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Transcript

"🌟 Histotripsy and Hepzato: The Future of Liver Cancer Treatment 🩺" · The Eye Believe Podcast

• 0:00
  let's
• 0:00
  give a big
• 0:00
  shout out.
• 0:01
  And,
• 0:01
  welcome
• 0:01
  to Doctor
• 0:01
  Moser from
• 0:02
  Honor
• 0:02
  Health
• 0:02
  Research
• 0:03
  Institute.
• 0:10
  Welcome,
• 0:10
  everyone.
• 0:11
  And thanks
• 0:11
  for coming
• 0:11
  both in
• 0:11
  person
• 0:12
  and
• 0:12
  online.
• 0:12
  we saw
• 0:13
  most of
• 0:13
  you guys
• 0:13
  yesterday.
• 0:14
  I think
• 0:14
  we even
• 0:14
  have
• 0:15
  more in
• 0:15
  attendance
• 0:15
  today,
• 0:16
  which is
• 0:16
  great.
• 0:17
  today
• 0:17
  the talks
• 0:18
  are more
• 0:18
  kind of
• 0:19
  medically
• 0:19
  focused.
• 0:20
  so
• 0:20
  we actually
• 0:20
  have a
• 0:20
  really
• 0:21
  good line
• 0:21
  up of
• 0:21
  people
• 0:22
  coming.
• 0:22
  we have a lot
• 0:23
  of
• 0:23
  different
• 0:23
  physicians
• 0:24
  and other
• 0:24
  people
• 0:24
  coming in
• 0:25
  to speak
• 0:25
  today.
• 0:25
  So
• 0:25
  it should
• 0:25
  be, a
• 0:26
  pretty
• 0:26
  good
• 0:26
  discussion.
• 0:27
  Most of
• 0:28
  the
• 0:28
  discussions
• 0:28
  today.
• 0:28
  We'll have
• 0:29
  slides to
• 0:29
  help
• 0:30
  guide it.
• 0:30
  But
• 0:30
  we really want
• 0:31
  these to
• 0:31
  be
• 0:31
  discussion.
• 0:32
  So if you
• 0:32
  have
• 0:32
  questions
• 0:33
  raise
• 0:33
  your hand.
• 0:34
  Most of it
• 0:34
  will be
• 0:34
  a panel
• 0:35
  format.
• 0:36
  And so
• 0:36
  we really
• 0:37
  want
• 0:37
  this to
• 0:37
  be
• 0:37
  interactive.
• 0:38
  So
• 0:38
  you guys
• 0:38
  can get
• 0:38
  the
• 0:38
  information
• 0:39
  that best
• 0:39
  serves
• 0:40
  you.
• 0:40
  when
• 0:40
  we're,
• 0:41
  talking
• 0:41
  about
• 0:42
  liver
• 0:42
  directed
• 0:42
  therapy,
• 0:43
  there's,
• 0:44
  two kind
• 0:45
  of ways
• 0:45
  that we
• 0:45
  can treat
• 0:46
  tumors in
• 0:46
  the liver.
• 0:47
  One are
• 0:47
  directly.
• 0:48
  sticking
• 0:48
  needles
• 0:49
  or probes
• 0:50
  into the
• 0:50
  liver to,
• 0:51
  treat
• 0:51
  the tumors.
• 0:52
  And then
• 0:52
  there's
• 0:52
  also the
• 0:53
  transarterial
• 0:54
  approach
• 0:54
  that
• 0:54
  we can
• 0:55
  use,
• 0:55
  taking
• 0:56
  advantage
• 0:56
  of the
• 0:57
  liver's
• 0:57
  unique
• 0:58
  dual blood
• 0:58
  supply
• 0:59
  to
• 0:59
  allow us
• 0:59
  to treat
• 1:00
  tumors
• 1:01
  through
• 1:01
  the
• 1:01
  hepatic
• 1:01
  artery.
• 1:02
  while
• 1:02
  letting
• 1:03
  the portal
• 1:03
  vein,
• 1:04
  which
• 1:04
  supplies
• 1:05
  most of
• 1:05
  the blood
• 1:06
  flow to
• 1:06
  the liver,
• 1:07
  to kind
• 1:07
  of keep
• 1:08
  the liver
• 1:08
  alive.
• 1:09
  we'll kind
• 1:09
  of break
• 1:09
  this talk
• 1:10
  briefly
• 1:10
  into two
• 1:11
  subsets
• 1:12
  of ways
• 1:12
  to treat.
• 1:13
  so we'll
• 1:13
  first talk
• 1:14
  about the
• 1:14
  percutaneous
• 1:15
  treatments
• 1:16
  for liver
• 1:17
  tumors.
• 1:17
  the
• 1:17
  mainstay
• 1:18
  of this
• 1:19
  treatment
• 1:19
  for
• 1:19
  percutaneous
• 1:20
  therapy is
• 1:21
  ablation.
• 1:22
  it
• 1:22
  could be
• 1:22
  either
• 1:23
  heat based
• 1:23
  or
• 1:24
  freezing
• 1:25
  based.
• 1:25
  So
• 1:26
  cryoablation
• 1:27
  or either
• 1:27
  microwave
• 1:28
  radiofrequency
• 1:29
  ablation
• 1:30
  where
• 1:30
  we're
• 1:30
  using
• 1:31
  temperature
• 1:32
  to create
• 1:33
  direct
• 1:33
  tissue
• 1:33
  damage
• 1:34
  and kill,
• 1:35
  whatever
• 1:35
  is in
• 1:35
  the tumor.
• 1:36
  with those
• 1:37
  temperature
• 1:37
  effects.
• 1:38
  the pros of
• 1:39
  this are
• 1:39
  it's,
• 1:40
  efficacy
• 1:40
  is similar
• 1:41
  to
• 1:41
  that of,
• 1:42
  if you
• 1:42
  go in
• 1:42
  and
• 1:42
  have the
• 1:43
  surgically
• 1:43
  removed,
• 1:44
  the cons
• 1:45
  are it
• 1:45
  does
• 1:46
  require
• 1:46
  that
• 1:46
  it has
• 1:47
  to be
• 1:47
  a small,
• 1:48
  relatively
• 1:48
  small
• 1:48
  size.
• 1:49
  And,
• 1:50
  we can only
• 1:50
  treat
• 1:51
  a certain
• 1:51
  amount
• 1:52
  based on,
• 1:52
  the size
• 1:53
  and kind
• 1:53
  of the
• 1:54
  tissue
• 1:54
  destruction
• 1:55
  that we
• 1:55
  cause.
• 1:55
  one thing
• 1:56
  that
• 1:56
  we also
• 1:57
  participate
• 1:57
  in is
• 1:57
  clinical
• 1:58
  trials
• 1:58
  where
• 1:58
  we're
• 1:58
  doing,
• 1:59
  intratumoral
• 2:00
  injection,
• 2:00
  where,
• 2:01
  we
• 2:01
  directly
• 2:02
  inject,
• 2:02
  whatever
• 2:03
  medicine
• 2:04
  they
• 2:04
  come up
• 2:05
  with for
• 2:05
  us,
• 2:06
  directly
• 2:06
  into the
• 2:06
  tumor
• 2:07
  to try
• 2:07
  and induce
• 2:08
  an immune
• 2:08
  response
• 2:09
  or, kind
• 2:10
  of
• 2:10
  affected
• 2:10
  directly
• 2:11
  into the
• 2:11
  tumor
• 2:12
  itself.
• 2:13
  so that's
• 2:14
  very well
• 2:14
  tolerated.
• 2:15
  and,
• 2:15
  very small
• 2:16
  needles.
• 2:16
  And it's
• 2:16
  very,
• 2:17
  straightforward
• 2:18
  for us
• 2:18
  to, to
• 2:18
  get the,
• 2:19
  the
• 2:20
  medication
• 2:20
  inside
• 2:21
  the tumor.
• 2:22
  and that's
• 2:22
  kind of
• 2:22
  all done
• 2:23
  on a
• 2:23
  clinical
• 2:23
  trial
• 2:24
  basis
• 2:24
  there are several,
• 2:25
  and then
• 2:25
  one of
• 2:26
  this is
• 2:26
  one of
• 2:26
  the new
• 2:27
  kind of
• 2:27
  cutting
• 2:27
  edge
• 2:28
  therapies
• 2:28
  that we're
• 2:29
  really
• 2:29
  excited
• 2:30
  about.
• 2:30
  coming on
• 2:31
  is,
• 2:32
  histotripsy
• 2:33
  So this is
• 2:33
  an
• 2:33
  ultrasound
• 2:34
  based
• 2:34
  technology
• 2:35
  where
• 2:35
  they give
• 2:36
  high
• 2:36
  frequency,
• 2:37
  high
• 2:37
  amplitude,
• 2:38
  pulses
• 2:39
  that,
• 2:39
  causes
• 2:40
  kind of
• 2:40
  direct
• 2:41
  vaporization
• 2:42
  of
• 2:43
  but what's
• 2:44
  really
• 2:44
  exciting
• 2:44
  is it's,
• 2:45
  completely,
• 2:46
  noninvasive.
• 2:47
  So it's
• 2:48
  all done
• 2:48
  without
• 2:49
  any
• 2:49
  incision.
• 2:50
  and very
• 2:51
  well
• 2:51
  tolerated
• 2:51
  just
• 2:51
  because
• 2:52
  there's,
• 2:52
  no
• 2:52
  incision
• 2:53
  or
• 2:53
  anything.
• 2:54
  And it
• 2:55
  still
• 2:55
  allows
• 2:55
  you to
• 2:55
  to treat
• 2:56
  tumors
• 2:56
  inside
• 2:57
  the liver.
• 2:57
  those are
• 2:57
  the
• 2:58
  percutaneous
• 2:59
  options
• 2:59
  that we
• 2:59
  have.
• 3:00
  so other
• 3:00
  things
• 3:00
  that
• 3:00
  we can
• 3:01
  work
• 3:02
  through
• 3:02
  are,
• 3:02
  transarterial
• 3:03
  approaches
• 3:04
  to,
• 3:04
  treating
• 3:04
  these
• 3:04
  tumors.
• 3:05
  there
• 3:05
  are many
• 3:07
  different
• 3:07
  ways.
• 3:08
  There's
• 3:08
  not a ton
• 3:08
  of data
• 3:09
  on most of
• 3:09
  them.
• 3:10
  I don't
• 3:10
  really
• 3:11
  have
• 3:11
  experience
• 3:12
  with,
• 3:12
  because
• 3:12
  this
• 3:12
  is done
• 3:13
  by the,
• 3:13
  surgeons,
• 3:14
  they can
• 3:15
  implant
• 3:15
  a,
• 3:16
  infusion
• 3:16
  catheter
• 3:17
  that the
• 3:18
  directly
• 3:18
  infuses,
• 3:19
  chemotherapy,
• 3:21
  liver
• 3:22
  through
• 3:22
  a port
• 3:23
  just
• 3:23
  beneath
• 3:23
  the skin.
• 3:24
  and where
• 3:24
  you can
• 3:25
  have
• 3:25
  kind of
• 3:25
  weekly
• 3:26
  infusions
• 3:26
  to, to
• 3:27
  treat
• 3:27
  directly
• 3:28
  into the,
• 3:28
  liver
• 3:29
  vasculature.
