Role of Interventional Oncology in Colorectal Cancer

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers is
00:02 --> 00:04provided by Smilow Cancer Hospital.
00:06 --> 00:07Welcome to Yale Cancer Answers
00:07 --> 00:08with your host
00:08 --> 00:10Doctor Anees Chagpar.
00:10 --> 00:11Yale Cancer Answers features
00:11 --> 00:14the latest information on cancer
00:14 --> 00:16care by welcoming oncologists and
00:16 --> 00:18specialists who are on the forefront
00:18 --> 00:21of the battle to fight cancer. This week,
00:21 --> 00:23it's a conversation about the role of
00:23 --> 00:25interventional radiology and colorectal
00:25 --> 00:27cancer with Doctor David Madoff.
00:27 --> 00:30Dr Madoff is a professor of radiology
00:30 --> 00:32and biomedical imaging and of medical
00:32 --> 00:35oncology at the Yale School of Medicine,
00:35 --> 00:36where Doctor Chagpar is a
00:36 --> 00:38professor of surgical oncology.
00:39 --> 00:41Thank you so much for joining me tonight.
00:41 --> 00:44Thanks Anees, it's great to be
00:44 --> 00:46here and since our first discussion
00:46 --> 00:49back in December of 2019, I think
00:49 --> 00:51the world has changed tremendously.
00:51 --> 00:55Boy, we could do a whole other show on that,
00:55 --> 00:57but for those of you who have not met
00:57 --> 01:00you through the radio waves as yet,
01:00 --> 01:02tell us a little bit more about
01:02 --> 01:03yourself and what it is that you do.
01:05 --> 01:06Practicing interventional radiologist
01:06 --> 01:09with now more than 20 years of expertise
01:09 --> 01:12in the field of interventional oncology,
01:12 --> 01:14my specific area is in of clinical
01:14 --> 01:17and research interests has been
01:17 --> 01:19in treating patients with primary
01:19 --> 01:21and metastatic liver cancer.
01:21 --> 01:23However, I also do treat patients
01:23 --> 01:26with lung and kidney cancer,
01:26 --> 01:29so just briefly having completed
01:29 --> 01:30my radiology residency,
01:30 --> 01:33I went to MD Anderson Cancer Center in
01:33 --> 01:35Houston for my final years of training.
01:35 --> 01:36It was really the top program
01:36 --> 01:38at the time for this field.
01:38 --> 01:40At that time there were doing cutting
01:40 --> 01:42edge work in various types of cancer
01:42 --> 01:44and I found myself intrigued by
01:44 --> 01:46the pathophysiology of the liver.
01:46 --> 01:48I then spent ten really exciting
01:48 --> 01:51years on their faculty and became
01:51 --> 01:53extremely passionate about treating
01:53 --> 01:55cancer by minimally invasive routes.
01:55 --> 01:56So as I mentioned,
01:56 --> 01:59I have had young children and a family,
01:59 --> 02:01so I decided to move back to the New
02:01 --> 02:03York area and I spent 8 1/2 years at
02:03 --> 02:04Weill Cornell Medical Center in New
02:04 --> 02:06York City where I served in the roles
02:06 --> 02:08of Chief of Interventional Radiology
02:08 --> 02:10as well as vice Chair for Academic
02:10 --> 02:12Affairs and in 2019 I was recruited
02:12 --> 02:15to Yale to take on the role of Vice
02:15 --> 02:17Chair for Clinical Research in Radiology,
02:17 --> 02:21and in this role I was tasked with really
02:21 --> 02:23developing a clinical research program.
02:23 --> 02:26Now Yale has always been a very strong.
02:26 --> 02:27Clinical powerhouse,
02:27 --> 02:30but it really needed a little bit of
02:30 --> 02:33kickstarting in terms of clinical research.
02:33 --> 02:35They've had a large
02:35 --> 02:36scientific research group,
02:36 --> 02:37but not necessarily as
02:37 --> 02:39much on the research side,
02:39 --> 02:42so I've been fortunate in being
02:42 --> 02:44able to really delve deep into
02:44 --> 02:46the clinical research aspects.
02:46 --> 02:49And now we have a number of NIH funded
02:49 --> 02:50laboratories of young investigators,
02:50 --> 02:53and in July of 2020,
02:53 --> 02:55I also became the chief of
02:55 --> 02:56Interventional Radiology.
