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

No Disclosures

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

What is Liver Directed Therapy?

• Oncologic treatment targeted solely at liver metastases– Minimally invasive– Tolerable side effects– Fast recovery– Relatively low risk

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

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

Curative Palliative

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%

Case Example

Catheter Directed Therapy

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

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

TACE Outcomes

Semin Intervent Radiol. 2013 Mar; 30(1): 39–48.

Radioembolization/Y90

Case Example

Case Example

Case Example

• 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

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

• 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

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

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