Latest / The Eye Believe Podcast / Breakthrough Liver Cancer Therapies: Insights from Dr. Padia

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Breakthrough Liver Cancer Therapies: Insights from Dr. Padia · The Eye Believe Podcast

0:00
Hey,
0:00
everybody.
0:00
Welcome
0:00
back.
0:01
today
0:01
I have
0:02
guest
0:02
Doctor
0:03
Padia,
0:03
who is
0:04
here.
0:04
He's an
0:05
interventional
0:05
radiologist
0:06
at UCLA
0:07
from
0:07
California.
0:08
And today
0:09
we're going
0:09
to be
0:09
chatting
0:10
about liver
0:10
directed
0:10
therapies
0:11
for
0:11
metastatic
0:12
disease
0:13
with some
0:13
exciting
0:13
updates
0:14
about
0:14
Hepzato
0:14
kit.
0:15
So
0:15
thanks
0:15
so much for
0:16
joining me
0:16
doctor
0:16
Padia.
0:17
Thanks and
0:18
thanks for
0:18
the
0:18
invitation.
0:19
glad
0:19
to, talk
0:20
about this
0:20
super
0:21
exciting
0:21
topic.
0:22
it's super
0:22
exciting
0:23
and it's
0:23
such an
0:24
important
0:24
thing
0:24
for us
0:25
as patients
0:25
If you're
0:26
dealing
0:26
with
0:26
metastatic
0:27
disease,
0:27
if you're
0:27
potentially
0:28
going to
0:28
be dealing
0:29
with it
0:29
in the future
0:30
or you're
0:30
worried
0:30
about that,
0:31
it can help
0:31
a lot
0:32
to get
0:32
this
0:32
information
0:33
and to
0:33
just have
0:33
a better
0:34
understanding
0:34
of what's
0:35
out there
0:35
so that
0:36
when or
0:36
if the
0:37
need
0:37
arises,
0:37
you're not
0:38
just trying
0:39
to scramble
0:40
for
0:40
information,
0:40
you now
0:41
have a
0:41
knowledge
0:42
base,
0:42
you know,
0:43
kind of
0:43
where to go
0:43
and
0:44
you know
0:44
what to do.
0:44
So,
0:45
Doctor
0:45
Padia,
0:45
can you
0:46
just help
0:46
me, define
0:47
Hepzato
0:47
kit,
0:47
what is it
0:48
and
0:48
how does
0:49
it work?
0:49
So great
0:50
question.
0:51
step back
0:51
one
0:52
step back.
0:52
I'm an
0:52
inventor
0:53
for
0:53
radiologists.
0:53
And what
0:54
we do,
0:54
what most
0:55
interventional
0:56
radiologists
0:56
do is
0:57
we use
0:57
imaging
0:58
guidance
0:59
to do
1:00
minimally
1:00
invasive
1:00
procedures.
1:01
And that's
1:01
most often
1:03
things
1:03
in the
1:03
blood
1:03
vessels
1:04
in your
1:04
arteries
1:04
and veins.
1:05
the
1:05
Hepzato kit
1:07
or the
1:07
Hepzato
1:07
procedure,
1:08
is
1:09
a procedure
1:09
that
1:09
is done
1:10
through the
1:10
arteries
1:11
and veins.
1:12
Specific
1:13
in your liver.
1:14
And this
1:16
device
1:16
and
1:16
procedure
1:17
is designed
1:17
for people
1:19
who have
1:19
uveal
1:20
melanoma,
1:20
where
1:21
the uveal
1:22
melanoma
1:22
has
1:22
metastasized
1:23
to their
1:24
liver
1:24
just to
1:25
the procedure
1:25
itself,
1:26
has become
1:27
commercially
1:27
available
1:28
in the
1:28
United
1:28
States
1:29
in 2024.
1:31
It was FDA
1:32
approved
1:33
in 2023.
1:35
and the
1:35
reason
1:36
it was
1:36
FDA
1:36
approved
1:37
was
1:37
there was
1:37
a clinical
1:38
trial done,
1:39
in multiple
1:40
centers,
1:40
both in the
1:40
United
1:41
States
1:41
and in
1:41
Europe,
1:42
where
1:43
they did
1:43
this
1:44
procedure
1:44
and
1:44
they compared
1:45
it to
1:46
what is
1:47
considered
1:47
the best
1:48
available
1:48
care in
1:48
so in
1:49
every
1:49
institution.
1:50
That might
1:50
be
1:50
different.
1:51
It might be
1:51
immunotherapy,
1:52
it might be
1:52
chemotherapy,
1:53
it might be
1:53
something
1:54
else.
1:55
And so
1:55
they compared it
1:56
to that.
1:57
And
1:57
they found
1:58
a
1:58
significantly
1:59
higher,
2:00
outcome.
2:01
And
2:01
that's in
2:01
two
2:02
respects.
2:02
Number one,
2:03
it shrunk
2:04
tumors
2:05
to a much
2:05
higher
2:06
degree,
2:06
compared to
2:07
the
2:07
patients
2:08
who
2:08
received,
2:09
let's say,
2:09
standard
2:09
immunotherapy.
2:11
And number
2:11
two, it
2:12
prolongs
2:12
survival,
2:13
which is,
2:13
I think
2:14
probably
2:15
the most
2:15
important
2:15
thing.
2:16
and number
2:16
three,
2:17
which
2:17
I think is
2:17
equally
2:18
as
2:18
important,
2:18
is it
2:19
preserve
2:19
people's
2:19
quality
2:20
of life.
2:20
So in other
2:21
words,
2:21
the side
2:22
effects
2:22
and the
2:22
complication
2:23
rate was
2:24
pretty
2:24
minimal
2:24
and
2:25
manageable,
2:26
where,
2:26
most people
2:27
can kind of
2:28
go on their
2:29
daily
2:29
lives.
2:30
And that's
2:30
what
2:30
we've
2:30
seen in
2:30
our
2:31
experience.
2:32
So what
2:33
is the
2:33
Hepzato KIt
2:34
it is
2:34
a, it's
2:35
a device.
2:36
It's using
2:36
a
2:36
procedure.
2:37
The procedure
2:38
is done
2:38
in the
2:38
hospital.
2:40
Currently,
2:40
there are
2:40
about 7
2:42
to 10
2:43
centers
2:44
in the
2:44
United States.
2:45
And I think
2:45
that number
2:46
is probably
2:46
growing
2:47
over
2:47
the next
2:48
several
2:48
months
2:49
as certain
2:50
centers,
2:51
kind of
2:51
come
2:52
online.
2:52
so few
2:53
centers
2:53
currently
2:53
doing this,
2:54
as you
2:54
can
2:55
imagine,
2:55
we tend
2:55
to get
2:56
a lot
2:56
of people
2:56
coming in
2:57
from
2:58
outside of
2:58
the Los
2:59
Angeles
2:59
area.
2:59
In fact,
3:00
I would say
3:00
half
3:00
the patients
3:01
that I've
3:01
treated
3:01
have been
3:02
from
3:02
outside of
3:03
Los Angeles
3:04
County.
3:05
the procedure
3:05
is done
3:05
in the
3:06
hospital.
3:06
It's done
3:07
under
3:07
anesthesia.
3:08
So we,
3:08
have an
3:08
anesthesiologist
3:10
who, puts
3:10
you to
3:11
sleep
3:11
just like
3:11
any other
3:12
surgery.
3:13
And
3:13
then what
3:14
we do is
3:14
we isolate
3:15
the liver
3:16
via
3:16
the blood
3:16
vessels.
3:17
That's done
3:18
two ways.
3:19
So the way
3:21
blood flow
3:21
works
3:22
in the
3:23
liver and
3:23
in,
3:24
let's say,
3:24
every organ,
3:25
you have
3:25
an artery
3:26
that takes
3:27
blood
3:28
from the
3:28
heart
3:29
to the liver,
3:31
and you
3:31
have a vein
3:32
that takes
3:32
blood
3:33
from the
3:34
liver
3:34
back to
3:35
the heart.
3:35
Okay.
3:35
So
3:36
and that
3:36
that
3:37
concept
3:37
works
3:37
for every
3:38
single
3:38
organ.