02:56 --> 02:59Here at Yale and also serve as a
02:59 --> 03:01director of Smilow's Interventional
03:01 --> 03:02Oncology program
03:03 --> 03:06so you know some of us have heard about
03:06 --> 03:08interventional radiology and we we
03:08 --> 03:10think about interventional radiology as
03:10 --> 03:14being the people who you know kind of do
03:14 --> 03:17things with catheters and xrays, right?
03:17 --> 03:20They take angiograms they they may
03:20 --> 03:24put in stents, things like that.
03:24 --> 03:28We may not be as familiar with
03:28 --> 03:30interventional oncology so so tell
03:30 --> 03:32us a little bit more about that.
03:33 --> 03:34Interventional Oncology
03:34 --> 03:39is a recent term, it's.
03:39 --> 03:41An interventional radiology subspecialty
03:41 --> 03:44that utilizes minimally invasive image
03:44 --> 03:46guided procedures to diagnose and treat
03:46 --> 03:49patients with various forms of cancer.
03:49 --> 03:51There are a number of benefits
03:51 --> 03:53of what I would consider primary
03:53 --> 03:55interventional oncology treatments,
03:55 --> 03:58and of course they include immediate tumor
03:58 --> 04:00cidal effects or uncle logical efficacy,
04:00 --> 04:02which really means that we know that
04:02 --> 04:04the tumors are being effectively
04:04 --> 04:06treated or killed by our techniques.
04:06 --> 04:08They're also minimally invasive,
04:08 --> 04:10meaning that most procedures are
04:10 --> 04:12performed with moderate sedation
04:12 --> 04:13and not general anesthesia,
04:13 --> 04:15and they are typically performed
04:15 --> 04:16in the outpatient setting.
04:16 --> 04:17That is,
04:17 --> 04:19patients typically go home the same day,
04:19 --> 04:21and of course this leads to
04:21 --> 04:23lower costs and time efficiency,
04:23 --> 04:24and lastly,
04:24 --> 04:29because they are local for the most part,
04:29 --> 04:31we have minimal systemic side effects,
04:31 --> 04:34meaning that the treatments are targeted
04:34 --> 04:36locally without having the systemic effects.
04:36 --> 04:39Usually thought of with intravenous
04:39 --> 04:41chemotherapy and because of this,
04:41 --> 04:43and because patients can avoid a major
04:43 --> 04:46surgery with prolonged recovery times.
04:46 --> 04:48Patients often have a better quality of
04:48 --> 04:50life and in some circumstances in fact,
04:50 --> 04:52patients can return to work within
04:52 --> 04:54a few days after treatment.
04:54 --> 04:56You know that all sounds great,
04:56 --> 04:57and I'm sure that many of
04:57 --> 04:57our listeners are thinking.
04:57 --> 05:00Geez, you know, if I can get out of
05:00 --> 05:03big surgery and chemotherapy and.
05:03 --> 05:05Get back to work in a couple of days
05:05 --> 05:07and have fewer systemic side effects.
05:07 --> 05:10All of that sounds perfect.
05:10 --> 05:13And yet not all patients are
05:13 --> 05:15offered kind of interventional
05:15 --> 05:17oncology to treat their cancers,
05:17 --> 05:20so can you talk a little bit
05:20 --> 05:23more about who might be the right
05:23 --> 05:25patient to be considered for
05:25 --> 05:27these kinds of procedures?
05:27 --> 05:30Maybe give us some examples of
05:30 --> 05:32what are the procedures that you
05:32 --> 05:34perform and how do you select
05:34 --> 05:37which patients benefit from this as
05:37 --> 05:39opposed to other other treatments?
05:39 --> 05:40Today
05:40 --> 05:42we're talking about?
05:42 --> 05:45Interventional oncology for colon cancer.
05:45 --> 05:48So the first thing I want to really state
05:48 --> 05:50is that colon that intervention oncology
05:50 --> 05:54does not treat the primary colon cancer.
05:54 --> 05:56Rather, we would treat the
05:56 --> 05:58metastasis from the colon cancer.
05:58 --> 06:00So for example, when they spread
06:00 --> 06:01to the liver or to the lung.
06:01 --> 06:04Now, the goals of therapy are
06:04 --> 06:07really including potential cure.
06:07 --> 06:10We could perform procedures that
06:10 --> 06:12can convert patients from resectable
06:12 --> 06:13from unresectable to resectable.
06:13 --> 06:16And we also could offer options
06:16 --> 06:18for palliation and what I mean by
06:18 --> 06:19palliation is that we can try to
06:19 --> 06:22extend a patient's life which is also
06:22 --> 06:24known as survival while trying to
06:24 --> 06:26maintain the best quality of life.