• 3:32
  one of
• 3:32
  the kind
• 3:33
  of
• 3:33
  mainstays
• 3:33
  of liver
• 3:34
  directed
• 3:34
  therapy
• 3:35
  that we've
• 3:35
  had for
• 3:35
  many years
• 3:36
  is
• 3:36
  transarterial
• 3:37
  embolization.
• 3:37
  there
• 3:38
  are many,
• 3:38
  many
• 3:38
  different
• 3:39
  ways to
• 3:39
  do this.
• 3:40
  It can be,
• 3:41
  what
• 3:41
  we call
• 3:41
  bland.
• 3:42
  So just,
• 3:43
  kind of
• 3:44
  impeding
• 3:45
  the blood
• 3:45
  flow to
• 3:45
  the
• 3:45
  tumors.
• 3:46
  the
• 3:46
  embolic effect,
• 3:48
  or it
• 3:48
  can be
• 3:48
  combined
• 3:49
  with many
• 3:50
  different
• 3:50
  chemotherapy
• 3:51
  drugs to,
• 3:52
  also
• 3:52
  deposit
• 3:53
  the
• 3:53
  chemotherapy
• 3:54
  directly
• 3:55
  into the
• 3:55
  liver
• 3:56
  tumors
• 3:56
  themselves.
• 3:58
  in the
• 3:58
  setting of
• 3:58
  uveal
• 3:59
  melanoma,
• 3:59
  there's
• 3:59
  not
• 4:00
  a lot of,
• 4:00
  data
• 4:00
  to show
• 4:01
  which
• 4:02
  combination
• 4:03
  works
• 4:03
  best.
• 4:04
  and the
• 4:04
  biggest
• 4:05
  kind of
• 4:05
  downside
• 4:05
  of this
• 4:06
  procedure
• 4:06
  is it
• 4:07
  can be
• 4:07
  painful,
• 4:08
  just
• 4:08
  because
• 4:09
  we are
• 4:09
  intentionally
• 4:10
  cutting
• 4:10
  off the
• 4:10
  blood
• 4:11
  supply.
• 4:11
  So
• 4:11
  it can be,
• 4:12
  quite
• 4:13
  painful
• 4:13
  if we
• 4:13
  if we're
• 4:14
  doing a
• 4:15
  large area
• 4:15
  of the
• 4:16
  liver.
• 4:16
  the other
• 4:17
  potential
• 4:17
  transarterial
• 4:18
  therapy
• 4:19
  is immuno
• 4:20
  embolization,
• 4:21
  where
• 4:22
  you try
• 4:22
  and induce
• 4:23
  an immune
• 4:23
  response
• 4:24
  by kind of
• 4:24
  directly,
• 4:25
  infusing
• 4:27
  these
• 4:27
  medications,
• 4:28
  the
• 4:29
  granulocyte
• 4:30
  macrophage
• 4:31
  colony
• 4:31
  stimulating
• 4:32
  factor
• 4:33
  directly
• 4:33
  into the
• 4:33
  liver
• 4:34
  to try
• 4:34
  and induce
• 4:35
  the immune
• 4:35
  response,
• 4:36
  of
• 4:36
  the tumors.
• 4:40
  So
• 4:40
  I'm sure
• 4:40
  most of
• 4:41
  you maybe
• 4:42
  have heard
• 4:42
  of y90
• 4:43
  radio
• 4:43
  embolization.
• 4:43
  That's
• 4:44
  kind
• 4:44
  of the,
• 4:45
  kind of
• 4:45
  mainstay
• 4:46
  of
• 4:47
  kind of
• 4:47
  treatment,
• 4:49
  currently
• 4:50
  for, a
• 4:50
  lot of
• 4:50
  liver
• 4:51
  directed
• 4:51
  therapies.
• 4:52
  and what
• 4:53
  that is,
• 4:53
  it's a,
• 4:54
  special
• 4:54
  radioisotope
• 4:55
  called
• 4:55
  yttrium 90
• 4:57
  that
• 4:57
  we can
• 4:58
  directly
• 4:58
  inject to
• 4:59
  the liver.
• 5:00
  and
• 5:01
  what it does
• 5:02
  is it
• 5:02
  deposits
• 5:03
  either
• 5:03
  resin or
• 5:05
  glass
• 5:05
  microspheres
• 5:06
  directly
• 5:07
  into
• 5:07
  the tumor.
• 5:08
  they
• 5:09
  release
• 5:09
  radiation
• 5:10
  directly
• 5:10
  into those
• 5:11
  tumor
• 5:11
  cells
• 5:12
  that only
• 5:12
  penetrates
• 5:13
  about
• 5:13
  two millimeters.
• 5:14
  so
• 5:15
  we can give
• 5:16
  high doses
• 5:16
  of
• 5:16
  radiation,
• 5:17
  directly
• 5:18
  to the
• 5:18
  liver
• 5:18
  without,
• 5:19
  causing
• 5:19
  effects
• 5:20
  elsewhere
• 5:20
  in the body.
• 5:22
  with y90,
• 5:23
  it's all
• 5:23
  about
• 5:23
  being able
• 5:24
  to get
• 5:25
  adequate
• 5:25
  dose to
• 5:26
  the tumor.
• 5:26
  So, in
• 5:27
  general,
• 5:28
  this works
• 5:28
  better
• 5:28
  for,
• 5:29
  kind of
• 5:30
  fewer
• 5:30
  number of
• 5:31
  lesions
• 5:31
  where
• 5:31
  we can
• 5:32
  really
• 5:32
  give high
• 5:32
  doses
• 5:33
  of
• 5:33
  radiation
• 5:33
  directly
• 5:34
  to the
• 5:34
  tumor.
• 5:34
  and it's
• 5:35
  actually
• 5:36
  very,
• 5:36
  quite well
• 5:37
  tolerated,
• 5:37
  from,
• 5:38
  from a
• 5:38
  symptomatic
• 5:39
  standpoint
• 5:39
  as well.
• 5:41
  And then,
• 5:41
  finally,
• 5:42
  one of,
• 5:43
  things
• 5:43
  that I'm
• 5:44
  very
• 5:44
  excited
• 5:44
  about and,
• 5:45
  a lot
• 5:46
  of us are
• 5:46
  very
• 5:46
  excited
• 5:46
  about
• 5:47
  is
• 5:47
  percutaneous
• 5:48
  hepatic
• 5:48
  perfusion
• 5:49
  with
• 5:49
  the hepzato kit.
• 5:50
  and so
• 5:51
  the principles
• 5:51
  of that
• 5:52
  are to,
• 5:52
  saturate
• 5:53
  the whole
• 5:54
  liver
• 5:54
  with
• 5:55
  melphalan
• 5:56
  with the
• 5:56
  chemotherapy
• 5:56
  agent,
• 5:57
  and then
• 5:58
  isolate
• 5:59
  all the
• 5:59
  blood
• 5:59
  flow,
• 6:00
  return
• 6:00
  out of
• 6:01
  the liver,
• 6:02
  to
• 6:02
  allow us
• 6:02
  to,
• 6:03
  filter out
• 6:04
  the chemotherapy
• 6:05
  prior
• 6:05
  to
• 6:05
  giving the
• 6:05
  blood
• 6:06
  back,
• 6:06
  to
• 6:06
  minimize
• 6:07
  the
• 6:07
  systemic
• 6:08
  toxicity
• 6:09
  of the
• 6:09
  chemotherapy
• 6:10
  agent.
• 6:11
  so that's,
• 6:12
  one of
• 6:12
  the things
• 6:13
  we're very
• 6:13
  excited
• 6:14
  about
• 6:14
  that's
• 6:14
  shown,
• 6:15
  good
• 6:15
  efficacy.
• 6:16
  in liver
• 6:16
  metastases.
• 6:18
  So
• 6:18
  I have a
• 6:18
  couple
• 6:18
  cases
• 6:19
  here,
• 6:20
  from
• 6:20
  Doctor ma
• 6:21
  at
• 6:22
  Wisconsin,
• 6:23
  kind of
• 6:23
  showing
• 6:23
  the
• 6:24
  efficacy
• 6:24
  of this
• 6:25
  was a
• 6:25
  hepzato
• 6:26
  case,
• 6:27
  where
• 6:27
  you can see,
• 6:28
  you
• 6:28
  can see
• 6:29
  here
• 6:29
  this is the
• 6:30
  a large
• 6:30
  tumor,
• 6:31
  in the
• 6:31
  liver
• 6:32
  here.
• 6:33
  you can
• 6:33
  see round
• 6:33
  here and
• 6:34
  this is,
• 6:36
  during the
• 6:37
  second
• 6:37
  cycle of
• 6:38
  the
• 6:39
  hepzato
• 6:39
  treatment,
• 6:40
  and
• 6:40
  you can
• 6:40
  see that
• 6:41
  it's much
• 6:41
  smaller
• 6:41
  even after
• 6:42
  one,
• 6:42
  therapy.
• 6:43
  so
• 6:43
  there was
• 6:44
  also a
• 6:44
  corresponding,
• 6:45
  decrease
• 6:46
  in the
• 6:46
  circulating
• 6:47
  tumor DNA.
• 6:48
  I think
• 6:48
  that was
• 6:48
  a really
• 6:48
  good
• 6:48
  rundown
• 6:49
  about the
• 6:50
  different
• 6:50
  liver
• 6:50
  directed
• 6:51
  options
• 6:51
  that are
• 6:52
  available.
• 6:53
  And, like
• 6:53
  Doctor
• 6:53
  low said,
• 6:55
  the great
• 6:55
  thing is
• 6:56
  there's
• 6:56
  a ton
• 6:56
  of
• 6:56
  options.
• 6:57
  The bad
• 6:57
  thing is
• 6:58
  we don't
• 6:58
  always
• 6:59
  have
• 6:59
  strong
• 7:00
  data about
• 7:00
  which
• 7:00
  is best.
• 7:01
  Obviously,
• 7:02
  hepzato is
• 7:03
  the only
• 7:04
  FDA
• 7:04
  approved
• 7:05
  liver
• 7:05
  directed
• 7:05
  therapy
• 7:06
  specifically
• 7:06
  for uveal
• 7:07
  melanoma,
• 7:07
  so
• 7:08
  we do have
• 7:08
  really
• 7:09
  strong
• 7:09
  data for
• 7:09
  that.
• 7:10
  But in
• 7:10
  terms of
• 7:11
  Ablations
• 7:12
  histotripsy
• 7:14
  histotripsy
• 7:14
  is
• 7:15
  approved
• 7:15
  for any
• 7:16
  liver
• 7:16
  metastasis.
• 7:17
  Is that
• 7:17
  correct?
• 7:18
  Jason.
• 7:18
  So not
• 7:18
  necessarily
• 7:19
  uveal
• 7:20
  but uveal
• 7:20
  your goes
• 7:20
  to the liver.
• 7:21
  So
• 7:21
  it is approved
• 7:21
  in that
• 7:22
  regard.
• 7:22
  But
• 7:22
  immunoembolization
• 7:24
  radioembolization,
• 7:25
  all of these
• 7:25
  things
• 7:25
  have data
• 7:26
  to support
• 7:27
  their use.
• 7:27
  But
• 7:27
  they've
• 7:27
  never
• 7:28
  really
• 7:28
  been
• 7:28
  compared
• 7:28
  head
• 7:29
  to head.
