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Local Therapies for Uveal Local Therapies for Uveal Melanoma Liver MetastasesMelanoma Liver Metastases
Interventional Radiology andImage-guided Medicine
Emory University Hospital, Emory University Hospital Midtown,Emory St. Joseph’s Hospital, Children’s at Egleston, Grady Memorial Hospital
WINSHIP CANCER INSTITUTE
Darren Kies, MDAssistant Professor of Radiology
Division of Interventional Radiology & Image-Guided Medicine
Director of Interventional Radiology Services at Emory University Hospital
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No Disclosures
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Objectives
• Understand the concept of liver directed therapy• Understand the difference between percutaneous
ablation and catheter directed liver therapy• Discuss the role of percutaneous ablation in uveal
melanoma• Discuss the role of catheter-directed liver therapy in
uveal melanoma
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What is Liver Directed Therapy?
• Oncologic treatment targeted solely at liver metastases– Minimally invasive– Tolerable side effects– Fast recovery– Relatively low risk
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Why is Liver Directed Therapy Helpful?
• Liver is a vital organ• Liver metastases will ultimately
lead to liver failure• Systemic therapies are limited in
uveal melanoma• Controlling liver metastases can
improve survival in certain cancers, particularly uveal melanoma
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Who Should Get Liver Directed Therapy?
• Patients with liver dominant metastatic disease– Primary tumor is known to respond to liver directed
therapy– Primary is removed or is under control– Low burden or no metastatic disease outside the liver– Liver involvement < 70% with metastatic disease
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Curative Palliative
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Percutaneous Ablation• Minimally invasive method of killing focal tumors in the liver
with either heat or cold– Size matters– Location matters– Extent of disease matters – limited role in uveal
melanoma• Heat vs. Cold
– Operator experience is key• Success Rate
– Local control: 85-95%
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Case Example
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Catheter Directed Therapy
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Catheter Directed Therapy• Transarterial Chemoembolization (TACE)
– Chemotherapy + embolic particles– Chemotherapy in the embolic particle
• Transarterial Radioembolization (TARE) – Yttrium 90 (Y90) – Selective Internal Radiation Therapy (SIRT)– Resin Microspheres– Glass Microspheres
• Immunoembolization– GM-CSF Embolization
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TACE• First performed in the early 1980’s• Targeted intra-arterial delivery of
chemotherapy followed by an embolic agent
• Drugs: No standard– BCNU– Cisplatin– Mitomycin C
• Embolic agent– Prevents drug washout– Induce ischemic necrosis
+ Lipiodol
PVAGelfoamhydrogel
PVA Embospheres
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TACE Outcomes
Semin Intervent Radiol. 2013 Mar; 30(1): 39–48.
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Radioembolization/Y90
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Case Example
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Case Example
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Case Example
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• Retrospective study• 13 patients treated with resin-based yttirum-90• PR or SD in 77% • OS 7 months
• Retrospective study• 32 patients treated with resin-
based yttirum-90• OS 10 month• PFS Liver 4.7 months• Less tumor burden = better
survival
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Immunoembolization
• Infusion of immunologic stimulant into liver followed by embolization
• Granulocyte-macrophage colony-stimulating factor (GM-CSF)– Protein secreted by immune cells that stimulates
immune activity
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• Immunoembolization w/ GM-CSF vs. Bland Embolization• OS: 21.5 vs. 17.2 months
– Pt with greater tumor burden had better response• Pro-inflammatory cytokine production was greater with
IE
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Conclusions
• Much more work is needed• Liver-directed therapy may improve survival• Liver-directed therapy may be the only reasonable
treatment option for selected patients
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How Do I Access Liver Directed Therapy?
• Talk to your oncologist– NCI Designated Cancer Centers– Tumor Board with Multiple Specialists
• Seek out an Interventional Oncologist– http://doctor-finder.sirweb.org