0:02

Hello, and welcome to Noon

0:03

conferences hosted by MRI Online.

0:05

In response to the changes happening around

0:06

the world and the shutting down of in-person

0:08

events, we have decided to provide free daily

0:10

noon conferences to all radiologists worldwide.

0:12

Today, we're joined by Dr. Ashwani Sharma.

0:14

He is board-certified interventional radiologist

0:16

and part of the URMC faculty since 2009.

0:20

He specializes in image-guided procedures,

0:22

primarily interventional oncology.

0:24

He works as an integral member of transplant

0:26

team as director of interventional oncology.

0:28

Reminder that there will be time at the

0:30

end of this hour for a Q and A session.

0:31

Please use that Q and A feature to ask

0:33

all of your questions, and we'll get to

0:34

as many as we can before our time is up.

0:36

That being said, thanks so much

0:37

for joining us today, Dr. Sharma.

0:39

I will let you take it from here.

0:42

Good afternoon, everyone.

0:44

Um, I'm delighted, uh, to be part of this,

0:46

uh, educational series and hopefully be of

0:50

some use to, uh, this wonderful audience.

0:53

So, let's get started.

0:55

Everyone can hear me, right?

0:58

Okay.

0:58

So, uh, first of all, uh, let's discuss, uh,

1:03

why we are, uh, what we are talking about.

1:06

So, we're gonna be talking about HCC.

1:10

So, why are we talking about HCC?

1:12

Because this is the most, uh, one of the

1:15

most common forms of cancer worldwide.

1:18

And, uh, the incidence is also

1:21

increasing, um, every day.

1:24

Uh, it's more common in men.

1:26

And, um, so whenever we find HCC, uh,

1:30

most of the patients are not resectable.

1:33

Only few people are resectable.

1:36

And the other thing, uh, important to

1:39

note is, uh, most of these HCC

1:42

cases, they occur in cirrhotic livers.

1:49

Um, so we are gonna talk about how

1:51

do we diagnose HCC in liver disease?

1:55

Then, we are gonna talk about how do we

1:57

image them, and do we really need a biopsy?

2:02

So, everyone, uh, should know this RAD system.

2:07

Uh, it's developed by ACR, and,

2:11

uh, we have a, this, uh, 2018 core

2:16

upgradation, and everyone should note this.

2:22

So, what is our RAD system?

2:24

It is developed by a multidisciplinary

2:27

international consortium of diagnostic

2:30

and interventional radiologists,

2:33

surgeons, hepatologists, and pathologists.

2:36

They are also part of it.

2:38

Um, it's contributed by both academic

2:41

and community-based physicians.

2:44

As well as members in learning.

2:48

So, why RAD is important, RAD is important and is

2:53

uniform because it is fully integrated with the

2:58

American Association for the Study of Liver

3:01

Disease, AASLD, and it's co-with NCCN guidelines.

3:07

And RAD is utilized by liver transplant centers in

3:12

the United States for procurement of the livers.

3:16

So, RAD system is very important,

3:18

and everyone understands it.

3:22

So, there are different, uh,

3:23

algorithms, um, in RAD system.

3:27

So, like ultrasound for surveillance, and

3:31

contrast-enhanced ultrasound for diagnosis.

3:35

For practical purposes for the diagnosis, staging,

3:39

and the response to locoregional therapy, we use

3:42

CT and MR, so we'll be talking about CT and MR.

3:49

So, whenever, uh, we talk about RAD,

3:53

um, multiphasic scan, so whenever someone gives

3:56

you just one scan and asks you to comment on it,

4:00

so you have to say that we cannot comment on it

4:03

because of one scan.

4:04

So, it has to be multiphasic, pre-contrast,

4:08

early enhancing, portal venous, and delayed scan.

4:11

So, we have to see all these scans so that we

4:14

can comment on the character of the lesion.

4:18

So, whenever we do RAD, we have to look

4:20

for early enhancement, washouts, capsule, or

4:25

if there's any threshold growth. In 2018, they

4:28

have changed that threshold growth criteria.

4:31

So, now it's, uh,

4:32

in less than six months when diameter increases 50%.

4:36

So, this is the, um, threshold growth.

4:40

Now, they have changed it.

4:42

There are some features that favor HCC,

4:45

like mild to moderate T2 hyperintensity,

4:49

restricted diffusion, corona enhancement, mosaic

4:54

architecture, nodular, and nodular architecture.

4:59

If there's any intralesional fat, or if there's

5:02

any iron sparing or fat sparing, or if there's

5:07

any blood products within the lesion, there

5:11

are some features that favor benign disease.

5:14

If it's homogeneously T2 hyperintense or

5:18

markedly hypointense, both favor benign disease.

5:23

If the vessels are not distorted or.

5:27

There's a stable lesion, or there's

5:30

a decrease in size of the lesion.

5:36

We have a spectrum of, um, RADS.

5:39

So, on one end of the spectrum, we have

5:42

benign disease, and the other is a definite HCC.

5:47

So, based on that,

5:49

we decide the management.

5:50

If it's benign, we just continue to do surveillance.

5:55

And if it is, uh, a malignant

5:57

disease, we try to do the treatment.

6:03

So, this is the spectrum from LR-1 to LR-5.