3:38
So if we're
3:39
in
3:39
the brain,
3:39
you have an artery
3:40
that goes
3:40
to
3:40
the brain,
3:41
from the heart.
3:42
And
3:42
then you
3:42
have a vein
3:43
that goes
3:43
from the,
3:44
from the
3:45
brain
3:45
back
3:45
to the heart.
3:46
So that's
3:46
how we do
3:46
our
3:46
circulation.
3:48
Your your
3:48
liver,
3:49
your,
3:49
brain,
3:49
your toes,
3:50
your
3:50
fingers,
3:51
etc..
3:52
The goal
3:53
is to
3:53
isolate
3:54
them.
3:54
What's
3:54
that?
3:55
I just said
3:56
all the
3:56
parts.
3:57
All the
3:57
parts.
3:57
So,
3:58
arteries
3:58
carry blood
3:59
from
3:59
the heart.
3:59
Veins carry
4:00
blood
4:01
back
4:01
to the heart.
4:01
And so
4:02
the goal
4:02
when we do
4:03
this
4:03
procedure,
4:04
which is,
4:04
known
4:05
as
4:05
percutaneous
4:06
hepatic
4:07
perfusion
4:07
with
4:07
melphaian
4:08
also known
4:08
as hepzato
4:09
kit
4:10
is to
4:10
isolate
4:11
both
4:12
the artery
4:12
and the
4:13
vein
4:13
in the liver.
4:14
And so
4:14
where
4:14
we're
4:15
giving
4:15
very high
4:16
doses
4:17
of
4:17
chemotherapy
4:18
the name of
4:19
the
4:19
chemotherapy
4:20
is
4:20
Melphalan
4:21
It's
4:21
actually
4:22
a quite
4:22
an old
4:23
chemotherapy.
4:24
but
4:25
the challenge
4:25
is that
4:26
when we
4:26
give this
4:27
chemotherapy,
4:28
let's say
4:28
through
4:28
an IV
4:29
in your
4:29
hand,
4:30
it goes
4:30
whole body.
4:31
And there's
4:32
only so
4:33
much of
4:33
a dose
4:33
that
4:34
your whole
4:34
body can
4:34
tolerate.
4:36
That
4:36
dose of
4:37
that
4:37
chemotherapy
4:38
is not
4:39
effective
4:40
for
4:40
your liver.
4:41
And so by
4:42
isolating
4:42
the liver
4:43
and
4:43
delivering
4:43
it directly
4:45
into
4:45
the artery
4:46
that
4:46
goes into
4:46
your liver,
4:48
and then
4:49
sucking the
4:50
chemo out
4:51
via
4:52
the vein
4:53
so it does
4:53
not
4:54
circulate
4:55
throughout
4:55
your whole
4:56
entire
4:56
body.
4:56
We can give
4:57
much higher
4:57
5 to 10
4:58
times
4:59
the dose,
5:00
because
5:00
almost
5:01
all of it
5:02
stays
5:02
within
5:02
the liver
5:03
or is
5:03
trapped
5:03
outside
5:04
of it.
5:05
Very little
5:05
of it
5:06
circulates
5:06
throughout
5:07
the rest
5:07
of the body.
5:08
So how does
5:09
this.
5:09
Let's take
5:10
one more
5:10
step
5:10
backwards.
5:11
How does this
5:11
work?
5:11
Okay,
5:12
so
5:12
you're put
5:13
under
5:13
anesthesia
5:13
in the
5:14
hospital.
5:14
And our
5:14
interventional
5:15
radiology
5:16
suite.
5:17
All of this
5:17
is done
5:18
through
5:18
tiny little
5:18
skin.
5:19
So
5:19
at the end
5:20
you just have
5:20
bandage.
5:21
There's no
5:21
big
5:21
stitches or
5:23
sutures
5:23
or anything
5:24
like that.
5:25
we have one
5:26
tiny little
5:26
catheter.
5:27
It's
5:27
the width
5:28
of, maybe
5:29
like the
5:29
tip of
5:29
a pen.
5:30
It goes
5:31
in the
5:31
upper, left
5:32
thigh.
5:34
That
5:34
catheter
5:34
goes
5:34
through
5:35
the
5:35
arteries
5:36
all the way
5:36
into the
5:37
artery
5:37
going into
5:38
your liver.
5:38
That is
5:39
called the
5:39
hepatic
5:40
artery.
5:41
We
5:41
then have
5:42
another
5:42
catheter
5:43
in the
5:43
right side.
5:44
In the
5:44
right vein,
5:46
in
5:46
your upper
5:46
thigh.
5:47
That goes
5:48
straight up
5:49
into
5:50
what's
5:50
called
5:50
the inferior
5:51
vena cava,
5:52
which
5:52
is the
5:52
blood
5:53
vessel
5:53
that drains
5:53
the veins
5:55
from the liver.
5:56
So now
5:57
we have
5:57
a catheter
5:57
in the
5:58
veins
5:58
from
5:58
the liver.
5:59
We have
5:59
catheter
5:59
the arteries
6:00
going to
6:00
the liver,
6:01
and
6:01
we infuse
6:03
the
6:04
melphalan
6:05
or the
6:05
chemotherapy
6:06
through the
6:07
catheter
6:07
in the
6:08
liver
6:09
artery
6:09
or the
6:09
hepatic
6:10
artery.
6:11
At the same
6:12
time,
6:13
we remove
6:14
the blood
6:15
from
6:16
the vein
6:16
of
6:17
the liver.
6:17
So
6:17
what it does
6:18
is it
6:18
washes
6:19
through
6:19
the liver,
6:20
similar to
6:21
if you
6:21
were
6:21
putting
6:21
like a
6:22
sponge
6:22
under
6:22
your
6:23
kitchen
6:23
sink
6:23
running
6:24
the faucet,
6:25
the water
6:26
will
6:26
come
6:26
down into
6:26
the sponge
6:27
and then
6:27
it'll
6:27
kind of
6:28
come out
6:28
at the
6:28
bottom of
6:29
the sponge
6:29
as it
6:29
percolates
6:30
through
6:30
the sponge.
6:31
The chemo
6:32
does
6:33
the same thing,
6:34
but instead
6:35
of leaving
6:35
and going,
6:36
returning
6:36
back
6:36
into the heart,
6:37
we suck it
6:38
out.
6:39
Through
6:39
that
6:39
catheter.
6:40
We put it
6:41
through a
6:41
filtration
6:42
circuit
6:43
to extract
6:44
all the chemo,
6:46
and we
6:46
return
6:47
the blood
6:47
back into
6:48
another
6:48
catheter,
6:49
into the patient.
6:50
So it's
6:50
essentially
6:51
a closed
6:52
circuit
6:52
where we
6:53
filter out
6:53
all
6:54
the chemo.
6:55
The
6:55
procedure
6:56
itself
6:56
takes
6:57
about two
6:58
and a half
6:58
to four
6:59
hours.
6:59
It's done
7:00
under
7:00
anesthesia
7:00
so
7:01
you don't
7:01
really feel
7:01
any pain.
7:02
And
7:02
at the end
7:03
we remove
7:03
all these
7:04
catheters
7:04
and we
7:04
put, you
7:05
know, 3
7:05
or 4
7:05
Band-Aids
7:06
on
7:07
the
7:07
recovery
7:07
is,
7:08
you know,
7:08
you recover
7:08
from
7:08
anesthesia.
7:09
And
7:10
in our practice,
7:10
we've been
7:11
sending
7:11
patients
7:11
home either
7:12
at the end
7:12
of the day
7:13
or the
7:14
next morning,
7:15
and
7:16
it takes
7:16
about 3
7:18
to 4 days
7:18
for you
7:19
to really,
7:19
there's 3
7:20
or 4 days
7:20
where
7:20
you're
7:20
feeling
7:20
a
7:21
little bit
7:21
of fatigue.
7:22
But most of
7:23
the patients
7:23
we've
7:23
treated
7:23
have gone
7:24
back
7:24
to work
7:25
either
7:25
by
7:25
the end of
7:25
the week or
7:26
early
7:26
next week.
7:28
this sounds
7:29
awesome.
