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right. Mm. Good evening, everyone. Thank you very much for joining another virtual international. I Our General Club, which has brought to you by the British Society of Interventional Radiology, is trainees Committee. And also I are juniors. We're working with the Society of Instant Radiology Trainees Group this month to bring you a really hot topic on day. Really excited Introduces great session. So my name is Jim Song, and I'm a training about introduce. My coach has been a hard born on When he Lu, you will be running this session so over to Katrina to introduce the topic and also all the Panelists and speakers. Thank you. So, um thanks, dude. About psychiatry. Harbel nonetheless it by by altering me looking in. The last thing is, do you really? Okay, I'm stuck doing really is one. Yesterday Six, I'll try and knees and then the estrogen is doing really fantastic panel. It's because tonight thank you so much for all of you going to join us. So from the Cristian mantra Steri. But, Doctor, I have a natural I am Dr John Bell on. We've also got Doctor Syndary in from the key opinion and then from the states. We have professor in dusky, um of Northwestern in Chicago on then. We've also got a representative from surtax of this tonight, but with Snowden. So thank you. Off the joint minutes, Onda. So tonight will be discussing the ceratohyal on gonna hand over to my like to John Lee, who's another I'll training from the last minute instantly and he's going to take us through the paper. Thanks very much on D say in terms off what we're looking at today. So you've got the ceratohyal sorafenib versus radioembolization in advance about cellular cost no more. So I should say that one of the S C fives in the West Midlands scenery also in the UK for those are interested. If the presentation goes out, then they'll be references to the article itself. So in terms of sorafenib is a, um, multi kind is inhibitor which is used in a number of treatments for different types of cancers, including that cellular carcinoma on down terms of radio embolization. So really, we're looking at certain for this particular trial on what that is is when you selectively cannulated the hepatic artery and you deploy microspheres which have bean coated, do we say with Yttrium 90 which is, Ah, radiotherapy agent on a tennis be used for in operable procedure inoperable. Hey CC's. All those are not fit for surgery and just as a side note that those that want to comparison so it's quite similar to taste the transport era Cuban amble is a shin. It's like difference being that the rather than being radiotherapy agents, taste is more more typically given a chemotherapy agent, doctor Gibson or MITOMYCIN C, and some trust regards to this area trial itself. So it was conducted between December 2011 on Beast. The population was related sorry from December 2011 to March 2015. It was designed as a open label, so participants on the caregivers knew what was being what a treatment option. Waas randomized split between the two study groups, which we'll discuss it later is controlled in the sense that there's a comparison group free for his trial multi center in 25 units and it was based in fronts on. But it was originally designed to look typically advanced hepatitis A pack to see a cast name is, but there was a slight change in the included population to include intermediate HCC's also and as we said before, is looking at Sorafenib versus search. So why was it conducted? So there's data at the time of the study to say ceratin it does increase survival particular compared to placebo is. But at the time when they did the literature search, there's no large scale randomized trials, too. Look at the effect off cert on Defend anything. There was a Cochran review that concluded, actually those insufficient evidence to assess the benefit or harm that was in given by self. So the question really added it. End of the day was, does certain increase median overall survival with fewer side effects on or better quality of life compared to sorafenib, so inclusion criteria. So, as the name of the study implied, it was supposed to have a diagnosis of hepatocellular carcinoma, either by histology on markers were tumor marker story or by typical imaging findings, CT MRI, and they characterized it into either locally advanced eight cc's so Barcelona Clinical Liver cancer stage see which were discussing a bit new. HTC is not for a section transplants or thermal ablation off the previous like you're hasty, See, either by surgery case and hey, HCC, which had two unsuccessful rounds of tastes. And there's more specifics in here. So over the age of 18, with a life expectancy of more than three months and then a few other categories which we'll discuss in a moment and at least one untreated target lesion for assessment by resist criteria. So the Barcelona Clinical liver cancers staging. So the area of interest a stage see looking at symptomatic tumors and that would also included vascular invasion, lymph node involvement on the testes is in terms of the Ekoko on scale. So we're looking at affectively how fit the patients were. So I'm fully active or slightly limited, able to carry out their normal working nice stop child Pugh score. So they were interested in a Class A scoring five or six or a Class B, Although it covers scores 7 to 10. I they were interested only really in the score seven, and this is based off of the was effectively a scoring system based on liver dysfunction. On probably part of the reason they included these was because the um, one year survival was extrapolated as 100% in Class A and 80% in class, be giving them at least hopefully the three months minimum life expectancy there included in the infusion criteria, and just a reminder for those that are where it's a recess criteria. So looking at complete response. So all the lesions, or least the target lesion resolves, or any lymph nodes that were involved, the short axis becomes less than one centimeter. Um, partial response. So 30 or more decrease in a total, some off the lesion along diameter, stable being it doesn't quite fit in between either partial or disease. Partial responsible disease progression. And this is progression being increase in size or 20 or more percent again of the totals. Target lesion diameter Exclusion criteria's So any other primary tumor will be it that have gotten a small print. Um, not including basis or constant or superficial bladder cancers. Any extra patrick metastases at the time of inclusion into the trial. Previous treatment from the current node of nodule. Rather not, including tastes any