ivan marri, camillo aliberti unit of oncological diagnostic and interventional radiology, delta...
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Ivan Marri, Camillo Aliberti
Unit of Oncological Diagnostic and Interventional Radiology,
Delta Hospital AUSL Ferrara, Ferrara Italy
GEST 2011 April 27-30 Paris
DC Bead Terumo Workshop
DEBIRI on colorectal cancer liver metastases: personal
experience and tips & tricks
Intra-arterial treatment of liver malignancy with drug eluting Beads:
Global Report of five years of experience (from March 2006 to March 2011)
• 357 patients treated • 626 TACE• 2 cases of major complications(1 acute pancreatitis and 1 liver abscess)
GEST 2011 April 27-30 Paris
DEBIRIDEBDOX CholangiocarcinomaCholangiocarcinoma: 54pts
Pancreatic Cancer: 8pts
Breast Cancer: 22pts
Gastric Cancer: 8pts
Carcinoid: 20pts
Sarcoma: 5pts
Willms Cancer: 2pts
Colorectal Cancer: 148pts
Uveal Melanoma: 78pts
Melanoma: 12pts
GEST 2011 April 27-30 Paris
Liver metastases of Colorectal Cancer: General Report (From 2006 to 2011)
• 148 patients treated • 254 TACE• 100% technical success• 1 major complication (acute pancreatitis)
GEST 2011 April 27-30 Paris
Pre-Treatment Imaging
Obtaining a triple-phase CT or MRI of the liver is mandatory to evaluate the indication to the treatment of metastases with DC-Bead
• Site and number of LM• % of liver substitution• Vascular map of the liver• Feeding vessels of the lesions• Morphologic evaluation of ileo-femoral arteries
Additional imaging examinations to rule out extrahepatic disease should be performed as appropriate.
GEST 2011 April 27-30 Paris
Loading dose of Irinotecan
Each vial of DC Bead (2ml of Beads) can load 100mg of Irinotecan (loading dose 50mg Irinotecan/ml of Beads)
Complete loading achieved within 60-120min: we usually load Beads the day before the TACE.
GEST 2011 April 27-30 Paris
Choice of DoseFor small lesions or lobar treatment:
100mg of Irinotecan loaded in 2ml of Beads
+100mg
Irinotecan
GEST 2011 April 27-30 Paris
Choice of DoseFor larger lesion or full liver treatment: a maximum
of 200mg of Irinotecan loaded in 4ml of Beads
Indication to treatment with DC Bead in patients with liver replacing less than 70% .In case of replacing more than 50% interventional and clinical expertise is required to manage patients.
+200mg
Irinotecan
GEST 2011 April 27-30 Paris
Choice of DC Bead size Optimizing drug delivery: preferable use
of small particles
Deeper penetration into the tumor vascular bed permits to deliver a greater effective dose of drug
ChemosaturationSize 100-300 μm Size 70-150 μm
GEST 2011 April 27-30 Paris
Before TACE After TACE
GEST 2011 April 27-30 Paris
Choice of DC Bead size Use of 100-300μm Beads for a standard procedure
CE Marked for use ONLY with Irinotecan
•Hypovascular metastases•Treatment of microsatellites lesions•Treatment of residual viable tissue after first TACE•Treatment of recurrent lesions
GEST 2011 April 27-30 Paris
Choice of DC Bead size
Hypovascularlesions
Treatment of microsatellites
Before TACE Before TACE
After TACE
After TACE
GEST 2011 April 27-30 Paris
Peri-procedural medicationPain treatment: •1 vial (10mg) of Morphine/100ml of physiological solution e.v. 30min. before the procedure•1 vial of Morphine/100ml of physiological solution e.v. slow infusion during the TACE•1 vial of Morphine/100ml of physiological solution very slow infusion afther the procedure
Prophylactic treatment against nausea: 1 vial (5mg) of Tropisetron/100ml of phs.sol. e.v. before TACE and at +6 hours
Antibiotic prophylaxis and gastric protection should be administered from day 0 to day 5
GEST 2011 April 27-30 Paris
Drug administration
1 Remove the overnatant fluid
2 Mix Beads with a solution of 5-10ml of contrast media / ml of DC Bead
GEST 2011 April 27-30 Paris
The use of microcatheter is advisable:•Reduces the vasospasm•Permits the catheterization of difficult arteries•Permits an optimal distribution of microspheres
Very Slow infusion of Beads!
GEST 2011 April 27-30 Paris
A selective (segmental or lobar) approach should be used; only in selected cases full liver treatment.