7:29
I don't
7:30
know about
7:30
you guys,
7:30
I know that
7:31
the more
7:31
that I
7:31
understand
7:32
about this
7:32
procedure,
7:33
the more excited
7:33
I am.
7:34
But it's
7:34
available
7:34
and that
7:34
it's,
7:35
you know,
7:35
like you
7:35
said, it's
7:35
FDA
7:36
approved
7:36
here
7:36
in the United States.
7:38
And I think
7:38
we'll we'll
7:39
probably
7:39
allude
7:39
to this
7:40
a
7:40
little bit later,
7:40
but it's
7:41
also
7:41
approved
7:42
for use
7:43
in Europe.
7:43
It's been
7:44
approved
7:45
for several
7:46
countries
7:47
in Europe,
7:47
including
7:47
the United
7:48
Kingdom,
7:48
Germany,
7:49
Netherlands,
7:50
those are
7:50
probably
7:50
the three
7:50
main
7:51
countries.
7:51
And they've
7:52
been
7:52
doing it
7:52
for
7:52
some time
7:53
now.
7:53
There are
7:54
centers
7:54
in Europe
7:55
that have
7:55
done,
7:56
in fact,
7:56
a probably
7:57
a few
7:57
hundred
7:58
by now.
7:58
and
7:58
it is nice
7:59
that it is
7:59
FDA
8:00
approved,
8:00
in the
8:00
United States
8:01
because of
8:01
the data.
8:02
That also
8:02
means
8:03
that
8:03
insurance
8:03
carriers
8:04
routinely
8:05
cover this.
8:05
Now,
8:05
even though
8:06
it is new.
8:07
it was a little bit,
8:09
I would say
8:09
rocking
8:10
the start
8:10
because
8:10
they never
8:10
even
8:11
heard of this.
8:12
but now
8:12
I would
8:12
say that
8:12
most
8:13
insurance
8:13
carriers
8:14
have,
8:14
if not
8:14
all of them
8:15
have
8:15
put this
8:16
into their
8:16
policies.
8:17
It is designed
8:18
for people
8:18
with liver
8:19
metastases.
8:20
So
8:20
it's not,
8:20
you know,
8:21
if you have
8:21
you'll be
8:22
able
8:22
melanoma
8:22
and it's
8:23
spread
8:24
all over
8:25
and
8:25
in the lungs
8:26
or in
8:26
the lymph
8:26
nodes.
8:27
It's not
8:27
going to do
8:27
that.
8:27
It's not
8:28
going
8:28
to really
8:29
be
8:29
effective
8:29
for that.
8:30
So
8:30
the key thing
8:30
to keep
8:31
in mind
8:31
is
8:31
that it's
8:31
really
8:32
addressing,
8:32
people
8:33
where
8:34
either all
8:35
or at least
8:36
most of
8:37
your tumors
8:37
have
8:38
metastasized
8:38
to the
8:39
liver.
8:40
just for
8:41
any of
8:41
us who are
8:41
visual
8:42
learners,
8:42
do you have
8:43
maybe
8:43
a video
8:44
or a short,
8:45
kind of
8:45
a picture
8:45
that we
8:45
can show
8:46
this closed
8:47
circuit?
8:47
Because
8:47
I think
8:48
that that's
8:48
one of the
8:48
most unique
8:49
things.
8:50
Is this,
8:50
I think
8:50
I've heard
8:51
it compared
8:51
to almost
8:52
like
8:52
putting the
8:52
liver on
8:53
bypass.
8:54
I think
8:54
that's a
8:54
maybe a
8:55
good way
8:56
to
8:56
describe
8:56
it.
8:56
Do you.
8:58
That's
8:58
absolutely
8:59
right.
8:59
And I'm
8:59
going
8:59
to try
9:00
to share
9:00
my other
9:00
screen
9:01
here.
9:08
Awesome.
9:08
All right.
9:09
So
9:10
let's talk
9:11
through
9:11
kind of
9:11
the visual.
9:12
And
9:12
what are we
9:12
what are
9:13
some of
9:13
these
9:13
kind of
9:13
images mean
9:14
in real
9:14
time in
9:14
real life.
9:15
Because
9:15
this looks
9:15
like an
9:16
actual
9:16
image of
9:16
the liver
9:17
or the
9:17
veins.
9:18
So the
9:19
so
9:19
these are
9:19
x rays
9:20
and it's
9:21
actually
9:21
almost
9:21
the same
9:22
x ray.
9:22
One is just
9:23
what's
9:23
called
9:23
digitally
9:24
subtracted.
9:25
So that one
9:25
on the left
9:26
where it's
9:26
almost
9:26
all white,
9:27
which is
9:27
some black
9:28
in
9:28
the middle
9:28
that's
9:28
digitally
9:29
subtracted.
9:29
So let's
9:29
go on the
9:30
on the
9:31
right side
9:31
of the image
9:31
you see
9:32
these two
9:32
circles,
9:33
right.
9:33
And it's
9:34
connected
9:34
with this
9:34
big thick
9:35
line.
9:35
So that's
9:36
the catheter
9:37
that
9:37
catheters
9:38
inserted in
9:38
the upper
9:39
right
9:40
thigh.
9:40
And
9:40
your vein.
9:41
And it goes
9:42
all the way
9:42
up into
9:42
a blood
9:43
vessel
9:43
called
9:43
the IVC.
9:45
We inflate
9:46
these two
9:47
balloons.
9:47
Would you
9:48
see these,
9:48
this big
9:48
circle
9:49
on the top
9:49
of
9:49
the image
9:50
and this
9:50
oval on
9:51
the bottom
9:51
of the image.
9:52
And so what
9:53
that does
9:54
is when
9:55
we inflate
9:56
those two
9:56
balloons,
9:57
it isolates
9:59
that
10:00
segment of
10:01
the vein
10:02
that's in
10:02
between
10:02
those two
10:03
balloons.
10:04
That
10:04
segment of
10:05
the vein is
10:05
what drains
10:06
the veins
10:07
in the liver.
10:07
So
10:07
the veins
10:08
in the liver
10:08
which is
10:09
on the left
10:10
side of
10:11
the image
10:12
and the
10:12
right side
10:12
of your body,
10:13
because
10:13
we look
10:13
at
10:13
everything
10:14
in kind of
10:14
in portrait
10:14
mode,
10:15
drains into
10:17
the region
10:18
that is
10:18
isolated
10:19
between the
10:19
two
10:19
balloons.
10:20
Now,
10:20
if you
10:21
look,
10:21
at that
10:21
bottom
10:22
balloon,
10:23
there's
10:23
this
10:23
horizontal
10:25
wavy line.
10:27
It's like a
10:27
and that's
10:28
the
10:28
catheter
10:29
or it's
10:30
another
10:30
catheter.
10:31
That
10:31
catheter is
10:32
the width
10:33
of the
10:34
tip of
10:35
a pen.
10:36
that
10:36
catheter
10:37
comes from
10:37
the left
10:39
leg.
10:39
So comes
10:40
all the way
10:40
from the
10:41
bottom of
10:41
the image.
10:42
And then
10:43
kind of
10:43
courses
10:44
to the
10:44
right upper
10:45
quadrant of
10:46
the patient,
10:47
in this
10:47
case
10:47
the left
10:48
side
10:48
of the image.
10:49
And that is
10:49
in the
10:50
hepatic
10:50
artery.
10:51
So where
10:52
your mouse
10:52
cursor is,
10:53
that's what
10:53
the tip of
10:54
the
10:54
catheter.
10:55
And that
10:56
at the back
10:57
end outside
10:58
the patient
10:58
is
10:58
connected
10:59
to the
10:59
chemo.
11:00
It's
11:00
infused
11:02
into
11:02
the liver.
11:03
And it is
11:04
then
11:05
withdrawn
11:07
through the
11:07
two
11:08
balloons.
11:08
So on
11:09
the left
11:10
image where
11:11
you see
11:11
that
11:11
black
11:12
stuff,
11:12
that's us
11:13
injecting
11:13
contrast
11:14
dye.
11:16
So that
11:16
thick
11:17
column
11:18
of black,
11:19
that is the IVC.
11:20
And then
11:21
those,
11:21
streaks
11:22
going to
11:22
the left
11:22
side of
11:23
the image.