contraindications to hepatic amble ization and rather severe complications from hepatic dysfunction. So active job leads and careful up these or refractory ascites in terms of the methodologies. So we're patients were randomly allocated to either having all roast a ref in it. Um, from the time off, inclusion in the or randomization to the groups up to either disease progression by radiological standards or up to a point where the disease sorry to adverse effects were unacceptable or if there was deficit well and usually don't occur within the next week from randomization. Bearing in mind, they were able to alter the dose or stop the treatment entirely, depending on the side effects that were occurring. And then the other group, which will launch swell somewhat interested in, I suppose so, the certain group. So they would start off if a angiogram looking for, well coiling off extra Patties branches and also to assess for the pulmonary strength fraction. And then the second stage would be the search itself with the atrium radioactive particles on do. Usually that would occur within 2 to 5 weeks after and um, ization. Interestingly, they did say that there was some evidence which implied well suggested sorry that the probably fraction percentage wasn't the main thing to be concerned about. So initially they were not, including patients that were getting 20% off the Pomalyst shunt, but rather than the data stroke that it was the overall dose. So the alternatives to that anyone who was receiving 25 graze, um or more two lungs was excluded or least not, given this option or deposition into the gastrointestinal tract or vascularity off, that couldn't be avoided in terms of the distribution. So they started off with 496 patients. After exclusion, they had 467 to randomize, eight of which was true consent, leaving intention to treat populations for each groups of 237 concerts 222 for the sorafenib further exclusion so either worsening disease, early death or other medical causes. The decisions would result in the safety population, which will describe in a bit more detail and then finally, after further exclusions and separation off whether they received the intended treatment or not, we're left with the purple to call population. So from this diagram, it's worth noting that this safety population group from a certain group actually doesn't say search treatment. It says the work up of it, which will come on two later and also 26 of the patients, although from the search allocation group and receiving sorafenib instead of certain. So just a recap intention to treat. So this is assessment of people based on their allocation off group, rather than whether they dropped out or if there was any changes to treatment, etcetera. Safety's population. So this is the group where I, the number of patients was used to assess for adverse effects on these were patients that received at least one dose of sorafenib or, as we were saying before, at least the workups of the angiogram four Certs rather than the tree, um itself and then the bottom group we discussed before. So per protocol analysis is actually looking at the patients that received the intended for treatment protocol. So whether they stuck with the sorafenib for outs on but the assert through the treatment plan as well. So in terms of the outcomes that the Angels, that primary outcome was overall survival and this is based on time, from the date of randomization up to either deaf, my any cause or if they were still live the last state that they were followed up, and then a multitude of secondary factors that they looked at so including the response to tumors the time duration where they would progression free safety i adverse effects of toxicity on also quality of life. This chart here is just Teo demonstrate that from the comparison of certain and sorafenib group, almost all of the percentages between the sub divisions were more or less the same for out. So very comparable group onda good randomization between the two groups in terms of analysis. So they looked, as we were saying before, at safety so adverse effects and poxes city from the treatments, quality of life based on a multitude of surveys and also CT based on recessed criteria, all of which were carried out from the baseline so as close to randomization as possible, um, one month and no three months, their own words for a least a year or until death. So here we've got diagram, which shows the overall survival on Red line being cert on blue lines. Sorafenib. There's no really notable difference as an eyeball was certainly by figures there more or less comparable. So in terms of the mortality, So 83% mortality from, um the sertraline, the Steffes within a certain group of 80% in the strap in a group, the one year survival again very comparable on the means, uh, Vival was more or less the same as well. So eight versus 9.9 months in the intention to treat on be slightly, um, interesting use of data is supposed to have gone for her protocol population, which showed it was exactly the same between the two groups. They were looking at progression free survival again very similar and curves on the grass on more specifics. Within the numbers, we've got the same progression free a number of patients who had progression free intervals on the duration of which was more or less the same. Here, we've got some a graph looking on progression of any disease, any sights on the left side again, more or less the same. But interestingly, on the left, on the right side. Rather, we've got progression in the liver as a first event, and there's a little 0.2 here just pointing out that a certain group is actually a lower incidence. Overall, this is just reiterating the same here. We've got comparisons off the disease, response to the treatments on difficult to tell based on those numbers. But community vly complete and partial response was better in the certain groups and 19% had completely partial response. This is a 12 from UM Sorafenib group. Moving on we've got on 104 patients had disease progression but was interesting is that the search group had MAWR progression outside of the liver alone, whereas comparatively they were more or less the same with the progression within the liver or both I/O of deliver itself. This is the graft is showing, or chance during the side effect. Profile on this was actually analyzed by a group external to those conducting the study itself, and there's a lot of numbers or sorry. There's a lot of numbers on this page, but overall, the serious or any form of adverse effect on a serious, um other or what they call great three adverse effects were significantly lower