BackTable Tumor Board

Is surgery truly the "cure" for hepatocellular carcinoma (HCC), and when is it a viable option? In this episode, Dr. Sabeen Dhand leads a roundtable discussion with interventional radiologist Dr. Siddharth Padia and transplant/hepatobiliary surgeons Dr. John Seal and Dr. Gabriel Schnickel, delving into the complexities of surgical treatments for HCC and the evolving landscape of liver resection and transplantation.Physicians, nurses, nurse practitioners, and physician assistants can follow this link to earn CME / CE credits for completing an accredited learning activity related to this discussion:https://www.cmeuniversity.com/course/take/125741---This podcast is supported by an educational grant from AstraZeneca Pharmaceuticals and Boston Scientific.---SYNPOSISThe doctors begin by discussing how they manage patient expectations regarding both palliative and curative treatments, highlighting the risk of recurrent HCC as a new lesion. They then outline key factors that influence their recommendations for liver transplant versus resection, such as the extent of underlying liver disease, the function of the future liver remnant, body habitus, overall health, and organ availability. The surgeons also review various surgical approaches to liver resection and recent advancements in liver transplantation, including living donor transplants and the ability to refer patients for downstaging procedures.Dr. Padia explains the original role of Y90 as a bridging treatment to downstage tumors and promote hypertrophy in the non-diseased liver segments, preparing the organ for surgical resection. However, Y90 treatment can also lead to the formation of adhesions, which may complicate future surgeries. Finally, the doctors discuss strategies to improve care coordination between community physicians and transplant centers to optimize patient outcomes.---TIMESTAMPS00:00 - Curative vs. Palliative Treatment04:03 - Choosing Between Transplantation and Resection05:47 - Liver Resection Types07:27 - Bridging Role of Y9012:14 - Evolving Landscape of Liver Transplantation20:59 - Patient Counseling in Minimally Invasive Procedures28:40 - Considerations for Surgery After Y9033:32 - Coordination Between Specialists40:08 - Immunotherapy as a Bridge to Transplant---RESOURCESCME Accreditation Information:https://f7cae4ec-b69e-490d-9e0f-19b16a6f146d.usrfiles.com/ugd/f7cae4_a7c37ea3cd1b4d3fa53d5edf8dfe255b.pdf

The process of liver transplantation involves many complexities, and each patient's path to transplant is unique. To offer insider perspectives on this process, Dr. Zachary Berman sits down with transplant and hepatobiliary surgeon Dr. John Seal, as well as transplant hepatologists Dr. Heather Patton and Dr. Steve Young.Physicians, nurses, nurse practitioners, and physician assistants can follow this link to earn CME / CE credits for completing an accredited learning activity related to this discussion:https://www.cmeuniversity.com/course/take/125740---This podcast is supported by an educational grant from AstraZeneca Pharmaceuticals and Boston Scientific.---SYNPOSISThe panel begins by discussing the multidisciplinary pre-transplant evaluation process, which assesses factors such as liver function, comorbidities, surgical risk, and the availability of psychosocial support. Once a patient is listed for transplant, they enter a system that prioritizes those with the highest Model for End-Stage Liver Disease (MELD) score. During the waiting period, several comorbidities should be carefully monitored. Dr. Seal explores the impact of portal vein hypertension and portal vein thrombosis, explaining how these conditions may necessitate intraoperative thrombectomy or bypass. Dr. Patton and Dr. Young focus on considerations for using anticoagulation in patients with a high baseline bleeding risk and selecting the appropriate anticoagulant for patients listed for transplant.For patients with hepatocellular carcinoma (HCC), eligibility for MELD exception points may depend on factors such as time spent on the waiting list, adherence to the Milan criteria, and the presence of extrahepatic complications of liver disease. The panel also discusses bridging therapies to transplant, including Y90 and TACE. In the peri-transplant phase, they highlight innovations such as living donor transplants, liver perfusion pumps, and the use of hepatitis C- and HIV-positive organs. Finally, the discussion turns to post-transplant considerations, including surgical complications, organ rejection, immunosuppression, predictors of HCC recurrence, and long-term surveillance.---TIMESTAMPS00:00 - Introduction01:16 - Current Landscape of Liver Transplantation03:22 - Transplant Evaluation Process09:48 - Timeline from Listing to Transplantion11:16 - Treating Portal Vein Thrombosis and Hypertension18:44 - MELD Exception Points22:05 - Bridging Therapies25:34 - Peri-Transplant Considerations30:53 - Post-Transplant Period37:39 - Repeat Transplantation---RESOURCESModel for end-stage liver disease (MELD) and allocation of donor livers (Wiesner et al, 2003):https://www.gastrojournal.org/article/S0016-5085%2803%2950022-1/fulltextLiver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis- Milan Criteria (Mazzaferro et al, 1996):https://pubmed.ncbi.nlm.nih.gov/8594428/Validation of the prognostic power of the RETREAT score for hepatocellular carcinoma recurrence using the UNOS database (Mehta et al, 2019):https://pmc.ncbi.nlm.nih.gov/articles/PMC6445634/CME Accreditation Information:https://f7cae4ec-b69e-490d-9e0f-19b16a6f146d.usrfiles.com/ugd/f7cae4_a7c37ea3cd1b4d3fa53d5edf8dfe255b.pdf

