 Well, I've been an interventional radiologist here at Stanford for, I think, this is my eighth year, and today I'll talk about interventional oncology, and I'll expand a little from the liver to actually kidney too, so I'll give you a complete overview. These are my disclosures, and this is my team, my interventional radiologist partners that I work with every single day. I'm an interventional radiologist, which is a subset or subspecialty of diagnostic radiology. You may have gone, got CT scans and MRIs. I'm in that same department, but I use the imaging to do minimally invasive procedures. Each one of us has a specialty, and my specialty is interventional oncology. This is where I go to work every single day. It's great at dinner parties, people ask me, what do you do for a living? It's very hard to explain. I say I'm a radiologist, people think I work on radios, or take films, but I'm lucky I get to go here every single day, and what you see before you is this is a fluoroscopic x-ray machine. So the patient, oh good, you see the arrow, the patient lies here on the table, and x-rays come from below through the patient and then get imaged from this detector right above the patient. So this is a real time imaging, and I use those images which get projected onto a large, actually it's not multiple screens anymore, it's a big 70 inch monitor in front of me, and I get to see what I'm doing inside of the person in real time. So I'm operating inside of people through small incisions in the body using x-ray or ultrasound or CT guidance. And underneath all this sterile paper is lead because of the x-rays, so I wear about 20 pounds of lead every single day, get a good workout. And this is what I use, the tools to do my procedures, needles, wires, small little catheters or tubing to basically travel through the body through the blood vessels or veins to get to where I'm going and do my operation. Today I'm going to focus on renal cell carcinoma, and of course it's a common cancer in the kidney, however a very uncommon cancer compared to the entire gamut of cancers. Also people who develop renal cell carcinoma of that small percent some travel to the liver and I'll talk about treatments within the liver as well. I'm the local regional therapy guy, kind of the SWAT team that goes in there and stamps out the cancer and treats it at the location where it's at. So today I'm going to focus on ablation on the kidney and then the liver, and then I'm going to talk about liver directed therapies in the liver and that'll be chemoembolization which is delivering chemotherapy directly to the liver and radioembolization which is delivering radiation directly to the liver. It's a form of brachytherapy. So first I'll start with ablation and that's basically destruction of tissues and within the liver we generally burn tissues by using RFA which is radiofrequency ablation or microwave and we go in there, we stick probes into the liver and we will basically destroy tissues by heating it up and cooking it. Within the kidney we place in probes but instead of burning the tissue we'll freeze the tissue until it's destroyed. So let me just talk about cryoablation and the kidney. So cryoablation just comes from, to break down the word is cryo meaning cold, ablation meaning tissue destruction. So we're destroying tissue using very, very cold temperatures, negative 40 degrees Celsius and we're able to do this within the kidney and destroy the tumor cells themselves. So the different ways about destroying or getting the probes into the kidney, urologists also do this as well. They do open cryoablation meaning they would do surgery incision, see the kidney, stick the probes directly into the kidney cancer or they can do it laparoscopically by placing in little ports blowing up the retroperitoneum or the space around the kidney and then putting in the probes directly. My favorite, the way I do it, is not of the two choices above but percutaneous and percutaneous means through the skin and that's how interventional radiologists pretty much do everything. We're kind of the band-aid surgery people because we just make a small little incision, put our tools inside a person and we guide the probes there by using CT. So you probably all, most people have gotten a CT scan here and we use that donut CT scanner to put our probes exactly within the tumor and then freeze the tissue. There are no large incisions and most people are discharged the next day. So a picture is worth a thousand words. So I'm just going to show you a little video here. As basically here's the CT scanner, you're lying on your stomach. Usually we do it under conscious sedation meaning no general anesthesia. The tumor is there in the kidney. We'll place multiple probes, usually about 17 gauge needles into the tumor and then freeze at the tip of the needles using pressurized gases, argon and helium and then we'll do a cycling of freeze, thaw, freeze, thaw and the tissue gets destroyed when it cycles through this kind of freezing and thawing cycle and we're able to spare all the kidney around it and be very targeted in our treatment. And as you probably know, freezing doesn't hurt as much as burning yourself. So that's why we're able to do this under conscious sedation rather than putting you under general anesthesia. If we were to burn something, we would definitely put you under general anesthesia because that is much more painful. So this is the probe that we stick into people and it's a 17 gauge needle and it has a hollow chamber and you pump in pressurized gas helium first and it freezes at the tip and creates an ice ball and which expands over time and then you unfreeze or thaw it out using argon, so using noble