• 7:29
  So
• 7:29
  it can get
• 7:30
  very
• 7:30
  confusing
• 7:31
  as
• 7:31
  a patient
• 7:32
  to try to
• 7:32
  figure
• 7:32
  out, well,
• 7:33
  which one
• 7:33
  should I
• 7:34
  do.
• 7:34
  because
• 7:34
  there's
• 7:35
  not great
• 7:35
  data,
• 7:36
  if you
• 7:36
  go see
• 7:37
  four
• 7:38
  different
• 7:38
  physicians,
• 7:38
  you might
• 7:39
  get six
• 7:39
  different
• 7:39
  answers.
• 7:40
  And that's
• 7:40
  because we
• 7:41
  don't
• 7:41
  necessarily
• 7:42
  always
• 7:42
  know what
• 7:42
  the best
• 7:43
  option is,
• 7:43
  because
• 7:44
  there's
• 7:44
  just
• 7:44
  limited
• 7:44
  data in
• 7:45
  rare
• 7:45
  tumors.
• 7:46
  So I think
• 7:46
  that was
• 7:46
  a really
• 7:46
  great
• 7:47
  overview.
• 7:47
  and we'll
• 7:48
  start
• 7:48
  with
• 7:48
  Doctor
• 7:48
  Hadfield.
• 7:49
  you're
• 7:49
  seeing a
• 7:49
  patient
• 7:49
  with uveal
• 7:50
  melanoma
• 7:51
  there's
• 7:51
  the
• 7:51
  systemic
• 7:52
  therapies
• 7:52
  that
• 7:52
  we have
• 7:53
  of
• 7:53
  kimmtrak
• 7:54
  and the
• 7:55
  clinical
• 7:56
  trials
• 7:56
  that are
• 7:56
  going on
• 7:57
  with
• 7:57
  ideaya
• 7:58
  and
• 7:58
  replimune
• 7:59
  And
• 8:00
  in octoriff
• 8:01
  but
• 8:02
  how do you
• 8:02
  approach
• 8:03
  a patient.
• 8:03
  When
• 8:03
  would you
• 8:04
  say, okay,
• 8:05
  I need
• 8:05
  to give
• 8:05
  this
• 8:05
  person
• 8:06
  systemic
• 8:06
  therapy,
• 8:07
  or when
• 8:08
  would you
• 8:08
  say, what
• 8:09
  liver
• 8:09
  directed
• 8:09
  option may
• 8:10
  be best
• 8:10
  for this
• 8:10
  patient?
• 8:11
  know,
• 8:11
  that was a
• 8:11
  wonderful
• 8:12
  overview.
• 8:12
  Of of
• 8:12
  liver
• 8:13
  directed
• 8:13
  therapies.
• 8:13
  And
• 8:13
  I think
• 8:14
  when you're
• 8:14
  you're
• 8:14
  meeting
• 8:15
  patients
• 8:15
  for
• 8:15
  the first
• 8:15
  time,
• 8:16
  there's
• 8:16
  a few
• 8:17
  things
• 8:17
  to kind of
• 8:17
  keep in
• 8:17
  mind.
• 8:18
  liver
• 8:18
  directed
• 8:19
  therapies
• 8:19
  are often
• 8:21
  technically
• 8:22
  challenging
• 8:22
  and in
• 8:23
  different
• 8:23
  ways.
• 8:24
  So,
• 8:24
  for
• 8:24
  instance,
• 8:25
  Sometimes
• 8:25
  patients
• 8:26
  just.
• 8:26
  Aren't
• 8:26
  good
• 8:26
  candidates
• 8:26
  for
• 8:27
  procedures.
• 8:27
  and
• 8:27
  they may
• 8:28
  be more
• 8:28
  amenable
• 8:28
  to
• 8:28
  systemic therapy.
• 8:30
  and that's
• 8:30
  something
• 8:30
  to
• 8:30
  consider.
• 8:31
  one thing
• 8:31
  that does
• 8:32
  come up,
• 8:32
  quite
• 8:32
  a bit,
• 8:32
  in
• 8:33
  my clinic,
• 8:33
  and I'm
• 8:33
  not sure
• 8:34
  if this
• 8:34
  resonates
• 8:34
  with
• 8:35
  anyone
• 8:35
  here,
• 8:35
  but
• 8:35
  oftentimes
• 8:36
  when
• 8:36
  I talk
• 8:36
  about
• 8:36
  liver
• 8:37
  directed
• 8:37
  therapy
• 8:37
  in
• 8:37
  conjunction
• 8:38
  with
• 8:38
  interventional
• 8:39
  radiology
• 8:39
  colleagues
• 8:40
  or
• 8:40
  surgical
• 8:41
  colleagues,
• 8:41
  one of the concerns
• 8:43
  is that
• 8:43
  when you
• 8:43
  you treat
• 8:44
  something
• 8:44
  just in
• 8:44
  the liver,
• 8:45
  it's only
• 8:46
  going to
• 8:46
  have an
• 8:46
  effect
• 8:47
  in the
• 8:47
  liver.
• 8:47
  And
• 8:47
  I think
• 8:47
  now we're
• 8:48
  starting
• 8:48
  to see
• 8:48
  some data
• 8:49
  that,
• 8:49
  if you
• 8:50
  treat
• 8:51
  liver
• 8:51
  directed
• 8:51
  lesions.
• 8:52
  particularly.
• 8:53
  With
• 8:53
  these.
• 8:53
  immune
• 8:54
  agonists
• 8:54
  and
• 8:54
  clinical.
• 8:54
  Trials,
• 8:55
  like, the.
• 8:55
  replimune
• 8:56
  study,
• 8:56
  you can
• 8:57
  actually,
• 8:57
  incite a
• 8:58
  more
• 8:58
  systemic
• 8:59
  immune
• 8:59
  response.
• 8:59
  And that's
• 9:00
  borne out
• 9:01
  with
• 9:01
  clinical
• 9:01
  data
• 9:02
  that's now
• 9:02
  becoming
• 9:03
  available.
• 9:03
  So,
• 9:04
  I think,
• 9:05
  it's
• 9:05
  certainly
• 9:05
  dependent
• 9:06
  on patient
• 9:07
  preference.
• 9:07
  some
• 9:07
  some patients
• 9:08
  don't
• 9:08
  want to
• 9:09
  undergo
• 9:09
  procedures
• 9:09
  and
• 9:09
  they're
• 9:10
  more
• 9:10
  comfortable
• 9:10
  with
• 9:10
  systemic
• 9:10
  therapies.
• 9:11
  but
• 9:12
  I think
• 9:12
  that's my
• 9:12
  general
• 9:13
  approach.
• 9:14
  So
• 9:14
  to expound
• 9:14
  on that.
• 9:15
  when
• 9:15
  you're
• 9:15
  looking
• 9:16
  at someone
• 9:16
  with just
• 9:16
  only liver
• 9:17
  Mets,
• 9:17
  I think
• 9:17
  liver
• 9:17
  directed
• 9:18
  therapy is
• 9:18
  reasonable.
• 9:19
  But you're
• 9:19
  absolutely
• 9:19
  right.
• 9:20
  there is a chance
• 9:21
  that it
• 9:21
  can spread
• 9:22
  outside
• 9:22
  the liver.
• 9:22
  And
• 9:22
  obviously
• 9:23
  you're
• 9:23
  not going
• 9:23
  to be
• 9:23
  treating
• 9:24
  that with
• 9:25
  uveal
• 9:25
  melanoma
• 9:26
  sometimes.
• 9:26
  And only
• 9:27
  the disease
• 9:27
  will stay
• 9:28
  in the
• 9:28
  liver
• 9:28
  for
• 9:28
  a couple
• 9:29
  of years.
• 9:29
  And
• 9:30
  I think
• 9:30
  a lot of
• 9:31
  the time,
• 9:31
  one of
• 9:31
  the things
• 9:32
  that can
• 9:32
  predict
• 9:32
  that
• 9:32
  is the
• 9:33
  volume
• 9:33
  of disease.
• 9:34
  So
• 9:34
  typically
• 9:35
  if I see
• 9:35
  someone
• 9:35
  with a
• 9:36
  high
• 9:36
  volume
• 9:37
  of disease
• 9:37
  in
• 9:37
  the liver,
• 9:38
  that makes me
• 9:39
  wonder
• 9:39
  if we
• 9:39
  should be
• 9:39
  doing
• 9:40
  a liver
• 9:40
  directed
• 9:40
  therapy,
• 9:41
  but also
• 9:42
  systemic
• 9:43
  therapy
• 9:43
  at the
• 9:43
  same time,
• 9:44
  or
• 9:44
  planning
• 9:44
  to
• 9:45
  sequence
• 9:45
  them very
• 9:45
  quickly.
• 9:46
  I think in
• 9:46
  general,
• 9:47
  people
• 9:47
  with very
• 9:48
  limited
• 9:48
  disease
• 9:48
  in
• 9:49
  the liver
• 9:49
  typically
• 9:50
  are more
• 9:50
  likely
• 9:50
  to benefit
• 9:51
  from the
• 9:51
  liver
• 9:51
  directed
• 9:52
  therapy
• 9:52
  long term,
• 9:53
  just
• 9:53
  because
• 9:53
  they're
• 9:54
  probably
• 9:54
  less
• 9:54
  likely
• 9:55
  to have it
• 9:55
  spread
• 9:55
  outside
• 9:56
  the liver.
• 9:56
  when we're
• 9:57
  differentiating,
• 9:58
  Jason
• 9:58
  did a
• 9:59
  really
• 9:59
  good job
• 9:59
  talking
• 9:59
  about the
• 10:00
  percutaneous
• 10:01
  stuff
• 10:01
  where we
• 10:02
  stick
• 10:02
  a needle
• 10:03
  in and
• 10:03
  inject
• 10:03
  or treat 1
• 10:04
  or 2
• 10:04
  lesions
• 10:05
  versus,
• 10:06
  the
• 10:07
  embolization
• 10:08
  and
• 10:08
  the more
• 10:08
  hepzato
• 10:09
  which
• 10:09
  treats the
• 10:09
  entire
• 10:10
  liver.
• 10:10
  Jason,
• 10:11
  would
• 10:11
  you want
• 10:11
  to comment
• 10:11
  on how
• 10:12
  you would
• 10:13
  look at on
• 10:13
  a scan
• 10:14
  to say,
• 10:14
  I can do
• 10:15
  this
• 10:15
  with a
• 10:16
  Perccutaneous
• 10:16
  ablation
• 10:17
  versus
• 10:17
  I need
• 10:17
  to
• 10:18
  treat the
• 10:18
  entire
• 10:18
  liver
• 10:19
  with
• 10:19
  hepzato
• 10:19
  or an
• 10:19
  embolization
• 10:20
  or
• 10:20
  something
• 10:20
  like that.
• 10:21
  That's a
• 10:21
  great
• 10:22
  question.
• 10:23
  the biggest
• 10:23
  thing
• 10:23
  is size
• 10:25
  and tumor
• 10:26
  number.
• 10:27
  if
• 10:27
  if you have
• 10:28
  somebody
• 10:28
  that has
• 10:29
  one, two,
• 10:31
  metastases
• 10:32
  in
• 10:32
  the liver
• 10:32
  that are
• 10:33
  smaller
• 10:33
  than three
• 10:33
  centimeters
• 10:34
  is kind of
• 10:34
  our
• 10:34
  cutoff.
