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Hi, everyone. Can you hear me? Is there someone in the audience? You can just pop in a chart or a shout out if you can hear the audio. Great. Thanks. Call us. So welcome to our seventh in the series of the'yre bite storks. Thanks for taking the time out of your evening to join us. Doctor, you will be speaking on the cutting edge treatment of liver cancer by interventional radiology. So liver cancer is thie fifth largest cause of cancer deaths. I'm once we include other cancers which conspired to the liver. It's It's such a large challenge there. Many patients were not suitable for radical surgery transplant on. Actually, I I can offer this group of patients quite a lot when he is a consultant in Coventry and West Midlands specializes in HPB intervention on she'll be talking about complex targeted treatments, technological breakthroughs and, most importantly, how to select which patients who will benefit from which treatments. Just before we begin our next talk eyes on Thursday, same time, and that's on M s. K. Interventions will take questions throughout if you just type them in the charts. So if you type of questions in the chat throughout. We'll read them out and go through everything and address them at the end on. Then after that, I think metal sends a few back for him, which allows you to claim certificate on day, one hour of COPD education on, um, after the session, the livestream in the notes will be available to you on metal. So, without out of the way over to you, Doctor. Thank you, Mike. Son around. Thanks for joining this'd Evening sessions and mining. It's really loomed. Consultant, interventional radiologist at the hospital Commentary more richer. So I have been asked to talk to you about intervention and liver cancer, So just got to go through liver directed therapy with you, This IV flank. So, um, what I would like to go through is some background on hepatic malignancies grading system on some treatment options on I would like to give you overview off the liver director therapy and types off difference liver doctor therapy that we do on the roll off interventional radiology in the management off liver cancer. So just some background about hepatic malignancy. So the primary liver tumor we treat very often is better cellular carcinoma and Cholangiocarcinoma. There would be some rarer tumor that retreat this well, but these two moles, current ones on the taking the read cancer I matar disease would be most commonly coming from Kabul. Rectal on your and the crying tumor off breast or sometimes cycle mark slightly rarer. There's some chronic liver disease going systems. The most common one now being used are the child Pugh score on male score. Mostly child Pugh score. Been used in staging liver cancer, particularly using for as a quite a urea for transplantation on other liver on by director therapy. So on the left table, there's a show you how the child Pugh score is calculated. It includes things like clinical size off ascites on a path of the and tests including Blue Ruben albumin and problem being timed on. Then you add up to schools, and they would give you a childhood plus a plus. Being classy. So, child Pugh A. Basically, is. The early stage be is into me. Dips and C is quite advanced. Um, aus score is slightly complicated. It's got some formula in it, and it's showing on the right side table. So I'm staging, particularly for HCC and those metastases will be completely different. And it's different. Different primary cancer. So I'm mainly just going to go through staging off, happen to sell a house, a normal in this talk. So I got the oh PTN staging, which is a shot in this diagram on what I particularly want to highlight to you is the land righty referral liver transplantation. This criteria has been used for decades and it's still being used. So essentially those are before, um in within criteria off the Milan criteria for transplantation is basically based Stage T two on opening T End staging, which essentially means if there is less than three little lesions which are a less than three centimeter, they are within criteria or, if there is a solid religion less than five centimeter, it's also with the liver transplantation criteria. So a lot of treatment algorithm, the most commonly used is the pass along the staging and treatment strategy, which has been reason the revised in 2022 on here is a bit complex it would encounter in. It will come in the patient stage off cirrhosis so very early stage early stage this age, advanced age and terminal stage That's actually calculated. How if I say liver diseases and also taking two accounts? What? How many lesions? They are actually on this table and that it wasn't give you the treatment options. So for the early stage, we would be talking about a glacier, which is a curative, intense treatment or surgical reception on Been in the media intermediate stage we're talking about patient will be referred for transplants. Oh, could be taste, which is chemo embolization. And then the more advanced age we will be, then be looking into systemic treatments came with therapy therapy. What is additional to this lots is in the lower part off the take. It does mention radio ambulance station, which I will talk to you about a bit bit more healthy. So what? Um, liver director therapy is essentially it. Direkt Lee target on cancer in the liver, and it's a minimal invasive treatment. So we're not talking about surgery. We not talk about surgically resect one lesion, so this is minimally minimally invasive treatment, mostly by interventional radiologist. Sometimes it can be done by surgeon during a open operation. So, for example, they can blaze a lesion with being and when the patient is open up, um, it is particularly used. Um patient is not fit before surgery or disease is not suitable for surgery, and it could be staying alone