6:08

So, if the multiple ancillary features

6:11

favor HCC, we move towards LR-5.

6:14

If there are features that favor

6:16

more benign disease, then we move

6:18

towards surveillance.

6:25

So, this is the chart that tells you if there's

6:29

any arterial enhancement, early arterial enhancement.

6:33

If there's any washout, capsule, based

6:36

on these, we, uh, the lesion will fall.

6:41

And based on that, you decide the management.

6:44

So, if it is a LR-1, 2, 3, we

6:48

probably may not do anything.

6:50

But if the size of the lesion keeps increasing, or if

6:53

there's a washout and capsule, all these add up to

6:57

a more aggressive lesion that needs to be treated.

7:07

So, how do we diagnose HCC?

7:11

So, if there's any

7:13

early arterial enhancement,

7:17

and in a delayed scan there's a washout,

7:21

we diagnose that as HCC, and we

7:24

say we don't need the biopsy.

7:28

Another, another example.

7:31

So, see, uh, non-con scan is a high-atten, and with, uh,

7:38

enhancement, early enhancing

7:40

lesion and delayed washout.

7:43

So, these are the cases we say these are HCC,

7:47

and we straightaway go to the management.

7:51

We don't even do biopsies.

7:53

So, if you do, this is angiogram.

7:58

If you do this angiogram, hyper-enhancing

8:02

hypervascular tumor in the liver,

8:07

these are all HCCs.

8:10

So, we can diagnose by angiogram,

8:13

or we can diagnose by imaging.

8:17

And so, coming to the biopsy part, so whenever

8:22

we do some imaging, uh, invasive procedure, so

8:27

there are always risks and benefits we have to see.

8:32

So, biopsy risk, patient can have pain,

8:36

patient can have bleeding, death, there

8:40

can be needle track seeding of the tumor.

8:44

And the other thing is even after

8:47

subjecting the patient to the biopsy, the

8:50

biopsy may turn out to be non-diagnostic.

8:52

That can either be due to a sample

8:55

inadequate, or maybe sometimes you miss the lesion.

9:01

And then, the benefit of the procedure,

9:07

whether it's gonna add some useful information

9:11

to what you already can see by imaging, but not

9:16

significantly increasing the risk to the patient.

9:20

So, that brings us to the first polling question.

9:25

When we do a

9:28

follow-up of a patient,

9:29

do we really need the biopsy or we do not?

9:34

Let's see what the audience thinks about it.

9:39

Okay.

9:39

I see that, uh, most of the people think, uh,

9:44

there's no need to do biopsy to confirm, um, HCC.

9:52

Okay.

9:53

Let's discuss, uh, why the biopsy is required.

9:57

I'm gonna present a case that,

9:58

uh, maybe a biopsy is required.

10:04

So, what are the

10:07

advantages of biopsy?

10:09

So, whatever we discussed before.

10:12

So, you have to understand one thing, very important,

10:17

RAD is given to diagnose HCC in liver disease.

10:25

So, whenever there is no liver disease, can we use RAD?

10:28

No.

10:29

The answer is no.

10:31

Only when you have cirrhosis, high-risk liver,

10:36

and there's a mass, then you can use your RAD.

10:39

Okay?

10:40

So, if there's no liver disease and you have a

10:45

mass, even if you have a washout, even if you

10:47

have, um, early arterial enhancement, you cannot say

10:50

it's the HCC. So, if there's a question whether

10:56

it's HCC or metastasis, you have to do biopsy.

11:01

If you have to distinguish between a benign

11:03

and malignant, you have to do biopsy.

11:06

Sometimes the lesion is small and

11:10

may not be able to tell bilateral.

11:11

Then you have to do biopsy.

11:14

In a non-cirrhotic background, as I said,

11:17

you cannot use your RAD.

11:23

And whenever, even if, uh, in cirrhotic patients,

11:26

sometimes you have a combination lesion,

11:29

HCC and cholangiocarcinoma, those patients,

11:34

they need biopsy for further management.

11:37

And whenever you are, uh, using new drugs and trials,

11:43

you need biopsy confirmation to see for the responses.

11:48

And the other thing is, uh, HCC has

11:50

different architectural subtypes, like

11:53

can be trabecular, or, or compact.

11:57

So when you do biopsy, you get additional

12:01

information about the grade of the

12:05

tumor, and it can help, help in prognosis.

12:11

And from the biopsy, we can do tissue markers.

12:15

We can find, uh, molecular signatures

12:18

as a predictor for potential responders.

12:21

So there is, uh, some role of, uh, biopsy.

12:26

Uh, so when biopsy is not required, biopsy is not

12:31

required when, uh, you have a cirrhotic patients

12:33

with, uh, typical findings of a mass as HCC.

12:37

Bilateral system, or even if sometimes

12:41

you may have a doubt, single lesion.

12:43

If the AFP is very high, you don't need a

12:47

biopsy, or biopsy is not required when there's

12:54

a very high risk for, uh, needle tract seeding.

12:58

So I would say there is a role.

13:01

So we should know, as a radiologist,

13:03

know when to biopsy, when not to biopsy.

13:08

So before I finish the role of biopsy,

13:11

I want to discuss, uh, a clinical

13:15

role for a liquid biopsy in HCC.

