When To Use Pressure Directed Devices with Y90 Radioembolization in Hepatocellular Carcinoma (HCC)

[Nainesh Parikh]
"...I would think about [the Surefire Infusion System] as both as an antireflux and as a pressure directed therapy device. And I probably wouldn't get too caught up in the details except to say: if you feel like you have a patient [and you] can't see the mass very well on angiography, or it's a small vessel or something like that, and you're going to have trouble getting in all of your dose, you might try pressure directed therapy to see if you can actually get all of your intended dose in. I think that might be an option for where you might try to use this device."

[Charles Nutting]
"Yeah, I agree, Nain. I think that probably low-capacitant vessels, when you inject and you really don't see the tumor very well, that may be a good indication to use an antireflux catheter to drive more of the therapy deeper into the tumor itself. Perhaps aberrant hepatic anatomy, or you have a gastrohepatic trunk and you want to make sure that you're not gonna reflux into any of the gastric branches, you could place that out in segments two and three, and drive the dose deeper without that concern for reflux into the stomach."

[Nainesh Parikh]
"So with these patients, all of the discussion we're having is that this is palliative and not curative. The holy grail of any therapy is that it's curative. If you think of the continuum of doing nothing versus doing a therapy that's curative, then where do we fall? Well we know that survival data, when we do liver-directed therapy, is on the order of twelve to twenty-four months - for HCC - of life extension. And so then, within that data, I think the question is how do you look at improved survival, and what's statistically significant, and what makes the most sense?

I agree with Charlie completely that therapy and patient outcomes are paramount, and costs shouldn't factor in, in that sense. I could tell you that at our institution, because we are, number one, a conservative place, but number two, all of our purchasing is centralized, and goes through the AT Committee, these discussions are held every day, about what the data shows, how much the cost of the catheter is, things like that.

And I think what we'd like to see, what I'd honestly love to see, is that there is a clear benefit. Because once the data bears out that there's a clear benefit, I think then you can start to say, okay, there's an obvious indication here, we need to do more work to prove other indications. But as Charlie said, the cost is not really something that is gonna be prohibited because the patients are going to benefit significantly from this.

So, Anish, in my - in our practice, and at our institution, I think, for us, that's why we're probably waiting, so to speak, to hear more data, because, given our practice patterns, we'd love to see a more concise situation. And I know Charlie and I have talked about it, but as an example, one of those indications might be for the guy that's in Tennessee, or even for us, doing two or three of these a day, hypovascular tumors that you otherwise feel are helpless when you're trying to do liver-directed therapy.

I'm very excited by the aspect of the thought around therapy for pressure-directed hypovascular tumors, I think it's something that could be great. But I do think that our institution, and for us, and for me, personally, I think about that equation by saying, okay, what's a clear indication, what's a questionable indication, and what do we think we're really gaining here?"