Treatment of hepatocellular carcinoma (HCC), like that of many other cancers, spans a spectrum from curative to palliative intent. To explore the "grey zone" of treatment goals for intermediate-stage HCC patients, Dr. Sabeen Dhand interviews a panel of experts in the field: medical oncologists Dr. Adam Burgoyne and Dr. Lingling Du, along with interventional radiologists Dr. Kirema Garcia-Reyes and Dr. Zachary Berman.Physicians, nurses, nurse practitioners, and physician assistants can follow this link to earn CME / CE credits for completing an accredited learning activity related to this discussion:https://www.cmeuniversity.com/course/take/125739---This podcast is supported by an educational grant from AstraZeneca Pharmaceuticals and Boston Scientific.---SYNPOSISThe discussion begins with an explanation of the Barcelona-Clinic Liver Cancer (BCLC) staging system. While this system takes into account helpful factors such as liver function, performance status, and tumor burden, it fails to fully capture the true heterogeneity of the HCC patient population. Additional considerations include tumor biology, response to previous treatments, and the location of metastases. The specialists then share their experiences in treating patients with comorbid gastrointestinal cancers and mixed tumors, discuss the benefits of an interventional oncology clinic setting, and highlight virtual opportunities for connecting with tumor boards. They also offer advice on patient education regarding treatment options.---TIMESTAMPS00:00 - Introduction to BCLC Staging03:02 - Impact of Performance Status06:29 - Predictors of Survival in HCC09:51 - Palliative versus Curative Treatment Intent13:55 - Comorbid and Mixed Gastrointestinal Cancers16:51 - Adverse Effects of Treatment20:37 - Interventional Oncology in the Clinic Setting23:06 - Navigating Multiple Provider Viewpoints28:01 - Complex Case Examples---RESOURCESBCLC strategy for prognosis prediction and treatment recommendation: The 2022 update (Reig et al, 2022):https://www.journal-of-hepatology.eu/article/S0168-8278(21)02223-6/fulltextCME Accreditation Information:https://f7cae4ec-b69e-490d-9e0f-19b16a6f146d.usrfiles.com/ugd/f7cae4_a7c37ea3cd1b4d3fa53d5edf8dfe255b.pdf

For hepatocellular carcinoma (HCC) patients who are not candidates for liver transplant or resection, lesion ablation can be a curative treatment. With multiple ablation options available and still under investigation, it can be challenging to navigate the differences between them. In this episode, Dr. Tyler Sandow hosts a discussion with interventional radiologists Dr. Kirema Garcia-Reyes, Dr. Sabeen Dhand, and Dr. Kevin Burns on the various ablation options for HCC and when to use each one.Physicians, nurses, nurse practitioners, and physician assistants can follow this link to earn CME / CE credits for completing an accredited learning activity related to this discussion:https://www.cmeuniversity.com/course/take/125738---This podcast is supported by an educational grant from AstraZeneca Pharmaceuticals and Boston Scientific.---SYNPOSISThe doctors first discuss Barcelona-Clinic Liver Cancer (BCLC) Stage A patients, where lesion size and location are key factors in deciding between ablation and transarterial therapies. They then compare cryoablation and microwave ablation, highlighting that cryoablation offers better visualization and control of the ablation zone, while microwave ablation is more effective for treating larger lesions.Dr. Burns introduces histotripsy, a noninvasive treatment that uses ultrasound energy to mechanically ablate tumors. He shares his experiences as an early adopter of this technology and discusses how intraoperative cone beam CT can help treat lesions located near critical structures or those poorly visualized on ultrasound. Finally, Dr. Garcia-Reyes and Dr. Berman provide insights into patient selection, pre-procedural imaging, and technical tips for Y90.---TIMESTAMPS00:00 - Introduction02:04 - Ablation vs Y90 in BCLC A Patients05:58 - Same-Day Y9015:55 - Y90 for Large Tumors17:51 - Ideal Cases for Cryoablation19:38 - Explanation of Histotripsy32:09 - Procedural Specifics for Histotripsy38:21 - Technical Tips for Y90---RESOURCESIncluding the Hollow Viscera (Stomach or Bowel) within the Ice Ball during Cryoablation: A Review of Adverse Events (Abramyan et al, 2024):https://www.jvir.org/article/S1051-0443(24)00681-X/abstractCME Accreditation Information:https://f7cae4ec-b69e-490d-9e0f-19b16a6f146d.usrfiles.com/ugd/f7cae4_a7c37ea3cd1b4d3fa53d5edf8dfe255b.pdf