13:19

This is, um, non-invasive.

13:23

So what is liquid biopsy in HCC,

13:27

circulating free tumor DNA or circulating

13:31

free tumor cells, they can be found in the

13:36

blood, and they can be used for

13:40

diagnostic and prognostic purposes.

13:44

These are potential biomarkers for the diagnosis

13:49

and management, and evidence suggests these can be

13:56

useful diagnostic markers for small and early lesions,

14:01

and they also provide prognostic information,

14:05

such as tumor behavior, any response to treatment,

14:10

overall survival, and recurrence after surgery.

14:15

But the studies, uh, very few studies are available,

14:19

and then work is still going on in this liquid biopsy.

14:22

So I want you guys to know a

14:26

little bit about liquid biopsy.

14:30

So after we have, uh, diagnosed, um, HCC,

14:34

by imaging or biopsy, we need to manage it.

14:39

So the management is decided by

14:41

the tumor board, and tumor board,

14:46

interventional radiology will sit with surgeon,

14:50

hepatologist, radiation oncologist, and medical

14:56

oncologist, and everyone decides together.

15:03

So any disease you want to

15:06

treat, we need to stage it first.

15:09

So this is the staging system which is used by

15:15

UNOS, UNOS, United Network for Organ Sharing.

15:22

So you guys need to know this staging system.

15:27

So there's a T1.

15:30

There's a T2, there's a T3, then

15:34

there's advanced stages, then nodal

15:39

metastasis, and extrahepatic metastasis.

15:44

So this brings us to the next polling question.

15:54

So the question is,

15:58

according to the Milan criteria, which

16:01

patient cannot get liver transplant.

16:08

One patient, one HCC with

16:11

diameter of five centimeter.

16:13

Two HCCs with diameter of four centimeters, three HCC with

16:18

diameter three centimeters, so which one cannot get.

16:25

So most of the people, they think three

16:29

lesions with three centimeter diameter,

16:33

they cannot get the liver transplant.

16:40

Okay?

16:41

So, and then, uh, half, 30, 31% thinks

16:47

two with D of four.

16:49

So the answer is B. B is the correct one.

16:52

So why do I say that?

16:56

I want you guys to remember one thing

17:00

in this whole staging system.

17:04

I want you guys to remember only T2 thing.

17:09

One lesion less than five centimeters, or

17:13

three nodules less than three centimeters.

17:16

Don't have to remember anything except one thing, one

17:21

less than five centimeters, or three less than three.

17:27

So these are the patients

17:29

who can get liver transplant.

17:32

So patients with, uh, stage two, T2, in

17:37

according to this system, they receive extra points.

17:45

We have to make sure there's no extrahepatic spread.

17:52

So whenever patients, they enroll

17:54

for the liver transplantation,

17:58

livers are not available right away.

18:02

So people, they have to wait on the waiting list.

18:08

It depends which state you come from.

18:12

The advantage is, um, kind of, uh, um,

18:17

confusing, but sometimes, you know, having

18:20

HCC is good for a cirrhotic patient.

18:24

Why do I say that?

18:26

If you have HCC, you get extra

18:30

points, and you go higher up the list.

18:40

So remember one thing, T2, one lesion less than

18:44

five centimeters, or three less than three centimeters,

18:50

and another staging system.

18:53

I want you to understand, I'm sorry,

18:55

there is a so many staging system, uh, but

18:58

whenever you manage HCC in a transplant

19:01

setup, so you have to know a few things, so.

19:06

One was TNM classification where

19:09

you need to remember T2.

19:12

And the other I want you to re

19:14

remember is, um, BCLC staging system.

19:18

It's called Barcel, Barcel

19:22

staging system.

19:24

So there's a Child-Pugh system,

19:27

everyone knows Child-Pugh system.

19:30

So based on that, we divide patients

19:32

into three groups, A, B, and C.

19:37

Working fine.

19:38

Moderate damage to the liver or severe liver damage,

19:42

then you need to understand the performance status.

19:48

So whenever you see a patient,

19:50

you, whenever you decide to treat a

19:54

patient, you have to see the patient.

19:56

Why do I say that?

19:58

The performance status is very important.

20:02

You need to know.

20:04

How the patient is doing in his

20:06

life, whether he's fully active,

20:11

or little bit less than fully active, spends more

20:17

than half of the day outside, or spends more than half

20:24

of the day in bed, or he needs help all the time.

20:30

So in the performance status,

20:32

the ECOG status, I want you to remember status two.

20:39

Any patient who spends more than half of

20:43

the day outside bed needs to be treated

20:50

like T2 in the same system here.

20:53

Also, ECOG 2.

20:55

I need you to remember this.

20:59

And this is the,

21:01

Barcelona system, staging system, is

21:04

divided into five parts: very early,

21:11

less than two centimeters, early stage T2,

21:17

stage three tumors less than three centimeters,

21:23

then intermediate and advanced, and very advanced.

21:31

So Barcelona system is a treatment strategy,

21:38

so whenever, uh, you have early stage or middle

21:42

stages or late stages, late stages, not much

21:47

we can do. Very early stages, if you

21:52

can do resection or transplantation.

21:57

The other thing, which we do as interventional

22:00

radiologists, we do ablative therapies,

22:04

so they are comparable to resection.

