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Yeah, wait for a few more people to join. That's uh thank you. Wait for like five minutes and then start. Yeah, hi. I just wanted to check. Are you using Safari? Yes, I am. Yeah, you might have audio issues in about 10 minutes. Okay. Just so you know, um if you wanted to whilst um you're waiting for more people to turn up, if you were able to switch to Chrome, it would be better audio for your delegates. It could start going. What you're here is like a robot. It will sound like a robotic voice. Um Right. It's that entirely up to you. Our preferences. Google Chrome. Sure. I've been on for over 10 minutes with me though and we've not okay. That issue has yet. Okay if you by all means carry on. But if it does, if it does happen, then what you're going to need to do is leave and come back in on Chrome. What are you on a Macbook? Yes, I am. And do you use Chrome at all for video conferencing at all? Not normally, but I have it on my Nytbook can do. So what you might need to do is just um you might need to allow settings in Chrome um like video share ing settings. You have to go to like your settings and then unclip your padlock and then allow chrome the video share NG um settings. All right, you'll see when you try to do it, you'll see that you have to do that and then you have to do a hard quit as well out of Chrome and look back in again because chrome just needs to update yourself. But by all means, if you wish to carry on, that's fine. And let me know how you get on. All right, if you need me a tool, you can get me by clicking on that blue circle on the right of your screen. That's got like a piece of paper in it with a smile on it. You can get me. They're all right. All right. Enjoy, take care. Great. Thanks. See. So I think we've got a few people now. Uh My name is Santosh. Um one of the interventional radiology ST fives uh in the US. It's called Radiology with Southampton Space. And currently placing vomit. Uh Today, I've been given the task of speaking to you about uh interventional oncology with a focus on a blatant geeks. So dive straight in. So, interventional oncology is considered a pillar and counts care alongside medical surgical and radiation oncology. Um So our patient's typically um preferred by the GP with symptoms, get seen um get a scan um and that there's an abnormality and they first see the get referred into the hospital to senior medical oncologists um who will then discuss this case in the MDT with relevant bits of information and various other specialties get involved as required. Um And if the case is suitable for an interventional procedure and they will then be referred onto the interventional radiologist and they get seen a radiology clinic which is often joint clinic with an oncologist or a hepatologist. Um and they will go through the interventional oncological procedure proposed with the patient. Um explain what is entails, get consent in clinic prior to proceed pride and data procedure, then give them data procedure. And on the date of procedure, confirm the consent with them prior to the procedure. So uh do not as following the consent guidelines, do not consent on the day of the procedure. Uh You're only confirming consent on the day. So, interventional ecological practice comprises various procedures. Um There's broadly categorized into diagnostic where we take uh tissue samples such as pharmacy or aspirants uh within guidance, vascular access signees, um simple Pickman lines or dialysis captors, um or porter cats, uh therapeutic procedures which include ablative techniques which we'll discuss in more detail today. Uh And catheter directed treatments such as trans arterial chemoembolization where we're delivering chemotherapy uh to an organ such as the liver uh or trans arterial radioembolization, otherwise called systemic internal radiation therapy where we're delivering beads, carrying radioactive material into the liver. Um and palliative procedures such as strangers which may be signs for refuge in biliary drainage is or nephrostomy. He's moving on to a blade two treatments which we'll talk about much more detail today. Again, broadly categorized into thermal and normal thermal techniques and off the thermal. We will be discussing radio frequency ablation, micro ablation and cry ablation of which radio frequency and microwave use heat. The cryo ablation uses cold non thermal ablation will be discussing irreversible let preparation which I have to admit, I don't have much experience with that all outside of a demo setting in conferences, radio frequency ablation in radio frequency ablation, we use a closed electrical circuit and so there'll be grounding pants on the patient's skin, uh usually on the thighs and that acts as the anodes and there have been inserted electrode into the body into the target lesion. Uh And that is the cathode and we'll pass alternative current through the electrode that causes resistive tissue team. The heat is conducted by indirect heating, the adjacent tissue forming an ablation zone by client. Let's necrosis. Now, tissue charring or boiling will raise the impedance or resistance and it is susceptible to the heat sink effect. Now, heat sink effect is a phenomenon where the that reduces the efficacy of the ablation. Uh when the target lesion is in close proximity, I within