or in combination with surgery or chemotherapy on those therapies and more systemic treatment and the treatment in turn for liver. The therapy. The's minimally invasive methods it could be curative could be bridging. And so meaning disease control before surgical resection or down staging to allow them to do social resection could be bridging before liver transplant. So we just control the growth of tumor so that they remain with being delivered transplant criteria. Or it could be related. So just a little diagram to show you the different types off liver director therapy that's often do by I. Also on the top, we've got trans arterial amble is Asian is essentially it's going fruit artery, then never get into the liver and give some direct therapy to liver itself, which would include bland and Bill is Asian. So we put in particles with no drops, so our taste, which is a sample ization we put in particles which has got drugs, chemotherapy long on to them or certain, which is radio active beads where you embolism a shin on at the bottom. The yellow is showing you the thermal ablation, so that's three mg that we mostly used. So read the frequency or cry operations on microwave ablation on Do the non. The normal ablation are more reasons technology, So I R E or his toll history trip see which I would explain to you but later on and the red is another procedure, which is a very specialized procedure, is only done by three or four center UK. I'm not currently using this, so it's essentially infusing the liver with very high concentration off chemotherapy. I will dislike that method to you a bit later on. And then we could protect IQ body radiation therapy, which is also counted as little diary for therapy. This technique is not used. My IR is on by the oncologist who do with radiotherapy so I won't be going through. That's today. So talk about operation so thermal ablation. This is what we've been trying to show only using in the last few decades. So it's most often is curative. So if a lesion is quite small, we're talking about less than three centimeter on, but they are in a place that is successful by these broke. Then we will choose to bleed it because this is a different type of essentially burn the tumor out on by the heat generated or the thermal energy January Touch base by three method. So it's either from radio frequency machine or microwave machine. Oh, a prioritization machine on the choice does depends on Schumer size. It's quiet. Ablation does allow us to burn out or treats slightly larger tumor slightly mawr than three centimeter, where the other two mainly retreat, ripping three centimeter limit. And also this could be done pachytene you asleep, ordering open surgery so painlessly we don't need to open up the abdomen. Actually, just put the probe through again under image guidance, or we do combined procedure. When the surgeon open up and reset some off the lesions, they want to reset, and then we can then go in a program. The patient has got open abdomen and then to go in with the program for the collision. So the minute the extent off surgical resection on the sometimes general might not be true might not be accessible talk. We're talking about populating this route when the patient is not suitable for any open MRI. Then we have to try getting to the liver lesion looking patients percutaneously. However, there's some time that it would not be suitable. For example, we correlation high up in the under the diaphragm. It was everything dressed you to do that or this close to a very important structure such as the Ivc. Then we might not be able to burn this lesion. So all these suitability will be discussed in the HPV. On the complications involved would be mainly though more injury from to the liver structures around. So we're talking about and the vessels or bile, that if the bottle get a thermal injury, they will become ischemic and they can constrict and have a restrictor. Oh, you can get a leak or the surrounding organs could be at risk. So if you got lesion right next to your bladder, that goblet quit protect perforates or bowel or kidney or die friend they can, or the risk off injury. If this tumor is very close to it, well, we boil it, um, so let's hope off ablation list on mon Thermal ablation on. So one off the technique is reversible electoral per a shin. This is essentially to create currents between two electoral which we insert around the lesion on do, um that would then start the electric currents and the cell membrane Komi a ble. And then they start leaking a lot. These material from the cells and the course, a reversible damage. The actual true myself. It is usually used to treat or trimmers us less than three centimeter on that you can see in the CT image in the right, lower issuing you ring enhancing lesion on in the middle diagram. Then it shows that this three electoral put into that lesion and then once we start the electric currents, it will start burning that lesions. And then the self is the right bottom, um, imaged, which showing you some gas thing in that populations like so this's normally use when a lesion is the main blood vessels because in set off burning, this does not cause any thermal injury. It only burn off the tumor cells. It doesn't cause injury to, but vessels and the other one, um, my thermal ablation is called histo trip see so anything trip scenes that we use ultrasound wave eso the sound wave itself. When it's pointed to the at a very high frequency, it will kill the kill the tumor. This is still being a face to trial at the moment on leads, and you Castle are quitting and for for this place to child. So we're waiting to see the result of it. But is that the most recently developed technology for liver tumor? This is completely non invasive, non a non issing and on thermal, and it does not involve putting even the needle into the patient. Need to be done under general