11:23
Those are
11:24
the veins
11:25
from
11:25
the liver.
11:25
So
11:26
you can see
11:26
everything
11:26
is
11:26
isolated.
11:27
So it's
11:27
basically
11:28
withdrawing
11:29
all that
11:30
contrast
11:30
which is
11:30
blood,
11:31
outside of
11:32
the body
11:33
filters
11:34
the chemo out
11:35
and then
11:35
re infuses
11:36
it, into
11:37
a different
11:38
catheter
11:38
in the into
11:39
the veins.
11:40
So that's
11:41
the
11:41
summary.
11:42
of what
11:42
we're
11:42
doing here.
11:44
Now, this
11:44
is that.
11:46
Remember
11:46
that wavy
11:47
catheter
11:47
we had
11:48
in the
11:48
hepatic
11:49
artery.
11:49
So this
11:49
is just an
11:50
isolated
11:51
picture
11:51
of that.
11:53
The black
11:53
stuff is
11:54
contrast
11:54
dye.
11:54
So
11:55
what we do
11:55
is before
11:56
we infuse
11:56
the chemo
11:57
we inject
11:58
contrast
11:59
dye.
12:00
And that
12:00
lights up
12:01
as black.
12:02
And
12:02
what happens
12:03
is we
12:03
digitally
12:04
subtract
12:05
out
12:05
the background,
12:05
which is
12:06
why
12:06
everything
12:06
looks,
12:07
faded out
12:07
or white
12:08
and all
12:09
these
12:09
squiggly
12:10
black
12:10
lines,
12:11
those are
12:11
the
12:11
arteries
12:12
in your liver.
12:12
And in this
12:13
case,
12:13
it is
12:14
the right
12:14
hepatic
12:14
lobe,
12:14
the right
12:15
side
12:15
of the liver.
12:16
And
12:16
those big
12:17
blotchy
12:18
gray
12:18
things,
12:19
those are
12:19
tumors in
12:20
the liver.
12:21
Okay.
12:21
So what
12:21
we're going
12:21
to do
12:22
is we
12:22
inject
12:22
the
12:22
contrast.
12:23
I make sure
12:24
we're in
12:25
a good spot.
12:26
And in this
12:26
case,
12:26
the right
12:27
side
12:27
of the liver.
12:28
And then
12:28
we, switch
12:29
the contrast
12:29
dye for
12:30
the chemo.
12:31
The chemo
12:31
you can't
12:32
see
12:32
on the screen.
12:33
and
12:33
then the
12:33
chemo
12:33
infuses
12:34
into these
12:35
black
12:35
lines,
12:36
these
12:36
arteries
12:37
into the
12:37
tumors
12:37
themselves.
12:38
And again,
12:39
this is
12:39
when we're
12:40
doing this.
12:40
The
12:40
balloons
12:41
are
12:41
inflated
12:42
in the vein
12:43
withdrawing
12:44
the
12:44
blood
12:44
at the
12:44
same time.
12:46
It's so
12:47
incredible
12:48
what
12:48
medicine
12:49
can do
12:49
and how
12:50
like how
12:50
advanced
12:51
this is.
12:52
Not
12:52
only that,
12:53
if
12:53
you think
12:53
about like
12:54
the
12:54
resolution,
12:55
this is
12:55
obviously
12:56
magnified
12:57
up.
12:57
this catheter
12:58
is about, 3
13:00
or 4
13:00
thousandths
13:01
of an
13:01
inch
13:02
in diameter
13:03
so that
13:03
that artery
13:04
is super
13:05
small.
13:05
It's, it's
13:06
like an
13:06
eighth
13:06
of an
13:07
inch
13:07
in width.
13:09
and so
13:09
those
13:09
distal
13:10
arteries,
13:10
the ones
13:11
downstream,
13:11
they're
13:12
basically
13:12
the size
13:13
of,
13:13
you know,
13:14
the human
13:14
hair.
13:15
That's
13:15
incredible.
13:16
so
13:16
we have covered
13:18
a lot
13:18
of really
13:19
neat stuff.
13:19
Is there
13:20
anything
13:20
that,
13:20
you know,
13:21
for anyone
13:21
who does
13:22
have liver
13:22
metastases
13:23
just as
13:23
far as kind
13:24
of
13:24
qualifications,
13:25
like for a
13:25
good
13:26
candidate
13:26
for hepzato
13:27
kit,
13:28
what are some
13:28
of the
13:28
kind of the
13:28
baseline
13:29
markers
13:29
aside
13:30
from
13:30
obviously
13:31
liver Mets,
13:31
that
13:31
you guys
13:32
are looking
13:32
for as
13:33
far as
13:33
a patient
13:34
health
13:34
and all of
13:34
that? Yeah.
13:35
So that's a
13:36
great question.
13:36
So of
13:37
course
13:37
you have
13:37
to have
13:38
liver
13:38
metastases
13:39
ideally
13:41
really
13:41
no
13:41
significant,
13:42
tumors
13:43
outside
13:43
the liver,
13:44
although
13:44
we have
13:44
treated
13:45
patients
13:46
who have
13:46
predominantly
13:47
the
13:47
metastases
13:48
because
13:48
it is
13:49
widely
13:49
believed
13:50
amongst
13:51
most
13:51
medical
13:51
oncologist
13:52
that once
13:53
you develop
13:53
liver
13:54
metastases,
13:55
that is
13:55
the
13:55
bleeding
13:56
edge of
13:57
the problem.
13:57
Even if you
13:58
have,
13:58
let's say
13:59
lung
13:59
metastases
14:00
and or
14:00
lymph
14:00
nodes,
14:01
there are
14:02
several
14:02
other
14:03
different
14:03
types
14:04
of liver
14:04
directed
14:05
therapies
14:05
that we can
14:06
perform in
14:06
the liver.
14:08
And
14:09
all of them
14:09
have their
14:10
advantages
14:11
and
14:11
disadvantages.
14:12
So when
14:12
I see
14:13
a patient
14:13
in
14:13
consultation,
14:15
let's say
14:15
for this,
14:16
I
14:16
look at them,
14:17
look
14:18
at what
14:18
they want
14:19
or what
14:19
what
14:20
they have
14:20
in mind.
14:21
I
14:21
look at their
14:22
liver, on
14:22
their
14:22
imaging,
14:23
typically
14:23
an MRI
14:25
to figure
14:25
out how
14:26
many tumors
14:26
they have,
14:27
where
14:27
the
14:27
distribution
14:28
of the
14:28
tumors are.
14:28
And then I
14:29
kind of
14:30
make
14:30
recommendations
14:31
as to,
14:31
okay,
14:31
you have
14:32
option A,
14:32
B, and C in
14:33
terms of,
14:34
your
14:34
treatment
14:34
options
14:34
for
14:35
your liver.
14:35
These are
14:36
the pros
14:36
and cons of
14:36
each.
14:37
So for
14:38
example,
14:39
most people
14:40
for hepzato
14:40
this is
14:41
meant as a
14:41
whole liver
14:42
treatment
14:42
okay.
14:42
So we don't
14:43
normally
14:43
just treat
14:44
one side
14:45
of a liver.
14:46
So most
14:47
people
14:47
should have
14:48
multiple
14:49
hepatic
14:50
metastases.
14:51
And in both
14:52
sides of
14:52
the liver
14:52
let's say
14:53
left and
14:53
right.
14:55
in
14:55
contrast,
14:56
if you had
14:56
let's say
14:56
one tumor
14:58
just on
14:59
the left
14:59
side,
15:00
I would
15:01
recommend
15:01
some other
15:02
procedure,
15:03
for
15:03
example, a
15:04
ablation
15:05
procedure
15:05
or a y90
15:07
radioembolization
15:07
procedure.
15:08
Those
15:09
are really
15:10
more
15:10
designed
15:10
for focal
15:11
treatments
15:12
within
15:12
the liver.
15:13
The great
15:14
thing about
15:14
Hepzato
15:15
is that
15:15
it is
15:16
designed
15:16
for a whole
15:17
liver
15:17
treatment.