22:08

And when the patient falls in the middle, we can do

22:15

arterial therapies.

22:16

Embolizations can give drugs,

22:19

or we can do radioembolization.

22:25

So whenever there is a tumor,

22:31

the curative is when the tumor is outside the body.

22:36

So either you do liver resection,

22:38

or you do complete transplantation.

22:41

The problem with the resection is it can

22:44

treat, uh, one tumor, but it does not treat

22:51

the cirrhotic liver, which

22:53

is a remnant for future HCC.

22:57

So therefore, for the treatment of HCC, the

23:01

established therapy is liver transplantation.

23:05

Need to remember the treatment

23:06

for HCC and cirrhotic patient.

23:08

The answer is liver transplantation.

23:14

So one more,

23:15

uh,

23:17

Milan criteria we discussed before: one

23:21

tumor less than five centimeters, or three

23:24

tumors less than three centimeters, provided

23:28

there is no vascular invasion, and

23:29

there is no extrahepatic metastasis.

23:33

So someone can ask me, uh, in

23:35

stage T1, T2, T3,

23:37

why, why do you choose only T2?

23:40

Why not T1 or T3?

23:42

So the answer lies in the five

23:45

year recurrence-free survival rate.

23:49

So studies have shown when you give liver to

23:54

people T2 and less, they have a very good

23:58

five-year recurrence-free survival rate, 83%.

24:04

If you are doing a surgery and you are giving a liver

24:07

to a patient, you want that patient to live long time.

24:10

So when you give liver to patients

24:12

with T1 or T2, they do good.

24:14

But if you give to T3 and

24:17

above, they do not do good.

24:20

So that is the reason we stop at T2.

24:25

The role of, uh, transplantation is, however,

24:29

limited by few availability of the donor organs.

24:34

Thus, everyone is not getting delivered.

24:37

They have to wait.

24:40

And what happens if they wait?

24:43

They may become ineligible for the transplantation

24:46

if the tumor progresses.

24:48

Like if the tumor was less than five, it becomes

24:50

more than five, or there were three tumors less

24:53

than three, they become more than three centimeters.

24:57

So what can we do for those people so we

25:00

can, um, bridge them to transplantation

25:06

by doing local regional therapy?

25:09

So what is the role of local regional therapy?

25:12

The role is to keep the patients who are in

25:16

Milan criteria to stay in the criteria, or

25:22

if they are not in the criteria, to downstage

25:26

the tumor so that they can meet the criteria,

25:30

and they can get the transplantation.

25:33

So what do I mean by that?

25:34

If the tumor is

25:35

six centimeter,

25:37

you do local regional therapy.

25:39

Bring the tumor to less than five centimeter.

25:42

Patient can be listed, and if the patient can stay in

25:46

the list for a long time and can get the liver, if

25:50

the patient is not in the list, we can still do all

25:53

these local regional therapies for unresectable tumor.

25:58

For palliations also.

26:02

So, where do we fit in as interventional radiology?

26:07

So we do, um, ablative procedures,

26:11

and we do transarterial procedures.

26:14

In the ablative procedures, we have, uh, thermal

26:19

procedures, and we have non-thermal procedures.

26:24

Non-thermal ablative procedure is IRE.

26:29

And in the thermal, we have two, again, two

26:32

types: heat based, like RFA microwave, or ice

26:38

based, cryoablation. And the transarterial,

26:42

we can do chemoembolization, or

26:45

we can do radioembolization.

26:49

I'm gonna talk a little bit about,

26:50

um, ablative, RFA, whether we do RFA

26:58

or, or we do microwave.

27:02

So when do we do these ablative procedures?

27:05

So we do these procedures when the

27:10

tumor is single and less than

27:14

preferably three centimeter.

27:16

There's no extrahepatic spread.

27:19

Performance status is good.

27:21

As we discussed,

27:22

we have to always look for the performance status.

27:25

There's no extrahepatic spread

27:29

to make sure that we do not

27:30

injure the nearby structures.

27:37

So do a CT scan.

27:39

You can localize the lesion, do a CT

27:43

scan with a grid, localize the lesion,

27:49

and put the needles in.

27:53

The other way to localize the lesion is by ultrasound.

27:58

So if you can see the lesion without

28:03

sound, you can advance under live

28:07

you can see the needle going into

28:09

the tumor, and you can do it.

28:11

So microwave or RF,

28:18

which one is better?

28:20

Back in the days, people used to do only RFA.

28:23

Now with new technology, microwave

28:26

is available, so which one is better?

28:30

So if you see a systematic review and meta-analysis,

28:34

and compare, complete response, local recurrence,

28:39

three-year survival, and the complications,

28:43

you see similar efficacy between the

28:48

two percutaneous techniques. Both are

28:52

similar, but sometimes people prefer

28:56

microwave over RF. Why? Because it can, um,

29:03

generate a lot of heat in less time.

29:06

So it is faster, and people usually prefer

29:10

because of that microwave for larger neoplasm.

29:14

But if you see studies,

29:18

both are same.

29:23

So if you compare, um, ablative therapies with

29:28

surgery, so people have seen that ablative therapies

29:34

by IR, they are satisfactory alternative to resection

29:40

if the tumor is three centimeter or smaller.