• 10:35
  then I
• 10:36
  think the,
• 10:37
  approach
• 10:38
  would
• 10:38
  be to
• 10:39
  try and
• 10:39
  treat
• 10:39
  both
• 10:40
  of those,
• 10:41
  with
• 10:41
  ablation
• 10:41
  because
• 10:42
  we know
• 10:42
  we have
• 10:43
  data just
• 10:43
  in general
• 10:44
  with
• 10:44
  ablation
• 10:44
  that,
• 10:45
  it can be
• 10:46
  roughly
• 10:47
  equivalent
• 10:47
  to,
• 10:48
  having
• 10:49
  surgical
• 10:49
  resection.
• 10:49
  it's all
• 10:50
  about kind
• 10:51
  of number
• 10:51
  of tumor.
• 10:52
  Now once
• 10:52
  you start
• 10:52
  getting
• 10:53
  multiple
• 10:53
  tumors,
• 10:53
  then then
• 10:55
  you
• 10:55
  have
• 10:55
  to kind
• 10:55
  of start
• 10:56
  thinking
• 10:56
  of more
• 10:57
  distribution
• 10:57
  of the
• 10:58
  therapy,
• 10:59
  where you
• 10:59
  can kind
• 10:59
  of treat,
• 11:02
  the liver
• 11:03
  in
• 11:03
  totality,
• 11:04
  because,
• 11:05
  you can
• 11:05
  only treat
• 11:06
  2 or 3
• 11:06
  lesions,
• 11:07
  with the
• 11:08
  percutaneous
• 11:08
  ablation
• 11:09
  technologies.
• 11:10
  Yeah,
• 11:11
  that's a
• 11:11
  great question.
• 11:11
  So I'll
• 11:12
  just
• 11:12
  repeat it
• 11:12
  so
• 11:12
  everyone
• 11:13
  on zoom
• 11:13
  can hear.
• 11:14
  with these
• 11:14
  local
• 11:14
  therapies
• 11:15
  we can
• 11:15
  treat the
• 11:16
  disease
• 11:16
  in the liver.
• 11:17
  But
• 11:17
  as we've
• 11:17
  talked
• 11:17
  about,
• 11:18
  there's
• 11:18
  a chance
• 11:18
  it could
• 11:19
  spread
• 11:19
  outside.
• 11:19
  So
• 11:19
  is there
• 11:20
  any
• 11:20
  thought
• 11:20
  about
• 11:21
  trying
• 11:21
  to combine
• 11:22
  systemic
• 11:22
  and liver
• 11:23
  directed
• 11:24
  therapies.
• 11:25
  we do that
• 11:25
  for
• 11:25
  some patients
• 11:26
  just
• 11:26
  because
• 11:27
  if they
• 11:27
  have a
• 11:27
  high
• 11:27
  disease,
• 11:28
  a burden,
• 11:28
  we feel
• 11:29
  like the
• 11:29
  systemic
• 11:30
  therapy
• 11:30
  may not be
• 11:31
  strong
• 11:31
  enough to
• 11:31
  shrink it.
• 11:32
  So we'll
• 11:32
  give the
• 11:33
  liver
• 11:33
  directed
• 11:33
  therapy
• 11:34
  with that.
• 11:35
  In terms
• 11:36
  of data,
• 11:36
  we are getting
• 11:37
  some data.
• 11:38
  So I think
• 11:39
  it's Kevin
• 11:39
  Kim at
• 11:40
  Sutter
• 11:40
  Health
• 11:41
  has done
• 11:41
  a clinical
• 11:41
  trial
• 11:42
  for a
• 11:42
  while
• 11:42
  combining
• 11:43
  ipi-nivo
• 11:44
  with radio
• 11:44
  embolization.
• 11:45
  I don't
• 11:45
  believe
• 11:46
  we've
• 11:46
  seen the
• 11:46
  full
• 11:46
  results
• 11:47
  from that.
• 11:48
  I know
• 11:48
  early on
• 11:49
  if you did
• 11:49
  them both
• 11:50
  at
• 11:50
  the same
• 11:50
  time, that
• 11:51
  there's
• 11:52
  a little
• 11:52
  risk for
• 11:52
  toxicity,
• 11:53
  so
• 11:53
  staggering
• 11:54
  them out,
• 11:54
  it's
• 11:54
  probably
• 11:54
  a little
• 11:54
  bit
• 11:55
  better.
• 11:55
  There's
• 11:55
  also a
• 11:56
  couple
• 11:56
  of
• 11:56
  different
• 11:57
  clinical
• 11:57
  trials
• 11:58
  going on
• 11:58
  with
• 11:58
  Delcath
• 11:59
  right now
• 12:00
  in Europe,
• 12:01
  where
• 12:01
  they're
• 12:01
  combining
• 12:02
  both
• 12:02
  the hepzado kit
• 12:03
  So
• 12:04
  the percutaneous
• 12:04
  hepatic
• 12:05
  perfusion
• 12:06
  with
• 12:06
  nivolumab
• 12:07
  and in
• 12:07
  ipilimab
• 12:08
  for
• 12:08
  patients
• 12:09
  with you
• 12:09
  for
• 12:09
  melanoma.
• 12:10
  So people
• 12:10
  are
• 12:11
  looking
• 12:11
  at that.
• 12:11
  We don't have the data.
• 12:13
  But
• 12:14
  I think
• 12:14
  for
• 12:14
  the patients
• 12:15
  where
• 12:15
  you say
• 12:15
  I need to
• 12:16
  treat
• 12:16
  stuff
• 12:16
  outside
• 12:17
  the liver,
• 12:18
  but also
• 12:18
  there's
• 12:18
  a lot
• 12:19
  of disease
• 12:19
  in the liver.
• 12:19
  And I
• 12:20
  needed to
• 12:20
  bulk it
• 12:21
  or shrink
• 12:21
  it
• 12:21
  because
• 12:21
  it's going
• 12:22
  to start
• 12:22
  causing
• 12:22
  side
• 12:23
  effects
• 12:23
  such
• 12:23
  as pain
• 12:24
  or other
• 12:25
  issues.
• 12:25
  Doing
• 12:26
  the combination
• 12:27
  is a
• 12:27
  reasonable
• 12:27
  approach,
• 12:28
  but
• 12:29
  as everything
• 12:29
  in
• 12:29
  medicine
• 12:30
  more,
• 12:31
  maybe
• 12:31
  better,
• 12:32
  but more
• 12:32
  also maybe
• 12:33
  more
• 12:33
  toxic too.
• 12:34
  So
• 12:34
  we have to
• 12:35
  balance
• 12:35
  out all of
• 12:36
  those
• 12:36
  different
• 12:36
  things.
• 12:36
  But I'm
• 12:37
  really
• 12:37
  looking
• 12:37
  forward to
• 12:37
  some of
• 12:38
  those
• 12:38
  trials
• 12:38
  reaching
• 12:39
  out to
• 12:39
  really
• 12:40
  show us
• 12:40
  if there's
• 12:40
  benefit
• 12:41
  and
• 12:41
  synergy
• 12:41
  between
• 12:42
  the two.
• 12:42
  when
• 12:42
  cancer
• 12:43
  starts, it
• 12:43
  starts in
• 12:43
  one place.
• 12:44
  in terms
• 12:45
  of uveal
• 12:45
  melanoma,
• 12:46
  the cancer
• 12:46
  started in
• 12:47
  your eye.
• 12:48
  and then,
• 12:49
  unfortunately,
• 12:50
  as the
• 12:50
  cancer
• 12:50
  progresses,
• 12:51
  it figures
• 12:52
  out ways
• 12:52
  to hide
• 12:52
  from your
• 12:53
  immune
• 12:53
  system,
• 12:53
  your immune
• 12:54
  system
• 12:55
  typically
• 12:55
  kills
• 12:56
  bacteria
• 12:56
  and
• 12:56
  viruses.
• 12:57
  It also
• 12:57
  kills
• 12:58
  cancer
• 12:58
  cells.
• 12:59
  And when
• 13:00
  the cancer
• 13:00
  figures
• 13:00
  out how to
• 13:01
  get around
• 13:01
  your
• 13:01
  immune
• 13:01
  system,
• 13:02
  it can
• 13:03
  then
• 13:03
  spread to
• 13:03
  other places.
• 13:04
  And that's
• 13:04
  typically
• 13:04
  through
• 13:05
  your
• 13:05
  lymphatics
• 13:06
  and
• 13:06
  your blood.
• 13:07
  And
• 13:07
  then it
• 13:07
  it shows
• 13:08
  up as
• 13:09
  is tumors
• 13:09
  and other
• 13:10
  parts of
• 13:10
  your body.
• 13:10
  uveal
• 13:11
  melanoma
• 13:11
  specifically
• 13:12
  has the
• 13:13
  highest
• 13:13
  propensity
• 13:13
  to to
• 13:14
  spread to
• 13:14
  your liver
• 13:15
  most of the time.
• 13:16
  But
• 13:17
  generally
• 13:17
  speaking,
• 13:18
  the cancer
• 13:18
  cells have
• 13:19
  started
• 13:19
  somewhere.
• 13:20
  And
• 13:20
  they're
• 13:20
  then
• 13:21
  dispersed
• 13:21
  throughout
• 13:21
  your body.
• 13:22
  It's just
• 13:22
  you're
• 13:22
  seeing
• 13:23
  the tumor
• 13:23
  somewhere
• 13:23
  else.
• 13:24
  And that's
• 13:24
  why
• 13:24
  things
• 13:25
  like
• 13:25
  circulating
• 13:25
  tumor DNA,
• 13:26
  which is
• 13:27
  a
• 13:27
  biomarker
• 13:28
  of the
• 13:28
  tumor,
• 13:29
  is so
• 13:29
  important
• 13:29
  in
• 13:30
  the blood
• 13:30
  for many
• 13:31
  of these
• 13:31
  treatments.
• 13:31
  That's
• 13:32
  so there's
• 13:32
  this.
• 13:32
  Type
• 13:33
  of seed
• 13:33
  and soil.
• 13:34
  Thought
• 13:35
  about
• 13:35
  metastasis,
• 13:36
  cancer
• 13:37
  spreading.
• 13:37
  We
• 13:37
  don't have
• 13:38
  a great
• 13:38
  understanding
• 13:39
  of why
• 13:39
  some
• 13:39
  cancers
• 13:40
  spread to
• 13:40
  certain
• 13:41
  places
• 13:41
  and others
• 13:41
  not,
• 13:42
  not to
• 13:42
  different
• 13:42
  parts of
• 13:43
  the body.
• 13:43
  And that's
• 13:43
  still
• 13:43
  something
• 13:44
  we're
• 13:44
  we're kind
• 13:44
  of
• 13:44
  learning.
• 13:45
  but I
• 13:45
  would love
• 13:45
  to get
• 13:46
  Doctor
• 13:46
  ma
• 13:46
  thoughts
• 13:46
  about,
• 13:47
  when
• 13:47
  looking at
• 13:48
  a patient
• 13:48
  who needs
• 13:49
  liver
• 13:49
  directed
• 13:49
  therapy,
• 13:50
  how does he
• 13:51
  choose
• 13:51
  hepzado
• 13:51
  out of
• 13:52
  versus,
• 13:52
  an ablation
• 13:53
  or some
• 13:53
  of these
• 13:53
  other
• 13:54
  different,
• 13:54
  local
• 13:55
  therapies
• 13:55
  that are
• 13:55
  out there?