15:18
Additionally,
15:19
there are,
15:20
certain
15:20
other
15:20
qualifications
15:21
that one
15:21
must have
15:22
since you
15:22
are
15:22
undergoing
15:23
general
15:23
anesthesia.
15:24
We want to
15:25
make sure
15:25
that people
15:26
can
15:26
tolerate
15:27
that.
15:27
And so what
15:28
are the
15:28
main risk
15:29
factors
15:29
for general
15:29
anesthesia?
15:30
Anyone
15:30
who's had
15:30
a heart
15:31
attack,
15:32
coronary
15:32
artery
15:33
disease,
15:34
congestive
15:34
heart
15:35
failure,
15:35
those people
15:36
wouldn't be
15:36
at
15:36
relatively
15:37
high risk
15:38
for general
15:39
anesthesia
15:39
and would
15:40
probably
15:40
not be
15:41
candidates.
15:42
Additionally,
15:42
since
15:42
you are
15:43
put to
15:43
sleep
15:43
with
15:43
anesthesia,
15:44
we want to
15:44
make sure
15:44
people
15:45
don't have
15:45
any
15:46
breathing
15:46
or lung
15:47
problems.
15:48
The
15:48
most common
15:48
things are
15:49
like
15:49
emphysema
15:50
or COPD.
15:51
and also
15:53
since
15:53
we are
15:53
putting
15:53
people
15:54
on blood
15:54
thinners
15:55
simply
15:56
during
15:57
the
15:57
procedure,
15:57
not afterwards
15:58
or
15:58
beforehand,
15:59
we want to
16:00
make sure
16:00
that they
16:00
can
16:00
tolerate
16:01
blood
16:01
thinners.
16:01
So,
16:02
for
16:02
example,
16:03
people
16:03
who have
16:03
had prior
16:04
bleeding
16:04
episodes
16:05
when may
16:06
not be
16:06
a candidate
16:07
or people
16:07
who have
16:08
metastases
16:09
in their
16:09
brain
16:10
may not be
16:10
a candidate.
16:11
So
16:12
we have basically
16:13
what we do
16:13
is when
16:14
we see
16:14
someone
16:14
in
16:14
consultation,
16:15
we have a checklist
16:16
and
16:16
we kind of
16:17
go through
16:17
the
16:17
checklist,
16:18
to make
16:19
sure
16:19
that they
16:19
are
16:20
candidates.
16:20
I would say
16:21
at least
16:22
in our
16:23
practice,
16:23
there's
16:24
a good
16:24
proportion
16:25
of patients
16:25
that are
16:25
candidates
16:26
for the
16:26
hepzado
16:27
procedure.
16:27
and there's
16:27
also a
16:28
lot of
16:28
patients
16:28
who are
16:29
better
16:30
candidates
16:30
for an
16:31
ablation
16:31
procedure
16:32
or a y90
16:33
radioembolization
16:34
procedure,
16:34
as well.
16:39
Okay.
16:39
So let's
16:40
kind of
16:41
do a
16:42
little
16:42
bit of
16:42
a, I guess
16:43
our role
16:43
play here.
16:44
So
16:44
you're an
16:45
interventional
16:45
radiologist
16:46
I'm
16:46
a metastatic
16:47
patient
16:47
who.
16:48
Well,
16:48
let's
16:48
just
16:48
pretend
16:49
I've just
16:49
learned
16:49
that
16:50
I've got
16:50
liver Mets
16:51
and I
16:52
unfortunately,
16:53
and I'm
16:54
going
16:54
to just
16:54
kind
16:54
of pull
16:54
from some
16:55
prior
16:55
experience
16:56
because
16:56
I've
16:56
actually
16:56
talked
16:56
to quite
16:57
a few of
16:57
you guys
16:58
in,
16:59
the omie
16:59
community
16:59
this week
17:00
alone.
17:00
And it's
17:01
been
17:01
kind of
17:02
incredible
17:02
to me.
17:02
and it's
17:03
I think
17:03
it's just
17:04
one of
17:04
those,
17:04
you know,
17:04
the more
17:04
things
17:05
you're
17:05
aware of,
17:07
or the,
17:07
you know,
17:08
when you
17:08
say you
17:08
want to buy
17:09
a blue car
17:09
and then
17:10
suddenly
17:10
you're
17:10
seeing
17:10
blue cars
17:11
everywhere.
17:11
Well, I'm
17:12
a young
17:12
patient
17:13
with
17:13
metastatic
17:14
disease.
17:14
And so I'm
17:15
constantly
17:16
aware of
17:16
the younger
17:17
patients
17:17
like me
17:18
who are
17:18
also being
17:19
diagnosed.
17:19
Not to say
17:20
that we are
17:20
the largest
17:21
percentage
17:21
of the
17:22
metastatic
17:22
community,
17:23
but
17:23
it feels
17:24
that way
17:24
sometimes
17:24
when I
17:25
have, you
17:25
know, 6
17:25
or 7
17:26
patients
17:26
who
17:26
message me
17:27
in a week.
17:27
so let's
17:28
just
17:28
pretend
17:28
I just got
17:29
MRI results
17:30
on Friday
17:30
and I'm
17:31
consulting
17:31
you
17:31
because
17:32
I've got
17:32
like, one
17:33
tumor up
17:34
here in
17:34
my liver
17:34
and one
17:35
kind of
17:35
down here
17:36
and, and
17:37
the
17:37
imaging
17:37
and, you
17:38
know,
17:38
all of the
17:38
things are
17:38
pointing to
17:39
I need
17:39
liver
17:40
directed
17:40
therapy.
17:41
And
17:41
I've heard
17:42
about
17:42
hepzato kit
17:43
can you
17:43
tell me why
17:43
or why not?
17:44
Would
17:44
hepzato kit
17:45
be a good
17:45
option
17:46
for me.
17:46
Okay.
17:47
Great
17:47
question.
17:48
So
17:48
let's say
17:49
you have
17:49
that
17:49
scenario
17:50
where
17:50
you have
17:50
two small
17:50
tumors,
17:51
one up
17:51
here, one
17:52
down there.
17:52
and it's
17:53
decided
17:53
that,
17:54
you know,
17:54
you want
17:54
to pursue
17:55
liver
17:55
directed
17:55
therapy.
17:55
And
17:55
the first thing
17:56
we do is,
17:57
you know,
17:57
we always
17:58
get in
17:58
touch
17:59
with your
17:59
medical
18:00
oncologist,
18:00
and we make
18:00
this kind
18:01
of a joint
18:01
decision.
18:02
That is,
18:02
is this
18:03
the right
18:03
approach
18:04
for you
18:05
just to
18:05
take one
18:06
step back?
18:06
In general,
18:07
any liver
18:08
directed
18:08
therapy
18:09
we perform
18:09
can be done
18:11
at the
18:11
same time
18:12
that
18:12
you are
18:12
getting
18:13
systemic
18:13
therapy
18:14
if you
18:14
are on
18:15
systemic
18:15
therapy.
18:15
So, for
18:16
example,
18:17
if you are
18:17
on a
18:18
medication
18:18
called
18:18
Tebentafusp,
18:19
also known
18:20
as
18:20
Kimmtrak,
18:21
if
18:21
you're on
18:22
and
18:22
immunotherapy
18:23
agents such
18:23
as
18:24
nivolumab
18:24
and
18:24
ipilimumab
18:26
those are
18:26
just
18:27
examples.
18:27
And two
18:27
of the more
18:28
common
18:28
ones,
18:29
we don't
18:29
even need
18:31
to
18:31
discontinue
18:32
that.
18:32
We can do it
18:33
exactly
18:34
at the
18:34
same time.
18:35
There's
18:35
no
18:35
interaction
18:37
that we are
18:37
aware of.
18:38
So for
18:39
someone
18:39
with two
18:39
small liver
18:40
metastases,
18:41
the goal is
18:41
to do
18:42
focal
18:42
treatments
18:43
of those
18:43
two.
18:44
And
18:44
the reason
18:45
is why
18:46
put your
18:46
liver,
18:47
your entire
18:48
liver
18:49
through
18:49
a procedure
18:50
when
18:50
we can just
18:51
knock off
18:51
those two
18:52
tiny lesions.
18:54
So it
18:54
depends on
18:54
the size
18:55
and
18:56
the location.