gases for all those people in chemistry to basically freeze and thaw tumors. So here's a little diagram. So here are the tumor cells. They're floating in some extracellular fluid and the difference is that the tumor cells have a different concentration of ions compared to the surrounding extracellular fluid and we take advantage of that and that also changes the freezing how fast they freeze. The outside freezes faster than the cell and then when it freezes and the difference in freezing it causes the ions to move out of the cell. The cell shrinks then we thaw and then it's still a little frozen in the cell and then that begins to thaw and then the little ions go back into the cell causes the swell and then burst. So that's how the actual killing part happens with freezing and thawing. So it's very effective. This percutaneous cryoblation 87% effective rate compared to still laparoscopic is more effective at 94%. It's nicer because short hospitals say you go home the next day and about 85% five-year recurrence free survival and if there's any residual tumor we can always go back in and touch it up. So go back in and blade again. So these are kind of bits and pieces of the cell so they're not live so it usually just gets reabsorbed over time. Yes, four centimeters. So I would say it's like the Goldilocks of you know for ablation it's all like Goldilocks has to be just right you know just the right size just the right location and that way we can do cryoblation not everyone's a candidate for it. Yes, yes to the liver we'll I'll talk about that we generally use the microwave or the radio frequency ablation for that just because we have more experience in data. We long we will do microwave some there's also external beam radiation so there are there are different choices depending on where it has misdasticized to. You can do nodes but they're much harder because usually it's location the nodes are usually surrounding very important structures like arteries veins things like that so you don't want to destroy those. Now it's hard because of the location and also yeah because it has to be just the right location because you're in danger of destroying surrounding tissue. So Spares kidney, yeah so the risk of the procedure is what I just talked about is destroying nearby tissues for example getting into the collecting system of the kidney you know intestines anything kind of nearby where you're trying to ablate burn and it is can be painful afterwards usually lasts about a week and it feels sore and bleeding is also a risk but it's about two percent complication rate and size it's four centimeters we can't ablate really large tumors because we'll miss pieces of it and because you just it only makes little circles and we do overlap you know there's only so much overlap of circles before you kind of miss pieces of it because you only can burn in circles and small circles at that uh usually has to be uh towards the back it has to you know almost be hanging off the kidney it makes it much easier for us if it's more central it's difficult because you know you have important blood vessels the collecting system it's just more challenging and I think at that point it would be more surgery and usually cryoblations reserved for patients who can't undergo surgery or you know have one kidney left and you can't take out the last kidney and otherwise go to dialysis so that was local regional therapy for the kidney and now I'm going to move on to the liver so the liver we generally burn just because we have more experience with that and this is radiofrequency ablation sticking in probes inside the liver and putting a current through it and heating up the tissue until it cooks and it's also very similar to cryoblation of the liver I mean of the kidney you know liver is very important on location as well location is very important because it can't be near very important structures like the colon gallbladder large blood vessels otherwise it'll suck away the heat so it has to be kind of just right and it can't be too sick and usually ablation is reserved for people who can't undergo surgery to resect the tumors and once again size is the most important thing usually less than three centimeters for us to get a you know over 90 success rate and when you're getting larger like three to five centimeters it's kind of like on the borderline and above five centimeters no because we're not able to completely kill the tumor so that yes heart oh that's for like a ep yeah rhythm is yeah similar but I think there are different for us it's like a slow cook because it's sort of like a the Thanksgiving turkey where you can't really cook it really fast and you're trying to cook a large area we have a cycle that we go through and it's similar technology but applied differently so for tumors now I'm going to talk about tumors within the liver that are too big you can't ablate you can't go undergo surgery now we're going into the realm of liver directed therapy where we generally have two choices either deliver chemotherapy directly to the tumor or deliver radioactive beads and the way we go about doing it is we puncture the artery near the groin because that's a large artery then using x-ray guidance will snake our little tubes and wires up into the liver and then we will take pictures or we call angiograms pictures of the arteries using our extra machine to map out what arteries feed the tumors then we will bring our little tube directly to the artery that feeds the cancer and we will inject in chemotherapy to the tumor itself so it's very different than taking a pill or get injection in the veins because we're delivering the fight directly to the tumor and the reason why this is good is