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Chemoembolization, Cryotherapy and Microwave Thermotherapy

Chemoembolization, Cryotherapy and Microwave Thermotherapy. Fred T. Lee Jr., MD University of Wisconsin Dept. of Radiology. Chemoembolization Chemoembolization+RF Cryotherapy Microwave thermotherapy Comparison of techniques. Chemoembolization.

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Chemoembolization, Cryotherapy and Microwave Thermotherapy

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  1. Chemoembolization, Cryotherapy and Microwave Thermotherapy Fred T. Lee Jr., MD University of Wisconsin Dept. of Radiology

  2. Chemoembolization • Chemoembolization+RF • Cryotherapy • Microwave thermotherapy • Comparison of techniques

  3. Chemoembolization • Delivery of concentrated chemotherapy to liver via hepatic artery • Used for hepatocellular carcinoma and metastases (lobar or segmental) • Less systemic side effects than IV chemotherapy

  4. Chemoembolization Indications • Unresectable HCC or liver mets • Nonsurgical candidates • Single or multiple lesions • Palliation/selective prolongation of life

  5. Chemoembolization:Contraindications • Total bilirubin>3.5 • Portal Vein Thrombosis • Active Infection

  6. Chemoembolization: • Prep: bowel, skin, Abx, steroids, hydration • Selective, superselective catherization of tumor vessels bypass GDA, cystic artery • Slowly inject “cocktail”

  7. Wisconsin “cocktail” Cisplatin 100 mg Mitomycin C 10 mg Adriamycin 50 mg Ethiodol 10 cc Contrast 8 cc Ivalon particles 300-500 µ McDermott J, Wojtowycz M, Sproat I, Omary R, Salem R, Wagner HJ

  8. Results (many different cocktails, protocols) • Mets:  response rates, but probably no survival advantage. Palliation. • HCC: High local tumor response rates. Probably no survival advantage vs. symptomatic rx. Less effective than surgery in resectable patients. Pelletier. J Hep 1998 Kanematsu. Cancer 1993

  9. RF Ablation: Why We Fail • Mets: local failures=30-50% • Miss lesion • Cover, but don’t kill entire tumor • Most failures occur in the rim: vessels!

  10. Cooled-tip electrode: Porcine Liver Slice

  11. Conventional RF: Current Density tumor 4 Current density=1/r

  12. Conventional RF: Current Density vessel tumor 4 Current density=1/r

  13. Vessels as cause of RF failures • Lu DS, RSNA 2000 • Gillams AR, Lees W. RSNA 1999, 2000

  14. Better RF Lesion Size/Shape with Vascular Occlusion • Bodie AW, Cancer Res 1986 • Goldberg SN, Radiology, JVIR 1998 • Patterson EJ, Ann Surg 1998 • Chinn SB, Lee FT, AJR 2001

  15. Decreased local recurrence (19%) of HCC with bland vascular occlusion • Rossi S, Garbagnati F, Lencioni R, et al. Radiology 2000;217

  16. RF ablation+chemoembolization:Rationale • Embo increases size, rounder • Deposits chemo in tumor, EDGES! • RF increases dwell time of chemo • Need long term results

  17. RF + Chembo: RSNA 2001 • Yamakado K • Pereira P Good local control of large HCC

  18. Chemoembolization + RF ablation

  19. Post Chemoembolization Post Chembo+RF

  20. Pre-treatment Post chembo+RF

  21. Microwave Coagulation Therapy

  22. UW coach's son gets 10 days for parrot's microwave death Chad Alvarez will begin jail term on Dec. 20 By Dennis Chaptman of the Journal Sentinel staff Last Updated: Dec. 10, 1999 Madison - The microwave-oven killing of Iago, a Quaker parrot owned by a fraternity brother, landed Chad Alvarez two felony convictions and a sentence of probation and

  23. Microwave Coagulation Therapy • Used in Japan for >10 years • No system currently available in the USA • Microwave “field” causes tissue heating • Net effect is much like RF

  24. RF ablation generator 4 Current drop 1/r 2 Heating drop 1/r

  25. MCT ablation generator No grounding pads necessary

  26. RF ablation Active zone Several mm’s Microwave 2 cm

  27. Microwave Coagulation Therapy

  28. Microwave vs RF • Microwave: Hotter, possibly faster, multiple probes, no ground pads. No USA experience • RF: Available, robust technology, increasing lesion size

  29. 48o 4Weeks Microwave vs RF RF MW Immediate

  30. MW vs. RF RF MW 48 Hours 4 Weeks

  31. Hepatic Cryoablation • Very powerful local ablation technique • Multiple probes can be used together to ablate a tumor of virtually any size • Freezes tissue to app. -150 degrees C. • Tissue death due to cellular rupture, vascular occlusion

  32. Cryoablation of liver tumors • First focal tumor ablation technology • Performed clinically since the early 1960’s • Combined with IOUS in 1980’s (Onik)

  33. Courtesy of G. Onik, MD

  34. In era of RF, is cryo still needed? • Very powerful. Multiple probes make a large iceball in a short period of time, can ablate up to large vessels.

  35. 4 months post Precryo POD 5

  36. In era of RF, is cryo still needed? • Very powerful. Multiple probes make a large iceball in a short period of time, can ablate adjacent to large vessels. • Low local recurrence rates

  37. Cryoablation: Local Recurrence • Deaconess (Kane) 5-year followup: 12% • Wisconsin (Lee) 28 mo f/u: 9% Surgical margin recurrences 11% RSNA 97 J GI Surg, 2001 • RF local recurrence 54% (Livraghi, Radiology 2001)

  38. Hepatic Cryoablation Cryoablation RF ablation

  39. In era of RF, is cryo still needed? • Very powerful. Multiple probes make a large iceball in a short period of time, can ablate adjacent to large vessels. • Low local recurrence rates • Visualize area being ablated

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