compared to this reference group. And there's just a less down here, which indicates what was considered a Grade three or more adverse event and in terms of the treatment related adverse, affects the ME number off adverse effects experience by each patient average less in a certain group compared to sorafenib, which it is no overly surprising. Given that Sorafenib is a systemic treatment as opposed to the targeted treatment we've set on this eye ground, we've got, AH, global health status. Based on the question is, and the red line again, is it certain versus dystrophin? Um, and overall, you can see that there's a slice decrease on the eyeballing the charts of sorafenib over time, certainly when they looked into the statistics of it in certain significant um, better result with certain group, both in the intention to tree and per protocol populations. So in terms off what we can glean from that, so there's no real difference off the overall survival. But the tumor response and quality of life was significantly better in a certain group. Off notes, they the serotype did include intermediate stage Hate CC, as opposed to some other trials or studies where they only included advanced a sec on at Baseline. Sarah excluded any extra Patrick involvement purely because the Seroquel was more interested in looking at systemic versus liver talked to treatments, and most of the patients in this trial had vascular extension, which is known to carry a worst prognosis. Competitive extra Patrick involvement Progression free survival didn't show any significant difference. It might be because Thea underlying improvement is being masked by then. Background liver parenchyma, which most of these patients have said severe chronic liver disease anyway. And so it's just, um, got much better progression rates compared to sorafenib at a intrahepatic level. But clearly there's a higher extra patrick progression rate as we still before again, probably because it's much more targeted specifically within the liver, rather than a systemic treatment option. On day were basically saying the same bottle Yeah, in terms of tumor response. So it was significantly higher in the search group, and it is possible that's the ready therapy. Particles could be hiding tumor response or even tumor progression. But the CT they felt it was robust enough to use a CT close to the red purple treatment to be able to detect that, um, but it's They did mention that there was potential for paradoxical increasing tumor size, which could be misinterpreted as progression rather than tumor response. But they were comfortable. They had Brady ologist with sufficient expertise, particularly within the liver itself. Overall so it's tolerability was much better, sort of. The side effect profile was much better, and quality of life, as we showed before, was significantly better in a certain group. What it did mention was that they didn't look at the cost effectiveness off both treatments, albeit both of them work. Knowledged is being very expensive. Onda probably useful to look at the specifics off the cost effective ist, particularly as the search group would have had, at least to, um, day case slash admissions based on the angiography as well as the treatment itself on Be interesting to know what the cost was off the Associated complications will be a There's MAWR complications within the sorafenib group to start the limitations. So they accepted that some of the service group did not receive the originally assigned treatment, although they didn't explain in full detail why that necessarily was so it could take a number of days We were worked up. So we've already said that there can be a delay of up to 2 to 5 weeks from randomization as opposed to sorafenib, which would be the week following. And as we've been saying the time from Randomization can be a lot longer. Many centers had very little experience with search, but within the prettier to be included with in the study the trial needed. Certain centers toe have a least 10 patients off administration, off certain as well, a certification to be included with in the trial on D. They didn't evaluate the actual dose related efficacy off certain itself. So in conclusion, so there's no significant difference overall between the survival. Um, off the two groups, quality of life was much better. Um, compared to use reference it, which might sway or help with in the decision making off which treatment options careful, Onda certain had a much better no call efficacy. And it may have a better than more appropriate role within treating less advanced age. She sees that particularly intermediate one's based on the current studies. Thanks very much, And the questions or discussion points, I still have some really get some, really be on. So you're on the paper for that on if any of our participants Do you have any questions? Please put me in the chapel. It's below, um, for the panel, Um, so that's one of the things I wanted to put this little of sets in treatment pages, See? And that's out defensively. You pay. This is the US Perhaps a week you'd go to on got to mash one in the Christie where you pay the sector. Yeah. Um, so recently, um, this has gone through a process where nice have approved the use of certain HCC with specific criteria. So it initially it Correctol metastases to live also recently gone through that same process, but with relatively strict criteria. Meaning only certain number of experts centers were allowed to deliver some treatment. And a C C is also gone through the same process. And again, it is available on the NHS again through a specific criteria and through specific centers. Um, there is a, um, private route as well where patients can receive, cert, but for a much wider criteria. Yeah, professor and dusky. Hell, um, how does that differ in the va? Sure. So, um, you know, radioembolization has been used, uh, the last 20 years. The United States, um, it uses expanded quite dramatically. Um, both in the types of cancers that are treated in a number of centers, um, that are offering globalization. Um, in the United States the FDA has approved. Um, they're a spare glasses, my Christian radio immunization for a pass on carcinoma. Previous, it was under a humanitarian device exemption. So more recently, it was approved Interestingly, um, or more segmental treatments rather than low bar. Like we're talking here. Um, for us for colorectal cancer, search fears is approved. Um uh, under under premarket approvable for colorectal cancer. Um, the approval indicates using an ah panic our infusion pump in a few TR but I think most probably do it off label here. That's not that that