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Dansk Dansk PancreasPancreas Cancer Cancer
Gruppe (DPCG)Gruppe (DPCG)
Session IV: Levertumor Gruppen Session IV: Levertumor Gruppen (DLGCG) (DLGCG)
ArterialArterial and Portal and Portal VeinVeinEmbolizationEmbolization
Poul Erik Andersen, MD, Poul Erik Andersen, MD, PhDPhD
DeptDept. . RadiologyRadiology, , InterventionalInterventional SectionSection
Odense Odense UniversityUniversity HospitalHospital
[email protected]@dadlnet.dk
InterventionalInterventional RadiologicalRadiological treatmenttreatment
options options ((MinimallyMinimally invasiveinvasive procedures)procedures)
neoneo--adjuvantadjuvant therapytherapy
�� TransarterialTransarterial�� HepaticHepatic arterialarterial infusion infusion therapytherapy (HAI)(HAI)
�� EmbolizationEmbolization
�� TranscatheterTranscatheter arterialarterial chemoembolizationchemoembolization(TACE)(TACE)
�� Radioembolization/brachytherapyRadioembolization/brachytherapy, , internalinternal radiation radiation (Y(Y9090glass glass microspheresmicrospheres ((TheraSphereTheraSphere),), 188Re 188Re HSAHSA--microspheresmicrospheres))
�� PercutaneousPercutaneous�� Portal Portal veinvein embolizationembolization
�� RadioFrequencyRadioFrequency ablationablation (RFA), (RFA), cryoablationcryoablation ((cookcook, , boilboil and and
freezefreeze))
HAIHAI
�� Infusion of Infusion of chemotherapychemotherapy directlydirectly intointo the the liver(tumorliver(tumor) ) –– regional regional chemotherapychemotherapy
�� TargetingTargeting the site of the tumor the site of the tumor whilewhileminimizingminimizing systemicsystemic exposureexposure and and resultant side resultant side effectseffects
�� AllowsAllows a a greatergreater concentrationconcentration of the drug of the drug to to reachreach the tumorthe tumor
�� ReduceReduce tumor tumor burdenburden to to allowallow for RFA for RFA ororsurgerysurgery
HAIHAI
�� AdministeredAdministered alonealone oror in in combinationcombination withwithsystemicsystemic chemotherapychemotherapy
�� OxaliplatinOxaliplatin everyevery 22’’nd nd weekweek and and systemicsystemicgemcitabinegemcitabine and and capecitabincapecitabin
�� ImproveImprove survivalsurvival rates and rates and decreasedecreaserecurrencerecurrence of liver of liver diseasedisease at at twotwo yearsyearscomparcompar. . withwith pttptt. . treatedtreated onlyonly withwithstandard standard systemicsystemic chemotherapychemotherapy. . SignificantlySignificantly betterbetter outcomeoutcome
�� Not in Not in extensiveextensive liver liver involvementinvolvement (> 75%) (> 75%) and portal and portal veinvein occlusionocclusion
HAI # 1HAI # 1
�� 46 46 yearyear oldold femalefemale
�� Mamma c. 1996Mamma c. 1996
�� OvarianOvarian c. c. stst T1 2005 T1 2005 –– nono recurrencerecurrence
HAI # 2HAI # 2
�� 57 57 yearyear oldold womanwoman
�� Mamma cancerMamma cancer
EmbolizationEmbolization
�� NonNon--surgicalsurgical, , minimallyminimally invasiveinvasive
procedureprocedure
�� SelectiveSelective occlusionocclusion of of bloodblood vesselsvessels by by
introducingintroducing emboliemboli
�� IschaemiaIschaemia, , necrosisnecrosis
–– ReduceReduce the the sizesize of of tumourtumour
HaemangiomaHaemangioma
�� 43 43 yearyear oldold femalefemale
TranscatheterTranscatheter arterialarterial
chemoembolizationchemoembolization (TACE)(TACE)
�� WellWell toleratedtolerated, , minimallyminimally invasiveinvasive procedure to procedure to deliver deliver chemoterapeuticchemoterapeutic drug and drug and restrictrestrict the the tumourtumour’’ss bloodblood supplysupply –– controlledcontrolled targetedtargetedchemoembolizationchemoembolization –– regional regional chemotherapychemotherapy
�� HigherHigher dosedose to the to the tissuetissue and and reducesreduces systemicsystemicexposureexposure –– likelike in HAIin HAI
�� ChemotherapeuticChemotherapeutic drug not drug not washedwashed out from the out from the tumor bed tumor bed afterafter embolizationembolization
�� SafeSafe and and effectiveeffective in in achievingachieving locallocal tumor tumor controlcontrol in HCC, in HCC, prolongingprolonging survivalsurvival
�� Stable Stable diseasedisease oror downstagingdownstaging, , combinationcombinationwithwith ablation/surgeryablation/surgery
TACETACE
�� TACE TACE superiorsuperior to to systemicsystemic therapytherapy re. re.