29:45

But if the tumor is very small, less

29:46

than two centimeter, RF or microwave

29:50

may be the first line of treatment.

29:54

So ablative therapies, if you

29:56

can do, they are very good.

30:00

So now comparison between these

30:02

ablative therapies and SBRT.

30:06

So meta-analysis and systematic review,

30:09

they have shown that RFA is associated

30:12

with better overall survival than SBRT.

30:20

And this analysis of National Cancer

30:23

Database has shown that RFA yields

30:27

superior survival compared to SBRT.

30:33

So does that mean SBRT is not good?

30:35

No.

30:36

SBRT is good, and SBRT is an effective alternative

30:41

treatment for HCC when RFA is not feasible,

30:47

that may be due to tumor location or tumor size.

30:55

So, I've shown few cases where you can

30:57

31:00

easily see the tumor on CT scan, on oral

31:04

ultrasound, and you can place the needle.

31:07

So what about, um, HCCs where you cannot see them

31:12

with the routine imaging modalities like this case?

31:18

So you cannot see it.

31:21

And, uh, if you go by enhancing

31:23

lesion, ugly enhancing.

31:26

You give contrast, you see the lesion, but it's

31:28

gonna disappear fast as the contrast is washed away.

31:31

And needle placement can take some time.

31:34

So if you can see the lesion in the delayed

31:39

phase for a long time, this can be used.

31:42

So giving contrast when you

31:43

cannot see the lesion helps.

31:47

The other is ultrasound is very good.

31:50

If you have a good sonographer, they

31:52

can always find the lesion for you.

31:55

You see the lesion, advance the needle under

31:58

ultrasound live guidance, and you know whether you

32:01

have hit the target or not, and you see good result.

32:08

The other thing which we do when we do not see

32:10

the lesion, like this is a lesion we cannot see.

32:14

So what do we do?

32:16

So we take the patient to angiographic suite.

32:22

And we do angiogram and we inject Lipiodol.

32:27

Lipiodol has tendencies to stay in the tumor.

32:32

Surprisingly, liver does not take up, and

32:34

the tumor takes it, and after you do a

32:38

CT scan, you can clearly see the lesion.

32:41

Once you see the lesion, you can easily place the

32:45

needles into the tumor, and you can easily ablate it.

32:52

And you get good response.

32:53

If you see the tumor, you get response.

32:57

Good response.

32:58

If you cannot see the lesion, needle

33:00

placement can never be perfect.

33:03

So always make sure whenever you do

33:05

ablation that you see the lesion properly.

33:10

This is another, uh, difficult subgroup of patients.

33:15

They are very challenging.

33:18

So why are they challenging?

33:21

So the tumor is in the dome.

33:24

If you use CT scan, there's a little lung all around.

33:28

There's a very high risk of,

33:29

uh, going through the lung.

33:30

You don't want to do that.

33:32

You want to go into abdominal compartment,

33:34

you do not want to go through the chest,

33:40

and there's a risk of pneumothorax

33:43

and spread to the other compartment.

33:46

So what you do, you angle the needle.

33:49

So either you angle the gantry, the CT gantry,

33:53

and you go from below, angle it up, see the tumor.

33:57

This is, the lung cannot go down,

34:01

so you have to angle the needle up.

34:04

If you see the lesion, you can place the needle.

34:09

If you place the needle good, you get good response.

34:15

So gonna talk about, uh, tumor responses.

34:20

So whenever you see a good, nicely

34:22

outlined tumor, you get good response.

34:27

Patient selection is very important

34:29

for a good response from ablation.

34:32

Why do I say that?

34:34

If you have a single lesion, which you can see and you

34:37

cut with needles, you're gonna get a good response.

34:39

But if you have a satellite, multiple satellite

34:42

lesions, or if the tumor is big, more than three,

34:45

four centimeter, you may not find good response.

34:50

So after you ablate the lesion, the

34:53

size of the lesion will increase.

34:55

But that doesn't mean that the tumor is increasing.

34:59

So whenever you in system, we always say,

35:03

enhancing component.

35:05

So there should not be any enhancing

35:07

component, even if the size is increasing,

35:10

and over time the size will decrease.

35:14

Sometimes it can take more than a

35:16

year for the tumor size to decrease.

35:22

So I'm gonna talk about after these ablative

35:24

therapies, I'm gonna talk about a little

35:27

bit about, uh, radioembolization and chemo.

35:30

These arterial-based therapies we do.

35:35

Before we go to, um, arterial-based

35:38

therapies, need to understand the anatomy.

35:42

This is a celiac artery angiogram.

35:45

The catheter tip is in the celiac axis.

35:48

See the splenic artery?

35:50

This is, um, common hepatic artery.

35:54

See GDA, you see left side hepatic

35:59

artery, then right hepatic artery.

36:03

This is a corresponding picture with CT angiogram.

36:07

This is a coronal reformat.

36:09

Again, the same artery, GDA, left

36:12

hepatic artery, and right hepatic artery.

36:22

So.

36:25

Before, uh, going into the treatment transarterial

36:30

therapy, we need to have a patient selection.

36:33

So what are the patients, uh,

36:38

eligible for, uh, transarterial therapies?