applied. But again, we use realization across the spectrum in a powder sailor carcinoma. I think 10 years ago the patient population studied in Sierra was what many of us United States saw those intermediate, advanced or early in the advanced patients. But if you probably looked at most Central United States were treating more early stage HCC than we are advanced stage HCC and a couple of reasons for that one. This paper was published believe in 2017. It was just before the explosion of systemic therapies or advanced to penicillin carcinoma. So it's rapid. It is really not the gold standard anymore, and there are a lot of options. So finding the role for radioembolization is an interesting discussion in these advanced patients these days. But, uh, given the segmental dose with ah long time to progressions high rates of complete anaphylactic necrosis utilizing this is a bridge deliver transplant, down, staging, deliver transplant. Definitive therapy is for those patients that tumors are outside of what we consider for ablation resection. We really We moved radioembolization earlier in the treatment paradigm, so it was really changed to the United States. While we still consider it for patients with locally advanced disease, we really think about it saying mentally for HTC and intensive, then how you treat that? Because we would not be heard too much about seven technique. I think it's not something you do you go to. Okay, So how how do you go about doing that? Um, well, I mean so there have been several studies now, um, mostly retrospective, but now it's several different centers. One being here at Northwestern in Chicago, another center, Universal Washington in Seattle and then Mount Sinai in New York, um, as well as ah group down in Florida, University of Florida and the main contributor moved to Jacksonville. Um, ao clinic, um, have been published several papers on on the concept of radiation segmentectomy and really the idea of and we look at time to put tumor progressions. Um, you know, we think about chemoembolization or bland embolization is it tends to be 3 to 6 months, but segmental radioembolization, it tends to be two or three years, and most of the time, maybe the studies at five years treated tumor has not progressed. His development of new tumors that it causes the progression metric to be met, um, and reaching segmental doses and the published literature currently is heavy, and the glass microspheres and people are using a resume. Crestor is I think there are some clinical trials now is terms of how to optimize the dosimetry but based on radiology pathology studies, if if you give a based on murder symmetry, which assumes a homogeneous distribution within the segments up to two segments, if you give 190 gray, there's about an 80 85% chance of getting complete pathological crosses. That explains so not radiologic outcomes but actual tissue outcomes. And more recently, um ah new, newer data suggesting we would get over 400 gray. We have all of the tumors have complete pathological crosis. Now the other retrospective studies, they're still small centers. I mean small, serious, single center, but is triangulating. This is a potentially a definitive therapy, and it's important we think about bridging and down staging liver transplant. But also, there is some evidence now that to suggest if you have complete pathological crosis at transplant on the explant, those patients have longer time to recurrence. Longer progression, free survival is that cetera? So I think that the the concept of having complete necrosis as you're bridging therapy is an important one, and that will be doing more and more of this as patients are waiting for a liver transplant. Well, thank you. Um, another question. He has a this toujeo. And three news is and about the training for a certain use of set on down. And then Doctor National was mentioned that it's allowed to do only certain seventies and you pay on So, doctor Natural Doctor about Do you have any side so bad in school? You can train is interested in trying this, um, know Winnie's um, usual coaches come to visit me and Christie and Doctor Bell as well. Um, I think in terms of training, because you are restricted and covitz not really help the situation and the keys to visit the centers, if you can, on break down the procedure to it's basic. So by the time you're visiting said therapy, you have the basics of angiography coil embolization under your belt on, but you need to do is really break it down to the basic principles off. What area of the liver you're treating Onda. How do you go about this safely? S o professor lavender skis talked about the advanced elements of search talking about high doses and said, man tech to me were playing a little bit of catch up there over here in the UK um so the traditional method of coiling off the GED a and courting off the right gastric and saying staying approximately treated The entire liver is really the old school with approaching this. And we are becoming a little bit more vocal on, but I think really the best way to do it into him. The training is to visit one of the centers if you can ah, know Kobe's restricting things and go through both processes. That's both the work up on the treatment process. Um, the indications for senators. Well, we'll defer your approach. So when we're talking about segmentectomy Hey, see? See, it's gonna be a slightly different approach to diffuse colorectal metastases. Um, so again, seeing different cases will also brought in your You're teaching a swell as how we approach each case. Um, so I've got a question from daughter Hammond. Um, so he asked, What's the evidence? What we require in order to abundant this technology. Um, Sara, provide this apologies to John England. I think you know, that's a lovely questions from Chris. Just just to go back to the training element to this, um, let me every day and I think mention the data from the legacy study so I don't stand still in. So So there's just changes all the time I'm thinking about. So when this paper was published, things that this has changed from that time technique. Use a condom CT with dye cemetery. So I, you know, touched on probably about the PSA being used. How we shifted towards petition for so based on symmetry you can when it's segments that to me, you know it's a single compartment because you're just blasting. The tumor was seeing people push those bases. So from a teaching, dispense it. You know, I hugely from my senior colleagues want to start it at the Christie just watching them. The cases We haven't NDTV to choose patients that we're going to treat, but then we bring those patients back