18:57
But
18:57
the more,
18:58
common
18:58
things
18:59
that we
18:59
would
18:59
recommend
19:00
in those
19:00
cases
19:01
is either
19:02
number one,
19:03
a thermal
19:03
ablation
19:05
or number
19:05
two,
19:06
a y-90
19:07
radioembolization
19:08
So what is
19:08
each one,
19:09
a thermal
19:09
ablations
19:10
where we
19:10
bring
19:11
you into
19:11
the
19:11
hospital?
19:11
It's an
19:12
outpatient
19:12
procedure.
19:13
We put you
19:13
to sleep
19:14
under
19:14
anesthesia.
19:15
We take a
19:16
tiny,
19:17
thin needle
19:18
similar to,
19:19
you know,
19:19
the needle
19:19
that you
19:19
may have
19:20
had during
19:20
a biopsy
19:21
procedure.
19:22
Numb up
19:22
your skin
19:23
using
19:23
an ultrasound
19:24
and a CT
19:25
scan,
19:26
we
19:27
guide it
19:27
into
19:27
your tumor.
19:28
So we're
19:29
cheating
19:29
the whole
19:30
way
19:30
through.
19:30
so we know
19:31
exactly
19:31
where
19:31
we're going.
19:32
So we know
19:33
not to
19:33
go through
19:34
dangerous
19:34
things.
19:36
At the end
19:36
of that
19:37
needle,
19:37
there's an
19:37
electrical
19:38
cord
19:38
connected
19:39
to a
19:39
generator
19:40
box.
19:40
We flip
19:41
the switch,
19:42
the tip
19:43
of the
19:43
needle
19:44
heats up to
19:45
about 150
19:45
to 180
19:46
degrees.
19:47
We
19:48
literally
19:48
cook
19:49
the tumor
19:50
for 10
19:50
to 15
19:51
minutes,
19:52
turn
19:52
the switch
19:52
off,
19:53
take the
19:53
needle out,
19:54
put a
19:54
Band-Aid on
19:55
you, send
19:55
you home.
19:56
That works
19:57
extraordinarily
19:58
well.
19:59
It is
19:59
designed
19:59
for small
20:00
tumors,
20:01
just like,
20:02
you know,
20:02
you have
20:02
a shish
20:03
kebab
20:03
on your
20:03
barbecue
20:03
at home to
20:04
the heat.
20:05
Will start
20:06
to
20:06
dissipate
20:07
the farther
20:08
you go away
20:08
from the heat.
20:09
So I
20:09
can't do a
20:10
large tumor
20:11
because of that.
20:12
Because
20:12
then
20:12
the heat
20:12
won't reach
20:13
all the way
20:13
to the
20:14
margin.
20:14
It also has
20:15
to be done
20:16
in a tumor
20:17
that is
20:17
in a
20:18
favorable
20:19
location.
20:19
In other
20:19
words,
20:19
I have to be
20:20
able to get
20:20
from
20:21
the skin
20:22
all the way
20:22
into the
20:23
tumor
20:24
safely
20:24
without
20:25
damaging
20:26
any
20:26
surrounding
20:27
structures
20:27
which
20:27
may be
20:28
sensitive
20:29
to heat.
20:30
So
20:30
a lot of
20:30
people
20:30
are
20:31
candidates
20:31
for that.
20:32
some people
20:32
are not.
20:33
And if,
20:35
you're not
20:35
a
20:35
candidate,
20:36
then
20:36
we would
20:36
kind of,
20:37
for safety
20:38
reasons
20:38
or let's
20:38
just say,
20:39
you're in a
20:39
tenuous
20:40
location
20:40
where
20:41
I don't
20:41
want to
20:41
deliver heat
20:42
because
20:42
there's
20:42
the colon
20:43
in the way,
20:43
for
20:44
example.
20:44
Then
20:45
we would
20:45
switch to
20:46
the next
20:46
treatment,
20:46
which is a
20:47
y-90
20:48
radioembolization.
20:49
Okay.
20:50
are there
20:51
and I
20:51
know, like,
20:52
this is
20:52
this is
20:53
maybe
20:53
just me
20:54
because I'm
20:54
a little
20:54
more aware
20:55
of it.
20:55
And
20:55
it's
20:55
kind of
20:56
a buzzword
20:56
now that is
20:57
being
20:57
talked
20:57
about in
20:58
liver
20:58
directed
20:58
therapies.
20:59
But for
20:59
like 1 or 2
21:00
small
21:00
spots.
21:01
has your
21:01
interventional
21:02
radiology
21:02
team had
21:03
any contact
21:04
with anyone
21:04
who's done
21:05
histotripsy
21:05
as an
21:06
ablation
21:07
option?
21:07
And when
21:08
do
21:08
you think
21:08
that would
21:08
be best
21:09
in your
21:09
opinion?
21:10
So
21:10
histotripsy
21:11
also just
21:12
came out
21:13
probably in
21:13
the last
21:14
year.
21:15
histotripsy
21:16
is a
21:16
relatively
21:17
new method
21:18
of
21:18
ablation.
21:18
So what
21:19
we've
21:19
typically
21:19
done is
21:20
something
21:20
called
21:20
thermal
21:21
ablation.
21:21
Thermal
21:21
meaning
21:22
temperature.
21:22
We heat the tissue
21:23
or
21:24
in some case
21:24
some people
21:25
will freeze
21:25
the tissue.
21:26
histotripsy
21:27
is done
21:28
by
21:28
ultrasound
21:29
waves.
21:29
So there's
21:29
no heat
21:30
or cold.
21:31
So the nice
21:32
thing is
21:32
remember
21:32
I mentioned
21:33
that
21:33
structures
21:33
may be
21:34
damaged
21:35
by heat,
21:36
histotripsy
21:36
doesn't
21:37
have that
21:38
issue
21:38
because
21:38
there's no
21:39
heat
21:39
deliver.
21:40
So that's
21:40
the great
21:41
advantage
21:42
of
21:42
histotripsy
21:43
in that,
21:44
the damage
21:45
to
21:46
surrounding
21:47
structures
21:47
is
21:47
essentially,
21:48
not there.
21:49
Now,
21:50
there are
21:50
some
21:50
challenges
21:50
of
21:51
histotripsy
21:51
number one,
21:52
when it was studied
21:54
and
21:54
when the trials
21:54
came out,
21:55
it wasn't
21:56
studied
21:56
specifically.
21:57
In uveal
21:58
melanoma
21:59
metastases,
22:00
they did it
22:01
in
22:01
all comers.
22:02
So people
22:03
with
22:04
primary
22:04
liver
22:04
cancer,
22:05
people
22:05
with
22:06
metastases
22:07
from
22:07
colorectal
22:08
cancer
22:08
or breast
22:08
cancer
22:09
or
22:09
melanoma.
22:10
So
22:10
it wasn't
22:11
really
22:11
they didn't
22:12
do a trial
22:12
specifically
22:13
for, uveal
22:14
melanoma.
22:15
Number two,
22:16
you also have
22:17
to be, able
22:18
to
22:18
technically
22:20
get to
22:21
the lesion
22:21
via
22:22
histotripsy
22:23
And
22:23
there are a
22:23
lot of
22:23
places in
22:24
the liver
22:25
where
22:25
the histotripsy
22:26
device
22:27
in its
22:27
current
22:27
version
22:28
doesn't
22:28
work or
22:29
will not
22:30
see
22:30
the lesion.
22:30
So it has
22:31
to be
22:31
approachable,
22:33
via
22:33
the histotripsy device
22:35
but I
22:35
think
22:35
it's a
22:36
great
22:36
option for,
22:38
small
22:38
tumors
22:39
where the
22:39
ablation
22:40
that our
22:40
typical
22:41
ablation
22:41
modalities,
22:42
such as
22:42
microwave
22:43
ablation
22:43
or
22:43
radiofrequency
22:44
ablation
22:44
or
22:44
cryoablation,
22:45
are
22:46
let's say,
22:46
high risk.
22:48
you're
22:48
telling me
22:48
that I have
22:49
a couple spots
22:50
and that
22:50
we should
22:50
do spot
22:51
treatment,
22:51
essentially,
22:52
but
22:52
why wouldn't
22:53
I want to
22:53
just do
22:54
the whole
22:54
treatment?