36:41

So any, any patient which we cannot do

36:43

ablative therapy on, meaning that tumors

36:47

are not single, so multifocal tumors,

36:50

or if there's a portal vein involvement.

36:54

Big tumor, multifocal tumor

36:58

cannot be ablated.

37:02

37:02

So we used, uh, these arterial-based therapies.

37:08

So very important to remember when selecting the

37:10

patients for, uh, chemo or radioembolization.

37:13

What, what are the liver function tests?

37:16

As a radiologist, we do not have this

37:18

habit of looking at the liver function

37:21

tests, but this is very, very important.

37:24

Before

37:27

you, you do all these ablative therapies, you

37:29

have to make sure the patient is not in failure,

37:33

the good synthetic function of the liver.

37:39

So this is, uh, a chart showing,

37:41

um, radioablation and chemo.

37:45

Patient, um, eligibility.

37:48

So whenever the liver functions are

37:49

good, you can do either of them.

37:52

Usually whenever there's a portal involvement, can

37:57

do both, but usually people prefer Y-90 over TACE.

38:04

The size is big, more than nine centimeters.

38:08

Usually people prefer Y-90.

38:12

Overall, both are.

38:16

But if you want some difference, I would say

38:20

portal vein involvement and very bulky tumors.

38:25

We prefer Y-90, but it depends on

38:29

the institution and can be debated.

38:31

Some people can say no.

38:32

Both are okay.

38:35

And I will say yes.

38:36

That's okay.

38:40

So this is, uh, two angiograms.

38:42

One is, uh.

38:46

Before treatment, and this is after treatment.

38:52

I want to see what people think about this.

38:55

So that brings us the next polling question.

38:58

The question will be, what

39:00

kind of treatment we did here?

39:03

Let's see, uh, let's give them, uh, 15 seconds more.

39:07

And so the question is what kind of treatment

39:10

was done, whether it was radioembolization

39:13

or chemoembolization.

39:17

So I see, uh, more people think, uh, chemo

39:20

embolization was done, and that is correct.

39:25

I'm gonna give you the answer later.

39:27

Why?

39:28

So

39:31

I'm gonna go to next slide.

39:33

And this is another patient.

39:34

This is, uh, pre-treatment and this is post-treatment.

39:38

That brings us the next polling question.

39:40

Let's see, what kind of treatment

39:42

was done in this patient?

39:45

Good.

39:46

Everyone is correct.

39:47

This is good.

39:48

So

39:51

let's, let's discuss what we are talking about.

39:56

So, so particle size is very important.

40:00

So whenever we do radioembolization, look

40:03

at the size of the particles, and when we do

40:08

chemoembolization,

40:09

see the size of the particles.

40:11

Mechanism of action is different.

40:14

When we do Y-90, mechanism of action is radiation.

40:19

And with chemo, it's a chemo plus embolization.

40:22

Because the size of the particles is so big, on top

40:27

of chemotherapy, we are also causing embolization.

40:30

So I'm gonna go back to the

40:33

pictures.

40:34

You see, this is the angiogram, and after

40:36

treatment you see the pruning of the vessels.

40:40

There's embolization of the vessel.

40:42

So this has to be this.

40:44

It cannot be Y-90.

40:46

And if you see this patient, this is the tumor, and

40:49

you did the treatment, there's no embolization.

40:51

That's because the size is too

40:54

small to cause embolization.

40:59

Okay, let's see the responses when we do

41:02

these procedures.

41:06

So this is one tumor on the right side, and

41:09

this same patient has a tumor on the left side.

41:14

Early enhancing lesion.

41:15

HCC in cirrhotic patient.

41:19

Do the angiogram whenever we do, uh,

41:23

all these, uh, arterial-based therapies.

41:27

Try to do

41:29

as selective as possible, you want to go, if

41:33

possible, into the tumor so that all the drug,

41:37

all the radiation beads go to the tumor

41:40

and not affect the surrounding normal liver.

41:45

Why do I say that?

41:46

These are cirrhotic patients already.

41:49

The liver reserve is low, so you want to

41:53

preserve whatever liver function is there.

41:58

So these, this is called segmentectomy.

42:02

You go into the segment and you inject.

42:06

So when you inject radiation or Y-90,

42:08

you call radiation segmentectomy.

42:15

So this is a

42:18

scan after the treatment, you see

42:23

the tumor has not grown.

42:25

But follow-up has shown, started

42:28

to show dystrophic calcification.

42:31

The tumor is dying, and the

42:33

tumor is showing calcification.

42:35

And this is further decreasing the size

42:38

and the calcification of the tumor.

42:40

It's called radiation segmentectomy.

42:46

So whenever we do

42:49

radiation chemotherapy, so sometimes, you know.

42:53

You have to make sure there's no enhancing

42:56

component, but the size of the tumor can take time,

43:03

can take time up to, up to a year, year.

43:08

But then you have to follow the

43:09

patient for the enhancing component.

43:11

Also, compare with AFP if, and the patient is

43:17

doing good.

43:18

AFP is going down.

43:19

No enhancing component.

43:20

Even if the size is not going

43:22

down, the patient is doing good.

43:27

Another way to see the tumor

43:28

response is you can do angiogram.

43:32

Even if the size of the tumor is still the same.

43:35

There's no angiographic hypervascular tumor.