to the end ETF to the work up to discuss about the dosimetry because it's absolutely key on. But we just learned from each other's experiences as well, so that the treatment has just evolved hugely in terms of questions, comments. I remember when the Sarah Dates was published in There was concern after So flocks that this in another negative study, and I think a lot of oncologists and you're on so this, you know, no improvement in April survival. So that sense is that, um, but there's so much to learn from this paper. There was a lot to learn from subgroups about the album, about less than 25% about the high sock analysis, like looking at 100 grade two tumors. Um, the disease control and the liver. All these things we learned from Sarah and then the study is move forward on. We don't see a lot of our cities in interventional college e d relieved, but it's all right. Prospective is the work. So that's ambitious of certain text to do, sir Flocks. So a servant to commit to these studies? Yeah, be careful. Survival wasn't bad, but there was a lot to take from. It's on. The recent reviews of Power talked about colorectal commissioning through evaluation, but for a sec, we have this multi technology appraisal, which lots of B cost effectiveness. I accept that that was against the afternoon, but now we're seeing the tes a bath coming in. It's a standard the car in the UK, but the process took three years, and it showed it was cost effective that it had a place, so I attended. That means that was about 30 people that making that decision So it's a very robust decision based on our cities. Um, but it's also role for real world data now, and there's definitely not, um, for certain in the patient pathway to remove more towards personalized therapy. So you have to take you learn from each of these are ct's. The treatment evolves on. That's definite position, but we need to continue to to build the evidence that it's definitely place. Radioembolization. Thank you. I think clearly would also like to make a comment on the cost effectiveness off certain swell clean if you'd like to elaborate. Yeah, things with me. I think. Thank you very much. I think John's already covered it. Actually, I think the cost effective analysis that was done after Sarah, um, servant, it waas a key part of what drove the nice decision on waas. A cost effectiveness of versus sorafenib. Is John funded out on Go? I just wanted to ask that because Jonathan was was unsure about where the cost effective it was played a part. So it did on the informed, the decision, that nightmare and Chris, I know where you live, all right? I don't by the way. Yeah, I want I want to point out some things mean I John mentioned this, but, you know, certain excuse a lot of credit for you're not just the serotype. I'll servant of trials. A ceramic trial, sir. Flocks. Um, you know, it's unfortunate that they ended up negative. Try as you know, in in essence, negative. But this these were bold ventures. Has it been mentioned? You know, pharmaceutical companies do these all the time. They have a little bit deeper pockets. Um, and then they have there are full of negative for all that there were. I couldn't even count how many negative trials came on after, um, sharpen in Asia Pacific to give us sorafenib met. You know, just many, many combinations of systemic therapy, Some that are we're using now. So you have to learn from these, and it's been pointed out a few times. But you know, the patient's election, you know, we as an intervention. Radiologists, they were excited about the technical aspects and the procedures, and you throw in dosimetry and had some complexity. But the patient's election is very important. And you look 45% in Sierra had chemoembolization. Where does that impact our ability to deliver? Why 90? Probably right. 34% had main vascular invasion. Those are patients. We tend not to offer radioembolization it. At least these days we don't. So these are bad patients. They're bad patients in this particular trial. Now again, not not nitpicking, because it's easier to look back and say, Well, those are fat patients. It's really hard to recruit and enroll patients, so you have given take. When you're developing that you make your criteria so stuff so strict you can't recruit patients. But you look at it's a the studies for systemic therapies. They do not have a lot of granularity, and oftentimes those patients are very healthy. They don't give you mean tumor size. They don't do a lot of different things. So so again, I think that there are potentially some challenges with this, and I want to repeat something. I think it might have been drawn again that brought this up. But there was a subset analysis from the, um, Sara study members. It was published, I believe, in radiology last year, where they looked at patients that received over 100. Gray is based on spec. C. T. So now we're talking about partition modeling retrospective of based on our planning day and patient that overhead over one and a great had better tumor control and better survival. So now we're seeing that Dosimetry does make a difference in these patients, right? And that was followed by a more recent study published in Lancet. I think Castro happened 2021 from 80 and green, and this was with glass microspheres. But this was called the dose. See spirit tried. It is very important if you look at it, they're very lot of granularity. Mean tumor size over 10 centimeters. Two thirds had vascular of agent. These are advanced patients, either big tumors and a randomized not versus chemotherapy was glass microspheres first class American. But he used the standard dose symmetry versus a personalized dosimetry using spectum. A delivering over, I think, was 205 gray. And he changed the response rates from 22% with standard dose symmetry to 77% with personalized dosimetry survival one from 11 months to 27 months. And then, really, interestingly, in this really subsidizes heavily bad disease patients, the secondary surgery Rachel patients converted to surgeon was 35% in that personalized of symmetry. Um, so again, thinking about when this study was developed, our knowledge of dosimetry was different. I think it would if we were to redo this study, our patients election would be different and are dosimetry would be different, right and maybe would have a different outcome. But the unfortunate thing is, now we're not looking at sorafenib. And now versus is diesel bed or something else. It's a moving target. And the reality is, I think most people now in this space think it's not one versus the other. It's some type of combination, right? How do we combine these therapies