anesthetics because it could be painful and there's a lot of set up and pay attention to. It does give immediate response. I am on the laboratory model, but we'll wait to see the result off the face, too, next weekend to talk about trans arterial embolism, a shin. So the reason why we can do ambulances Asian and Schumer is because off the special blood supply into the liver and into the tumor, So the normal liver parenchyma is normally supplied by portal vein, which supplies 75 off the blood going into the liver and only 25% off blood going into the supply divided artery. However, the true murmur which generates a new blood vessels forming they are from the artery. So 95% off tumor Blood flow is coming from the artery. So you can imagine if we put something into the artery that would prefrontal go into the tumor which allow us to give special, um, to give more collides treatment in the tumor without causing too much harm off the liver tissue surrounding on the typesof beats that we put in is could be a bland, non drug longer beat that went This is bland vision or we give feats has contains king with her repeat. So, um, this is a team age diagram showing Translate your chemo embolization, but you will see the same kind of happened and you gram in a bland and like, you can't tell by just looking at a hepatic angiogram. But for this case, this is a chemo embolization. So in a way, you can see this one blood vessel going into the armed tumor. Um, this is a very hyper vascular tumor. So once we see that we will inject thie. Keep hold of beads into it on. But it was that the tumor and then this tumor would start to die off with the help with the king. With therapy eso we normally for a lot patients after weeks to see the tumor response with either CT scan. All right, Andi has been effective treatment for liver the primary like a tumor or colorectal Tartus. See, But we mostly do this in hepatocellular carcinoma at the moment. And this, however, is no accurate if intense treatments because Jima wolf on a new blood vessels your blood supply. So this is mainly a disease control treatment or we all the tumor growth. Enough with the patient to remain on the transplant list. And this, um, I'm going to talk about slow, which is selective. Internal Asian therapy is another type off. Transacted around Bill is a shin, but what is different from chemo embolization is the's beats or spears. It will be, um, it's a radioactive isotope on the actual radiation killing do tumor cells. So it's essentially it's like giving radiotherapy to a tumor, but through transit, your route to be done as a curative intent off bridging interns or a polluted on the radioactive trace that we use is why 90 which is the most common one and more recently home on this wine is being in the chest Commissions. Treatment is normally done juice treatments because we need to do planning to know that what stalls we should give to the actual true more. So the work is we give, like a ghost spear to do some, calculate the medicine skin and then once we've done the calculation and decide what those off the actual fields we should give, we will get the patient back in two weeks time to give the treatment. And those calculation has been fine to the most crucial elements to achieve good results because we have to give the girls about 120 TOB able to get a good for for the tumor. So this is a technique or better infusion chemotherapy. Currently, I don't do this done in very specialized cancer center, but essentially is require one capsule to go into do hepatic artery on day Thea other catheter basically block off the vein before and after the hepatic vein that all the treatment you give from the artery. It stays in the liver in food for, and the chemotherapy will work better than a systemic chemotherapy. Um, So, um, with the diagram explains this you can see in the ivc about stir liver, and below that on, then we'll start infusion through the machine on this left into in the patient for for about 24 48 hours to to the chemotherapy running. So in Greece, um, the treatment for hepatic militancy are evolving. This new techniques coming out every few years on it's rapidly growing area and with a lot of innovation, which it's all sounds very promising. But we wait to see more results from or these clinical trials. Plans are very complex sometimes, and we do go up and down the treatment from time to time. And so no one treatment plan suit all on this spot or discuss in special specialist center a few BMD tea, and that's a lot of research opportunity, if any. If you want to get into, please contact me. And thanks money. That was a really interesting talk on the great instructions. All the treatment modalities. Um, we've got, um one question from phase job. I was asked, Um is wondering if there's any places in the UK that give introduce moral immunotherapy. Has that something you do it your sense of entry? No, no, this is not something I do. I have heard of this and sometime is given by the gastroenterologist. Sometimes it's done by oncologists, but not I haven't known. And the IRS doing that in this country. Okay, on, um, I know, uh, on sort of a theoretical level when you live tumor cells, there's an immune response to that. Um, is there sort of, ah, joined up pathway to give systemic immunotherapy? Um, after or around, um ablation eso? Yeah, we're talking about micro metastases, and often when patients intermediate or advanced age and the oncologist will be very keen to give some chemotherapy. So sometimes it could be a Patients go on a king with therapy for some time, and then the cancer is being controlled. And then they will then refer us for ablation or taser or even surgical resection. Sometimes it could be both treatment. Go along each other s so it's very variable. It depends on the behavior off the actual tumor. And how's the patient has seen has been doing S Oh, yes, combined treatment