This document discusses and compares local ablative therapy options for treating liver metastases, including surgery (metastatectomy), thermal ablation techniques (radiofrequency ablation (RFA), cryoablation), chemotherapy (transarterial chemoembolization (TACE), transarterial radioembolization (TARE)), and radiotherapy (stereotactic body radiation therapy (SBRT), brachytherapy). It provides details on techniques such as RFA and SBRT and reviews studies comparing the effectiveness and safety of RFA versus SBRT. Overall, the document analyzes the benefits and limitations of different local treatment approaches for liver cancer metastases.

1. LOCAL ABLATIVE THERAPY IN LIVER METS
OPTIONS IN COMPARISON TO SBRT
DR KANHU CHARAN PATRO

2. INTRODUCTION
• Liver metastasis is a common site of
metastasis in abdominal malignancy
• Colorectal malignancy is more common.
• Apart form systemic chemotherapy local
ablative therapy is a good option.
• With oligometastatic trend 5 year survival are
encouraging.

3. OPTIONS
• NON INVASIVE
– SBRT
• MINIMALLY INVASIVE
– BRACHYTHERAPY
– RFA
– TACE
– TARE
– COMBINATION OF PROCEDURES
– CRYOABLATION
• INVASIVE
– METSTATECTOMY

4. OPTIONS
• SURGERY
– METASTATECTOMY
• THERMAL ABLATIVE
– CRYOABLATION
– RFA
– HYPERTHERMIC COAGULATION
– INTRATUMORAL INJECTION OF ETHANOL
• CHEMOTHERAPY
– SYSTEMIC
– REGIONAL
• RADIOTHERAPY
– SBRT
– INTERNAL
– BRACHYTHERAPY

5. CHOOSING THE BEST
• Noninvasive
• Availability
• Expertise
• Evidence based
• Less toxic
• Result

6. BUT
• No/Few randomized trials
• No Metaanalysis
• Only pilot, retrospective, single institution
studies

9. METASTATECTOMY
Resection surgery is a simple operation. It is
mainly about the removal of partial liver tissues
through surgery where the liver still can function
well. Small tumor or unhealthy small portion of
tissues in liver can be removed by operation.

10. OUTCOMES IN METASTATECTOMY

11. RFA-RADIOFREQUENCY ABLATION
This process involves the heating of liver tissues.
One or more needles are inserted into the small incisions
at the abdominal part of the body by using ultrasound or
CT scan as a guide. The needles are then heated using
electricity and destroy the liver’s cancerous cell.

12. RFA-RADIOFREQUENCY ABLATION

13. RFA

14. RFA-RADIOFREQUENCY ABLATION

15. RFA

16. RFA

17. RFA-RADIOFREQUENCY ABLATION

18. RFA VS RESECTION

19. HEAT SINK EFFECT
Thermal ablation of
liver tumors near large
blood vessels is affected
by the cooling effect of
blood flow, leading to
incomplete ablation.

20. RFA -COMPLICATIONS
1. Incidence 10 percent
2. Liver abscess
3. Pleural effusion and skin burns
4. Hypoxemia during treatment
5. Pneumothorax
6. Subcapsular hematoma
7. Acute renal insufficiency, hemoperitoneum, and
needle tract seeding
8. Intestinal perforation

21. CONTRAINDICATIONS-SURGERY/RFA
1. Surgery is often contraindicated for liver tumors near the hepatic
hilum because patients with deteriorated liver function do not
tolerate extended resection, such as right lobe resection.
2. RFA is often contraindicated because it is difficult to perform safely
to the tumors near vessels and the CBS, and it is less effective
because the blood flow near the tumor prevents the temperature
from remaining high enough to treat the lesion.
3. Vicinity of the metastasis to great vessels, as those might cause a
heat sink effect,
4. Location close to the liver capsule, as RFA is more painful to those
patients
5. NEAR BOWEL

22. CRYO-ABLATION
1. In this treatment, the process involved in called
cryoablation which uses extremely cold temperate to
kill the cancerous cells.
2. A probe called cryoprobe which is an instrument
used in the treatment contains liquid nitrogen in
injected in to the diseased part of the liver or the
tumor to destroy the cells.
3. For auxiliary, ultrasound images guide the probe and
monitor the freezing of the cancerous cells

23. CHEMOEMBOLIZATION

24. CHEMOEMBOLIZATION

25. TARE-TRANSARTERIAL RADIOEMBOLIZATION
1. Radioembolization is a combination of radiation
therapy and a procedure called embolizationton
treat cancer of the liver.
2. In radioembolization, tiny glass or resin beads called
microspheres are placed inside the blood vessels
that feed a tumor in order to block the supply of
blood to the cancer cells.
3. Once these microspheres, which are filled with
The radioactive isotope yttrium Y-90, become
lodged at the tumor site, they deliver a high dose of
radiation to the tumor and not to normal tissues.

27. SBRT-STEREOTACTIC BODY RADIOTHERAPY
Stereotactic body radiation therapy (SBRT), also
known as stereotactic ablative radiotherapy,
administers very high doses of radiation, using
several beams of various intensities aimed at
different angles to precisely target the tumor.

28. SBRT
• High dose per fraction
• Accurate targeting
– Motion management
– IGRT

29. CONVENTIONAL RADIOTHERAPY

30. SBRT RADIOBIOLOGY
• Vascular damage
• No/minimal repair
• Abscopal effect by cytokines
• Shorter treatment time-minimal repopulation
• Unlikely reoxygenation
• Kills in all phases of cell-no redistribution
phenomenon
• Imunogenesis

31. IMMUNOGENESIS

32. MOTION MANAGEMENT

33. IN SIMPLE WORDS

34. MOTION MANAGEMENT

35. MOTION MANAGEMENT

37. SET-UP VERIFICATION
• CBCT CORRECTIONS

40. ADAJACENT STRACTURES

41. DOSE SELECTION

42. SBRT-SGPGI STUDY

43. SBRT-SGPGI STUDY

44. SBRT-SGPGI STUDY

45. SBRT-ITALY STUDY

46. SBRT-ITALY STUDY

47. SBRT- PHASE II STUDIES

48. RFA VS SBRT-MUNICH STUDY

49. RFA VS SBRT-MUNICH STUDY

50. RFA VS SBRT-MUNICH STUDY

51. RFA VS SBRT-MUNICH STUDY

52. RFA VS SBRT-MUNICH STUDY

53. SBRT- CENTRAL LESION

56. WHY SBRT
• NON INVASIVE
• NO ANAESTHESIA
• GOOD RESULTS
• SAFE PROCEDURE
• EASILY AVAILABLE
• GOOD RADIOBIOLOGY

57. BRACHYTHERAPY

59. APPLICATION IN OTHER SITES