together? Thank you, I think. Yeah, I've heard about some places doing sort of just before receptionists, Well, and, um but we get to see more published evidence about combines treatment. I just want to ask the panel. And what's your view about using surface of bridging treatment? What do you think? Do you think it actually increased the respectability? Oh, increased chance of transplantation on subsequently. Do you think it? We have enough evidence to say that the patient who managed to go on to have resection or a transplant to date that they improve the survival way hurt before that. You know it does. And it comes from a very much the American perspective because we're we're starting on the right inside of B cell C. and moving across the left. And they that's so strong on the on the left hand side and not so much experience there. So the US perspective we're learning from all the time. But it's that time of the secondary treatment. It's It's massively more cost effective than taste because, you know, once it will hold people for a longer period of time. There's also it down staging to transplant as well on this downstage into recession. So was your book called a Curative intent sort of strategy. The role for PSA is massive, and we're quite in experience that that from from the UK perspective, because we've been treating Colorado all for years and it's a different area for us. So be interested to hear what cough low and ask, You said, You know before about that, In his view, yeah, some interesting observations in few of the centers showing after a certain that is ah contralateral. So in some centers, I think they started using this as a replacement. Are conjunction for a portal vein immunization before uh, cholangiocarcinoma a section sell it also the steps so that that is one point which maybe in the future can give us some more options in in terms of treatment. Yeah. Oh, no, go out. I'll go after that. It's like, Thank you. I just wanted to after what John saying And most of you probably know The Newcastle group got some very promising early data which, with both resections on bridge into surgery on, did indeed, with a small number of patients going on to a transplant list, I'm staying on the transplant list safely. It longer and things like that. So was the data is limited compared to the data that professor live in Dallas, he can provide on the signs of certainly certainly very promising. A zit does actually obviously treat the disease in the liver while skier waiting rather than just holding the patient. I was gonna come back to you. I mentioned earlier that most of my patients that I treat with the penicillin carcinoma now or early stage, um and you know now the rules here are that that patients that are within Milan criteria have to wait six months before they get their meld upgrade exception points. So we bridge almost everybody, and we had our institution we used to bridge with chemo embolization. But we've converted to radioembolization because, ah, the both the longer time to tumor progression and the high rates of pathologic necrosis that explant which we think is gonna proceed, give a better outcome. Overall, they're much, much more work has to be done with that. We also use it, um, in downsizing, Um, and you know, you can use a lot of different things and, you know, in our region, when we first started doing this, it was based on the size Resist, not m resist. So, you know, if you're just basing it on the crosis you you could jump right at it with taste or bland. Advil is a shin, but we found a a higher rate of downsizing based on size with white 90 versus chemo embolization. People use ablation for bridging, and that's a very reasonable thing to do. But there is a risk of tracks seeding. It might be small, but there is a risk, and we've seen it occasionally, Um, such that we don't have to bridge somebody putting a needle into these tumors. We don't biopsy many of these because of the risk. And I know you can oblate the tract and things, but well, we can. We can give in a blade of dose through the arteries for that that so ridging and down Staging makes a lot of sense for us in those regards. And then something that been alluded to is, the idea is what's been termed radiation lobectomy. But the idea is if if somebody is a surgical resection candidate, but they're future liver remnant amount of the liver that would be left behind after surgery, it's not large enough to sustain metabolic function of the liver. There are methods to increase that fl are on a portal vein. Embolization is something that's been reported, and it's It is a really fun procedure for us eventually ologists there a lot of debate as to what the best way is it with liquid and ball. It's which most people are sort of going towards now is that particles and coils etcetera? Um, I think the evidence for portal vein embolization is better or more more robust. There's more of it in in patients with metastatic colorectal cancer, there is some controversy of portal vein embolization in the cirrhotic HCC world in the hepatology world. Um, these patients may have some underlying portal hypertension. You from boasts It could propagated that cirrhosis gets worse. And I have main portal vein invasion if they don't undergo resection. If you want to do chemo embolization now you've embolize the portal vein. So there there are things that make sense. Everything is with HCC. I think we're all very comes with the biologic test of time, right? We watch these tumors so they get to a certain size they get put on a list. I have to wait six months. We're comfortable with this biologic test of time, more so than we are with same medicine ical rectal cancer. So I bring that up because the hypertrophy after, um, portal vein embolization is likely more rapid than it is after radioembolization. But you have the benefit of treating the tumor at the same time. So it is something of great interest here in the United States. A lot of us are studying this. We are using it. We do it from our tumor board. There are growing publications and projects on this as a means to facilitate resection. So again really stage a lot of applications for regionalization. Thank you. I think that's what. It's nicely on two, and you want to switch about the future upset weeks. I have to say, That's you touched on so many things there in terms of the UK What the next step scores. So commend people looking at the five year nice strategy. So there's a shift now towards really, well data. Um, so we heard about legacy study before, I think being on the first studies breakfast active that the FDA of locks on be approved. The device for, uh so the