22:54
Like,
22:55
why wouldn't
22:55
I want
22:55
to have
22:56
my entire
22:56
liver
22:56
just dosed
22:57
and get it
22:57
over with?
22:58
Make sure
22:58
that
22:58
anything
22:59
tiny, you
22:59
know, can't
23:00
come back.
23:01
What's
23:02
the harm of that?
23:03
So what
23:03
we're
23:03
trying to do
23:04
and what
23:05
this is
23:05
something
23:05
that I
23:05
think
23:05
that we've
23:06
learned
23:06
in the last
23:07
ten years,
23:09
what
23:09
we want
23:09
to do
23:10
is design
23:10
these
23:10
therapies
23:11
as a
23:11
marathon
23:12
and
23:12
not a sprint.
23:13
So
23:13
what does that
23:14
mean?
23:14
That means
23:14
that
23:15
let's say
23:15
you come
23:16
into
23:16
my office
23:16
for
23:17
those two
23:17
tiny
23:17
lesions,
23:19
it's,
23:19
you know,
23:20
August
23:21
2024.
23:21
I want to
23:22
design
23:23
treatments
23:23
for you
23:24
for the
23:24
next
23:25
several
23:25
years.
23:26
What
23:26
I don't
23:26
want to do
23:27
is design
23:27
a treatment
23:28
for you
23:28
for August
23:29
and
23:29
September
23:30
and October
23:30
of 2024,
23:32
and then
23:33
if you
23:33
pop up
23:34
new tumor
23:34
six months
23:35
later
23:35
or a year
23:36
later,
23:37
I tell you,
23:38
I don't
23:38
have,
23:39
you know,
23:39
all
23:39
all of our
23:40
tools are
23:41
kind of,
23:42
used up.
23:43
And so
23:44
this becomes
23:45
we want to
23:45
stretch
23:46
things out
23:47
so
23:47
you can
23:47
live
23:48
as long
23:48
as possible
23:49
with,
23:51
complete
23:51
preservation,
23:52
in terms of
23:52
quality
23:53
of life.
23:53
So today
23:54
you might
23:55
have
23:55
two lesions
23:56
and
23:56
we can get
23:57
rid of
23:57
those.
23:57
And in
23:58
many
23:58
patients
23:58
we've done
23:59
that.
23:59
And,
24:00
we just
24:01
monitor
24:01
them with
24:02
an MRI
24:02
every
24:02
three months,
24:03
and
24:03
they don't
24:03
ever pop up
24:04
new ones,
24:05
at least
24:05
for several
24:06
years.
24:06
And in
24:06
others,
24:07
they may
24:08
pop up
24:08
a bunch of
24:09
new ones.
24:09
And then
24:10
what we do
24:11
is we start
24:12
all over
24:12
We'd say,
24:12
okay,
24:12
what
24:13
is your best
24:14
option
24:14
at that
24:15
point?
24:16
Okay.
24:16
If we're
24:16
careful
24:17
and
24:17
selective,
24:19
and
24:19
preserve
24:20
the rest of
24:20
the liver,
24:21
we can
24:21
repeat
24:22
these
24:22
treatments
24:23
over
24:23
and over
24:24
and over
24:25
again
24:25
as long as
24:26
you
24:26
tolerate
24:26
them.
24:27
So
24:27
we can get
24:28
the most
24:29
amount
24:30
of
24:30
longevity
24:31
for you
24:32
again,
24:33
while
24:33
preserving
24:34
your
24:34
quality
24:34
of life.
24:35
The goal is
24:35
to.
24:36
If you're
24:36
working
24:36
a job,
24:37
I want you
24:37
to keep
24:37
on working.
24:38
If you're,
24:39
you know,
24:40
like to
24:40
go fishing,
24:41
I want you
24:41
to keep on
24:42
going
24:42
fishing.
24:42
The goal is
24:42
not to
24:43
put you
24:43
in bed
24:44
all day.
24:45
really,
24:45
in general,
24:45
when you're
24:46
doing
24:46
any liver
24:46
directed
24:47
therapy,
24:47
I think
24:48
what
24:48
you told me
24:48
before, was
24:49
you want to
24:49
treat the
24:49
cancer?
24:50
Of course,
24:50
like that's
24:51
number
24:51
one goal.
24:52
And then
24:52
it sounds
24:52
like
24:52
patient
24:53
learning
24:53
with
24:53
longevity
24:54
is number
24:54
two goal.
24:55
And then
24:55
that also
24:56
kind of
24:56
encompasses
24:57
that high
24:57
quality
24:57
of life
24:58
for as long
24:58
as
24:58
possible.
24:59
Like those
25:00
three
25:00
kind of
25:00
main
25:00
things.
25:01
So having
25:02
the entire
25:02
liver
25:03
treated
25:03
isn't
25:03
necessarily
25:04
going to be
25:04
the most ideal
25:05
because
25:05
like you
25:05
said, it's
25:06
going to
25:07
almost,
25:07
use it
25:08
too early
25:08
in the marathon,
25:09
so to
25:09
speak.
25:10
Exactly.
25:10
So
25:11
let's say
25:11
you did
25:11
come in
25:12
and I
25:12
did decide
25:12
to do
25:13
a hepzato
25:13
procedure
25:13
which is
25:14
fine
25:14
and would
25:14
probably
25:15
work in
25:15
someone
25:16
with a
25:16
that low
25:17
of a tumor
25:17
burden.
25:18
And
25:19
then you
25:19
came to me
25:20
a year
25:20
later
25:21
and
25:21
you sprouted
25:23
a bunch
25:23
of
25:23
new tumors.
25:24
So then
25:25
I got a problem
25:26
because
25:26
I've
25:26
already
25:26
used up
25:27
my main
25:27
tool,
25:28
which is the hepzato
25:28
So I don't
25:29
I can't
25:30
necessarily
25:30
go back
25:31
and do
25:31
ablation
25:32
if
25:32
let's say
25:32
you
25:32
sprout up
25:33
ten tumors.
25:34
And so we
25:35
may have
25:35
used up
25:36
that option
25:37
when I
25:37
could
25:38
have used
25:38
something
25:39
else. Yeah.
25:40
And so
25:40
that's
25:40
where we're
25:41
trying to
25:42
kind of
25:43
do this
25:44
in a
25:44
sequential
25:45
stepwise
25:46
and
25:47
thoughtful
25:47
manner,
25:48
fully
25:48
realizing
25:50
that
25:51
there's no
25:51
data as
25:52
to which
25:53
therapy
25:54
you should
25:54
do first.
25:56
this is really
25:57
where
25:57
the art
25:58
of
25:58
medicine,
25:59
becomes
25:59
just as
25:59
important
26:00
as the
26:00
science.
26:01
Yeah,
26:02
exactly.
26:02
Okay.
26:03
okay, so
26:04
for
26:04
those of
26:04
you guys
26:04
listening,
26:05
let's
26:05
just say
26:06
this isn't
26:06
an option
26:07
for you,
26:07
right?
26:07
Like,
26:08
you can't
26:08
just have
26:08
1 or 2
26:09
tumors
26:09
treated.
26:10
Let's say
26:10
you've got
26:10
a little
26:11
bit more
26:11
involvement.
26:11
Maybe
26:12
you've
26:12
got a
26:12
larger
26:12
tumor,
26:13
something
26:13
bigger than
26:14
a
26:14
centimeter
26:15
or two.
26:15
you
26:15
mentioned
26:16
some y-90
26:17
options
26:17
and just
26:18
some other
26:18
kind of
26:19
a little
26:20
bit more
26:20
than just
26:21
an ablation
26:21
or,
26:22
histotripsy
26:22
treatment.
26:23
what would be
26:24
kind of the
26:25
ideal
26:25
situation
26:26
for that
26:26
patient?
26:27
Okay.
26:28
So let's
26:28
say we
26:29
actually
26:29
just saw
26:30
somebody
26:30
you
26:30
follow up
26:30
two days
26:31
ago.
26:32
he had a single
26:33
tumor
26:34
that was
26:35
six
26:36
centimeters.