• 13:57
  I
• 13:57
  believe I
• 13:57
  heard
• 13:58
  from,
• 13:59
  doctor
• 13:59
  Moser
• 14:00
  about,
• 14:00
  one of
• 14:00
  the case
• 14:01
  examples
• 14:01
  that
• 14:02
  we had
• 14:02
  displayed
• 14:03
  up there.
• 14:03
  what was
• 14:04
  interesting
• 14:04
  was,
• 14:05
  we were one
• 14:05
  of the
• 14:05
  very few,
• 14:07
  centers
• 14:07
  in the
• 14:07
  US that,
• 14:08
  had
• 14:08
  hepzado
• 14:09
  available
• 14:09
  when it became
• 14:10
  FDA
• 14:10
  approved.
• 14:10
  we treated
• 14:11
  the number
• 14:11
  of
• 14:11
  patients
• 14:12
  at this
• 14:12
  point.
• 14:13
  one of the case
• 14:14
  examples
• 14:14
  that we
• 14:15
  submitted
• 14:15
  or had
• 14:16
  displayed
• 14:16
  was
• 14:18
  a patient
• 14:18
  who
• 14:19
  we found
• 14:20
  actually
• 14:21
  had a
• 14:21
  pretty
• 14:22
  significant
• 14:22
  response
• 14:23
  to
• 14:23
  treatment.
• 14:24
  after one
• 14:24
  cycle
• 14:25
  of therapy
• 14:26
  this was
• 14:26
  actually
• 14:26
  our first
• 14:27
  patient.
• 14:27
  And so,
• 14:28
  we were
• 14:29
  fortunate
• 14:30
  to
• 14:30
  actually
• 14:30
  have
• 14:31
  one of
• 14:32
  our
• 14:32
  interventional
• 14:33
  radiologists.
• 14:34
  is able
• 14:34
  to obtain
• 14:35
  images
• 14:36
  at
• 14:36
  the time
• 14:36
  of the
• 14:36
  procedure.
• 14:37
  And so
• 14:37
  by
• 14:37
  the time
• 14:38
  the
• 14:38
  patient
• 14:38
  received
• 14:39
  their
• 14:39
  second
• 14:40
  dose
• 14:40
  or prior
• 14:41
  to their
• 14:41
  second
• 14:42
  dose,of
• 14:42
  hepzado
• 14:43
  we were
• 14:43
  actually
• 14:43
  able to
• 14:45
  visualize
• 14:45
  how much
• 14:46
  their
• 14:46
  disease
• 14:47
  burden,
• 14:47
  the
• 14:48
  metastatic
• 14:48
  uveal
• 14:49
  melanoma
• 14:50
  burden in
• 14:50
  a liver,
• 14:50
  was able
• 14:51
  to shrink,
• 14:52
  almost
• 14:53
  greater
• 14:53
  than 50%
• 14:54
  after a
• 14:54
  six week
• 14:55
  interval
• 14:55
  therapy.
• 14:57
  And, we're
• 14:57
  pleased
• 14:58
  to say
• 14:58
  that he
• 14:58
  continues,
• 14:59
  to respond
• 15:00
  well
• 15:00
  to therapy
• 15:01
  and, and
• 15:01
  receive
• 15:02
  their
• 15:02
  fourth
• 15:02
  dose,
• 15:03
  this past
• 15:04
  week.
• 15:05
  and so,
• 15:06
  what's
• 15:06
  great,
• 15:06
  as opposed
• 15:07
  to some of
• 15:08
  the other
• 15:08
  systemic
• 15:08
  therapy
• 15:09
  options,
• 15:10
  is that
• 15:10
  with this
• 15:11
  being sort
• 15:12
  of a liver
• 15:12
  directed
• 15:13
  therapy,
• 15:13
  he's
• 15:14
  actually
• 15:14
  kind of
• 15:14
  feeling
• 15:15
  minimal,
• 15:15
  toxicity
• 15:16
  associated
• 15:17
  with it.
• 15:17
  Great.
• 15:18
  thanks for
• 15:18
  that.
• 15:18
  Vince, and
• 15:19
  in addition,
• 15:20
  we were
• 15:20
  discussing
• 15:21
  how to
• 15:21
  choose
• 15:21
  liver
• 15:22
  directed
• 15:22
  therapies
• 15:23
  and
• 15:23
  with your
• 15:23
  experience
• 15:24
  with the
• 15:24
  Hepzado
• 15:24
  kit
• 15:25
  Could you
• 15:25
  walk us
• 15:26
  through,
• 15:26
  when
• 15:27
  you look
• 15:27
  at a patient,
• 15:27
  what guides
• 15:28
  you to
• 15:28
  say?
• 15:29
  I think
• 15:29
  we should
• 15:30
  do an
• 15:30
  embolization
• 15:31
  or an
• 15:31
  ablation
• 15:32
  or hepzado
• 15:33
  choose
• 15:34
  the patients
• 15:35
  that you
• 15:35
  think
• 15:36
  would
• 15:36
  benefit
• 15:36
  most from
• 15:37
  hepzado
• 15:37
  versus
• 15:38
  these other
• 15:38
  liver
• 15:38
  directed
• 15:39
  therapies?
• 15:41
  Yeah,
• 15:41
  that's a
• 15:41
  great
• 15:41
  question.
• 15:43
  oftentimes
• 15:45
  when I
• 15:45
  read,
• 15:46
  a patient
• 15:46
  with
• 15:47
  metastatic
• 15:47
  melanoma,
• 15:48
  in
• 15:48
  my clinic,
• 15:49
  we often
• 15:50
  times
• 15:50
  review
• 15:50
  the
• 15:50
  imaging
• 15:51
  together
• 15:51
  and,
• 15:52
  and also
• 15:53
  discuss
• 15:53
  the case,
• 15:54
  within a
• 15:54
  multidisciplinary
• 15:56
  setting.
• 15:57
  so we have
• 15:57
  specialists,
• 15:58
  including,
• 15:58
  surgeons,
• 15:59
  radiation
• 16:00
  oncologist,
• 16:01
  interventional
• 16:02
  radiology
• 16:03
  present
• 16:03
  at these
• 16:03
  tumor
• 16:04
  board.
• 16:04
  And,
• 16:05
  we'll
• 16:05
  extensively
• 16:06
  review
• 16:06
  the
• 16:07
  imaging,
• 16:07
  particularly
• 16:08
  the liver.
• 16:09
  and at
• 16:09
  that
• 16:09
  point,
• 16:10
  we'll kind
• 16:10
  of assess,
• 16:11
  for
• 16:11
  example,
• 16:11
  how much,
• 16:12
  disease
• 16:13
  involvement
• 16:13
  is there
• 16:14
  specifically
• 16:15
  in the
• 16:15
  liver,
• 16:15
  for cases
• 16:16
  where
• 16:16
  we're
• 16:16
  seeing,
• 16:17
  maybe one,
• 16:18
  maybe
• 16:18
  up to
• 16:19
  five
• 16:19
  lesions,
• 16:20
  where
• 16:20
  it is
• 16:21
  quite
• 16:21
  accessible
• 16:22
  by the
• 16:22
  surgeon.
• 16:23
  we'll
• 16:23
  often
• 16:24
  times
• 16:24
  consider a
• 16:25
  resection
• 16:25
  of the
• 16:26
  disease.
• 16:27
  by
• 16:27
  surgery.
• 16:28
  But, for
• 16:29
  some cases
• 16:30
  where,
• 16:30
  surgery
• 16:30
  may not
• 16:31
  be
• 16:31
  permissible,
• 16:32
  and
• 16:32
  we want to
• 16:33
  take what
• 16:33
  we call
• 16:33
  a more
• 16:34
  palatable
• 16:34
  approach,
• 16:35
  less
• 16:35
  invasive.
• 16:36
  I will
• 16:37
  sometimes
• 16:37
  consider
• 16:38
  just using
• 16:38
  radiation
• 16:39
  therapy
• 16:39
  alone,
• 16:41
  for cases
• 16:41
  where
• 16:42
  there's
• 16:42
  maybe
• 16:42
  multifocal
• 16:43
  disease
• 16:44
  these
• 16:44
  factors,
• 16:45
  extensive
• 16:46
  disease
• 16:47
  involvement
• 16:47
  of the
• 16:48
  liver,
• 16:48
  will often
• 16:49
  at that
• 16:49
  point
• 16:50
  really
• 16:50
  think
• 16:50
  about,
• 16:51
  using sort
• 16:52
  of THP
• 16:52
  or
• 16:54
  perfusion
• 16:54
  therapy
• 16:55
  with
• 16:55
  hepzado
• 16:56
  and one of
• 16:57
  the nice
• 16:57
  advantages
• 16:58
  of hepzado
• 16:58
  is that
• 16:59
  the
• 16:59
  ability
• 16:59
  to
• 17:00
  saturate
• 17:01
  or treat
• 17:01
  the entire
• 17:02
  liver,
• 17:02
  with
• 17:03
  chemotherapy
• 17:03
  in
• 17:03
  multiple
• 17:04
  and
• 17:05
  in those
• 17:05
  cases, you
• 17:06
  will also
• 17:07
  assess
• 17:07
  the patient's
• 17:08
  general
• 17:08
  candidacy
• 17:09
  for
• 17:09
  therapy
• 17:10
  because as
• 17:11
  of right
• 17:11
  now,
• 17:11
  the FDA
• 17:12
  approval
• 17:12
  for
• 17:13
  hepzado
• 17:13
  that, less
• 17:13
  than
• 17:14
  50% of
• 17:15
  the liver
• 17:15
  has been
• 17:16
  by the
• 17:17
  disease
• 17:17
  itself.
• 17:18
  We also have
• 17:19
  to
• 17:19
  make sure
• 17:19
  that
• 17:19
  there
• 17:19
  is no
• 17:20
  other
• 17:20
  sites
• 17:20
  of disease
• 17:21
  elsewhere
• 17:22
  outside
• 17:22
  the liver
• 17:23
  in order
• 17:24
  to be
• 17:24
  a candidate.
• 17:25
  but
• 17:25
  if there is
• 17:26
  disease
• 17:26
  outside
• 17:27
  the liver,
• 17:27
  we'll
• 17:28
  oftentimes
• 17:28
  need to
• 17:28
  consider
• 17:29
  definitive
• 17:30
  surgery
• 17:30
  or
• 17:30
  radiation.
• 17:31
  For
• 17:31
  example,
• 17:31
  if there's
• 17:32
  metastatic
• 17:33
  disease
• 17:33
  in the
• 17:33
  lungs,
• 17:34
  bones
• 17:34
  or skin,
• 17:36
  those do
• 17:36
  need to be
• 17:37
  treated
• 17:37
  before
• 17:37
  consideration.
• 17:38
  hepzado
• 17:40
  But
• 17:40
  generally
• 17:40
  speaking,
• 17:41
  for the
• 17:42
  liver,
• 17:42
  only
• 17:42
  disease
• 17:43
  will
• 17:43
  definitely
• 17:43
  strongly.
• 17:44
  Consider
• 17:44
  a liver
• 17:44
  directed
• 17:45
  therapy.
