Opportunities in interventional oncology Dr. Henry Wanga Consultant Interventional Radiologist Zenith Medical Centre General Accident Insurance House Ralph Bunche Road, Upper Hill Nairobi

KESHO Kenya Society of Hematology and Oncology Third

Annual Scientific Conference Panafric Hotel, Nairobi Kenya 28th November 2014

Angiography, Biopsy and Drainage Interventional Radiology(IR) is a clinical subspecialty with a rich history of

innovations We approach our work through clinical problem solving with our referring

specialists Many IR practices have shifted from peripheral vascular interventions to

interventional oncology Multimodal imaging methods have superseded the traditional arteriography Embolic agents can be permanent, temporary, or combined with an agent

such as chemotherapy Pelvic malignancies may cause lower extremity deep vein thrombosis.

Treatment is by placing permanent or temporary inferior vena cava filters Complications in IR practice are uncommon

Oncologic applications VASULAR A. diagnostic information(e.g. vascular invasion, biopsy) Diagnosis and treatment of associated conditions,(DVT,

central venous access, hemorrhage) Local delivery of chemotherapy Embolotherapy Brachytherapy delivery 2. NON-VASCULAR Diagnostic information(PTHC, biopsy) Treatment of associated conditions (e.g. GI/GU/ biliary

obstruction) Local tumor ablation(RF/ thermal, ethanol,acetic

acid,cisplatin -epigel)

Continued Oncologic applications Brachytherapy delivery 3. Disease control vs. palliation 4. Connections with Basic Science(small animal, cellular

culture, etc) and Clinical Research(clinical trials)

Interventional Radiology locally practices

Image guided tumor ablation with ethanol Transcatheter arterial embolization(TAE) Transcatheter arterial chemoembolization(TACE) Combined TAE and TACE

Agents used in embolization treatment of malignancies Gelfoam sponge temporary –haemostasis Poly vinyl alcohol particles (PVA) - permanent occlusion.

Comes in sizes 100, 200, 300, 500,700,or 1000 microns Drug eluting beads (DEB) Coils

Chemo infusion Agents Cisplatin Doxorubicin Mitomycin c Paclitaxel And many others

Hepatocellular carcinoma: Solitary tumor <3 cm

Treatment/Procedure Rating   Comments       

Systemic chemotherapy 3           

Resection 8           

Transplantation 9           

Chemical ablation 6           

Thermal ablation 8           

Tran arterial embolization (TAE) 5           

Tran arterial chemoembolization (TACE) 5           

Selective internal radiation therapy (SIRT) 5           

Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate         

Hepatocellular carcinoma: Solitary tumor 5 cm

  Treatment/Procedure Rating     Comments 

              

  Systemic chemotherapy   3      

               

  Resection   8      

               

  Transplantation   9      

               

           The tumor is too large for chemical ablation. May 

  Chemical ablation   3    use it instead of or in addition to thermal ablation 

           depending on tumor location. 

  Thermal ablation   5      

             

  Tran arterial embolization (TAE) 6      

             

  Tran arterial chemoembolization (TACE) 7      

               

 Selective internal radiation therapy (SIRT) 7

   Especially applicable in portal vein thrombosis or 

     extensive bilobar disease.  

            

  Transarterial chemoembolization (TACE)7

      

 combined with thermal ablation

      

          

  Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate 

Metastatic liver disease: Multifocal colorectal carcinoma (liver dominant or isolated), 5 cmtumors.

  Treatment/Procedure Rating     Comments 

              

  Systemic chemotherapy   9      

               

  Resection   7      

               

  Transplantation   1      

               

  Chemical ablation   1      

               

  Thermal ablation   2      

             

  Hepatic arterial chemotherapy infusion 5      

             

  Transarterial embolization (TAE) 5      

             

  Transarterial chemoembolization (TACE) 5      

             

  Selective internal radiation therapy (SIRT) 5      

             

  Transarterial chemoembolization (TACE)5

   

Depends on tumor burden. 

 combined with thermal ablation

    

          

  Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate 

Radionuclide Bone Scan

Normal bone scan

Metastatic breast cancer Radionuclide 99Tc studies

IGS for Interventional Oncology Innova* Image Guided Systems (IGS) for Interventional

Oncology provide excellent image quality with exceptional dose efficiency. Get excellent organ coverage for tumor embolization, ablation techniques, and 3D guidance. Our flagship Innova IGS 540 with the Innova CT option enhances soft tissue visualization for imaging of high- and low-density tissues.

IGS for Interventional Oncology

Liver surgical anatomy

Anterior surface showing eight divisions

Hepatic veins and portal veins

Segmental Porto-venous circulation

The Mater hospital Cat lab

Ceiling suspended C-ARM Angiography unit

Left hepatic lobe hemangioma Achieved complete hemangioma embolisation end point

Hepatic hemangioma Symptoms: nausea, right hypochondriac pains and

anorexia. All disappeared after treatment with poly vinyl alcohol

particles

TACE and Chemoembolization After a second course

HEPATOMA

Embolisation with coils, following polyvinyl alcohol particles

Discussion

Hepatocellulacr carcinoma is the most common primary malignancy of the liver

Predisposed in patients with chronic liver diseases such as cirrhosis, hemochromatosis, alcoholism and glycogen storage disease

Hepatitis Chas been attributed to lead to increase HCC in the United States. Age at presentation is in the sixth and seventh decades

In Kenya the incidence is in the fourth and fifth decades

Major patterns of growth of HCC

Solitary mass Multifocal masses Diffusely infiltrating mass

Hepatic metastasis

This is the most common malignancy of the liver arising from the colon, stomach, pancreas, breast, and lung neoplasm

In children, metastases are commonly from neuroblastoma and Wilm’s tumor

Prognosis depends on the primary tumor site.

Metastatic cholangiocarcinoma

Axial CT scan slice

Biliary drainage

Ward nurses

PAA

Let us go on a hunting mission

Masai Mara

Acknowledgements Aga Khan University hospital, Karachi, Pakistan Lifestyle, hospital, Pretoria The Nairobi Hospital Many colleagues; Dr. Abwao, Dr. Njuguna, Dr.

Ndagwatha, Dr. Githaiga, Dr. Otele, Dr. Nyongesa, Dr. Ochieng( now studying in South Africa)

Radiology colleagues especially the late Dr. Sara Goretti Tata

Colleagues at Mulago Hospital, Makerere University, Kampala Uganda

Indeed all of YOU