4. 4thleading cause of global cancer death Incidence has
tripled in the last 3 decades, and continues to increase in the
Western worldParkin DM, Bray F, Ferlay J, et al. Global cancer
statistics, 2002. CA Cancer J Clin. 2005;55:74108.
5. In western world, cirrhosis precedes HCC in 95% of
casesChronic liver injury -> regeneration -> dysplasia ->
malignancy Hepatitis C cirrhosis (3%/year) Hepatitis B cirrhosis
(2.5%/year) Alcoholism (1.6%/year) Hemochromatosis (1.5%/year)
Autoimmune hepatitis (1.1%/year) Hepatitis B infection (0.5%/year)
Nonalcoholic steatohepatitis (unknown) Less commonly in Wilsons
disease, PBC, PSCBruno S, Silini E, Crosignani A, et al. Hepatitis
C virus genotypes and risk of hepatocellular carcinoma in
cirrhosis: a prospective study. Hepatology.1997;25:75475.Fattovich
G, Giustina G, Schalm SW, et al. Occurrence of hepatocellular
carcinoma and decompensation in western European patients with
cirrhosistype B. The EUROHEP Study Group on Hepatitis B Virus and
Cirrhosis. Hepatology. 1995;21:778
6. Screening at-risk patients saves lives HCC detected after
onset of symptoms has dismal prognosis (0-10% 5-year survival)
Screening reduces HCC-related mortality by 37%, despite 20 is 60%
sensitive, 40% specific for HCCUltrasound sensitivity is reduced
(3, Vascular invasion, >50% tumor, extrahepatic spread, AST or
ALT >5x normal 1 vial 300-500, 1 vial 500-700 micron LC beads,
75 mg doxo/vial vs. 150 mg doxo in Ethiodol with operator choice
embolic Treatments q2 months up to 3 treatments; tumor response
evaluated at 6 months Tendency toward better response with DEB-TACE
(52vs. 44%) Significant reduction in liver toxicity and side
effects withDEB-TACE Survival was not an endpoint (too short
f/u)
60. Expandable microspheres made ofsodium acrylate/vinyl
alcoholcopolymer Ionically binds doxorubicin Arrive dehydrated;
when placed insaline or contrast, they increase involume (50-100
micron goes to150-300 micron) Soft and deformable, conform tovessel
wall
61. Single-arm trial of 50 patients Child A Exclusion criteria
Tumor size >10 cm, Portal vein invasion, Extrahepatic disease 50
mg doxo or epirubicin per treatment, repeated on demand? Survival ?
6-month results:? Durable effect ? CR in 52% PR in 26% PD in 23% ?
Comparison to LC Only 31/50 followed upbeads or cTACE ? Safe,
well-tolerated and efficientagent to produce tumor necrosis
62. 164 patients with segmental or 125 patients with main PV
281 consecutive patientsmajor PV invasioninvasionwith PV invasion
studied 84 treated with TACE vs. 80 with 83 treated with
superselectiveretrospectivelysupportive careTACE vs. 42 with
supportive 1-year survival 31% vs. 4% care Repeated TACE showed
2-year survival 9% vs. 0% Aggressive repeated TACEsurvival benefit
(5.6 vs. 2.2 Significant advantage for TACE inmonths)was well
tolerated and both segmental and major PV 29% morbidity rate
(similar toshowed significant survivalinvasionsupportive care), no
mortalitybenefits (median survival No procedure-related mortality
Selection bias?10 vs 2 months)
63. Retrospective study of >1000patients 843 patients 70
Elderly patients had more comorbid disease (64 vs 33%) but had
earlier stage of HCC Overall survival better for the old people 14
vs. 8 months TACE tolerated equally well TACE is good for young and
oldalike
64. 114 patients who underwentTACE for post-surgicalrecurrence
50% of recurrences were single nodular Mean size of recurrent tumor
= 2.1 cm Overall survival was 32% at 5 years TACE is safe and
effective forHCC recurrence after surgery
66. Transarterial administration of radioactivemicrospheres
(Yttrium-90) Half-life 64 hours; decays into stable zirconium-90
Beta-emitter with path length of 2.5 mm Particles lodge in the
tumor, producing very high local radiation dose (100-1000 Gy or
more) Not dependent on flow occlusion TheraSpheres FDA approved
under Humanitarian Device Exemption for use in treatment of HCC
Glass particle, 15-35 micron diameter 1.2-8 million spheres per
vial (3GBq) Minimally embolic Two scenarios must be avoided with
Y90 Shunting into lung (radiation pneumonitis) Nontarget
embolization of GI tract (ulceration)
67. Liver-only or liver-dominant tumor, not suitablefor radical
therapy Resection Liver transplantation Ablation Preserved
functional status ECOG 0-2 Preserved hepatic function Total bili =
3.0 No ascites or other clinical signs of liver failure Low risk of
pulmonary effects