06:26 --> 06:29So we have a number of different options
06:29 --> 06:34that we can use depending on the patients.
06:34 --> 06:36I guess Histology of disease,
06:36 --> 06:38the number of tumors,
06:38 --> 06:39the location of tumors,
06:39 --> 06:42whether or not they are focused
06:42 --> 06:43throughout the body,
06:43 --> 06:46or whether or not they are within
06:46 --> 06:47a single organ.
06:47 --> 06:50So some of the therapies that we
06:50 --> 06:53can offer include thermal ablation,
06:53 --> 06:54which, for example,
06:54 --> 06:56is when a patient has a
06:56 --> 06:58very small tumor burden,
06:58 --> 07:00meaning that there's maybe one or
07:00 --> 07:03two small tumors within the liver,
07:03 --> 07:04and we can go.
07:04 --> 07:07With a needle under imaging guidance
07:07 --> 07:10and basically burn out the tumor,
07:10 --> 07:12unfortunately most patients
07:12 --> 07:15don't come in that fashion.
07:15 --> 07:16They typically come with
07:16 --> 07:17more advanced disease,
07:17 --> 07:21such as patients that have multiple liver
07:21 --> 07:23lesions scattered throughout their liver,
07:23 --> 07:26and in those patients we would
07:26 --> 07:28perform what's called a regional
07:28 --> 07:30therapy or a transarterial therapy,
07:30 --> 07:34where we would sneak a small tube from the.
07:34 --> 07:34Artery,
07:34 --> 07:36typically in the groin.
07:36 --> 07:39A tube which is also called a catheter,
07:39 --> 07:42and by doing angiography we can then
07:42 --> 07:44localize where the tumors are and
07:44 --> 07:47by doing so we can infuse either
07:47 --> 07:50chemotherapy or we can infuse radio
07:50 --> 07:53radioactive beads and help kill
07:53 --> 07:55the the tumors in that fashion.
07:55 --> 07:57Now of course.
07:57 --> 08:00What we do is typically done within the
08:00 --> 08:04auspices of a multidisciplinary tumor board,
08:04 --> 08:05so it's not typically that the
08:05 --> 08:07patient would come to me directly,
08:07 --> 08:09although that does occur,
08:09 --> 08:11and we do this within the
08:11 --> 08:14setting of a tumor board where
08:14 --> 08:15we have a multidisciplinary,
08:15 --> 08:18a very large multidisciplinary group,
08:18 --> 08:20and they could include surgical
08:20 --> 08:23oncologists and that may be colorectal,
08:23 --> 08:27hepatobiliary or general surgical oncologist.
08:27 --> 08:29We have medical oncologists,
08:29 --> 08:31radiologists and that includes both
08:31 --> 08:33diagnostic and interventional.
08:33 --> 08:36We also have radiation oncologists and
08:36 --> 08:38pathologists and many others who are
08:38 --> 08:41involved in the management of these patients.
08:41 --> 08:45So typically what would happen
08:45 --> 08:46is that if a patient,
08:46 --> 08:49for example has colorectal liver metastases,
08:49 --> 08:51patients would first be evaluated
08:51 --> 08:53for what you would consider a quote,
08:53 --> 08:55UN quote, curative surgery,
08:55 --> 08:57and if they're not able to
08:57 --> 08:59have that definitive surgery,
08:59 --> 09:02they would most likely be seen
09:02 --> 09:04by a medical oncologist,
09:04 --> 09:06sometimes with medical oncology
09:06 --> 09:07with systemic therapy,
09:07 --> 09:10patients can get down staged to
09:10 --> 09:12having surgery. That means that.
09:12 --> 09:15A patient that would be initially
09:15 --> 09:17considered unresectable or not able to
09:17 --> 09:20have surgery could then have their tumors
09:20 --> 09:22treated to a point where the surgeon
09:22 --> 09:25could get out all of the viable tumors.
09:25 --> 09:29There are times when patients have very,
09:29 --> 09:30you know, have a great
09:30 --> 09:31response to chemotherapy.
09:31 --> 09:35However, there may be one or two
09:35 --> 09:37small tumors that are still there,
09:37 --> 09:40and in those cases, we would treat
09:40 --> 09:42the ones that were not responsive to.
09:42 --> 09:44The therapy that was offered
09:44 --> 09:46by the medical oncologists
09:46 --> 09:49so it sounds like you know this is
09:49 --> 09:51really multi disciplinary decision
09:51 --> 09:55making and that patients may still
09:55 --> 09:59require or benefit from surgery and
09:59 --> 10:01chemotherapy but that interventional
10:01 --> 10:04oncology kind of adds yet another option.