boundaries is sort of changing That includes for nice as well. So we there's a need for all CT's but doesn't need for registries as well. I'm just more that that that I see on the Nice Interventional Procedures Advisory Committee, where we look a 79 efficacy, and it often doesn't lead to commissioning and reimbursement. So there's a disconnect sometimes between the evidence, and it can be frustrating seeing that bills over time, you know, drugs coming on board the shifting environment in which we work, and it seems to take a long time to get our hands on on the innovative medical devices. I don't say they're so it's been around for a long time. When I saw it through these processes, I could picture patients who had been down states the reception and cured. Where's the people in the room? Could just look at the evidence putting from the front of them, and it was challenging times. But the right verdict was reached in in the end. So I think there's definitely gonna be changes now with more really well data coming into play and helping Dr Decisions. And there will be a registry in in the UK to collect a little data. Now that may be part of registry, which is a Gorder ATC registry, which collects a lot more information. But we're trying to add some pages to that. That there's symmetry, um, for combination therapies with immunotherapy. A swell, um So yes, there needs to be studied two immunotherapy and everything but some real well data as well. Hopefully a PSA community. We could be better with the symmetry patient put selection on driving the therapy forward with studies such as doses fear that that I think honestly portray It's in a positive light, and maybe we need to be more focused on patient selection than not to general and more types of studies. Um, so clearly you've got thank you dot a bell cleaned. You've got a question for Professor dusky. Um, so you asked, um Is the evidence to suggest the contralateral hypertrophy, um, achieved with are you produce more efficient liver tissue than portal vein? So this is going back to the portal vein. And Bill is Asian. What do you mean by efficient? I think a source of gator that said that whilst with portal vein embolization or about it very normalization, you get a rapid liver growth. The quality of the liver that grows isn't actually, I don't know how to phrase it. Forgive me. Doesn't actually do the job was, well, a zip. It grows more naturally and slower. This is true for Alps, isn't it? But I don't know. I'm not seeing anything between TV and radio and visitation, but without it, it's definitely the quality liver is, um there is it that you get that rapid regeneration, but the function it's affected. I'm not sure about PG and radioembolization. I tell you, I didn't realize it's beautiful outside. Yeah, I mean, I think it's a little bit immature. I haven't seen, um, in terms of comparing PPE versus radiation will back to me. Um, it's it's an interesting question. Um, again, I think that when you treat the tumor, um, that biologic test of time is is good even in. You know, I hate to say it, but in colon cancer, it is to if you're rushing to get to the oars, probably not the right thing for patients. Um, you know, I mean, times we've seen RESECTIONS and then within six months or ablations for colon cancer within six months, they've Rickard, it's a pretty common, but, um, that that's likely to be a good source. I think there's a lot of interest and actually studying PV versus radiation will back to me. I worry that know center is gonna have a large enough volume. Um, it's gonna be a difficult thing to do. And there's a lot of we talked about head originated and how people do things. I mean, there's no consensus how to do poorly on embolization, and yet how to do radiation will back to me. So I think those are are challenging to do. But I think that there's a lot of interest in the good news is the interest comes from our surgical oncology and transplant surgeons have paddle biliary surgeons. I wish is good that they're interested in the things that we can do. And and that's great, because what we do is getting these patients the surgery that otherwise couldn't get there. The the other things throwing the mixes pee in a positive venous deprivation now as well, which boys Gearin open Denise have bean being pushing. So there's always too many options. Thank you very much. Um, I just want to know, like, job for telling us about the plan for you Kayin. And we touch on training side of things just now. A path mention that I've seen coming to Christie thanks to join and path, that's who. Let me come and observe some search. But I just want to say that it is very limited training on which opportunity in the UK because there are very limited numbers off centers doing such a moment. So we've got some training audience that who may be interested in arranged training. So I think now the the training opportunity is is mainly based on. Maybe I also fellowship on do if you can arrange any out of program training that that would be the main opportunity. But the dean, a retraining is really limited, depending on where you are. Which center is available to you at your dinner, every so I don't do them. The panel has got more suggestion on how train you can maximize their training opportunity. I think that's for the UK That is the key, really. So I was a fellow, the Christie, and that's where I learned the principles of search on Garrett on a consultant. And you're right. It is very limited at the moment, and again, Kobe's made it even more limited. Um, there are two main method really is number one. If you're lucky enough to have be within a dealer, that does have a center, which most Dean Aries should do, um, in the UK Arrange with your local side, too, to visit regularly to let the basics of certain. And the second method is to apply for my A fellowships, and we have one at the Christie Um, and again it is. It's a. As everyone of the panel have said, it's a moving target of the moment so things are going to change quite significantly. So when I learned to do certain alone with John and Doctor Lawrence on Doctor Miller and again the basics word to treat the entire liver, we were quite modest on the dose. See it now, particularly John's been pushing higher doses, and the evidence is there to profess 11 dose keys and also talked about how we get a good responses with higher doses. So the key really is if you get a much experience is possible, um, by those two methods are visiting center that deliver said. But also look at iron fellowships. A swell. It is a relatively complex topic, and I think if you are looking to develop your overboard practice