median median survivalsurvival, tumor , tumor responseresponse and and
time to time to hepatichepatic progression in liver progression in liver
metastases from metastases from colorectcolorect. and mamma . and mamma
c.c.
�� More More effectiveeffective thanthan bland bland embolizationembolization
oror HAIHAI
�� More More effectiveeffective in the right liver in the right liver lobelobe
thanthan the the leftleft
TACETACE
�� DoxorubicinDoxorubicin oror irinotecanirinotecan--elutingeluting beadsbeadsDcBeads/HepaSphereDcBeads/HepaSphere
�� Cisplatin/lipiodolCisplatin/lipiodol, , EmboCeptEmboCept
�� MitomycinMitomycin (+(+gemcitabinegemcitabine), ), irinotecanirinotecan + + mitomycinmitomycin+ + embolizationembolization ((lipiodollipiodol, , emboceptembocept))
�� AnthracyclinAnthracyclin idarubicinidarubicin--TACETACE
�� EpirubicinEpirubicin--loadedloaded beadsbeads
�� Not in Not in extensiveextensive liver liver involvementinvolvement (> 75%) (> 75%) and portal and portal veinvein occlusionocclusion
TACE # 1TACE # 1
�� 69 69 yearyear oldold malemale
�� NeuroendocrineNeuroendocrine gastricgastric carcinomacarcinoma
TACE # 2TACE # 2
�� 68 68 yearyear oldold malemale
�� HCC HCC JulyJuly 20102010
Future developments ?
Delcath is dedicated to...
Concentrating the Power of Chemotherapyby chemosaturation of the liver. The idea is to manage
liver metastases through isolation of the organ,
saturation with ultra-high doses of chemotherapeutic
agent, and filtration of the blood to minimize systemic
toxicity before returning it to the patient.
Because chemosaturation is intended to be a minimally
invasive, repeatable way to deliver high-dose chemo-
therapy to the liver, it may have the potential to comple-
ment existing systemic treatments for a patient’s primary
disease.
PreoperativePreoperative portal portal veinvein
embolizationembolization (PVE)(PVE)
�� IncreaseIncrease in future in future remnantremnant liver liver functionfunction to to allowallow safesafe resectionresection
�� Future Future remnantremnant liver liver functionfunction increasesincreasessignificantlysignificantly more more thanthan future future remnantremnant liver liver volumevolume
�� NecessaryNecessary waitingwaiting time time untiluntil resectionresection maymaybebe shortershorter thanthan indicatedindicated by by volumetricvolumetricparametersparameters
�� BrBr J J SurgSurg 2011;98:8252011;98:825--834834
PVEPVE
�� ImprovesImproves resectabilityresectability and and maymay improveimprove
diseasedisease--freefree survivalsurvival for patients for patients withwith HCC HCC
requiringrequiring right right hepatectomyhepatectomy
�� J J SurgSurg OncolOncol 2011;104:6412011;104:641--646646
PVE # 1PVE # 1
�� 52 52 yearyear oldold malemale
�� PrimaryPrimary rectumrectum cancer T3 N1 V0/M0cancer T3 N1 V0/M0
MinimallyMinimally invasiveinvasive interventionalinterventional
radiologicalradiological treatmentstreatments
�� MakesMakes sensesense to give the drug to give the drug targetedtargeted to to
increaseincrease the the tumourtumour dosis and dosis and avoidavoid
general side general side effectseffects –– betterbetter QOLQOL
�� The The effecteffect onon tumourtumour sizesize and median and median
survivalsurvival is is evidenceevidence basedbased
�� SelectedSelected patients patients –– enterenter protocolsprotocols
�� FurtherFurther studies/investigationsstudies/investigations necessarynecessary