• 17:46
  generally
• 17:47
  speaking,
• 17:47
  because
• 17:48
  we know
• 17:48
  how
• 17:49
  extensive
• 17:50
  and how
• 17:50
  morbid
• 17:52
  liver
• 17:52
  involvements
• 17:53
  by cancer
• 17:53
  can be.
• 17:54
  and so
• 17:55
  it's
• 17:55
  important
• 17:55
  to really,
• 17:56
  be
• 17:57
  aggressive
• 17:57
  with
• 17:58
  treating
• 17:58
  the disease
• 17:58
  as much
• 17:59
  as
• 17:59
  possible.
• 18:00
  and
• 18:01
  especially
• 18:02
  for,
• 18:02
  melanoma,
• 18:03
  where 90,
• 18:04
  95% of
• 18:05
  patients
• 18:05
  have,
• 18:07
  disease
• 18:07
  involving
• 18:07
  the liver
• 18:08
  at the
• 18:08
  time of
• 18:08
  stage four
• 18:09
  diagnosis.
• 18:11
  it's a
• 18:11
  significant
• 18:12
  cause for
• 18:13
  white
• 18:13
  patients
• 18:13
  overall
• 18:14
  decline.
• 18:15
  and
• 18:16
  .........
• 18:17
  if
• 18:17
  the disease
• 18:18
  itself
• 18:18
  is not,
• 18:19
  well
• 18:19
  managed,
• 18:20
  quickly
• 18:20
  and
• 18:20
  efficiently.
• 18:21
  Great.
• 18:21
  I think
• 18:22
  that was a
• 18:22
  great
• 18:22
  discussion.
• 18:23
  Any questions
• 18:24
  from the
• 18:24
  audience
• 18:25
  or any
• 18:26
  questions
• 18:27
  from
• 18:27
  the zoom
• 18:28
  back
• 18:28
  in the back?
• 18:28
  How
• 18:29
  rapidly.
• 18:30
  Can the
• 18:31
  cancer.
• 18:31
  Grow
• 18:31
  within
• 18:32
  the liver?
• 18:33
  So if
• 18:33
  someone
• 18:33
  is.
• 18:33
  Scanned
• 18:34
  every six
• 18:34
  months.
• 18:35
  Month one,
• 18:36
  they're
• 18:36
  clear.
• 18:37
  Month six
• 18:38
  could it
• 18:38
  be more
• 18:38
  than.
• 18:39
  50% of
• 18:39
  the liver
• 18:40
  involved
• 18:40
  with
• 18:41
  cancer?
• 18:41
  Typically
• 18:42
  not.
• 18:42
  we know
• 18:43
  from the
• 18:43
  updated
• 18:44
  coog
• 18:44
  2.1 study
• 18:45
  which
• 18:45
  Doctor
• 18:46
  Harbor
• 18:46
  we'll
• 18:47
  talk about
• 18:47
  in a
• 18:48
  prerecorded,
• 18:49
  lecture
• 18:49
  later
• 18:49
  today
• 18:50
  that
• 18:51
  if you
• 18:51
  have uveal
• 18:52
  melanoma
• 18:53
  and you're
• 18:53
  getting
• 18:54
  scans
• 18:54
  the median
• 18:55
  time to
• 18:56
  developing
• 18:56
  disease
• 18:57
  in the
• 18:57
  liver,
• 18:58
  it depends
• 18:59
  a little
• 18:59
  bit
• 18:59
  on your
• 18:59
  genetic
• 19:00
  risk.
• 19:00
  But
• 19:00
  the earliest
• 19:01
  is kind
• 19:01
  of a year
• 19:02
  and
• 19:02
  a half.
• 19:02
  And
• 19:02
  sometimes
• 19:03
  it's up
• 19:03
  to 2 to 2
• 19:04
  in a year
• 19:05
  or 2 or 2
• 19:05
  and a
• 19:06
  half
• 19:06
  years.
• 19:07
  Now
• 19:07
  obviously
• 19:08
  there's
• 19:08
  extremes.
• 19:09
  Have I
• 19:09
  seen
• 19:09
  people go
• 19:10
  from
• 19:10
  nothing
• 19:11
  to
• 19:11
  significant
• 19:12
  disease
• 19:12
  in six
• 19:12
  months?
• 19:13
  Yes,
• 19:13
  but that's
• 19:14
  very rare
• 19:15
  most
• 19:15
  of the time.
• 19:16
  And if you
• 19:17
  have,
• 19:18
  kind of
• 19:18
  intermediate
• 19:19
  or low
• 19:19
  risk, it's
• 19:20
  going
• 19:20
  to grow
• 19:20
  fairly
• 19:21
  slow.
• 19:22
  And so
• 19:22
  there
• 19:23
  won't be
• 19:23
  much
• 19:24
  change
• 19:24
  within
• 19:25
  six
• 19:25
  months.
• 19:25
  If
• 19:25
  you're a
• 19:26
  high risk,
• 19:26
  most of us
• 19:27
  will do
• 19:27
  scans
• 19:28
  every
• 19:28
  three
• 19:28
  months
• 19:29
  after your
• 19:29
  treatment.
• 19:30
  Although
• 19:30
  those are
• 19:31
  those
• 19:31
  guidelines
• 19:31
  are
• 19:32
  very soft.
• 19:32
  And so
• 19:33
  there's a
• 19:33
  lot of
• 19:34
  variability
• 19:34
  there.
• 19:35
  And so
• 19:35
  we
• 19:36
  wouldn't
• 19:36
  catch
• 19:36
  that.
• 19:36
  But it's
• 19:37
  very rare
• 19:37
  that
• 19:37
  someone's
• 19:38
  cancer
• 19:38
  grows
• 19:38
  that fast.
• 19:40
  Unfortunately.
• 19:40
  The reality
• 19:41
  is
• 19:42
  if you're
• 19:43
  if your
• 19:43
  cancer
• 19:44
  is growing
• 19:44
  that fast,
• 19:46
  that's a
• 19:46
  reflection
• 19:47
  of just
• 19:47
  how
• 19:47
  aggressive
• 19:48
  the cancer
• 19:48
  is.
• 19:49
  And
• 19:49
  it means
• 19:50
  that
• 19:50
  you're
• 19:50
  less
• 19:50
  likely
• 19:51
  to respond
• 19:51
  to
• 19:51
  the therapy.
• 19:52
  So
• 19:52
  a lot of
• 19:52
  people in
• 19:53
  those
• 19:53
  situations
• 19:53
  will
• 19:54
  think, oh,
• 19:54
  I should
• 19:55
  have done
• 19:55
  something
• 19:55
  different.
• 19:56
  I should have
• 19:56
  scanned
• 19:56
  sooner.
• 19:57
  But that
• 19:58
  may not
• 19:58
  have
• 19:58
  always
• 19:58
  changed
• 19:59
  anything
• 19:59
  because at
• 20:00
  the end,
• 20:00
  at the
• 20:01
  end of the day,
• 20:01
  it was the
• 20:02
  cancer's
• 20:02
  aggressiveness,
• 20:03
  not
• 20:04
  something
• 20:05
  you did
• 20:05
  or your
• 20:05
  physician
• 20:06
  did or
• 20:06
  something
• 20:07
  like that.
• 20:07
  Okay,
• 20:08
  so I'll
• 20:08
  throw a
• 20:08
  question
• 20:09
  to Doctor
• 20:09
  Low then.
• 20:09
  So
• 20:12
  most of
• 20:12
  us these
• 20:12
  days are
• 20:13
  doing
• 20:13
  surveillance
• 20:14
  scans
• 20:14
  for
• 20:14
  patients
• 20:15
  who have
• 20:15
  treated
• 20:15
  uveal
• 20:15
  melanoma.
• 20:16
  So we are
• 20:16
  catching
• 20:17
  patients
• 20:17
  with liver
• 20:18
  metastases
• 20:19
  when they
• 20:19
  may have 1
• 20:20
  or 2 liver
• 20:21
  metastases
• 20:22
  or
• 20:23
  very low
• 20:23
  disease
• 20:24
  burden.
• 20:25
  So when
• 20:26
  we're
• 20:26
  seeing
• 20:26
  these
• 20:26
  patients,
• 20:26
  a
• 20:27
  lot of times
• 20:27
  we consider
• 20:27
  them for
• 20:28
  a liver
• 20:28
  directed
• 20:28
  therapy.
• 20:29
  If
• 20:30
  a patient
• 20:30
  were to
• 20:30
  ask you
• 20:31
  and say
• 20:31
  okay,
• 20:32
  of all
• 20:32
  the liver
• 20:32
  directed
• 20:33
  therapies
• 20:33
  ablation
• 20:34
  embolization,
• 20:35
  either
• 20:35
  radio
• 20:36
  or immuno,
• 20:37
  immobilization
• 20:37
  or hepzado
• 20:37
  kit
• 20:38
  what are the side
• 20:39
  effects
• 20:39
  and
• 20:39
  what do you think
• 20:40
  is kind of
• 20:40
  the most
• 20:41
  side
• 20:42
  effect one
• 20:43
  or what
• 20:44
  is the
• 20:44
  easiest
• 20:44
  one to do?
• 20:45
  just kind
• 20:46
  of help
• 20:46
  guide that
• 20:46
  discussion
• 20:47
  about
• 20:48
  what is it
• 20:48
  like for
• 20:49
  the patients
• 20:49
  to go
• 20:49
  through
• 20:50
  when
• 20:50
  we think
• 20:50
  they're a
• 20:50
  good
• 20:50
  candidate
• 20:51
  for any of
• 20:51
  these
• 20:51
  liver
• 20:52
  directed
• 20:52
  therapies?
• 20:53
  that's a
• 20:53
  really good point.
• 20:53
  They all
• 20:54
  do have
• 20:54
  their own
• 20:55
  kind of
• 20:55
  separate,
• 20:57
  unique
• 20:57
  side
• 20:57
  effects
• 20:58
  for each
• 20:58
  treatment.
• 20:59
  So if
• 21:00
  we're
• 21:00
  talking
• 21:00
  about,
• 21:01
  ablation,
• 21:02
  first of
• 21:02
  all, in
• 21:03
  general,
• 21:03
  they do
• 21:04
  require
• 21:04
  the procedure
• 21:05
  to be done
• 21:05
  under
• 21:06
  general
• 21:06
  anesthesia.
• 21:07
  they often
• 21:07
  will
• 21:08
  require
• 21:08
  overnight
• 21:09
  admission
• 21:09
  to
• 21:09
  the hospital.
• 21:10
  they're
• 21:10
  generally
• 21:11
  well
• 21:11
  tolerated,
• 21:11
  but they
• 21:12
  they can
• 21:12
  be
• 21:13
  painful.
• 21:13
  You can have
• 21:14
  discomfort,
• 21:14
  from from
• 21:15
  the
• 21:16
  ablation
• 21:16
  itself.
• 21:17
  and they,
• 21:18
  do have
• 21:18
  an
• 21:19
  infection
• 21:19
  risk
• 21:20
  as well.
• 21:20
  just
• 21:20
  because,
• 21:21
  we're
• 21:22
  destroying
• 21:22
  the,
• 21:23
  the area
• 21:23
  that
• 21:23
  we're,
• 21:24
  we're
• 21:24
  either
• 21:24
  heating
• 21:25
  or
• 21:25
  cooling,
• 21:26
  in the
• 21:26
  liver.
