.png){kind=small}
.png){kind=small}
BackTable / VI / Article
Hepatocellular Carcinoma in Practice: Optimizing Workflows & Treatment Decisions
Jack Felkner • Updated Oct 10, 2024 • 39 hits
Hepatocellular carcinoma (HCC) management is a rapidly evolving and multidisciplinary field that incorporates a variety of interventional procedures either as definitive therapy or as part of a bridging process before liver transplant. As new data is collected on the outcomes of these different therapies, the treatment algorithm and workflow within an interventional oncology practice must adapt accordingly. Dr. Juan Gimenez and Dr. Tyler Sandow explain how they built their HCC practice, the finer points of their patient workflows, and how they make treatment decisions favoring a high volume of Y90 radioembolization.
This article features transcripts for the BackTable Podcast. We’ve provided the highlight reel here, and you can listen to the full podcast below.
The BackTable Brief
• Dr. Gimenez and Dr. Sandow’s practice operates at a high capacity, performing 20-40 complex cases daily, including a high volume of interventional oncology that incorporates significant Y90 radioembolization.
• Optimal management of HCC requires an efficient team of advanced practice providers, avoiding unnecessary biopsies, and ownership over patient outcomes.
• The team adheres to the BCLC algorithm while aiming to maximize durability when treating HCC. This approach results in a high rate of Y90 or radiofrequency ablation.
• The clinic has minimized the use of transarterial chemoembolization (TACE), reserving it for rare cases where Y90 is not feasible, due to high lung shunt fractions or exhausted Y90 options.
Table of Contents
(1) Building an Interventional Hepatocellular Carcinoma Practice
(2) Hepatocellular Carcinoma Practice Workflow
(3) Determining the Optimal Hepatocellular Carcinoma Treatment
Building an Interventional Hepatocellular Carcinoma Practice
Dr. Gimenez and Dr. Sandow highlight the demanding and high-volume nature of their leading interventional oncology practice, known for its significant contributions to hepatocellular carcinoma treatment. The team manages an impressive caseload daily, including complex procedures such as portal vein recanalizations, transjugular intrahepatic portosystemic shunts (TIPS), and extensive biliary work.
Their oncology service is particularly notable for its volume of Y90 radioembolizations, surpassing many institutions in the U.S. The practice operates in a high-pressure environment, balancing a wide array of procedures from high-end oncology to routine interventions. The success and efficiency of their practice are attributed to a strong collaborative team and a legacy of foundational work laid by predecessors, demonstrating the critical role of teamwork and continuous innovation in interventional oncology.
[Dr. Chris Beck]:
I really want to hear about the practice, because to just say you guys do some high-end work is an understatement. When you talk about just the day-to-day, we'll get into the interventional oncology. I just know from these guys, presenting it to my board, and from the cases y'all show me on your cell phones that it's the real deal. This is the absolute in the trenches. I guess you can call it kind of academic, but more balls to the wall, private practice, blowing and going right.
[Dr. Tyler Sandow]:
Yes, I would say we're a bit hybrid is probably the best way to call it because we don't – I'm jealous of some of these academic places where we hear that they do a couple high-end cases and then they go home, by like three or five o'clock. I feel like Juan built a monster, and now we're stuck trying to keep that monster going. I would say on a nice day, an easy day, we probably do about 20-25 cases between two or three IR staff. On a rough day, it's somewhere between 30 and 40.
We have an incredible team that we work with, nurses and techs that can turn over rooms and flip rooms fast. When we're doing those cases, they're not just abscess drains. It’s complex portal vein recans, TIPS. We do incredible biliary work, biliary scopes. Then on the flip side, our oncology volume is insane. Again, I think the majority of that credit goes to Juan and some of my predecessors for the product that they have built. Man, we probably do – I would say if we're not doing three or four mappings or deliveries on a day, it's a slow day for us. It's the monster that Juan built.
[Dr. Juan Gimenez]:
I was going to say, Tyler likes to give me a lot of the credit, but this is a team sport. It takes a lot of people to get this going and get it running. I think we got to give a shout-out to one of our old partners, Vijay Ramalingam. I would say our predecessor Vijay, Tyler and I did a good job getting the practice started. It was easy for us to come in and take it to the next level. We are lucky in that we work at one of the biggest transplant centers in the country, which brings a lot of people to our hospital. We're also one of the tertiary referral centers for the region as well.
On top of everything that Tyler said, we also have a growing practice when it comes to, even bread and butter stuff, GU, dialysis. We're going to get a little bit more into PAV. One or two of our newer colleagues are starting to grow and expand all of the venous side of the practice as well, including the reconstructions, IVC filter retrievals, and things like that.