10:04 --> 10:06Sometimes something that can
10:06 --> 10:08help to make things resectable,
10:08 --> 10:13so make surgery easier or may help too.
10:13 --> 10:14Target the systemic therapy
10:14 --> 10:17in terms of medical oncology.
10:17 --> 10:17Is that right?
10:18 --> 10:19That's absolutely correct.
10:19 --> 10:21Now one of the things I want to
10:21 --> 10:23bring up that I guess I did not,
10:23 --> 10:25is that interventional oncology.
10:25 --> 10:28Although we do offer what you
10:28 --> 10:30would call primary therapy,
10:30 --> 10:31that means you're actually
10:31 --> 10:33going in to treat the tumor.
10:33 --> 10:33Specifically,
10:33 --> 10:36interventional oncologists do a whole
10:36 --> 10:39gamut of other types of procedures,
10:39 --> 10:41and these of course include
10:41 --> 10:43image guided biopsy, which.
10:43 --> 10:46Without that may be very difficult
10:46 --> 10:49to even treat a patient at all.
10:49 --> 10:52We also do a lot of the central
10:52 --> 10:53venous access.
10:53 --> 10:55So for example, those patients that
10:55 --> 10:57are getting systemic chemotherapy,
10:57 --> 11:00they get their chemotherapy via a
11:00 --> 11:02port that's placed under the skin,
11:02 --> 11:04and that's done by an
11:04 --> 11:05interventional oncologist.
11:05 --> 11:08And then there's others where we deal
11:08 --> 11:10with either post operative complications,
11:10 --> 11:12such as those that happen during
11:12 --> 11:14surgery or sometimes from the.
11:14 --> 11:15Cancers themselves.
11:15 --> 11:17And that's just really a
11:17 --> 11:20short list of what we do as
11:20 --> 11:21interventional oncologists.
11:23 --> 11:27When you talk about things like doing
11:27 --> 11:31image guided biopsies or putting in a port,
11:31 --> 11:33or perhaps you know draining
11:33 --> 11:35an Abscess after surgery.
11:35 --> 11:37If that's a postoperative
11:37 --> 11:39complication for people who may be
11:39 --> 11:41outside of large academic centers,
11:41 --> 11:45oftentimes that may be done by a radiologist
11:45 --> 11:48or an interventional radiologist.
11:48 --> 11:50But I guess one thing that was kind of
11:50 --> 11:52intriguing that you mentioned is that
11:52 --> 11:56patients can come and see you directly,
11:56 --> 11:58which is not something that we usually
11:58 --> 12:00ascribe to interventional radiologists.
12:00 --> 12:02So tell us a little bit more
12:02 --> 12:05about how that happens.
12:05 --> 12:07Thank you, that's a great question
12:07 --> 12:09and something I definitely
12:09 --> 12:11wanted to bring up today.
12:11 --> 12:12Interventional radiologists are
12:12 --> 12:15similar to any other doctor that
12:15 --> 12:17you would see in a medical office,
12:17 --> 12:19and there are interventional oncologists
12:19 --> 12:22that actually do the same kind of office
12:22 --> 12:24hours as any other medical oncologist.
12:24 --> 12:28I attend pretty much
12:28 --> 12:31four different tumor boards.
12:31 --> 12:33I attend the the lung,
12:33 --> 12:36the gastrointestinal, the genitourinary and
12:36 --> 12:38the primary liver and through
12:38 --> 12:41those I end up getting referrals
12:41 --> 12:44from a lot of the members of the
12:44 --> 12:46the Multidisciplinary tumor Board.
12:46 --> 12:48That being said,
12:48 --> 12:50there are patients that self refer,
12:50 --> 12:53and there are also others throughout
12:53 --> 12:55the Community that also will
12:55 --> 12:57directly refer patients to my office.
12:57 --> 13:00Now I have office hours on Friday mornings,
13:00 --> 13:04so I see about 10 or more patients
13:04 --> 13:06both for primary therapies,
13:06 --> 13:08meaning that they're like new patients.
13:08 --> 13:11And there are others that I see in follow up,
13:11 --> 13:13such as those that have already had
13:13 --> 13:16a procedure and I want to follow them
13:16 --> 13:18with imaging to see if either anymore
13:18 --> 13:21therapy is necessary or if if I
13:21 --> 13:24would send them back to their primary
13:24 --> 13:27oncologist for their further evaluation.