Right lobe Lefth lobe L+R lobe
101/254 40% 75/254 30% 76/254 30%
GEST 2011 April 27-30 Paris
Drug administration
Lobar approach: Place the catheter as selectively as possible in the right or left hepatic artery
GEST 2011 April 27-30 Paris
Whole liver treatment:Place the catheter as selectively as possible in tumors feeding arteries in right and left lobe Do not infuse Beads in common trunk of hepatic artery! High risk of administration of even a few DC Beads into extra-hepatic vessels
6 months after TACE
GEST 2011 April 27-30 Paris
DEBIRI administrationPay attention to identify the origin of
cystic and pancreatic artery!
Cystic artery
Pancreatic artery
GEST 2011 April 27-30 Paris
Embolization EndpointInjection should be continued until “near stasis” is observed in the artery directly feeding the tumor
No additional embolization should be performed
BEFORE TACE AFTER TACE
Endpoint: FULL DOSE (not stasis)
The aim of TACE with DC Bead is drug delivery not embolotherapy!
GEST 2011 April 27-30 Paris
Treatment response should be assessed according to modified RECIST (mRECIST)
GEST 2011 April 27-30 Paris
DEBIRI in Colorectal L.M.: Report of 120 pts
Median survival time 22,4 months.
Median time to progression 8.04 months
Duration of response (months)121086420
Pro
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1.0
0.8
0.6
0.4
0.2
0.0
Median duration of response 5,6 months
Aliberti et al. JVIR in press
GEST 2011 April 27-30 Paris
Only DEBIRI 53/116•Median survival time 15,7months•Median duration of response 3,2months•Median time to progression 4,6months
DEBIRI+Sistemic therapy63/116 •Median survival time 24,6months•Median duration of response 8,2months•Median time to progression 10,2months
The association with sistemic therapy increase the response to treatment
GEST 2011 April 27-30 Paris
DEBIRI Colorectal Liver Metastases treatment algorithm
DEBIRI TACE 2/4 ml of Beads Loaded with 100-200mg od Drug
4 week CT/MR or PET
Complete Response
Follow up and other oncological therapy
Partial Response
TACE
Progression
Other oncological therapy
Progression
TACE
GEST 2011 April 27-30 Paris
Liver metastases from Uveal Melanoma• 60-70% Intrahepatic diffuse, 30-40% oligonodular
• Surgery is feasible in only a minority of patients (30%) .
• Systemic chemotherapy (nitrosureas, DITC, Cisplatin and Interferons) has achieved a low median survival (range 5-7 months)
• Conventional TACE showed slightly better median survival (10 months)
• Other therapeutic approaches (Photodynamic, RT, HIFU) are still investigational and require further supporting data.
Palliative therapies have not been shown to significantly improve survival
GEST 2011 April 27-30 Paris
General report(from May 2007 to March 2011):
• 78 Patients treated • 104 TACE
GEST 2011 April 27-30 Paris
Liver metastases from Uveal Melanoma
Treatment ScheduleBead size 100-300μm
Dose of drug 75-150mg (when is possible use the maximum dose)
Segmental or lobar approch if necessary is possible to treat whole liver.
Peri-procedural medication is the same of colorectal metastases
GEST 2011 April 27-30 Paris
Liver metastases from Uveal Melanoma
One month after TACE we observed a significant reduction (>50%) of the lesional contrast enhancement in 93% of patients
We observed an overall Response Rate of 45/52 pts (86%) followed RECIST-modified criteria at 3 months f.u.
Results: clinical responses
37 patients out 52 are alive at time of analysis, with a median time to progression of 7,5 months and median follow-up of 10 months (range 1-24 months)
40% of entire population are alive at 15 months
Fiorentini G, Aliberti C, Del Conte A, Tilli M, Rossi S, Ballardini P, Turrisi G, Benea G: Intra-arterial hepatic chemoembolization (TACE) of liver metastases from ocular melanoma with slow-release irinotecan-eluting beads. Early results of a phase II clinical study. In Vivo; 2009 Jan-Feb;23(1):131-7
GEST 2011 April 27-30 Paris
Liver metastases from Uveal Melanoma
After TACE
After TACEBefore TACE
Before TACE
DSA
Liver metastases from Uveal Melanoma
GEST 2011 April 27-30 Paris
• Absence of systemic toxicity
• Good treatment option for patients with toxicity of chemotheraphy waiting for further therapy (Chemo-Holiday)
• Effective palliation in preminent hepatic metastatic disease from various tumors
• Probably the best treatment in ocular melanoma patients
GEST 2011 April 27-30 Paris
Advantages of TACE with DEBIRI in Liver Metastases