scenario, then either a fellowship is really essential. Yeah, as a doctor, John said, the centers which do limited certain opportunities, I think being a following a great opportunity to learn because you'll be more spending or more attack. I'm concentrating, leading to the procedures, I think, with the nice accepting, uh, more indication. Probably the numbers will also gradually increasing gradually. The centers also will start the services, so probably in the future near future. Most dentists will be offering the service in more times off. Going to do a Can I ask Winnie? So in what context did you organize your sessions at the Christie? Because that's out of program. Or how do you know about didn't know is completely because I'm at the end off my training on, But, um, I have been doing HPV mg T. And I felt that is have a gap that I haven't seen any certain because off multiple issues, Birmingham hasn't been able to list any surgery in my time and power, partly because of cough it hands. I tried to reach out to Teo other centers, and lucky enough that's not about was let me come and visit. So yeah, yeah, it's been unfortunate, meaning because I'm going to give you I had enough not enough cases with promesa to do the cases in Straight off our direct, um, things are, At least I'm done with them 78 cases in those one enough years because of corporate. Unfortunate I wouldn't have. He's doing that time. It's a difficult side has been difficult. Hear it because a lot of politics treatments were stopped in the NHS, so it was Tony treatments with a curative intent were allowed to continue a path selling our clinical vital through the coated. So was able to keep certain going and actually changed it to a day case that we said we didn't need as many hospital admissions and so we could keep the service running. A lot of places that service stopped. And now we've had a positive nice anti a decision, some trust driving their feet in starting radioembolization because they have a huge backlog of cases to catch up with. So I would say, You know, we're a close network. We know the 10 centers that offer radioembolization. It's a small community on Just did. You did when you just reach out. When it comes to our program experience and things like that, you're not supposed to take it, and you're finally your training. It depends how good an understanding your post graduate beans are, but they should pay, and you don't really need to tell him you can. Just if you agree with your consultant that you can have you come over and get experience that neighboring trust the organization, they should be very willing for you to you to do that on. We're happy to take Christine. The the other thing as well is to make. The other thing to mention is that curve. It eventually will hopefully allow us to interact again. And we've been working quite closely with certain text to develop some form of virtual setting where we can teach the basics inserted. But we hope one day we can have in house courses again know which we have done in the past, which is an excellent opportunity for both trainees as well as consultants who want to get a little bit more experience Insert. No, babe, I useful. Yes, I think the other thing is, well, sorry, Teo. To interrupt is the empty T. So No John and both John and Professor Libido, ski mentioned Tumor Board and MDT. They are essential to the process of Sirte. It's the actual process of performing. Assert. Therapy is relatively similar to other embolic therapies. There are principles behind, um, dozing, of course, but I think if you can attend or get gained, some experience in the tumor board on the MDT process in how your Celexa it is as essential is a process itself. I just got a final question from one off the audience. I'm any advice for consultant wishing to gain experience? Insert. Is that from Chris Michael? Um, but yeah, just the surface consultants. So we're seeing now with a nice decision that the easy thing is for the 10 centers that were commissioned before. Continue with expecting other centers to come online in year, two years, three years and numbers grow. Trying to build the service is not just about the IR is ready. Pharmacy it. You can that So it's a whole training program going. Glenn is mentioned here that surtax Boston on through my whole have training programs, which often in involved traveling. So I'm sure they've adopted and come up with different methods. But often these are driven by the companies to support your training needs. But it would just be the IR be a whole group. So you need to say everybody with you. You can't do this service unless you have the support off the you know, whole team of people. I don't think it's complex it until I see another sense to try and start it because I take for granted the people out. We were a quest on the way that their ducts and you just think about the therapy eso It's not easy to start a new service because you need to get all the online. But, um, if people reach out to us than that more than welcome to Glen, any of the Boston Wraps through miralax will help drive it as well. Yeah, well, thank you. I think we're coming up thio and time now. So does anyone have any final points that they wanted to lay add? You know, I was just going to bring up a tissue in the United States, the site of intervention Radiology has had a wine 90 course for many years, and I always been 7 10 years. It happens usually January, February. And, um, you know, if you remember and I think as a trainee, you might be able to get pretty cheap membership. You could probably get in and start to see. I i Again, I don't know what the logistics are, but I'm pretty comprehensive program from patients. Election dosimetry angiography cover some of the basics of more common cancer types. That's another way that at least gained some experience. Actually, some of them actually included the physics. Ah, rehabilitation. Um, Well, so it'll probably happen again in 2022 again. Look for it early in the year, but it is something to consider. Not definitely. Sign up with that. That's great. Um well, uh, I think we are just not ready to about this session out. So I just, um It's a huge thinking too, about Panelists on for agreeing to come. You're on. Do discuss this with us. Thank you, too, John, for the presentation on until million Gym for helping to organize this session on. Yeah, please complete the form that we've just placed into the chat on. Be useful to me, Get you back on the sessions and also suggests that even want to discuss in future. Gentle, clipped on. Um, look forward to seeing you and make sense. Thanks very much, everybody. You take care