• 21:27
  now,
• 21:27
  when we're
• 21:28
  talking
• 21:28
  about
• 21:28
  transarterial
• 21:29
  therapies,
• 21:30
  as I said,
• 21:31
  the chemo
• 21:32
  embolization
• 21:33
  or,
• 21:34
  kind
• 21:34
  of the
• 21:34
  embolic
• 21:35
  technology
• 21:36
  or
• 21:36
  treatments,
• 21:37
  they
• 21:37
  tend to
• 21:38
  be,
• 21:38
  painful.
• 21:40
  just
• 21:40
  because,
• 21:41
  we are
• 21:41
  intentionally
• 21:42
  blocking
• 21:42
  off the
• 21:43
  blood flow
• 21:43
  to, to
• 21:44
  whatever
• 21:45
  area of
• 21:45
  the liver
• 21:46
  we decide.
• 21:46
  So,
• 21:47
  I tell
• 21:48
  patients
• 21:48
  that,
• 21:49
  you
• 21:49
  will have
• 21:50
  pain,
• 21:50
  and
• 21:51
  we just
• 21:51
  have to do
• 21:52
  our best
• 21:52
  to, manage
• 21:53
  that, for
• 21:53
  the, week
• 21:54
  or so
• 21:55
  it
• 21:55
  takes for
• 21:55
  your body
• 21:56
  to,
• 21:56
  to recover
• 21:57
  from that,
• 21:58
  y90 is
• 22:00
  very well
• 22:00
  tolerated
• 22:01
  from a
• 22:01
  pain
• 22:01
  standpoint.
• 22:03
  the most
• 22:04
  common
• 22:04
  thing
• 22:04
  people
• 22:05
  have is,
• 22:05
  is kind of
• 22:06
  just a
• 22:06
  generalized
• 22:07
  flu like
• 22:08
  illness.
• 22:08
  So just
• 22:09
  a few days
• 22:10
  of,
• 22:10
  fatigue,
• 22:12
  nausea,
• 22:13
  things
• 22:13
  like that.
• 22:14
  Now, there
• 22:14
  are some
• 22:15
  serious
• 22:15
  side
• 22:15
  effects
• 22:16
  that can
• 22:16
  happen
• 22:17
  from y90
• 22:18
  you can get
• 22:19
  ulcerations
• 22:19
  in your
• 22:20
  stomach,
• 22:21
  intestines.
• 22:22
  you can
• 22:22
  get
• 22:22
  radiation
• 22:23
  fibrosis
• 22:24
  to your lungs.
• 22:25
  but
• 22:25
  those are
• 22:26
  things
• 22:26
  that we,
• 22:27
  are very
• 22:28
  careful
• 22:29
  about
• 22:30
  not causing.
• 22:31
  And so
• 22:31
  that's why
• 22:32
  anyone
• 22:33
  we do
• 22:33
  actually
• 22:33
  has a
• 22:34
  procedure
• 22:34
  beforehand
• 22:35
  where we
• 22:36
  completely
• 22:37
  map out
• 22:37
  the blood
• 22:38
  flow
• 22:38
  to the liver,
• 22:39
  and find
• 22:40
  any of
• 22:40
  those
• 22:40
  little
• 22:41
  arteries
• 22:41
  that could
• 22:42
  potentially
• 22:43
  go to
• 22:43
  the
• 22:43
  stomach
• 22:44
  that could
• 22:44
  cause
• 22:44
  problems.
• 22:45
  And we do
• 22:47
  actually
• 22:47
  quantify
• 22:48
  how much,
• 22:49
  radiation
• 22:50
  will be
• 22:50
  given to
• 22:51
  the lungs
• 22:51
  as well.
• 22:52
  during
• 22:53
  our, our
• 22:53
  planning
• 22:54
  phase.
• 22:55
  And, with
• 22:56
  the
• 22:56
  Hepzado,
• 22:57
  we've,
• 22:59
  seen that,
• 22:59
  overall
• 23:00
  the,
• 23:00
  the systemic
• 23:01
  effects
• 23:02
  are quite
• 23:03
  mild.
• 23:03
  Most
• 23:04
  commonly
• 23:04
  people
• 23:05
  will have
• 23:05
  some,
• 23:06
  gi upset
• 23:07
  or nausea
• 23:08
  related
• 23:08
  to it.
• 23:10
  and, that
• 23:11
  also
• 23:11
  requires
• 23:11
  an
• 23:12
  overnight
• 23:12
  admission
• 23:13
  to
• 23:13
  the hospital
• 23:14
  just for,
• 23:14
  for
• 23:14
  monitoring
• 23:15
  and,
• 23:16
  we can
• 23:16
  induce,
• 23:17
  low
• 23:17
  platelets,
• 23:18
  different
• 23:19
  things
• 23:20
  in the
• 23:20
  blood
• 23:20
  profile
• 23:21
  that we
• 23:21
  require
• 23:22
  blood
• 23:22
  transfusions
• 23:23
  and things
• 23:23
  like that
• 23:23
  with
• 23:24
  hepzado
• 23:24
  as well.
• 23:25
  So
• 23:25
  one of the treatments
• 23:26
  that's
• 23:26
  commonly
• 23:27
  used for
• 23:27
  early
• 23:28
  or low
• 23:29
  volume
• 23:29
  disease
• 23:30
  in the
• 23:30
  liver
• 23:30
  at
• 23:30
  a lot of
• 23:31
  centers
• 23:31
  around
• 23:31
  the US
• 23:32
  is immuno
• 23:32
  embolization,
• 23:33
  which is
• 23:33
  given kind
• 23:34
  of
• 23:35
  repetitively
• 23:35
  every
• 23:36
  eight
• 23:36
  weeks
• 23:37
  for up
• 23:37
  to
• 23:37
  sometimes
• 23:38
  6-10
• 23:39
  treatments.
• 23:39
  Is there
• 23:40
  any risk
• 23:40
  to
• 23:41
  repetitively
• 23:42
  embolising
• 23:42
  your liver
• 23:43
  every
• 23:43
  two months
• 23:44
  for that
• 23:44
  number of
• 23:44
  treatments,
• 23:45
  or do
• 23:46
  you
• 23:46
  typically
• 23:46
  see that
• 23:46
  it's well
• 23:47
  tolerated
• 23:47
  throughout?
• 23:49
  so it's
• 23:50
  usually
• 23:51
  well
• 23:51
  tolerated.
• 23:52
  And given
• 23:53
  a few
• 23:53
  weeks
• 23:53
  separation,
• 23:54
  the liver
• 23:55
  recovers,
• 23:56
  the immuno
• 23:58
  embolization
• 23:59
  doesn't
• 23:59
  appear
• 24:00
  to have as
• 24:02
  toxic
• 24:02
  effects
• 24:03
  on the
• 24:03
  blood
• 24:03
  vessels.
• 24:04
  So
• 24:04
  whenever
• 24:04
  we're
• 24:04
  going in
• 24:05
  to do a
• 24:05
  transarterial
• 24:06
  treatment,
• 24:07
  when
• 24:07
  we look
• 24:08
  at the
• 24:08
  small
• 24:08
  blood
• 24:08
  vessels
• 24:09
  in the liver,
• 24:10
  if we do
• 24:10
  multiple
• 24:11
  of those
• 24:12
  procedures
• 24:12
  where
• 24:12
  we give
• 24:13
  the chemo
• 24:13
  embolization,
• 24:15
  that can
• 24:15
  really
• 24:15
  affect,
• 24:17
  the blood
• 24:17
  vessels
• 24:17
  over time.
• 24:18
  But the
• 24:18
  Immuno
• 24:18
  embolization
• 24:19
  doesn't
• 24:20
  seem to,
• 24:21
  to do that
• 24:21
  sort of
• 24:22
  allows
• 24:22
  us to,
• 24:22
  to kind
• 24:23
  of do
• 24:23
  the
• 24:24
  treatment
• 24:24
  repetitively.
• 24:25
  more so
• 24:25
  the issue
• 24:26
  with
• 24:26
  repeated
• 24:27
  trans
• 24:28
  arterial
• 24:28
  treatments
• 24:28
  is we
• 24:29
  start
• 24:29
  running
• 24:29
  out of
• 24:30
  access
• 24:30
  sites.
• 24:30
  So because
• 24:31
  we can
• 24:31
  only
• 24:31
  use the
• 24:32
  wrist or,
• 24:33
  or the
• 24:34
  arteries
• 24:34
  in the
• 24:34
  groin.
• 24:35
  So,
• 24:35
  there's
• 24:36
  kind of
• 24:36
  we have to
• 24:37
  be
• 24:38
  judicious
• 24:38
  about
• 24:39
  where
• 24:39
  we're
• 24:39
  accessing
• 24:40
  for these
• 24:40
  procedures
• 24:41
  just
• 24:41
  to kind of
• 24:42
  let the,
• 24:42
  the access
• 24:43
  arteries
• 24:43
  heal.
• 24:44
  whenever
• 24:45
  we're
• 24:45
  kind of,
• 24:46
  doing
• 24:47
  consecutive
• 24:47
  treatments
• 24:48
  over, over
• 24:48
  time.
• 24:49
  For any
• 24:49
  last
• 24:50
  questions
• 24:51
  from the
• 24:51
  audience
• 24:52
  before
• 24:52
  we
• 24:53
  wrap this
• 24:53
  session
• 24:53
  up early.
• 24:55
  That's a
• 24:56
  great
• 24:56
  question.
• 24:56
  So just
• 24:57
  to repeat
• 24:57
  that for
• 24:57
  zoom.
• 24:58
  So if we
• 24:58
  treat
• 24:58
  a lesion
• 24:59
  in
• 24:59
  the liver,
• 25:00
  does it
• 25:00
  go away
• 25:00
  on the scans
• 25:01
  or is
• 25:02
  something
• 25:02
  still
• 25:02
  there
• 25:03
  most of
• 25:03
  the time
• 25:04
  we will
• 25:04
  see some
• 25:05
  shrinkage
• 25:05
  or some
• 25:05
  changes,
• 25:06
  but
• 25:06
  there will be
• 25:07
  something
• 25:08
  there.
• 25:08
  I think
• 25:09
  one of
• 25:09
  the things
• 25:09
  we've
• 25:10
  learned
• 25:10
  about
• 25:11
  uveal
• 25:11
  melanoma,
• 25:12
  liver
• 25:12
  metastases
• 25:13
  in
• 25:13
  the past
• 25:13
  couple of years
• 25:14
  is that
• 25:15
  the way
• 25:15
  the liver
• 25:16
  heals,
• 25:16
  the scans
• 25:17
  never
• 25:18
  look like
• 25:19
  it's fully
• 25:20
  gone away.
• 25:20
  But
• 25:21
  if we do
• 25:21
  other
• 25:21
  tests like
• 25:22
  circulating
• 25:22
  tumor DNA,
• 25:23
  which
• 25:23
  we'll talk
• 25:24
  about
• 25:24
  later,
• 25:25
  or these
• 25:25
  other
• 25:25
  tests
• 25:26
  to say,
• 25:26
  is there
• 25:27
  cancer
• 25:27
  still in
• 25:27
  the body,
• 25:28
  we're
• 25:28
  finding
• 25:29
  that
• 25:29
  those may
• 25:29
  be more
• 25:30
  accurate
• 25:30
  for
• 25:30
  determining
• 25:31
  response,
• 25:32
  because
• 25:32
  the liver
• 25:33
  doesn't
• 25:33
  always
• 25:33
  shrink
• 25:34
  as much
• 25:34
  as we
• 25:34
  would
• 25:34
  expect.