a centimeter off a large vessel that is defined as being less than report greater than equal to three millimeters. Okay. So if it is within a centimeter of a three millimeter best a lot more, um you are susceptible heats and effect, which means that the blood flowing within their blood, they're still close to the target collusion will cause cooling and reduce the efficacy of the ablation. Clinical applications of RFA. You can use, use it for hepatocellular carcinoma or liver metastases these when you're using it for uh either you give the option of an interventional logical procedure when there's up to three lesion's that are less than three centimeters in size and there's no extra batting disease. Okay. When you have extra batic disease, these curative treatments go out of the algorithm. The RCC is you want it to be less than four centimeters which is typically a T one a tumor uh for long. Uh it needs to be less than three centimeters and over a centimeter away from key structures such as the trachea, main bronchitis, esophagus and central vessels. All of these changes. Patient selection is through MDT where the imaging is discussed uh with all the relevant oncologist and clinical team present. Uh electorate placement will be under CT or ultrasound guidance and the treatment is per departmental orc it related guidance, different departments use different kits and guidance varies with the kit. Follow up. Imaging is typically in a month to assess response. RFA S are typically quick day case procedures usually with sedation, radiological, let's sedation rather than anesthetic exacerbation. This is an image of a Boston Scientific Levine system. And so you've got, don't know if you can see my cursor on the screen. So this is the box where you connect the grounding pads on here and you set the energy on here. That's the wattage and the time on here. So you typically start about 50 watts increasing 10 watts every 10 seconds up to about 90 watts. And then uh you'll wait for about five minutes from the start of treatment. And what you're looking for is a rising impedance uh where you have this number 50 go up to about 900 odd and this bar will go right up to the top. So when you get the impotence, we call it roll off. When, when you've obtained Rohloff, you stop, wait for five minutes and then start again and again, you're looking for a roll off again. So there's phase one treatment and then a face to your treatment. Um The end point being attainment of roll off and these are the needles. Um So this is a un deployed needle. Um So you insert this through a collapsible introducer uh into the patient on the CT and, or have some guidance. Uh And then once you are happy that you're in the lesion, you press a button at the top and that will deploy the times these are called times and with these times you want them through the lesion extending beyond the lesion. So the times the approximate bit of the time should be uh through with the lesion and the distal bits of the times should be beyond the lesion. Uh That is why that is how you get an ablative margin. So you're burning the tumor and a little bit of uh normal tissue around the tumor. Typically about five millimeters, it's the five millimeters a normal tissue around the tumor. So just as you just talk about reflection margins and surgery, you have a belated margins. And the aim is about five millimeters, normal tissue around the tumor to reduce the risk of accountants or residual disease. Moving on to the next modality micro inflation. So microwave, you use electromagnetic energy and you create an ellipse oil or zone of tissue. Uh heating by dye electric hysteresis that is water molecules aligned themselves with an oscillating electrical fields producing can take energy that is converted to heat. Microwave produces more predictable uh ablation zones, produce higher temperatures. It is faster than RFA and produce a larger ablation zones. It is less reliant on conduction of heat and hence less susceptible to hit the heating effect. It can be applied to treat larger level Asians and you can use multiple probes simultaneously. Whereas an RFA, you know, you use one probe at a time. Clinical applications are similar to RFA though only indifference been making music for larger Asians. So for a sec and Mets, again, up to three lesion's normally, but size. Um There's a different chicken treat up to eight centimetres uh for our CCS very similar, less than four centimeters, 41 hms. Um for long, variable practices. So if it's a primary lung vision, you need it to be less than three centimeters and then tests is less than 3.5 centimeters and up to five regions. Although again, there are variations in different practice settings we inborn with have treated longer Taskings. Patient's who've had up to nine metastases. Patient selection is through MBT. Um um Electrode placement is again under CT or sound guidance and treatment are circulated guidance. All of imaging again typically that month. Um It's typically a day case uh in Southampton, all my grave livers are done under general anesthetic. Um but enormous. Um some of them are done under sedation. Um radiological flat sedation. Yeah, there are a couple of um microwave systems on the left. You have the new wave system which we use in South hunting, um which is quite bulky. Uh And you've got planning software