13:29 --> 13:31And so these are like office visits,
13:31 --> 13:34not necessarily the day that you'll
13:34 --> 13:36do the procedure, but they may be
13:36 --> 13:37just consultations that you'll have
13:37 --> 13:39with the patient to talk about.
13:39 --> 13:40The procedure. Is that right?
13:41 --> 13:42That's exactly correct.
13:42 --> 13:47It used to be in days gone by that you would
13:47 --> 13:50really have the patient or the procedure
13:50 --> 13:54scheduled by the referring physician.
13:54 --> 13:57And like a technologist or or a technician,
13:57 --> 13:59you would kind of do the procedure.
13:59 --> 14:02That they request nowadays because we
14:02 --> 14:06have so much more breadth of training,
14:06 --> 14:10which means that I can do oblations and
14:10 --> 14:12and what you'd call embolization's,
14:12 --> 14:15which is the one of the transarterial
14:15 --> 14:16procedures that I perform.
14:16 --> 14:19I can then decide which one is safer
14:19 --> 14:22and which one would give a better
14:22 --> 14:25result than previously it used to be
14:25 --> 14:28in many institutions that there were,
14:28 --> 14:29for example, Oblation IST.
14:29 --> 14:32And those that only did embolization,
14:32 --> 14:36and depending on where you would be seen,
14:36 --> 14:38that may alter the type of therapy
14:38 --> 14:39that you may receive.
14:39 --> 14:41However, nowadays,
14:41 --> 14:45with such a global training like I said.
14:45 --> 14:49I, as the now consultant are able
14:49 --> 14:51to make that decision on my own.
14:51 --> 14:52However,
14:52 --> 14:55I do discuss this in Full disclosure
14:55 --> 14:58with with the patient and their
14:58 --> 14:59referring physicians,
14:59 --> 15:01so we're all on the same page.
15:02 --> 15:04Well, we're going to learn a lot
15:04 --> 15:06more about interventional oncology
15:06 --> 15:08and it's role in colorectal
15:08 --> 15:10cancer right after we take a
15:10 --> 15:12short break for a medical minute.
15:12 --> 15:13Please stay tuned to learn more
15:13 --> 15:15with my guest Doctor David Madoff.
15:16 --> 15:18Funding for Yale Cancer Answers comes
15:18 --> 15:20from Smilow Cancer Hospital hosting
15:20 --> 15:22an event in honor of colorectal
15:22 --> 15:25Cancer Awareness Month, March 16th.
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16:23 --> 16:25Welcome back to Yale Cancer answers.
16:25 --> 16:28This is doctor Anees Chagpar and I'm joined
16:28 --> 16:30tonight by my guest Doctor David Madoff.
16:30 --> 16:33We're learning about the role of
16:33 --> 16:35interventional oncology in colorectal
16:35 --> 16:38cancer now, right before the break.
16:38 --> 16:41David you were talking about the fact
16:41 --> 16:42that interventional oncology is really
16:42 --> 16:45evolved as a specialty in and of its own
16:45 --> 16:48right in that and that you really form
16:48 --> 16:51a part of this multidisciplinary team,
16:51 --> 16:53you consult with patients.
16:53 --> 16:57And and are able to kind of decide
16:57 --> 16:58what interventional oncology
16:58 --> 17:01treatment might be best for them.
17:01 --> 17:04Now, right before the break you were
17:04 --> 17:07talking about two particular interventions,
17:07 --> 17:10one called ablation and
17:10 --> 17:11another called embolization,
17:11 --> 17:15both of which could be used for liver
17:15 --> 17:17metastases for colorectal cancer,
17:17 --> 17:18and I was hoping that you could
17:18 --> 17:20delve a little bit deeper into that.
17:20 --> 17:22Tell us what the differences are
17:22 --> 17:24between those two techniques and.
17:24 --> 17:26Who might be right for one or the other?
17:26 --> 17:28How do you make those decisions?
17:29 --> 17:31Well, that's a great
17:31 --> 17:33question and they're very,
17:33 --> 17:35very different types of procedures.
17:35 --> 17:39Ablation is where you take a
17:39 --> 17:41needle and you directly puncture
17:41 --> 17:45into the liver from outside.
17:45 --> 17:47These procedures are typically
17:47 --> 17:49done under general anesthesia.
17:49 --> 17:50At least that's how I do them.
17:50 --> 17:53Although I did say earlier that
17:53 --> 17:55many of the procedures that we do
17:55 --> 17:57offer are under moderate sedation
17:57 --> 17:59and not general anesthesia.