• 25:35
  if you
• 25:36
  treat
• 25:36
  something
• 25:36
  in the lung,
• 25:36
  it tends
• 25:37
  to fully
• 25:37
  go away.
• 25:38
  We just don't
• 25:38
  see that
• 25:39
  in the liver.
• 25:40
  So usually
• 25:40
  there
• 25:41
  may be
• 25:41
  some
• 25:41
  shrinkage,
• 25:42
  but
• 25:42
  otherwise
• 25:43
  there's
• 25:43
  normally
• 25:43
  something
• 25:44
  there.
• 25:44
  Either
• 25:44
  it's
• 25:44
  scars,
• 25:45
  it becomes
• 25:46
  hollow and
• 25:46
  cystic.
• 25:47
  It just
• 25:48
  changes
• 25:48
  textures.
• 25:49
  It loses
• 25:49
  enhancement.
• 25:50
  but
• 25:51
  usually
• 25:51
  the scans
• 25:51
  don't
• 25:52
  completely
• 25:52
  go away.
• 25:53
  I
• 25:54
  have a question
• 25:54
  just based
• 25:55
  on.
• 25:55
  I've had
• 25:55
  a few
• 25:56
  patients
• 25:56
  reach
• 25:56
  out to me
• 25:57
  who've had
• 25:57
  recent
• 25:58
  treatment,
• 25:58
  and,
• 25:59
  I've
• 25:59
  actually
• 25:59
  was
• 26:00
  talking
• 26:00
  to Doctor
• 26:01
  Johnny
• 26:01
  John,
• 26:01
  which
• 26:01
  I don't
• 26:02
  see him
• 26:02
  in here,
• 26:03
  so
• 26:03
  we may not
• 26:04
  have him
• 26:04
  to defer
• 26:05
  to.
• 26:05
  but I
• 26:06
  was
• 26:06
  curious.
• 26:07
  procedurally,
• 26:08
  when
• 26:09
  we talk
• 26:09
  about
• 26:09
  immuno
• 26:09
  embolization
• 26:11
  and chemo
• 26:11
  embolization,
• 26:12
  like in
• 26:13
  Philly,
• 26:13
  where
• 26:13
  Doctor
• 26:14
  soto and
• 26:14
  Doctor
• 26:14
  Orloff
• 26:15
  have
• 26:15
  performed
• 26:15
  that with
• 26:16
  doctor
• 26:16
  O'Donnell,
• 26:17
  there's
• 26:17
  this
• 26:17
  period
• 26:17
  of time
• 26:18
  where
• 26:18
  you're
• 26:18
  required
• 26:18
  to lay
• 26:19
  on
• 26:19
  your back.
• 26:20
  is that
• 26:21
  the case
• 26:21
  with
• 26:21
  hepzado
• 26:22
  kit?
• 26:22
  Why or
• 26:22
  why not?
• 26:23
  because
• 26:23
  I've heard
• 26:23
  mixed
• 26:24
  things
• 26:24
  from
• 26:24
  various
• 26:25
  different
• 26:25
  interventional
• 26:25
  radiology
• 26:26
  teams.
• 26:27
  the short
• 26:28
  answer
• 26:28
  is yes,
• 26:29
  there is.
• 26:29
  There
• 26:30
  will be
• 26:30
  a, minimum
• 26:32
  kind of
• 26:32
  three hours
• 26:33
  that
• 26:33
  you'll be
• 26:34
  in bed.
• 26:35
  Okay.
• 26:35
  with,
• 26:35
  with
• 26:36
  the hepzato
• 26:36
  kit.
• 26:37
  And
• 26:37
  the biggest
• 26:37
  thing is
• 26:38
  the
• 26:39
  arterial access.
• 26:40
  So
• 26:40
  any time
• 26:40
  you stick
• 26:41
  to
• 26:41
  the artery,
• 26:42
  we put a little
• 26:43
  sheath in,
• 26:44
  and
• 26:44
  we have
• 26:44
  to be
• 26:44
  very
• 26:44
  careful
• 26:45
  when
• 26:45
  we put
• 26:45
  people on
• 26:46
  bedrest.
• 26:46
  They can't
• 26:46
  bend their
• 26:47
  hip,
• 26:47
  during
• 26:48
  that time,
• 26:48
  just
• 26:48
  because,
• 26:49
  bleeding
• 26:50
  can occur
• 26:50
  and
• 26:51
  you can
• 26:51
  get
• 26:51
  hematomas
• 26:52
  and things
• 26:52
  like that
• 26:52
  at the,
• 26:53
  at the
• 26:53
  access
• 26:53
  site.
• 26:54
  so we're
• 26:54
  all, for
• 26:56
  the
• 26:56
  hepzado,
• 26:56
  it's,
• 26:57
  for access
• 26:58
  point.
• 26:58
  So it's
• 26:59
  both,
• 26:59
  sides of
• 27:00
  the neck,
• 27:00
  both
• 27:01
  groin,
• 27:02
  an
• 27:02
  arterial
• 27:02
  and venous
• 27:03
  in the groin.
• 27:04
  so there
• 27:04
  is,
• 27:05
  minimum
• 27:05
  three
• 27:06
  hour,
• 27:06
  we have
• 27:06
  devices
• 27:07
  we can use
• 27:07
  to plug
• 27:08
  up
• 27:08
  the hole
• 27:08
  in the artery.
• 27:10
  but
• 27:10
  that still
• 27:11
  requires
• 27:11
  three
• 27:12
  hours of
• 27:12
  of of bed
• 27:13
  rest,
• 27:13
  minimum.
• 27:14
  Okay.
• 27:14
  People are
• 27:14
  about six.
• 27:15
  Yeah.
• 27:16
  I was going
• 27:16
  to say
• 27:16
  I'm.
• 27:16
  I'm
• 27:17
  hearing a
• 27:17
  more
• 27:17
  common
• 27:17
  number is
• 27:18
  maybe
• 27:18
  about
• 27:18
  six hours
• 27:19
  of, of
• 27:19
  time.
• 27:20
  And
• 27:20
  is that
• 27:20
  going
• 27:20
  to kind
• 27:21
  of include
• 27:21
  some period
• 27:22
  of I mean,
• 27:22
  I just
• 27:23
  know
• 27:23
  anesthesia.
• 27:24
  Let's
• 27:24
  pretend,
• 27:24
  you're
• 27:24
  under
• 27:24
  anesthesia.
• 27:25
  That time
• 27:26
  counts
• 27:26
  as some of
• 27:27
  the time
• 27:27
  you're
• 27:27
  under
• 27:27
  as long
• 27:28
  as the
• 27:28
  the
• 27:29
  catheters
• 27:29
  have been
• 27:29
  removed.
• 27:31
  That's a
• 27:31
  good
• 27:31
  question.
• 27:32
  So I'm
• 27:32
  counting it
• 27:33
  when
• 27:33
  we get
• 27:33
  all the
• 27:33
  catheters
• 27:34
  out.
• 27:34
  So
• 27:34
  we're all,
• 27:35
  this is
• 27:35
  still
• 27:36
  fairly
• 27:36
  new.
• 27:37
  So, and
• 27:38
  each
• 27:38
  patient
• 27:38
  we're
• 27:38
  finding
• 27:39
  is a
• 27:39
  little bit
• 27:39
  different.
• 27:39
  And what
• 27:40
  they
• 27:40
  require
• 27:41
  from a
• 27:42
  blood
• 27:42
  product
• 27:42
  standpoint
• 27:43
  afterwards,
• 27:43
  whether
• 27:44
  they need
• 27:44
  platelets
• 27:45
  or,
• 27:46
  plasma,
• 27:47
  to take
• 27:48
  correct
• 27:49
  any
• 27:49
  of the coagulopathy
• 27:50
  that
• 27:51
  needs to
• 27:51
  be
• 27:51
  corrected
• 27:52
  before
• 27:52
  we can
• 27:52
  safely
• 27:53
  remove
• 27:54
  all those
• 27:54
  access
• 27:54
  points.
• 27:56
  so I think
• 27:56
  the more
• 27:57
  and more
• 27:57
  we do,
• 27:58
  the more
• 27:58
  we'll see
• 27:58
  and
• 27:59
  the more
• 27:59
  we'll
• 27:59
  be able
• 27:59
  to kind of
• 28:00
  shrink
• 28:00
  that that
• 28:01
  time to
• 28:01
  a time
• 28:02
  frame down
• 28:02
  where
• 28:02
  we can
• 28:03
  start,
• 28:03
  they have
• 28:03
  closure
• 28:04
  devices
• 28:04
  for veins
• 28:05
  that we
• 28:05
  can use,
• 28:06
  to kind of
• 28:07
  minimize
• 28:08
  that time
• 28:08
  where
• 28:09
  people
• 28:09
  are kind
• 28:10
  of stuck
• 28:10
  in bed.
• 28:10
  Yeah.
• 28:11
  And that
• 28:11
  makes
• 28:11
  sense too,
• 28:12
  the
• 28:12
  procedure
• 28:12
  would,
• 28:13
  as you go
• 28:13
  from new
• 28:14
  to doing
• 28:14
  the
• 28:14
  procedure
• 28:15
  to more,
• 28:15
  seasoned,
• 28:16
  I suppose
• 28:16
  that
• 28:16
  you would
• 28:17
  get
• 28:17
  faster,
• 28:17
  you'd get
• 28:17
  a little
• 28:18
  more
• 28:18
  efficient.
• 28:18
  The team
• 28:19
  kind of
• 28:19
  figures
• 28:19
  out
• 28:19
  the best
• 28:20
  ways to
• 28:20
  do
• 28:20
  everything.
• 28:21
  anyway.
• 28:21
  I feel like
• 28:22
  that helps
• 28:22
  answer
• 28:22
  my
• 28:23
  question.
• 28:23
  That
• 28:23
  there is
• 28:23
  some
• 28:24
  level of
• 28:24
  you
• 28:24
  have to
• 28:24
  lay flat,
• 28:25
  even in
• 28:26
  hepzado
• 28:26
  kit
• 28:26
  Any of the
• 28:26
  trans
• 28:27
  arterial
• 28:27
  therapies.
• 28:28
  There will
• 28:28
  be a,
• 28:29
  3 to 6
• 28:30
  hour bed
• 28:30
  rest
• 28:31
  hours,
• 28:31
  unless
• 28:32
  you go
• 28:32
  through
• 28:32
  the rest,
• 28:33
  which
• 28:33
  you can
• 28:33
  do, which
• 28:34
  had.
• 28:34
  But for
• 28:35
  absorber
• 28:35
  you can go
• 28:36
  through
• 28:36
  the rest.
• 28:37
  Thank
• 28:37
  you so
• 28:37
  much,
• 28:38
  Doctor
• 28:38
  Lowe.
• 28:40
  Great.
• 28:40
  So unless
• 28:41
  there's
• 28:41
  any other
• 28:41
  questions,
• 28:42
  we'll wrap
• 28:42
  up
• 28:42
  the session
• 28:43
  a couple
• 28:43
  minutes
• 28:43
  early.
• 28:44
  All right.
• 28:45
  Thank
• 28:45
  you guys.