might be more aggressive but something that big is not necessarily more

aggressive so, if you can find those ones that aren't, then they can do well in transplant but those ones are aggressive then you've weeded them out, so that's how we do it so unless there is a question.

Just finishing up, neurolysis and nerve ablation. We talked a little bit about this, but the goal is to permanently disrupt the axons and the myelin sheath. You can do it chemically with alcohol or phenol. But more and more people now are offering

radiofrequency ablation or cryoablation as a more precise way of performing these ablations. Radiofrequency ablation probably has the most data after alcohol and phenol. It's inexpensive and it has a long track record. Cryoablation is now being reported in the literature.

It's easy to see on CT as my colleagues have demonstrated. It's good in soft tissue tumors, but we still have very early data. Some people are actually looking at MR-guided focus ultrasound, very sexy, very expensive technology, very niche.

I don't really see that becoming a major player. I think it's really gonna be RFA and cryoablation,

But I'm really gonna focus on percutaneous ablation because it's particularly well suited to this application, minimally invasive for these potentially frail and elderly patients,

as well as high kill rate with tumors of many different histologies. So when we're choosing, this is the technique, so how do we do it? If we were facing a metastasis in the scapula like this, we can treat it with heat,

radiofrequency, or microwave ablation, or we can treat it with cryoablation, extreme cold temperatures, extreme cold or extreme heat, they'll both kill the tumor. How do we decide? Well, if we compare cryoablation versus microwave ablation

or radiofrequency ablation, ease of use, the heat-based therapies are certainly easier to use. They're generally faster, so the procedure duration is quite a bit shorter, but the energy transmission into bone is better with cryoablation.

It'll go through the cortex, whereas heat is limited in that regard. The predictability of the ablation zone, the cryoablation. As you can see in that scapular picture, we can actually see the edge of the ablation with several different modalities, CTMR and ultrasound.

Our ability to monitor that ablation then and prevent it from escaping into adjacent collateral structures. And then the ablation zone size, we can usually treat a larger area with cryoablation, and patient tolerance, their pain scores are generally less

after a cryoablation than a heat-based therapy. So in general, most of us who are treating for local tumor control would use cryoablation. These factors are a little less true these days where there are newer bipolar radiofrequency devices that are designed specifically for bone

so have better ability to control tumors within these sites.

Why are fast injection rates important? It is important because it allows for optimum enhancement of normal and abnormal structures in the body. It adds quality, value, and extent to the images.

At our institution, the maximum injection rate we currently use is 6 ml per second for CT angiographies. And when we are faced with the issue of image quality versus the risk of extravasation, I always remember what our favorite radiologist

always tells us: Maria, image quality is important, but patient safety comes first. There is a reason why we love him. But also, it depends on who you're talking to. Some radiologists would not even think of that. And here are studies that require fast injection rates

that we usually perform at our institution. And of all these studies, it is the liver and the pancreas studies that make up a large percentage of imaging that we perform at our institution. Now these are images of a CT of the chest

with IV contrast utilizing a one ml per second injection on your left, and a 2.5 ml injection on your right. You can see there is better enhancement, the blood vessels are clearer, the structures are clearer. And I have another slide

that will show us the CT of the abdomen with IV contrast utilizing a one ml per second injection versus a 2.5 ml per second injection. What can you see in the images on the right that you cannot see on the left? Blood vessels, yes, thank you.

You can see very clearly on the right, there are the normal structures, and you have the lesion on the liver, and there's something on the kidney that looks like maybe it's mets, or maybe it's just a cyst, hopefully.

And you see the spleen and the stomach, and there you can see, let me try this, right there, yay, okay, that is the main portal vein, and somewhere here is the hepatic artery, arteries. So having said that,

(laughs) I'm almost done. (Maria and audience laughing) Having said that, these images, oh, sorry, okay, these images clearly demonstrate that fast injection rates are essential

to achieve high quality diagnosis. However, as nurses, and as advocates for our patients, we should always remember that patient safety is still our priority.

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