17:59 --> 18:01However, for this particular one,
18:01 --> 18:05because we are heating up the
18:05 --> 18:06tumors to a very high temperature,
18:06 --> 18:08and that's usually around
18:08 --> 18:09100 degrees Celsius,
18:09 --> 18:11I feel more comfortable and the
18:11 --> 18:13patient probably would feel more
18:13 --> 18:15comfortable not being awake for this.
18:15 --> 18:18So typically patients that are
18:18 --> 18:21candidates for thermal ablation.
18:21 --> 18:24Include those that have
18:24 --> 18:26very small volume disease.
18:26 --> 18:29That means that a patient
18:29 --> 18:32that has maybe 1 tumor,
18:32 --> 18:34maybe one or two centimeters in
18:34 --> 18:37diameter within the liver that
18:37 --> 18:39really needs to be treated.
18:39 --> 18:41Medical oncology or systemic chemotherapy
18:41 --> 18:44may be very hard on the patient,
18:44 --> 18:46and patients can often have
18:46 --> 18:48what we call a chemo holiday.
18:48 --> 18:50Alternatively a patient.
18:50 --> 18:54May need surgery and depending on the
18:54 --> 18:58location of the lesion would require
18:58 --> 19:03a very large surgery so we would instead.
19:03 --> 19:05Just like I said,
19:05 --> 19:06directly puncture into the
19:06 --> 19:08liver under imaging guidance or
19:08 --> 19:11whether it be ultrasound or cat.
19:11 --> 19:15Scan and target the tumor and burn it.
19:15 --> 19:18Now there's multiple ways you can do
19:18 --> 19:20it with different types of energy.
19:20 --> 19:22They include radiofrequency,
19:22 --> 19:26which is the original energy microwave.
19:26 --> 19:27There's also cryoablation,
19:27 --> 19:30and now there's what's called
19:30 --> 19:31irreversible electroporation
19:31 --> 19:33or IRI where you can actually.
19:33 --> 19:36Electrocute the tumor is,
19:36 --> 19:37interestingly enough,
19:37 --> 19:40the one that we typically use nowadays
19:40 --> 19:43would be would be microwave ablation.
19:43 --> 19:44Now,
19:44 --> 19:46after the procedure is over,
19:46 --> 19:48I typically do a.
19:48 --> 19:51I typically do a contrast enhanced
19:51 --> 19:53cat scan to make sure that
19:53 --> 19:55the entire tumor was treated,
19:55 --> 19:57and like I said,
19:57 --> 19:59we would see the patients back
19:59 --> 20:02in about about a month.
20:02 --> 20:04Embolization is very different.
20:04 --> 20:06Embolization is where you're most
20:06 --> 20:09likely trying to treat a region of
20:09 --> 20:11the liver rather than one small area.
20:11 --> 20:14Most patients that I see have what you
20:14 --> 20:17would call by low bar liver metastases,
20:17 --> 20:19meaning that they have lesions
20:19 --> 20:21within both sides,
20:21 --> 20:24or both halves of the liver.
20:24 --> 20:26These procedures are typically
20:26 --> 20:27done with a tiny incision,
20:27 --> 20:31usually a couple of millimeters in the groin,
20:31 --> 20:34and we snake a small tube or catheter.
20:34 --> 20:38Into the artery which is in the groin
20:38 --> 20:40and we sneak it up into the artery
20:40 --> 20:43that supplies the the liver and we
20:43 --> 20:46then do a series of angiograms and
20:46 --> 20:49we can determine whether or not
20:49 --> 20:52these tumors are hyper or hypo.
20:52 --> 20:53Vascular hypervascular means
20:53 --> 20:55that they're very vascular.
20:55 --> 20:58Hypervascular means that they're less
20:58 --> 21:01vascular than the surrounding liver,
21:01 --> 21:04and by doing this we can then infuse.
21:04 --> 21:07Like I said, whether it be chemotherapy,
21:07 --> 21:10we can do a procedure called
21:10 --> 21:12chemoembolization where we mix
21:12 --> 21:14chemotherapy with an agent that
21:14 --> 21:16then blocks the blood supply.
21:16 --> 21:19Or we can do a procedure called
21:19 --> 21:20radio embolization,
21:20 --> 21:23where there's small microspheres that
21:23 --> 21:27are impregnated with a radiation source.
21:27 --> 21:30Usually this source is yttrium 90.
21:30 --> 21:32I don't want to get into all the
21:32 --> 21:35details about the how that works, but.
21:35 --> 21:38By and large, we infuse the material
21:38 --> 21:41into the liver and because the
21:41 --> 21:43tumors are typically hypervascular,
21:43 --> 21:47they soak up the beads or microspheres
21:47 --> 21:50and treat the tumor without too much.