In the past five years, the use of immunotherapeutic agents for advanced cancers has emerged as a promising alternative to tyrosine kinase inhibitors and chemotherapy, making it an exciting time to be practicing oncology. In this episode, Dr. Tyler Sandow interviews oncology experts about the landscape of advanced hepatocellular carcinoma (HCC) and the current state of immunotherapy treatments. He is joined by medical oncologists Dr. Jonathan Mizrah, Dr. Lingling Du, and Dr. Adam Burgoyne, as well as interventional oncologist Dr. Zachary Berman.Physicians, nurses, nurse practitioners, and physician assistants can follow this link to earn CME / CE credits for completing an accredited learning activity related to this discussion:https://www.cmeuniversity.com/course/take/125737---This podcast is supported by an educational grant from AstraZeneca Pharmaceuticals and Boston Scientific.---SYNPOSISDrs. Burgoyne and Mizrahi provide a primer on immunotherapy and explain how they communicate the principles of this treatment to their patients. Dr. Du discusses the Imbrave clinical trial and how recent studies have shown improved overall survival when immunotherapeutic agents are used, especially when multiple agents targeting various pathways are employed. When choosing between different regimens, the doctors consider factors such as the patient's underlying liver function, symptom burden, and prior treatments.Importantly, the doctors also discuss contraindications to immunotherapy, including a history of organ transplant, autoimmune disease, and poor performance status—all of which put patients at high risk for deterioration with this treatment. The treatment of patients with poor liver function remains controversial, as underlying cirrhosis may prevent the recovery of liver function. Dr. Berman outlines recent clinical trials studying the effects of transarterial chemoembolization (TACE) combined with immunotherapy. Finally, the doctors discuss the future of HCC treatment and the benefits of continued innovation in both interventional and medical oncology.---TIMESTAMPS00:00 - Introduction to Immunotherapy04:32 - Notable Clinical Trials13:39 - HCC Etiology and Immunotherapy Outcomes18:43 - Contraindications for Immunotherapy23:05 - Adverse Effects from Treatment25:14 - Combination Therapy36:22 - Considerations for Immunotherapy Dosing40:26 - The Future of HCC Treatment---RESOURCESAtezolizumab plus Bevacizumab in Unresectable Hepatocellular Carcinoma, IMbrave150 Trial (Finn et al, 2020):https://pubmed.ncbi.nlm.nih.gov/32402160/Tremelimumab plus Durvalumab in Unresectable Hepatocellular Carcinoma, HIMALAYA Trial (Abou-Alfa et al, 2022):https://evidence.nejm.org/doi/full/10.1056/EVIDoa2100070Nivolumab versus sorafenib in advanced hepatocellular carcinoma (CheckMate 459): a randomised, multicentre, open-label, phase 3 trial (Yau, 2022):https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(21)00604-5/abstractNivolumab (NIVO) plus ipilimumab (IPI) vs lenvatinib (LEN) or sorafenib (SOR) as first-line treatment for unresectable hepatocellular carcinoma (uHCC): First results from CheckMate 9DW (Galle, 2024):https://ascopubs.org/doi/10.1200/JCO.2024.42.17_suppl.LBA4008Randomized Phase 3 LEAP-012 Study: Transarterial Chemoembolization With or Without Lenvatinib Plus Pembrolizumab for Intermediate-Stage Hepatocellular Carcinoma Not Amenable to Curative Treatment (Llovet, 2022):https://pubmed.ncbi.nlm.nih.gov/35119481/EMERALD-1: A phase 3, randomized, placebo-controlled study of transarterial chemoembolization combined with durvalumab with or without bevacizumab in participants with unresectable hepatocellular carcinoma eligible for embolization (Lencioni, 2024):https://ascopubs.org/doi/10.1200/JCO.2024.42.3_suppl.LBA432CME Accreditation Information:https://f7cae4ec-b69e-490d-9e0f-19b16a6f146d.usrfiles.com/ugd/f7cae4_a7c37ea3cd1b4d3fa53d5edf8dfe255b.pdf

