Upload
others
View
3
Download
0
Embed Size (px)
Citation preview
L’Interventisica Locoregionale:L Interventisica Locoregionale: Quale ruolo specie nella malattia biologicamente
indolente?
Florindo Laurino Fac Medicina e Psicologia SapienzaFlorindo Laurino, Fac. Medicina e Psicologia, SapienzaAz. Osp. Sant’Andrea, Roma
Metastatic Colorectal Cancer:Metastatic Colorectal Cancer:the magnitude of the problem in Europe Colorectal Cancer: 450.000 per year (the second most frequent cancercancer
• 200.000 deaths/y about• The CRC-related 5-year survival : 60%• the m-CRC-related 5-year survival: only 6%
Metastases Occurence: • 75% of pts will have metastasis (25% at diagnosis,50%
during the desese) th 330 000 f RCR• more than 330.000 of mRCR new cases per year
Liver Metastases:• 85% of metastases are located in the liver
Indolent DiseaseIndolent Disease
Multidisciplinary Teamy
Oncologic Oncologic ggIRIR
RadiofrequencyRadiofrequency• Tumoral tissue heating
(60° - 100° C)( )• Cell death
(thermocoagulation necrosis)(thermocoagulation necrosis)
Molecules ionic collision
Heat productionHeat production(coagulative necrosis)
MicrowavesMicrowaves
Tumoral tissue heating• Tumoral tissue heating (65° - 150° C)C ll d th• Cell death (thermocoagulation necrosis)
No corrent flow through the patient
CryoablationCryoablation
El t tiElectroporation
HAI(Hepatic Arterial
I f i )Infusion)
• Transfemoral accessTransfemoral access
• Angiography
• GDA obstructedC th t l d i t• Catheter placed into
common hepatic artery
TACE / TAETACE / TAE
• High selective
• Less Data
SIRTSIRT(Selective Internal (Radiation Therapy)
90• Y
90
• glass spheres
resin spheres• resin spheres
Li M t tLiver MetastasesLiver is usually the firs site of metastases
• Hematogenic spread: portal vein -> liver -> lung -> other organs(1541 CRC necropsies *)( p )
Vascolarization:Vascolarization: • CRLM: almost exclusively by hepatic artery (e.p. if > 3cm)
N l li f ti ll b t l i• Normal liver: preferentially by portal vein
*Weiss L et al., J Pathol 1986, 150:195-203
New terapies have determined an increase of OSof pts with non resectable CRC LMp
Minimally Invasive Therapy
RF TACE
MWAMWA
HIFUHIFU
SIRTHAI
TAEHAI
TACETACERationale
• Irinotecan is a major drug for the treatment of• Irinotecan is a major drug for the treatment of metastatic colorectal cancer
• Anti - angiogenetic agents have shown an efficacy in the systemic treatment of mCRCthe systemic treatment of mCRC
• Increase of local concentration of drug has always given a benefit when compared with IV administration
Dc Beads it is possible to load chemotherapyDc Beads, it is possible to load chemotherapy into the Beads
It li Ph IIIItalian Phase III
P i bj ti i 2 OS b 40%• Primary objective: increase 2-yr OS by 40%
Fiorenitini G, et al. Anticancer Research 2012;32:1387-96
TACETACE
Fiorenitini G, et al. Anticancer Research 2012;32:1387-96
DEBIRI: a high level of evidence, a need for standardization
Single metastasis
Embolization
May 2014 prey p
September 2014 postSeptember 2014 post
PostPre
Ablation Therapy
Indications
• 3 or less liver lesions (< 3cm)• 3 or less liver lesions (< 3cm)
• Poor response to CTPoor response to CT
• Residual cancer after CT
• Pts unsuitable for resection
• Associated to resection
Ablation Therapy
Negative Prognostic Factors
• 4 or more liver lesions
f• Diameter of the lesion > 5cm
• Safety halo < 1cmSafety halo < 1cm
• High levels of CEA
Ablation Therapy
Lung MetastasesB k dBackground
Most cited primary malignancy: colorectal cncerMost cited primary malignancy: colorectal cncer
Main Actor: clinical oncologist
BackgroundBackground
• 5-years survival between • 17 studies, 1684 patients
Mortality rate less than 2 5%
y41% and 56% (median 48%)
• Mortality rate less than 2,5%• Single metastasis: better
outcome
Best Candidate: SurgeryBest Candidate: Surgery
• Prolonged disease free internal between primary and metastases
N l CEA• Normal CEA
• No nodal involvement
• Single metastases
New Trend: SurgeryNew Trend: Surgery
The beginningThe beginning
• 4 patients with 5 metastases
• Not suitable for surgery (comorbidity, refusal, etc.)
Ablation: the firstAblation: the first prospective studyprospective study
• Multi-centric, single arm, prospective trial
• 73 metastatic patients
• Patient selection: unsuitable for surgery SBRT and CT• Patient selection: unsuitable for surgery, SBRT and CT
• Overall survival: 66% and 64% at 2 years for CRM and other
metastases respectively
Need for comparative trialsNeed for comparative trials
Ablation:Ablation: today
• Overall survival rate 51% at 5-years as per the major surgical series
• 24% of retreatments up to 4 times with no change in respiratory functionrespiratory function
More than surgeryg y
S h t t d ?So what to do?
• > 50 pts, > 24 months follow up
• 27 studies: 4 RFA, 23 surgery (no SRBT eligible)
ConclusionConclusion
• Lack of phase III trialsac o p ase a s
• Surgery: largest series and longer follow up
Trials OngoingTrials Ongoing
No comparative or randomised trials at the momentNo comparative or randomised trials at the moment
Ethical implications?Ethical implications?Long lasting recruiting time?
Population dimension?
C l iConclusionAblation Therapy Embolization
• Minimally invasiveRapid execution
• Effective in second lineand further• Rapid execution
• Low rate of complications,bidi d li
and further• First line?
morbidity and mortality• Low cost (Day Hospital)
• + systemic CTx?• Waiting for SIRT trials in
• High rate of effectiveness• First choice in lung
gprogress
• First choice in lungmetastases?
GrazieGrazie