Center for Liver Disease Management and Transplantation The Medical City HCC in the Philippines
• 4th leading cause of 10,000
cancer overall 7,600 7,477 8,000 – 2nd among men and 7th among women 6,000
4,000 • 2nd leading cause of cancer death overall 2,000
0 New Cases of H CC Deaths from H CC
Ngelangel CA. Jpn J Clin Oncol 2002; 32 (S1): S52-S61
Data from Philippine Cancer Society, 2005 Treatment Options for HCC • Surgical – Liver resection – Liver transplantation • Non-surgical – Local ablation • RFA, PEI, Microwave ablation, HIFU – Locoregional • TACE • DEB-TACE • SIRT – Systemic • Chemotherapy, molecular targeted, biological agents – Palliative care Selective Internal Radiation Therapy (SIRT) SIRT in the Asia Pacific
Korea Taiwan
Hong Kong Vietnam
India Singapore Philippines
Thailand Australia Malaysia
New Zealand SIRT in the Philippines • SIR spheres approved by Philippine FDA in early 2008 • First 2 cases on July 30, 2008 • Performed at TMC & MMC • Centers that offer SIRT and no. of cases – The Medical City 40 – Makati Medical Center 20 – St. Luke’s Medical Center 17 First SIRT in the Philippines
Dr. Ramon Dr. Lourens
Santos-Ocampo Bester Protocol Initial Visit: History and P.E. Work-up: Laboratory tests, Imaging Diagnosis Multidisciplinary Conference SIRT Yes No Mapping angiography + MAA scan Other options
Implantation of Y90 beads
Follow-up • Lab tests and imaging at 1 month • Lab tests and imaging at 3 months • Every 3 months thereafter SIRT Experience - The Medical City • Retrospective, descriptive • July 2008 – November 15, 2013 • Chart review • Interview of patients, relatives, MDs & staff • Number of cases – Mapping 49 – SIRT 40 – 8 (SIRveNIB) = 32 Demographics 32 cases • Age, yrs Mean (Range) 63 ± 12.5 (30-83) • Sex – Male 24 (75%) – Female 8 (25%) • Race – Filipino 29 (91%) – Canadian 1 (3%) – Korean 1 (3%) – Sri Lankan 1 (3%) Tumor Diagnosis 32 cases • Etiology – Hepatocellular Carcinoma (HCC) 22 (69%) – Cholangiocarcinoma (CCa) 5 (16%) – Colorectal Liver Mets (CRLM) 3 (9%) – Others 2 (6%) • Breast Ca Liver Mets • Adrenal tumor with invasion of the liver D.U. 71/M CRLM SIRT on July 30, 2008 J.C. 30/M CRLM SIRT on January 23, 2013
November 2012 May 2013
C.R. 78/F CCa SIRT on Dec. 12, 2008
November 2008 February 2011
*Expired August 2012, SV 44 months Survival Outcome 32 cases SIRT for HCC 22 cases • Age, yrs Mean (Range) 63 ± 11.6 (44-83) • Sex – Male 19 (86%) – Female 3 (14%) • Race – Filipino 22 (100%) SIRT for HCC 22 cases Etiology of Liver Disease 9 8 7 6 5 4 3 2 1 0 SIRT for HCC 22 cases • Prior treatment received Surgery 2 TACE 3 RFA 2 DCT 2 • ECOG status 0 13 (59%) 1 6 (27) 2 3 (14%) SIRT for HCC 22 cases Parameter Yes No
Cirrhosis 7 (32%) 15 (68%)
Portal Vein 6 (27%) 16 (73%) Thrombosis Ascites 2 (9%) 20 (91%) Extrahepatic 5 (23%) 17 (77%) Disease SIRT for HCC Pre-treatment Lab Data Parameter Mean ± SD Range Total Bilirubin (mg/dL) 0.98 ± 0.49 0.45 – 2.30 Albumin (g/dL) 3.77 ± 0.52 2.79 – 4.6 INR 1.08 ± 0.11 0.96 – 1.3 ALT (U/L) 63.31 ± 46.98 22- 232 AST (U/L) 99.08 ± 74.54 23 - 296 Creatinine (mg/dL) 0.93 ± 0.36 0.37 – 1.92 BCLC Staging System