is not uncommon. Okay, that's really interesting. Thanks. There's another question from Moustapha Abdulrahim. He's asking, what are the indications for percutaneous ethanol injection? HCC. And how far is it effective? Right. Okay, that's all right. I know. I don't think is a common practice in UK to do injection or HCC because we've got a lot off other ablations My buds on death know is known to be very painful. So on And the results I don't think it's anything better than any of the foam or Blaszczyk, so I think most commonly using UK is a relation for mobilization. Excellent. And then there's one more question quite open. Open space wires tastes not curative. So taste. It's essentially infusing the liver tumor with chemotherapy on. You can imagine chemotherapy normally just control a tumor. Um, so, um and true, my will grow. So unless your master cool off or the cells the tremor will will, um, we will grow again on. But it was suck more blood supply and have more Nugent and angiogenesis. So tasas because you're only giving chemotherapy to a special region. It's licensed in my therapy is never a curative. Um however, start radioembolization tends to kill off the tumor. Self mortification. Really? So most often we see curative and result insert rather than tastes. Does that answer the question? I've got one more question. If I might, could you sort of for the sort of patient journey from oncology to getting, um, an IR procedure? Um, could you just talk Talk about the steps because it seems like it's quite ah um big commitment to make with, you know, some of the check procedure before the certain eso do you have like, a clinic when you see the patient and explain everything Or do you leave that to the oncologist? Yeah, sure. So normally, for example, in HCC so the patient would normally be under surveillance Under Hepatologist Onda, it's often is picked up by the hepatologist. That's there are the AFP zero Merapi is rising on Ben. When they do a scan, they find the liver lesion which apply HCC. So then this. Then get with fires to HPV mdt. So initially, BMD tea. We will have the issue The surgeons we will have interventional radiologist but diagnostic radiologist on with the hepatologists. We've also got oncologist, so it depends on how admires that patient's disease is. So if the patients got multi focal disease, which does not fit million criteria for transplantation, then we will then talking about treatment. So either it's a local regional treatment done by. I are. The patient has got a lesion that is completely receptible or it can come out in the hepatitis A me Have you have protecting me? Then you will be managed by report to the surgeon. It has got more extensive disease, and we think ablations or Tasers, or so I'm not suitable than he will be. Refer for oncology. So we often make some decision in the HPV entity, and also depending on the house that the patient is, then it would determine what's treatment the patient's suitable. There will be some lesions that's completely picked up, incidentally, by other scans against the often would come through to HPV entity for other cancers. They will be picked up, For example, is a colorectal metastases, the liver lesion picked up on the colorectal follow up scan. They will again get discussed in the car or Acto colorectal MDT, and then get referred to a HPV and et cause some off the nation might be resectable or treatable. So by by the liver surgeon told my I. Also this is normally the referral pathway we get, and then it fall on to that. Once we decide the treatments. Normally it will be the primary clinician who will see the patient first because they noticed patients background better and they know their fitness better on. Then they would discuss the treatment options that's given by the BND tea and if the patient's agree and want to consider that than the if it's for I are so example population or thirties. They were then referred to us and we will see the patient in clinic. Okay, thank you. So it's That's a really good example of my eyes, you know, moving out of the reporting room in the procedure to seeing there in patients in the clinic before procedure, which is always great to see. I think most of my are consultants now would have a clinic. So which you see also different things fibroids for for college. So okay, one more question. Would you usually biopsy the lesion before treatment or proceed with treatment based on imaging findings on Balfa feta protein. Yet so quick questions. This's a process that is currently changing. Now more traditionally, we depends very much on imaging because HCC, it's mostly diagnostic on an MRI. So if we see a lesion that has got our to enhance month and they wash out very quickly with the patient with background, liver disease, cirrhosis it, liver, then we wouldn't say that this is a CC now, because now in in when the therapy has come into the treatment, our thumb on that would definitely require a biopsy to see whether the patient is suitable put you on therapy. So most of the time now we do try to do a biopsy before we treat solution, so that if the patient thus progress after and the local regional therapy, we can refer straight for in therapy. And it's easy for us to do you when when we go in the blades. A lesion. We can easily just took a biopsy before Blake in on day. So we do do that increasingly now. But very good question. Excellent. Well, thank you, Doctor. You That was a really interesting talk. A great introduction to all the treatments we can offer on, Yes, such a thorough explanation of the patients pathway from the diagnosis through to your treatment. So thanks for talk. Next session will be next week on SK Interventions on That's the same time Thursday, seven PM Uh, um in the session Now, unless anyone has any further questions. All right, then. Thank you again, Doctor Liu Onda. Have have a good evening, everyone. I