[Dr. Chris Beck]:
Is there anyone else that helped build the Ochsner way that paved the way for you guys?
[Dr. Tyler Sandow]:
Yes, I think we definitely have to highlight when we talk about our predecessors, David Kirsch, Dan Devon, those guys laid the foundation for building local regional treatment at Ochsner, and because of the work that they've done and the presence that they established at our tumor boards, we've been able to build on those pillars and grow the practice the way that we have.
[Dr. Juan Gimenez]:
Yes, to Tyler's point, we wouldn't be here without them. They set the groundstone for everything that's happened since.
[Dr. Chris Beck]:
Very nice. I've just been texting with Ricky and Tim from TheraSphere. I'm guessing you guys probably don't keep up with this thing, but according to Ricky and verified by Tim, you guys have had more Y90 deliveries in 2023 than every other institution in the US.
[Dr. Tyler Sandow]:
It's what we hear.
[Dr. Chris Beck]:
Not that anyone's keeping track, but I'm just trying to paint a picture that we're talking to two guys who are doing a lot of Y90.
[Dr. Tyler Sandow]:
We do a little bit. We do a pretty fair amount.
Listen to the Full Podcast
Stay Up To Date
Follow:
Subscribe:
Sign Up:
Hepatocellular Carcinoma Practice Workflow
The process of preparing patients for hepatocellular carcinoma (HCC) procedures at this practice involves a highly coordinated approach that maximizes efficiency and patient care. After a liver conference, the team, including advanced practice providers (APPs) and schedulers, rapidly transitions patients to clinic visits, adhering to a protocol that prioritizes advanced cases.
The team strategically avoids unnecessary biopsies, relying on imaging criteria for diagnosis to prevent complications such as tract seeding. When biopsies are necessary, they are often combined with mapping procedures to reduce delays. This streamlined process, combined with a strong emphasis on ownership of each patient’s journey through imaging, clinic visits, and procedures, exemplifies the practice's commitment to maintaining a well-organized system that optimizes patient outcomes.
[Dr. Chris Beck]:
Okay, once they get plugged in with you guys and they've been through MDC, they get seen in clinic, labs, imaging. Take us through the process of getting your patients ready for what may end up being a procedure.
[Dr. Tyler Sandow]:
We have incredible APPs. I think we should plug everybody that is involved in our entire team in this process. We have some incredible APPs and schedulers that help coordinate the care of these patients. What tends to happen is after a liver conference, we try to get them scheduled in clinic that week or the following week. Then Juan pushes us to maintain the protocol. I can let him talk to that a lot more. We have an algorithm and a protocol for how we evaluate these patients and how we get them set up for treatment.
[Dr. Juan Gimenez]:
It's pretty straightforward. APPs come to conference with us. We, interventional radiology, run these conferences. We review all the imaging, make all treatment recommendations as it pertains predominantly to IR. Sometimes the recommendation is, hey, this patient is systemic. That's coming from us, which I think is very valuable to the entire team. APPs sit with us during conference. They know exactly what happens. The moment conference finishes, we just set them up for clinic. The entire team notifies the patient and then we move on.
We try to stratify patients, so the ones that tend to be more advanced jump to the top of the list, and we try to get them in for procedures sooner than somebody that's at an earlier stage has a single tumor and can wait a little bit longer. Having labs and imaging, within 30 days is very important. We typically don't biopsy these patients. If they have HCC imaging criteria, we will avoid it. We've had several patients that have had biopsies. We ended up seeing recurrences along tract or tract seating, I should say. Then they drop out of the transplant list. We don't favor biopsy unless it's absolutely necessary.
If it is somebody that we suspect has HCC and they have, let's say, an elevated AFP but they don't meet criteria, we'll map and biopsy them at the same time, effectively saving them one appointment. You avoid delay of care by doing that. To Tyler's point, everybody, not only within the transplant, hepatology, and oncology teams but even our teams, like he said, our APPs and our schedulers, everybody's plugged in, and it's become a very well-oiled machine to try to get patients seen and treated as soon as we can.
[Dr. Chris Beck]:
You've given us a rundown of the process, Juan. If you had to give advice to someone who's either at a big academic center or someone who's just on the cusp of forming a well-oiled machine, what were some of your big unlocks that led for increased throughput, or making sure the right patients were prioritized? I would always say MDC is at the core of that, but I just want to hear what you guys think.
[Dr. Juan Gimenez]:
It's ownership. You literally have to own every step of the way, particularly when you're first starting. I think there's this belief that IR just does what comes to them. Trying to change that thought process in people saying, look, I want to be an active participant in the patient's care. I'm going to take them from the beginning, own their imaging, see them in clinic. We'll take this patient and make sure that everything that pertains to us, we'll handle without you having to worry about it. I think that's been key.