21:50 --> 21:53What you would call nontarget
21:53 --> 21:54embolization now.
21:54 --> 21:56Like I said, both of these
21:56 --> 21:58procedures that I mentioned ablation
21:58 --> 22:00and radio or chemoembolization,
22:00 --> 22:04are done typically as outpatient procedures.
22:04 --> 22:06The latter procedure that I talked about.
22:06 --> 22:08Embolization is typically done
22:08 --> 22:10with moderate sedation,
22:10 --> 22:13and I think that these procedures typically
22:13 --> 22:16work very well in keeping the cheap
22:16 --> 22:18and keeping the tumors under control.
22:20 --> 22:22And so have they been
22:22 --> 22:24shown to improve survival?
22:25 --> 22:27Well, the answer to that
22:27 --> 22:29question is still up in the air.
22:29 --> 22:32I would say the answer is yes in
22:32 --> 22:34appropriately selected patients.
22:34 --> 22:36Now there are prospective clinical
22:36 --> 22:39trials that do show the benefit
22:39 --> 22:42of a of this in the setting of
22:42 --> 22:44colorectal liver metastases,
22:44 --> 22:48where the tumors did not progress OK.
22:48 --> 22:50However, it within the liver.
22:50 --> 22:54However, there are a lot more.
22:54 --> 22:56There are a lot more reasons
22:56 --> 22:58why patients fail than simply
22:58 --> 23:00what you did within the liver.
23:00 --> 23:03Now it is important to understand
23:03 --> 23:05that when most patients fail and I
23:05 --> 23:08would say that 2/3 of patients with
23:08 --> 23:10metastatic colon cancer actually do
23:10 --> 23:13have involvement within the liver and
23:13 --> 23:16it is the liver that is where patients
23:16 --> 23:18actually succumb to the disease.
23:18 --> 23:21So we typically do these in
23:21 --> 23:23combination with other therapies,
23:23 --> 23:26so there are confounding variables in there.
23:26 --> 23:27So patients are already.
23:27 --> 23:30Like I said, getting systemic chemotherapy,
23:30 --> 23:33they may be on biological
23:33 --> 23:35therapy or immunotherapy,
23:35 --> 23:37and there's a lot of work seem to
23:37 --> 23:40be done on combining the different
23:40 --> 23:41interventional oncology techniques
23:41 --> 23:45with a lot of systemic techniques
23:45 --> 23:47in prospective clinical trials.
23:48 --> 23:50Yeah, that's what that's what I
23:50 --> 23:51was going to ask you next is,
23:51 --> 23:54it sounds to me like this is an area
23:54 --> 23:57ripe for research where you know we
23:57 --> 24:00could really study the the impact of
24:00 --> 24:02various interventional techniques,
24:02 --> 24:05especially in a world where we seem
24:05 --> 24:08to be trying to deescalate therapy.
24:08 --> 24:11That is to say, to instead of
24:11 --> 24:14using kind of a shotgun approach,
24:14 --> 24:18be much more targeted trying to minimize.
24:18 --> 24:19Side effects and so on.
24:19 --> 24:22So tell us a little bit more about the
24:22 --> 24:24future of interventional oncology and
24:24 --> 24:26some of the exciting work that might be
24:26 --> 24:29going on in terms of advancing this field.
24:29 --> 24:31Yeah, so that's a great question
24:31 --> 24:34and I love to talk about this.
24:34 --> 24:38Let's just say that there are continuously
24:38 --> 24:41being advances in both medical device
24:41 --> 24:44technology as well as imaging technology,
24:44 --> 24:47and that helps us with better target
24:47 --> 24:49the therapy as well as helping us.
24:49 --> 24:53Guide and treat the tumors better,
24:53 --> 24:54whether it be larger size,
24:54 --> 24:56ablation zones, etc.
24:56 --> 24:59Now, in terms of really the future,
24:59 --> 25:03there's always a discussion on
25:03 --> 25:05artificial intelligence which can
25:05 --> 25:07help in interventional radiology.
25:07 --> 25:10It used to be thought that artificial
25:10 --> 25:13intelligence was only for diagnostic
25:13 --> 25:16imaging and trying to determine or
25:16 --> 25:19understand or diagnose tumors on an image.