HCC
Stage 0 Stage A-C Stage D
PS 0, Child-Pugh A Okuda 1-2, PS 0-2, Child-Pugh A-B Okuda 3, PS > 2, Child-Pugh C
Very early stage (0) Early stage (A) Intermediate Advanced stage (C) Terminal Single < 2 cm Single or 3 nodules stage (B) Portal invasion, stage (D) Carcinoma in situ < 3 cm, PS 0 Multinodular/Large, N1, M1, PS 1-2 PS 0
Llovet JM, et al. Design and endpoints of clinical trials in hepatocellular carcinoma. Journal of the National Cancer Institute. 2008;100(10):698-711, by permission of Oxford University Press. 22 SIRT for HCC 22 cases • Child Pugh Stage A 20 (91%) B 2 (9%) C 0 • BCLC Stage B (Intermediate) 13 (59%) C (Advanced) 9 (41%) SIRT for HCC Tumor-related Data • Size of biggest lesion Mean ± SD (range) 12.3 ± 3.4 (5.15-17.1) • Distribution Solitary 4 (18%) Multifocal 18 (82%) • Number of lesions 1 4 (18%) 2-5 12 (55%) >5 6 (27%) SIRT for HCC Tumor-related Data • Location Unilobar 14 (64%) Bilobar 8 (36%) • AFP <400 14 (64%) >400 6 (36%) SIRT for HCC Treatment-related Data • Lung Shunt <10% 14 (64%) 10-20% 7 (32%) >20% 1 (4%) • Dose administered, GBq Mean ± SD (range) 1.7 ± 0.31 (1.1-2.3) SIRT for HCC Treatment-related Data • No. of treatments 1 22 2 0 • Target of treatment Whole liver 8 (36%) Right lobe 12 (55%) Left lobe 2 (9%) Segmental 0 Outcomes Toxicities Sign/Symptom Yes No Fatigue 8 (38%) 13 (62%) Anorexia 5 (24%) 16 (76%) Nausea/Vomiting 3 (14%) 18 (86%) Fever 2 (10%) 19 (90%) Pain 5 (24%) 16 (76%) Bloating 1 (5%) 21 (95%) Outcomes Other Complications • Radiation gastritis 0 • Radiation pnuemonitis 0 • REILD 0 • Pleural effusion 2 • Skin rash, back 3 • Ascites 1 • Anxiety-induced COPD exacerbations and hypertension 1 Skin rash, back Other Treatment post SIRT • TACE 3 • DEB-TACE 1 • RFA 1 • Surgery 5 – Resected 4 N.C. 77/M HCC SIRT on July 20, 2012
16 cm 6 cm June 2012 January 2013 Partial Hepatectomy March 2013 Specimen Histopathology
HEMORRHAGIC NECROSIS SMALL LARGE AREAS OF
OF MAIN TUMOR VIABLE NECROSIS TUMOR Outcomes
Status Progressive Stable or Unknown
Disease No Status at Disease Death Dead 8 3 Alive 4 2
*Only patients followed ≥ 3 months included, n=17
Survival ECOG Status Survival Child-Pugh Stage Survival BCLC Stage Survival Presence of Cirrhosis Survival Presence of PVT Survival Extrahepatic Disease at Baseline Survival Post-SIRT Treatment Conclusion • SIRT can now be successfully performed in the Philippines • The most common etiology is HCC associated with Hepatitis B • Acceptable outcomes with minimal toxicity although our numbers are still small • Applicability limited by cost constraints • Maximize benefit possibly in combination with other treatment modalities • May effectively be used to bridge to liver resection or transplantation Thank you
Charles Catton, Brian O'Sullivan, Robert Dinniwell, Anthony Griffin, Peter C Ferguson, Rebecca Gladdy, David Mccready, Martin Blackstein, Abha Gupta, Lisa W Le, Peter Chung
Charles Catton, Brian O'Sullivan, Robert Dinniwell, Anthony Griffin, Peter C Ferguson, Rebecca Gladdy, David Mccready, Martin Blackstein, Abha Gupta, Lisa W Le, Peter Chung