because we're reducing systemic toxicities and we're able to deliver higher levels of chemotherapy directly to the tumors and essentially marinate the tumors in chemotherapy that what we use is drug-alluding beads with doxorubicin these are small little beads with chemotherapy stuck on them and these beads are biocompatible and the drug kind of just leaks out of it over the course of about two weeks and you stay overnight in the hospital and then go home the next day most people are a candidate if your liver function is intact and your functional status is good meaning you're you know like everyone here able to carry on their activities of daily living and unfortunately there's not a lot of data with renal cell carcinoma and chemo embolization chemo embolization is mainly used for primary tumors within the liver like hepaticellular carcinoma and also neuroendocrine tumors but for the experience with renal cell carcinoma and chemo embolization hasn't been that great most of the time you just get stable disease after a treatment so we haven't been so excited about using chemo embolization on tumors within the liver or metastasis but it is an option and something we think about to give directed therapy a better option would be radio embolization and radio embolization is it instead of injecting little beads with chemotherapy injecting beads with radiation loaded onto them and you're delivering high levels of radiation about 100 to 3000 grade just to give you a sense of how much that is it only takes about 70 grade to destroy tumors and you're delivering multiple folds more than is necessary and these little beads are delivered through a small little tube just the same way as chemo embolization we puncture the artery in the groin travel up to the liver and we inject it into the liver itself and 64 hours and so the radiation is pretty much gone after about two months and the reason why we're able to do this in the liver we can't do it anywhere else we've done it one time in the kidney and we're still waiting for results on that but essentially the kidney is a special or I mean the liver is a special organ has a dual blood supply 70% of the blood supply is comes from the portal vein about 30% from the paddock artery if you were just to inject the little radioactive beads into the liver you just kind of spread all the way around evenly distributing into the liver and essentially kill the liver but you throw in a tumor in there very hypervascular meaning lots of blood vessels hungry little guy and it's getting almost 100% of its blood supply from the liver artery then you inject in these radioactive particles and they'll concentrate up within the tumor about three or ten to one compared to the background and essentially radiate the tumor from the inside out this is more radiation than you can hope to achieve from the external beam radiation where they shine the radiation oncologist where they shine the radiation from the outside in because there's a lot of good tissue to go through before you hit a tumor and the liver is a very radio sensitive organ so here are the beads under electron microscope they're about 30 microns so one third the width of the human hair and I'll just pass around this little sample which is non-radioactive for people to look at so that is the human hair right next to it so you can see what it looks like in comparison and there are two brands sershers and theracers and we use sershers to deliver the radioactive particles it's used for colorectal cancer theracers used for hepaticellular carcinoma but we can use them for renal cell carcinoma as well so they're made in a nuclear reactor so those little beads that you see there they're yttrium 89 they pop them into the nuclear reactor they could become yttrium 90 which is a pure beta emitter and what that means to you is that the ionizing or damaging radiation only acts two and a half millimeters away from that sphere so it kills very locally maximum penetration 11 millimeters and half life is 64 hours and they're attached to biocompatible spheres one comes from canada the other one comes from australia and then it decays to zirconium so it'll be inert after a little while two months so the people who are a candidate for this kind of treatment are people who have metastasis to the liver and predominant so i always ask the question what's going to kill the patient is it going to be the little lymph nodes you know maybe in the retroperitoneum or is it the big masses within the liver if the answer is the big masses in the liver then you're a candidate for this treatment and provided that you have a good functional status meaning you're able to you know get around you're not sleeping more than half the day these are people we're trying to maintain their quality of life and to help them live longer we're definitely not a cure for cancer but the whole purpose and treatment of our of our radio embolization is to help people live better so the way we go about doing it is you'll see us in clinic we'll talk about this procedure answer all your questions we're even on youtube you can see our videos if you like beforehand and then we'll go for and get it authorized by the churns company and it'll be two outpatient two to three outpatient procedures meaning no overnight stay in the hospital and then we'll meet again to make sure you recovered from the radio embolization and also we'll get imaging or follow-up imaging in about 10 to 12 weeks and we'll meet again to go over the imaging and to basically discuss what to do next we always work in conjunction with oncologists surgeons we work as a big team and tumor boards and things like that in order to determine what is the best care so we never work