embedded into the system. It is connected to your imaging network and you can load the planning CT onto this uh register the target lesion, uh define the target lesion, register, register the probe and it will give you a predicted ablation volume. Um On the right here, you have a much simpler system which is the comedian imprint system. So this is the comedian imprint probe and that's the new wave probe on the COVID in imprint system. You know, we have the ability to set the energy um time. Uh That's about it. You know, all the planning is not involving the system itself. Differences between RFA and microwave, we will discuss most of them and RFA uses electric current, microwave, electromagnetic energy. Uh RFA uses grounding pads and hence has the added risk of uh skin burns. Uh no grounding pounds and microwave RFA. That's tissue chartering and boiling rise in impedance that will reduce the electrical thermal conductivity. Uh We don't have that in microwave and there's rapid and modernise heating and iron and polarization. Um you attain lower inter general temperatures. RFA, high entertainment pressures in microwave, very procedural pain tends to be high with RFA than microwave, less predictable ablation zone with RFA more predictable and microwave. Our affair more susceptible to the heat sink effect. Uh microwave less susceptible than you think and RFA typically single lesion at a time, whereas microwave, multiple probes can be used simultaneously, more procedural time with RFA and less procedural time with microwave, less ablation volume with RFA, more with my crave. And most uh important for me, I think is surgical clips and pacemakers are contraindications for RFA. The signal, not contraindications for Michael to kind of new small lately force at this point. Anybody speak up, ask any questions so far. Anything that doesn't make sense? Okay. I've asked them to put the questions on the chat so far. We haven't had any questions. OK. Audio. Okay, so far. Yeah, so good, good bowel movement. So moving on to cry ablation. Um So in cryo, we use a combination of rapid cooling produced by decompression of argon gas within the probe that you placed in the patient. And it's called dual Thompson effect. That's a decompression of gas causing a drop in temperature. And it's followed by thawing and the thawing can be either passive or active and passive is without any use of gas. And active is by passive meal and gas through the same Reckford. Uh It leads to coagulate or necrosis and seldom by formation of interesting that mice crystals, these ice crystals are interrupting cellular membrane and selling Mettetal is um and cause ischemia by causing vascular thrombosis. The one of the major advantages with cryo is that you can monitor the treatment. Uh inter procedure by imaging, you can see the eye small form. Um and if it's not forming the shape or region that you wanted it to, you can readjust needles procedure, although most people are known to do that. Um So being able to see the ice cores will increase the chance of you having a complete ablation and reducing risk of injury to critical structures. It is less painful compared to eat based therapies when involving structures such as subcutaneous tissues, poor and diaphragm. Um and it has a wide range of clinical applications including lung, breast, kidney, bone, soapdish tumor's um when it comes to the lung and kidney, most of these procedures on the G A and um hence, they tend to have an overnight stay and the storm supporting day patient selection. As women, anything through MBT probes are placed under CT MRI or, or stand items or whatever you can see the lesion in properly, whether you're going to use for inter procedural monitoring, uh score pra placement. Uh And it's very common to use of multiple probes. Um Typical cycle has a 10 minute freeze uh and you do 10 minutes all and then a 10 minute freeze again and then usually typically two minutes or, and then you can try and have a pull on the needle, a gentle pull on the needle and see if it comes, comes out, um then withdrawal the needles and put some dressings on. And that's it. Uh Most renal cases, as I said, on the G A discharge following day full of imaging tickety in one month. This is an image of a collaboration parentis that's been used in Bournemouth, um marked by Boston Scientific. It's called the Ice Ethics Ice Fx System. Um So this is on this apparatus here, you can uh set the mode to freezing or throwing um and it can set the time for it. And on this, you can connect up to eight needles. So two on each port. Um And they've got a wide variety of probes as demonstrated here and each of these probes um they have literature showing you what shape and size that you can expect of the eye small to form. Each probe will produce the different shape size of the export, moving on to the norm thermal technique that will be discussing which has given us for recuperation, which is what I don't have any experience with. Uh Here, there's news of norm thermal energy based ablation. Um Let me create pause and the selling them and brain spine delivering short bursts of high walls into electrical pulses, typically direct current uh as opposed to alternative current. Uh RFA um the extracellular tissue architecture is preserved and so we can use this, they're at risk structures such as the biliary tree or