Podcast Transcript: Management of HCC: Focus on Radiation Segmentectomy Part 1

[Dr. Chris Beck]:
Okay, yes. We're going to talk about HCC. We can get a little bit into metastatic disease, but I wanted to talk about how Ochsner got to where you’re at because we're going to be talking about Y90, but obviously, that's not the only game in town for modality of treating HCC. Previously, I know that you guys were using resin but made the jump to glass. I was interested in why, and when looking back, in any pluses, or minuses.

[Dr. Juan Gimenez]:
Yes. I feel like it was all like the perfect storm, right? Around 2018 or 2019, we had several things happen. Vijay joined us in about 2017, and he really came in and upped our ablation game. It's one of the things he does really well, and he really pushed the envelope. When you also look at what was happening around that time, Premiere came out which was a new I guess way of looking at bridging HCC.

Around that same time, the organ allocation rules for transplant changed. Before all of this, it would take sometimes three weeks to a month for some of our patients to get transplanted, and now everybody had to wait at least six months to get a liver. We had to start thinking about if we needed to change not only with all of this new data coming out, but also with all of the changes that were going to affect our practice. We did realize that we had a pretty good working system. Everybody was getting TACEd, everybody was getting transplanted.

I guess there was a little bit of a resistance to trying to change our process. Tyler had an excellent relationship with transplant surgeons, and because of that, they trusted him and they confided in him. When we tried to implement some of these changes, there was not that much of a pushback. I think he was key in us being able to change our paradigm for treatment of these patients. I would say, little by little, as we changed, our results spoke for themselves. Then it just became, it was just simple. Tyler, what do you think?

[Dr. Tyler Sandow]:
I was going to say, to add to Juan's point, for a decade, we were – Ochsner, I should say, I shouldn't say we because this is a transplant thing, but Ochsner was the largest transplant center, year over year, for a solid decade. They did more liver transplants than any other place in the country. We didn't need to change at that point. TACE worked well because all we had to do was bridge to a certain point. Then they got transplanted in several weeks.

Then when you change the allocation scheme and now to get exception points, you’ve got to sit for six months, and it was Juan's pushing. He was like, it's time for us to change because we watched a few patients. By a few, I should say we started to notice a trend. We watched some patients start to progress or it was harder and harder to keep these patients stable or bridged on the transplant list. That was a big impetus to change. It was Juan's pushing that did it. For the longest time, man, when you're doing 250 livers a year, and you can turn and burn, we didn't need to. Things changed, so we did.

[Dr. Chris Beck]:
I do want to talk about the different modalities that you'll work through and your algorithm, so when you settle on Y90 and how you think about delivery. One of the things I wanted to talk about is referral patterns. Are all these patients coming through the transplant system or are some of them coming for oncology? I want to know, how does everyone get sent to you guys? Then once you put them into the IR process, what does that look like?

[Dr. Tyler Sandow]:
It used to be that it only came through our liver conference, our multidisciplinary transplant liver conference, because a lot of these patients with HCC would either have underlying cirrhosis and they would be referred by hepatology, or entered into the conference via hepatology for transplant eval. As we grew, as the conference grew, we started to notice that we had quite a few patients with more aggressive tumor burden, infiltrated disease. We had more of a buy-in from oncology. Now our referral patterns come from oncology, hepatology, transplant, and then we catch everything you can imagine across the Gulf Coast.

Anybody with HCC tends to get referred through the conference. Juan, you might have more to add to that, too.

[Dr. Juan Gimenez]:
Not much, I think you summarized it well. At the end of the day, I think our practice is a multidisciplinary approach and it's not only for HCC but also for metastatic disease, neuroendocrine. We truly believe in the value of all our colleagues and specialties to come to a table and work together to give the patients the best outcome. To Tyler's point, hepatology, oncology, surgeon, transplant, all of us participate. Every patient gets run through a conference, and the decisions are made collectively for the best outcome for the patient. Sometimes they come to us. Lately, we've been working very closely with oncology doing some of the combination therapies to treat these patients.