We see a lot of sometimes particular patients come from other facilities or other regions. A lot of clinicians don't necessarily feel very comfortable dealing with HCC. For us to be able to bring them into our system and help them navigate that, has been very important and very good for patient care.
Determining the Optimal Hepatocellular Carcinoma Treatment
Multiple interventional treatment modalities exist during the bridging period between HCC diagnosis and liver transplant. In this section, Dr. Sandow and Dr. Gimenez describe their role in this process and how they determine which treatment is most appropriate for each patient.
Their treatment approach follows the BCLC algorithm but is flexible based on patient-specific factors and outcomes data. They emphasize a preference for ablative modalities, such as Y90 and ablation, over TACE, which they now use infrequently due to its limited effectiveness and patient eligibility criteria. Their practice adapts treatments to provide the most durable outcomes, incorporating data-driven insights and lessons learned from past practices.
[Dr. Chris Beck]:
Past the workup, you're getting them ready for some kind of treatment. There's not just Y90. Can you guys talk about which patients end up with which treatments? We can exclude systemic therapies, but which treatments that you guys offer?
[Dr. Tyler Sandow]:
I'll say we follow the BCLC algorithm as closely to the T as possible. If there's a patient that meets criteria for ablation, then we're going to ablate it unless we feel like it's a high-risk ablation and Y90 made more sense. We go for, our process is, regardless of whether or not they're going to transplant, we want to give them, even if it's a bridging strategy, we want to give them the most durable outcome possible. I think if you look at the BCLC structure, the durability comes from ablative modalities, whether that be Y90 or ablation.
The majority of the patients that we see either have pretty advanced cirrhosis, so if they weren't transplant eligible, our surgeons don't necessarily want to take an advanced cirrhotic to resection. That's where an alternate ablated modality that probably provides just as durable of a result makes the most sense.
We have, and we can dive in, at some point, we can talk about the research we do. We've been tracking outcomes on these patients for a very long time. We've noticed trends in our outcomes to allow us to alternate a little bit, or deviate, I should say, a little bit away from a purist BCLC scheme. We don't necessarily ablate everybody anymore because we've noticed trends in our data that would probably push us more towards an intra-arterial therapy, and we know that Y90 is probably going to be the best for those. We can talk about that later, too, if we have time to talk about our research stuff.
[Dr. Chris Beck]:
Anything to add on that, Juan? Specifically, I guess one of the things I wanted to paint is, you guys don't shy away from ablation. You’re more than happy to ablate. I think one time you even told me sometimes patients are candidates for both, like you may ablate, then something else may be a better candidate for intra-arterial therapy.
[Dr. Juan Gimenez]:
Yes, I think at the end of the day, we want to provide them a complete response with whichever modality works best. To Tyler's point, being able to look at our data has allowed us to fine-tune the way we cater to every patient, but at the center of it is the BCLC algorithm.
[Dr. Chris Beck]:
Okay, what about anything else for intra-arterial, like is TACE on y'all's treatment list anymore, or TACE ablay, anything else?
[Dr. Tyler Sandow]:
I would say 2% of the time might be what we might TACE now. That's going from a place that was maybe 98% TACE six years ago. We'll TACE very rarely, only in patients that probably maxed out their lung dose for Y90, or have lung shunts that are through the moon, so we wouldn't be able to get a good treatment dose in. Those would be our candidates for TACE. Back to ablation, we're not afraid of ablating. We owe Vijay, he pushed us hard to do ablation. He made us ablate on the heart, he made us ablate at the hilum, he made us ablate on the IVC. We're not afraid of anything, and that's because he pushed us to do it. He helped us up our game when it comes to ablation. Regarding TACE, man, it's rare. It's I think high lung shunts or patients that don't have any more Y90 options available.
Podcast Contributors
Dr. Juan Gimenez
Dr. Juan Gimenez is an interventional and diagnostic radiologist with Ochsner Health in New Orleans, Louisiana.
Dr. Tyler Sandow
Dr. Tyler Sandow is an interventional radiologist with Ochsner Health in New Orleans, Louisiana.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite This Podcast
BackTable, LLC (Producer). (2023, October 23). Ep. 377 – Management of HCC: Focus on Radiation Segmentectomy Part 1 [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Podcasts
Articles
Planning for HCC Radiation Segmentectomy: Mapping, Margins & Dosage
Moving Y90 from the Hospital to the OBL: A Quickstart Guide for Physicians
Y90 in the OBL: Benefits & Considerations
Procedure Kit For Pressure Directed Therapy in Y90 Radioembolization of HCC