Of all the topics covered during interventional radiology training, dosimetry education is often delayed until after IRs enter clinical practice. In this episode, Drs. Tyler Sandow and Sabeen Dhand host a roundtable discussion with experts on the dosimetry fundamentals that all Y90 operators should understand. They are joined by interventional radiologists Drs. Zachary Berman, Kirema Garcia-Reyes, and Siddharth Padia, who provide their expert insights.Physicians, nurses, nurse practitioners, and physician assistants can follow this link to earn CME / CE credits for completing an accredited learning activity related to this discussion:https://www.cmeuniversity.com/course/take/125736---This podcast is supported by an educational grant from AstraZeneca Pharmaceuticals and Boston Scientific.---SYNPOSISThe group agrees that dosimetry is not a one-size-fits-all approach. Dosing strategies depend on factors such as tumor size, perfusion territory, underlying liver function, the choice between glass versus resin spheres, and treatment intent. These considerations are illustrated with real-life case examples. The doctors also explore voxel-based dosimetry, a method for calculating the amount of radiation absorbed by different parts of the tumor. They stress the importance of learning how to perform accurate dosage calculations.Finally, the conversation touches on data from major Y90 trials, current guidelines, and the evolving perspective on Y90 as a potential curative treatment, rather than merely a bridging therapy.---TIMESTAMPS00:00 - Introduction01:59 - Dosimetry Education During Training05:46 - Benefit of Individualized Dosing11:01 - Complications from High Doses15:19 - Dosage Calculation Cases22:51 - Duration of Response to Y9025:00 - Dosing Based on Treatment Intent29:11 - Challenging Case Example42:31 - Voxel-Based Dosimetry45:15 - Using Dosimetry Software---RESOURCESLEGACY Trial (Salem et al, 2021):https://pmc.ncbi.nlm.nih.gov/articles/PMC8596669/Voxel-based tumor dose correlates to complete pathologic necrosis after transarterial radioembolization for hepatocellular carcinoma (Pianka et al, 2024):https://pubmed.ncbi.nlm.nih.gov/38913189/RAPY90D Trial (Kappadath et al, 2023):https://jnm.snmjournals.org/content/64/supplement_1/P268Clinical, dosimetric, and reporting considerations for Y-90 glass microspheres in hepatocellular carcinoma: updated 2022 recommendations from an international multidisciplinary working group (Salem et al, 2023):https://pubmed.ncbi.nlm.nih.gov/36114872/International recommendations for personalised selective internal radiation therapy of primary and metastatic liver diseases with yttrium-90 resin microspheres (Levillain, 2021):https://link.springer.com/article/10.1007/s00259-020-05163-5)CME Accreditation Information:https://f7cae4ec-b69e-490d-9e0f-19b16a6f146d.usrfiles.com/ugd/f7cae4_a7c37ea3cd1b4d3fa53d5edf8dfe255b.pdf

Welcome to the first episode of BackTable Tumor Board, and our first recording session at our new in-person studio! Guest host Dr. Tyler Sandow (interventional radiologist) leads a multidisciplinary discussion about patient care coordination in hepatocellular carcinoma (HCC) diagnosis and treatment, with insights from his colleagues at Ochsner Health– Dr. Steven Young (hepatologist), Dr. Jonathan Mizrahi (medical oncologist), and Deondra Bonds-Adams (patient navigator).Physicians, nurses, nurse practitioners, and physician assistants can follow this link to earn CME / CE credits for completing an accredited learning activity related to this discussion:https://www.cmeuniversity.com/course/take/125735---This podcast is supported by an educational grant from AstraZeneca Pharmaceuticals and Boston Scientific.---SYNPOSISThe team speaks on the value of having multiple specialties weigh in on treatment conversations that are tailored to each patient’s medical history and risk factors, such as underlying cirrhosis and portal hypertension. Deondra highlights the importance of assessing the patient’s understanding of their disease and the role of physician extenders and schedulers in patient education. Dr. Young discusses the value of outreach clinics and streamlining the transplant evaluation process. Finally, Dr. Mizrahi gives advice on building referral networks and establishing early contact with transplant centers.---TIMESTAMPS00:00 - Introduction00:46 - Multidisciplinary Tumor Board06:00 - Patient Experience in Treatment Pathways10:10 - Barriers to Treatment16:03 - Benefits of IR Clinic19:33 - HCC Screening and Risk Factors24:08 - Building Referral Networks30:34 - Strategies for Effective Scheduling35:43 - The Future of HCC Treatment---RESOURCESCME Accreditation Information:https://f7cae4ec-b69e-490d-9e0f-19b16a6f146d.usrfiles.com/ugd/f7cae4_a7c37ea3cd1b4d3fa53d5edf8dfe255b.pdf