25:19 --> 25:22However, we are now able to assess
25:22 --> 25:24imaging features that then can
25:24 --> 25:26predict which patients will respond
25:26 --> 25:29to the therapy and which will not,
25:29 --> 25:31and therefore if we can make a
25:31 --> 25:33prediction of which will not weaken,
25:33 --> 25:35then switch the therapies earlier
25:35 --> 25:38in the patient course and maybe give
25:38 --> 25:40them a better chance of survival.
25:40 --> 25:43I think that's one really
25:43 --> 25:44important research area.
25:44 --> 25:46There are others.
25:46 --> 25:47As I mentioned,
25:47 --> 25:49advancing technology we're now involved.
25:49 --> 25:52With robotics and I know that sounds
25:52 --> 25:55like more of a surgery type thing,
25:55 --> 25:58but there's been a lot of interest in
25:58 --> 26:00the past few years on interventional
26:00 --> 26:02radiology treatments and using
26:02 --> 26:04robotics to quickly guide the needle
26:04 --> 26:06into the tumors and make it much
26:06 --> 26:09more safe as well as we talked about
26:09 --> 26:11being in a location where you may
26:11 --> 26:13not have interventional oncologists,
26:13 --> 26:17you may be able to further democratize the
26:17 --> 26:20techniques such as biopsies or oblations.
26:20 --> 26:22And then of course,
26:22 --> 26:25we're always in involved in discussing
26:25 --> 26:26augmented and virtual reality,
26:26 --> 26:28and that's also something that
26:28 --> 26:31is coming down the Pike in
26:31 --> 26:32interventional radiology now.
26:32 --> 26:34There's also other interesting research
26:34 --> 26:36we kind of mentioned doing immunotherapy,
26:36 --> 26:38combined with transarterial therapies
26:38 --> 26:41such as radio embolization,
26:41 --> 26:42will probably be doing that at Yale
26:42 --> 26:44at sometime in the near future.
26:44 --> 26:47We're also involved in a clinical
26:47 --> 26:49trial right now called Dragon,
26:49 --> 26:52in which we're looking at ways to.
26:52 --> 26:55Rapidly regenerate the liver so that
26:55 --> 26:59patients can have surgery and not necessary,
26:59 --> 27:02or have a better opportunity to have
27:02 --> 27:04surgery with less complications
27:04 --> 27:07and less prolonged recovery times.
27:07 --> 27:09So that's another study that we're
27:09 --> 27:11currently working on here at Yale.
27:12 --> 27:15And so as we think about these technologies,
27:15 --> 27:18especially the newer ones that you
27:18 --> 27:21mentioned using robotics and virtual
27:21 --> 27:23reality and artificial intelligence.
27:23 --> 27:25All of that sounds really
27:25 --> 27:26cool and cutting edge.
27:26 --> 27:28And anytime we think about cool and
27:28 --> 27:31cutting edge, we also think about cost.
27:31 --> 27:34So can you tell us a little bit more
27:34 --> 27:37about whether these technologies are
27:37 --> 27:40covered by most people's insurance is.
27:40 --> 27:42And and the cost?
27:42 --> 27:45Well, that's actually a great question,
27:45 --> 27:47and again, it's something that
27:47 --> 27:49we're still working out now.
27:49 --> 27:51Robotics for example.
27:51 --> 27:54I don't believe that that this is
27:54 --> 27:57a procedure that's built for OK.
27:57 --> 27:59However, it does increase the
27:59 --> 28:02throughput and workflow of an
28:02 --> 28:05interventional radiology department,
28:05 --> 28:09so you really do get many
28:09 --> 28:11more patients to be treated.
28:11 --> 28:15In a or diagnosed with a
28:15 --> 28:17much more rapid timeframe.
28:17 --> 28:21The others are still in research development,
28:21 --> 28:24so I would say that a lot of that
28:24 --> 28:26is actually covered by research.
28:26 --> 28:28I wouldn't say that it would actually
28:28 --> 28:30go through insurance companies.
28:31 --> 28:33Doctor David Madoff is a professor
28:33 --> 28:34of radiology and biomedical
28:35 --> 28:36imaging and of medical oncology
28:36 --> 28:39at the Yale School of Medicine.
28:39 --> 28:41If you have questions,
28:41 --> 28:43the address is canceranswers@yale.edu
28:43 --> 28:45and past editions of the program
28:45 --> 28:48are available in audio and written
28:48 --> 28:49form at yalecancercenter.org.
28:49 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public
28:55 --> 28:56radio funding for Yale Cancer Answers
28:56 --> 29:00is provided by Smilow Cancer Hospital.

Information

Role of Interventional Oncology in Colorectal Cancer with guest Dr. David Madoff March 13, 2022 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095