vascular structures. It is not susceptible to heat, think. So it avoids incomplete ablation in major blood vessels, which is one of one of its perks. Um because you're preserving blood flow into the ablation zone, the inflammatory cells that flood to the area remained perfused and instigates a systemic antitumor immune response resulting in an abscopal effect. And what abscopal effect is, uh it is a regression of nontarget logins. For example, if you've got liver lesion and the lung met and you're targeting the liver lesion with ire. Uh follow up imaging, you may see that the liver lesion has responded. I you have a zone covering the Asian. Uh and the lung lesion may have either reduce the size or disappear altogether. So that's what abscopal effect is. It's pretty cool. It is time consuming and technically challenging. Um Because it requires power replacement in multiple electorates, often under CT guidance. Uh it can cause muscle contractions and cause cardiac arrhythmias. And therefore, uh usually requires G A for muscle provinces, hand cardiac synchronization. Uh and we cannot try to be late. So translation is when uh we at the end of treatment, if you're removing an RFA probe or in microwave probe, um you can set it to a low energy and short time on the apparatus as you withdrawing it so that you are burning the track through which you're withdrawing the needle through. Um by doing that, you're reducing the risk of sealing the track with tumor. We can't do that at night. Sorry, clinical applications of our memory, you can use it in the liver for perry biliary allusions. So, Asians close to the biliary tree uh in prostate and in locally advanced pancreatic cancer, this is an image of a nanny night system again, quite bulky machines. Um That's the practice and the probe and cardiac synchronization device we want case. So before we start the case, I got a couple of cases, we'll go through them. Uh Any questions so far this is naturally vessel stop tour through a belated techniques that I have some experience in. Yeah, no questions on chat so far. Cool. Receive it. Thank God. So place one is a 63 year old lady with a previous history of right and effectively for RCC with renal cell cancer are now presenting with multiple lesions in her single left kidney uh that was suspicious for RCC into. So she went through the MDT. Um she was out of area and she was referred in um for treatment because we operate locally. Um um On pre treatment imaging, we can identify up to four lesions in her single let kidney on the day of the procedure. On the pre treatment imaging. On the day, we identified six lesion's. Um So as highlighted care at the upper pole, this this one here as we go down to more lesion's another end of it occasion here and I'll see you more further down the six lesion's and we ended up using nine needles on this lady. So you can count 12345678 and 99 cryoablatian needles plus three hydrodissection needles, hydrodissection is where we place in Cannulas on different sides of the kidney. Um and inject fluid mixed with contrast uh that is visible on the CT uh too push away key structures such as bowel and or other solid organs that's close to the kidney. Um to avoid a risk of injury to those with the help of energy that we're delivering into the tumor's. Um So nine new prior needles, 300 section needles, 12 needles in a few simple space around the kidney. It's quite crowd ID and plus the biopsy as well. So this is the uh treatment, mid treatment imaging. So we typically do um as I said, 10 minute freeze, 10 minutes or 10 minute threes. And at four minutes from the first freecycle, we do one CT uh then at eight minutes in the first three cycle and on the CT um to see the eye sports form and this is giving us the opportunity to readjust our needles if we need to. Um And then in the second cycle, typically another CT a peek minutes of the second cycle and that's it. Um So here this is the four minutes um for that cycle, CT um inter procedure. So you can see the needle 121211112. You can see the ice ball nicely forming those areas of hypo attenuation very well circumscribed round ice balls with an indoor right bang in the center of it. And what you're seeing is high density around the kidney is the hydro dissection fluid that is pushing away bowel and liver. No way for the kidney. This is the CT image from uh one month post treatment. I'm showing the ablation zones areas. What were the enhancing tumor's? Now there's no enhancement in these areas. Complete treatments don't take the songs. It's pretty good, good way to treat cancer case too. Uh We have a six year old male um incidental detection of a large 13 centimeter hepatocellular carcinoma on long health check CT. So H CCS are um those uh if we've got conclusive imaging, if we are quite confident imaging, they're often not biopsied and they proceed straight to treatment, uh surgical or interventional uh palliative because they're quite confident imaging characteristics that often present, which is hard to your face and handsome with this washer. Um One CT. So this is uh he had a smoker lung health check ct noncontrast abnormality in the liver. MBT proceeded to proper CT that shell HCC and he underwent certain the systemic internal radiation therapy or tear trans arterial radioembolization for large white lobe disease on follow up imaging. After