43:39

The tumor is gone.

43:44

So we were discussing, uh, arterial therapy, whether it is

43:49

radiation or it is chemotherapy, which one is better?

43:56

If you do a systematic review and meta-

43:59

analysis, you find there's not much

44:03

difference between TACE versus TARE.

44:07

If you see the recurrence rate, again, it's the same.

44:12

So it's more of an institutional preference,

44:16

whether you work at one particular center

44:20

that is academic, or it's community-based.

44:23

So many factors, they determine which kind of

44:27

treatment you're doing, whether you're doing

44:30

chemoembolization or radioembolization.

44:35

The other thing is, uh, chemoembolization.

44:38

Sometimes patients, they stay,

44:41

overnight, get the treatment, go

44:42

home. With radiation embolization,

44:46

they have to come for multiple visits, but

44:49

then it's, uh, outpatient, they come and go.

44:53

So depending on, uh, the patient preference and

44:55

the institutional preference, both can be done.

44:59

But the important thing is,

45:02

systematic review and meta-analysis,

45:04

they have shown not much difference.

45:06

So both are good, whichever suits

45:08

the patient or the institution.

45:15

Again, meta-analysis of multiple randomized trials

45:19

have shown both radioablation and chemoablation,

45:25

they have similar outcomes in unresectable HCC.

45:34

So another meta-analysis.

45:39

Overall survival rate is the same, both radio,

45:46

radioembolization and chemoembolization,

45:49

they have the same survival rate and

45:54

comparable complication profile.

46:01

So, showed you some good results with

46:04

ablation and arterial therapies.

46:09

I'm gonna show you some bad results

46:11

also, because every story does not

46:13

end, does not have a happy ending.

46:17

So this was a small tumor.

46:22

Put the needle in, ablated it.

46:28

And the follow-up scan showed this.

46:32

So there's so many things we

46:33

do not know about the disease.

46:37

Every time you feel that maybe this is a chip

46:41

shot, and then you're gonna have a good result,

46:44

so it may not go the way you want it to go.

46:50

I'm gonna show you another bad biology.

46:54

So this patient came for an arterial therapy.

46:58

One lesion was on the right side.

47:00

Another small lesion was on the left side.

47:03

We did Y-90 on the right side.

47:07

Patient was supposed to get

47:09

treatment on the left side.

47:12

But in three weeks after we treated the right side,

47:15

he came with abdominal pain, and we did a scan, saw

47:19

the explosion on the left side from the tiny tumor.

47:24

So what I'm trying to say is, do

47:27

not know much about the disease.

47:33

I'm gonna end by saying that a lot

47:35

of research still needs to be done

47:40

for the treatment of HCC.

47:43

We started with saying that whether we need

47:45

biopsy or not, but we do need the biopsy.

47:50

We want a biopsy, and we hope

47:52

in future, like other diseases, we can

47:56

find some receptors and we can do targeted

48:00

therapy in HCC like we do for other cancers.

48:07

One more thing, the latest thing

48:08

is, uh, checkpoint inhibitors.

48:10

I want you guys to know the role of, uh,

48:13

immunotherapy for, uh, immunotherapy.

48:17

Like other diseases, need to do biopsy.

48:21

You need to find expression of

48:24

these ligands, PD-1 or PD-L1.

48:28

If they are present, immunotherapy can be used.

48:33

So with this, I'm gonna add

48:38

my slide

48:41

questions.

48:42

Perfect.

48:43

I do see a couple of questions in the Q and A feature,

48:45

if you don't mind opening that up and answering the

48:47

ones that you see, uh, fit for your presentation.

48:56

So this fatty infiltration is a

48:58

risk for HCC? Answer is yes.

49:02

Liver disease.

49:03

So usually, so usually whenever, uh, HCCs, they arise,

49:12

they arise in, uh, liver disease.

49:15

HCC, whenever they arise in,

49:16

uh, livers, they usually arise.

49:19

In liver disease, if there's no liver disease,

49:23

always doubt and biopsy the lesion and make sure

49:27

we are dealing with HCC, not something else.

49:31

So yes, fat infiltration,

49:32

yeah, this can cause HCC.

49:37

So other question is, uh, LI-RADS

49:39

system used in fatty liver or not?

49:43

So fatty liver, if you see, a lot

49:45

of people, they have fatty liver.

49:49

So the LI-RADS system, you know that it was

49:53

developed as for cirrhotic patients

50:00

and high-risk patients.

50:05

So I will not use the LI-RADS system in fatty liver.

50:15

So the question is, uh, TNM HCC is the latest one.

50:19

So, um,

50:23

in TNM classification, all I need to

50:27

see is T2 formula and criteria.

50:35

One lesion less than five centimeter, or

50:37

three lesions less than three centimeter.

50:40

So the other question is, uh, liver

50:42

functions are always deranged in patients.

50:45

So when a patient is very ill, is there

50:47

a way to decide when to not stick, or

50:53

cutoff points of bilirubin, et cetera?

50:55

So these patients are always sick, but if you

50:59

remember, I discussed about, uh, performance status.

51:04

So you have to know the performance status,

51:09

and if the bilirubin cutoff

51:11

points you are talking about.