in a vacuum it's a huge team working so the first outpatient procedure when you come to stanford is we'll map out the arteries to see what arteries feed the tumors but more importantly we'll look for arteries that lead away from the liver sometimes there's small little arteries that go to the stomach or the duodenum and we want to plug them up permanently with coils you're not going to miss those arteries you're not going to feel it but it does make it safer for us to receive the radioactive particles later we don't want to cause ulcers and that's what you're seeing here is little ulcers and beads within the stomach because your gut is very sensitive to radiation and we want to avoid that kind of complication even though we're super careful still ulcers happen in about four percent of our patients and after we make it safe we'll inject in a radioactive tracer to see where are those particles going to go once we inject them most of them will stay in the liver some will pass through the liver and go to the lung and based upon the amount that's going to the lung so this is kind of the mapping what it looks like how much is in the liver and how much is in the lung based upon that shunt based upon your liver volume i will order the dose made special at the nuclear reactor because we don't have it sitting on our shelf you're going to come back a week later it's going to be fed extover you're going to come back in for another outpatient procedure where we puncture the artery travel up the liver again and then deliver the radioactive particles directly to the liver and we use this little complex box so basically we don't radiate ourselves or spill it anywhere because the nuclear regulatory agency take it seriously so we have radiation physicists running around with Geiger counters to make sure that we don't spill any of this stuff because if little that stuff dropped on the floor you'd never see it never had any accidents yet so what to expect afterwards over half my patients feel really tired and not very hungry and it takes about two to four weeks to recover the younger you are the more robust you are the faster you recover say you're 80 and you're kind of a little slow you know slower movement that will your recovery will probably be a month a quarter of my patients will will feel pain or nausea but pretty much people feel normal back to about a month if you're really young you know in your 30s or 40s you'll probably get better within less than a week probably within days and the major complications as I mentioned before ulcers four percent and liver failure is like one percent those are the kind of the main complications and in our Stanford experience we reviewed all the renal cell carcinoma patients that we treated all of them had clear cell and three we had amazing responses and that's why we will push to treat patients with liver metastasis with radio embolization rather than chemo embolization is because our experience has been positive and we've published it and we did six patients and we had three complete responses and one partial response two patients had just progression in other locations outside the liver that couldn't assess that whether it was successful in the liver or not but they didn't die of liver disease they passed away from something else but the overwhelming results have been positive with radio embolization complete responses when you we don't say cure but when you don't see the tumors anymore or that are live in the liver on CT or MRI we call that a complete response where you have no detectable viable tumor within the liver it doesn't mean it's not gone anymore I mean it's not there anymore it could be there and that's why you have to continue to see your oncologist and continue to get follow up scans because it'll likely come up either somewhere else or maybe back in the liver again so this is an example of a 61 year old woman with renal cell carcinoma and that's basically the pictures I look at everything's subtracted out the bones the soft tissues the only thing left are the vessels and the little round balls are the tumors and we'll inject in the radioactive tracer and this is what they look like all the kind of pretend tracers kind of concentrate up within the tumors and then we'll follow this patient over time getting a CT scan at three months then six months then 19 months then 50 59 months and you can see we'll call this complete response because this is the liver this is the tumor which is bright white and then this is the tumor afterwards which is dark and there's no longer enhancing with contrast meaning it's no longer viable and you'll see it shrink over time it's like a scar that kind of gets smaller and smaller because we're not going in there and scooping it out it has to absorb by the body over time and then unfortunately although you get these great responses in the liver you have growth elsewhere in the body here is in the other remaining kidney you have a tumor and then within the pancreas you have a tumor so that's why you get to need to be continued to be followed with your oncologist and also continue to get scanned so in conclusion local regional therapy it's for liver predominant disease and we're not curing cancer but we're helping people live longer and maintain their quality of life and we're able to locally treat tumors within the liver or the kidney using freezing or burning techniques called ablation and it's a minimally invasive procedures that patients can come get treated go home either the day of or the next day and I just call it kind of band-aid procedures because all the procedures that I just described you just wake up with a band-aid so thank you very much for your attention and yes