cert there was in evolution of the right lobe disease but with new focus in the left lobe and went through MDT again. And recommendation was for ablation not focusing so on this CT image. So we've got that's the aorta there, vertebral body and the aorta is very bright, but this contrast is mostly in the aorta. So it's a material face ct and this is the in blue, we've got highlighted the right lobe bulky lesion and that the street of insert adjacent, that is the is a rounded structure with less contrast on the aorta. And that's the hepatic Kaveh in Fiorina, Kaveh and adjacent. This light globe is actually the left lobe. So you've got like lobe atrophy scerotic patient and left lobe hypertrophy. So the solution is in the left lobe, a tiny lesion of arterial phase enhancement um in keeping with and there was this face wash up. So this was some keeping with consistency as well. A further lesion further down still in the left lobe. Um And these sort of selected for ablation, the liver in Southampton, we do microwave and you're using the NuWave system. So this was intra procedure need replacement uh new wave system. And this is the post treatment image on the same day showing low attenuation didn't deliver with peripheral peripheral constant. That's the ablation zone. And this is the needle through the second lesion that we were going to treat. And that's a low attenuation treat, delusion revelations own that's in blue is the previously treated illusion that's assert radiation think intervention in the right lobe. However, this patient did not have as a favorable an outcome as sitting previous patient. It's just because the disease was aggressive um on form of imaging a couple of months down the line, we have disease, residual disease or recurrencies at the same sites um with continued evolution of the right lobe disease. But although it continued to involute, which is what you expect after uh certain or tear, there remained continued enhancement. So they re boxing about and there was still viable disease in that as well. So he did not do very well. That brings us to the end of today's talk. A couple of my references. Thank you. That's the end of my presentation. We can make it more interactive. Now, any questions to drive me then wouldn't go any questions. Um feel free to put on the chat. I don't think it allows people to an mute and um ask the questions. So just put on the chat. Thanks very much, Santos for the talk. It's great. That's right. Thank you. Have you managed to see any of these procedures yet myself? I haven't seen any of those. No, but you know, maybe in two months time. Yeah, but fax them down here we go. Um It's Louis. Um So hi, all, I'm Louis 40 of medicine that bsms and previous mention, alcohol, the chair at bonus. Um He says very interesting and you could talk, mentioned the scope of abscopal effect. He asked, have you seen some of the data around using immunotherapy to enhance the abscopal effect? And if so, do you think it's promising? Yes. Um So initial results are promising and again, data out there is limited and we need lots more uh data for it, but it is definitely an area of interest um uh issue is also promising that good question. Something that more and more people will start doing now and generating data in the process. Okay. It doesn't look like we've got any more questions. Um Thank you Santoshi. Um Just plug for next week, next week we've got talk on your aneurysm. So, um, I'm just gonna post a link on here. Now, next week again, every Thursday 5 p.m. we've got, um, I are bites. So, again, welcome to join. Um, ah, here we go. So, Louis has said, and since the pillow is still very, really dependent, what further research is needed to bring. Are you having to go standard? I mean, I owe is gold standard. And even if you are out of area, you are still um referred into areas that are offering it. Um And to make it uh more widely available, it's training, training, training, training, increasing the numbers of people coming into radiology, um getting people into interventional radiology, getting an interest in intervention oncology, selling it through um teaching sessions such as this and every conference opportunity available and getting more people doing intervention oncology. Um That's, that's the only thing that's going to make it more widely available in every center. And then even though you've got the, it's quite complex is that you've got people to do it. There's always a question of funding and all of those need to be agreed. Um And I'm sure Iouk will do its bit in trying to get more funding in uh centers that don't offer it by health capacity to or, or interest to uh and the BSIR and the Eye, you can't be working together to do that. But manpower is the main. Sure that we have at the moment. And I agree. I think there's definitely quite a discrepancy between demand for interventional radiologists and international oncologists. Um lessen the number of people were training at the moment. Awesome late anti for your questions. Okay. I'm just going to send the feedback form to everyone. Uh would be great if you fill that out. Thank you very much for attending today. Thank you status for the talk. Um And please join us next week. Thanks. Thanks everybody for attending. Bye bye. Thanks everyone. I've just put the link for next week's talk um in the chat.