51:14

If bilirubin is a little bit high,

51:17

say three, but this is stable,

51:20

three, I'll be more inclined to treating

51:23

that patient than a bilirubin of 1.5

51:28

that is climbing from 0.5 to one to 1.5.

51:32

So, yes, liver functions are important,

51:36

but you have to see the follow-up.

51:42

So another question is, um, when we can use

51:47

combined therapy RFA, this is also very important.

51:52

So these are the sick patients.

51:54

If you can use one therapy, I'm gonna

51:57

use one therapy, but if it's a big tumor,

52:00

you can use two therapies, but you have to understand,

52:03

whenever, uh, you use multiple therapies, you are

52:07

giving more insult to the patient, to the liver.

52:11

As long as liver functions are good, you can combine

52:14

them, make sure the liver functions are good.

52:19

If there's a big tumor, you can

52:21

always ablate and TACE together.

52:23

Yes.

52:25

The thing is, the other flip thing,

52:28

is these patients, they stay on the

52:31

transplant list for a long time.

52:35

So you can always use either combined

52:37

therapy or sequential therapy, treat

52:40

one, and then wait, see the response.

52:42

And you can use TACE or SBRT

52:45

later, or you can combine them.

52:49

So other question is, uh, use

52:51

intraoperative RFA while resecting.

52:55

Yes.

52:57

Intraoperative, um, ablative therapies can be used.

53:05

Depends.

53:05

It's ablative therapies.

53:07

This is operator dependent.

53:11

If you are comfortable, uh, using ultrasound,

53:14

you can use, uh, ablative therapies.

53:16

The problem is, um, if you're not very good

53:19

with ultrasound and you cannot use CT for, uh,

53:23

CT during surgery, then, um, localizing

53:26

the lesion can be very difficult.

53:29

As I was discussing, that when you can

53:31

see the lesion, you can ablate it.

53:34

If you cannot see the lesion,

53:37

the responses may not be good.

53:40

So another question, uh, in known family

53:42

history of HCC and the liver disease,

53:45

what is the workup we need to do?

53:48

So these are high-risk patients.

53:51

So for surveillance and diagnosis, if you

53:55

see AASLD system, they recommend ultrasound.

54:00

Ultrasound is screening, uh, modality.

54:07

So someone has a LI-RADS system to fatty liver.

54:14

So I explained, so LI-RADS system, this.

54:19

The system, there's nothing black and white.

54:21

Whenever you treat patients,

54:25

there's nothing black and white.

54:26

Everything is, uh, gray.

54:29

So when they describe LI-RADS system,

54:31

what they say is the system is described for

54:36

cirrhotic population and high-risk population.

54:42

If a patient comes and there's a fatty liver,

54:47

and you use a,

54:51

there's a high clinical suspicion for HCC, and

54:54

there's an early enhancing lesion and a washout.

55:00

We discuss the role of biopsy, if there's

55:02

a doubt, should always do the biopsy.

55:07

So to answer the question, the system was

55:11

developed for high-risk patients,

55:13

cirrhotic patients, and high-risk patients.

55:16

Cannot start using LI-RADS in any fatty liver because

55:20

LI-RADS, we discussed, is a multiphasic scan.

55:26

So usually patients, they do not get multiphasic scans.

55:31

Most of the patients, they

55:32

just get one scan and they go.

55:38

So you have to see the patient

55:42

in totality.

55:44

If there are no other risk factors,

55:46

then I would not use LI-RADS system.

55:48

I'm gonna just go to biopsy.

55:56

So another question, how to deal with the

55:57

post-transplantation arterial thrombosis.

56:03

Do you use stent or TPA only?

56:06

So depends, you know, post-transplantation,

56:08

how far you are into the transplantation.

56:15

Usually,

56:19

they should.

56:20

We have to find out the reason

56:21

for the transplantation.

56:24

I'm not a big, big fan of putting

56:27

stents or metals in the body, so

56:33

most of the times I've seen recent transplantations,

56:36

when you do

56:39

wire and catheter, these are

56:40

very high risk of, uh, complications.

56:43

So we have to discuss with the surgeon, and

56:46

if there's a thrombosis for no reason,

56:54

if there's a narrowing, then we

56:55

have to get rid of the narrowing.

56:58

Usually, uh, these should be dealt

57:01

with before doing the transplantation.

57:07

So there's no simple answer to stent or TPA, if it

57:14

is recent, right within a few days of transplantation

57:18

and the patient developed arterial thrombosis,

57:22

I may not.

57:23

I may do maybe TPA, but may want the surgeon to

57:28

take the patient back and see what's going on.

57:31

Angiogram is important though, to diagnose.

57:36

Perfect.

57:36

I think we got through all the questions.

57:38

So as we bring this to a close, I wanted to

57:39

thank you, Dr. Sharma, for your time today.

57:41

And thanks to all of you for

57:42

participating in this noon conference.

57:43

A reminder that it will be made

57:44

available on demand at mrionline.com.

57:47

In addition to all previous noon

57:48

conferences, these are made available

57:49

complimentary, and tomorrow please join us.

57:52

We'll be replaying a popular

57:53

conference by Dr. Steven J. Pomerance.

57:55

You can register for that at mrionline.com.

57:57

Thank you and have a wonderful day.

57:59

Okay, thank you.