26:36
So about
26:37
two and
26:38
a half
26:38
to three
26:38
inches
26:39
and a
26:39
second
26:40
smaller one
26:41
next to it.
26:42
again,
26:42
the rest of
26:42
the liver
26:43
was fine.
26:43
It was all
26:43
in
26:43
the middle
26:44
of the liver.
26:45
and so
26:45
I didn't
26:46
want to
26:46
treat the
26:47
whole liver
26:48
at the same
26:48
time.
26:48
The tumor
26:49
was too big
26:50
for to
26:50
for me
26:51
to get a
26:51
successful
26:52
ablation.
26:53
Because
26:53
you can
26:53
imagine
26:54
if I take
26:54
a tumor
26:55
that's
26:55
the size
26:55
of a golf
26:56
ball,
26:56
and I put
26:57
a tiny
26:57
needle
26:58
in the middle,
26:59
the heat may
27:00
not go
27:00
to the edge
27:01
of that
27:01
golf ball.
27:02
And so
27:03
the y- 90
27:04
radioembolization
27:04
is a great
27:05
option
27:05
in this
27:05
case
27:06
similar to
27:07
the Hepzato
27:08
procedure.
27:08
It is done
27:09
through
27:09
the artery
27:10
in the liver.
27:10
So remember
27:11
the artery
27:11
is the one
27:12
that
27:12
carries
27:12
blood
27:12
from the
27:12
heart
27:13
to the liver.
27:14
And we
27:14
infuse
27:16
tiny
27:17
radioactive
27:17
particles.
27:18
These
27:18
particles
27:18
are so small
27:19
you can't
27:20
even see
27:20
them.
27:21
There are
27:21
several
27:22
million
27:22
of them.
27:23
and
27:24
the infusion
27:25
is is
27:25
completely
27:25
painless.
27:26
So
27:26
we do this
27:27
under
27:27
sedation,
27:28
not under
27:28
anesthesia.
27:30
So what
27:30
we do is
27:31
we position
27:31
that
27:31
catheter
27:32
in the
27:33
specific
27:34
artery,
27:35
that goes
27:35
towards,
27:36
towards
27:37
that tumor
27:38
to
27:38
make sure
27:39
that we're
27:39
not going
27:39
somewhere else
27:40
or even in
27:40
the rest of
27:41
the liver.
27:41
We infuse
27:42
those, tiny
27:44
radioactive
27:45
particles,
27:46
we take
27:46
the
27:46
catheter
27:47
out, put
27:47
a Band-Aid
27:48
on you,
27:48
send
27:48
you home.
27:49
That
27:49
procedure
27:49
again,
27:49
takes about
27:50
1 to 2
27:51
hours,
27:51
and it's
27:51
done under
27:51
sedation.
27:52
It is
27:53
also very
27:54
well
27:54
tolerated.
27:55
there are,
27:57
again,
27:57
just like
27:58
every
27:58
therapy,
27:59
there are
27:59
advantages
28:00
and
28:00
disadvantages.
28:01
So that
28:01
works
28:02
extraordinarily
28:03
well.
28:03
When we're
28:04
targeted
28:04
and focal,
28:05
we can give
28:06
very high
28:06
doses
28:07
of
28:07
radiation,
28:08
to that
28:08
tumor.
28:09
And there's
28:09
no spread
28:11
of the
28:11
radiation
28:12
elsewhere.
28:13
The downside
28:14
comes
28:14
when
28:15
we have
28:15
to treat
28:15
someone's
28:16
whole
28:16
liver.
28:17
Let's say
28:17
someone
28:17
presents
28:18
with 10
28:18
or 12
28:19
lesions,
28:20
then
28:20
we have to
28:21
irradiate
28:22
the entire
28:22
liver.
28:23
And that's
28:23
where,
28:24
I think
28:24
we have
28:25
some
28:25
challenges
28:25
and where
28:26
the hepzato
28:27
procedure
28:27
might be
28:28
a better
28:28
option.
28:29
Yeah.
28:29
For sure.
28:30
Okay,
28:31
so we've
28:32
got the y-90.
28:33
what
28:33
can you
28:33
tell us
28:33
just
28:34
briefly
28:34
about Linac
28:35
radiation
28:35
and the IHI
28:37
and the C
28:37
procedures?
28:38
feel free
28:38
to touch
28:39
on either
28:39
or both
28:40
of those
28:40
briefly.
28:42
So
28:42
the line of
28:42
radiation
28:43
is
28:43
I would say
28:44
right now,
28:45
it's done
28:46
again
28:46
by
28:46
radiation
28:46
oncologist.
28:47
It's still
28:48
very early
28:49
in its
28:50
development
28:50
and phases.
28:51
there's
28:52
no
28:52
significant
28:53
or really
28:54
large scale
28:55
data sets
28:55
right now.
28:56
So I think
28:56
we're still
28:57
learning
28:57
about it.
28:58
Okay.
28:58
and that's
28:58
probably
28:59
mostly
28:59
what I can
29:00
say.
29:00
it's still
29:01
kind of
29:01
a work
29:02
in
29:02
progress.
29:03
Okay.
29:03
So kind
29:04
of the
29:04
buzzword
29:05
for,
29:05
you know,
29:06
for one
29:07
lobe or for
29:07
kind of
29:08
whole lobe
29:09
or whole
29:09
liver
29:10
treatment
29:10
where
29:10
you're
29:10
treating
29:11
both of
29:11
the lobes.
29:12
the buzz
29:12
conversation
29:13
in the
29:13
metastatic
29:14
community,
29:15
like we're
29:15
talking
29:15
about
29:16
things like
29:16
ie And ce
29:17
so
29:18
the immuno
29:18
embolization
29:19
for those
29:19
of you
29:19
listening
29:20
and chemo
29:20
embolization,
29:21
how is this
29:22
different
29:22
than
29:22
hepzato kit.
29:23
And
29:24
what do you think
29:24
are the
29:25
risks,
29:25
the data
29:26
maybe
29:26
the
29:26
benefits
29:26
okay.
29:27
So immune
29:28
embolization
29:28
and chemo
29:29
embolization
29:29
are similar
29:30
to that y90
29:31
where
29:31
we put that
29:32
catheter
29:32
in.
29:32
And instead
29:33
of infusing
29:33
radioactive
29:34
particles
29:34
you give
29:35
chemo
29:36
laced
29:36
particles
29:37
or immuno
29:38
laced
29:38
particles.
29:39
I would say
29:39
two things.
29:40
Number one,
29:41
it compared
29:41
to let's
29:42
say hepzato
29:42
kit,
29:43
the efficacy
29:44
in terms
29:45
of tumor
29:45
shrinkage
29:46
is far
29:47
lower
29:48
and
29:49
the side
29:49
effects are
29:50
far higher.
29:51
So
29:51
I think
29:51
it's really
29:52
fallen
29:52
out of
29:53
favor
29:53
to do chemo
29:54
embolization
29:55
or immuno
29:55
embolization
29:57
with the
29:58
arrival of
29:59
hepzato
29:59
kit.
30:02
in our
30:02
experience
30:04
in patients
30:04
undergoing
30:05
chemo
30:05
embolization
30:05
or immuno
30:06
embolization,
30:06
it's
30:07
not easy
30:07
to
30:07
tolerate.
30:08
You're
30:09
quite sick
30:10
for the
30:10
next
30:10
several
30:11
days
30:11
afterwards,
30:12
and you
30:12
have to
30:13
repeat the
30:13
procedure
30:14
time and
30:15
time again,
30:15
you know,
30:15
several
30:16
times.
30:17
So what?
30:18
We've
30:18
always
30:19
kind of,
30:20
philosophically
30:21
thought
30:21
in our
30:22
field
30:22
in
30:22
interventional radiology,
30:24
which is
30:24
really why
30:25
I went
30:25
into this
30:26
field,
30:26
is that
30:27
I like
30:28
to see
30:28
patients
30:29
go home
30:29
that day
30:30
and not
30:31
be
30:32
miserable
30:32
in the hospital.
30:33
That was
30:34
kind
30:34
of what
30:35
drove me
30:35
into this.
30:36
and so
30:37
when I hear
30:37
about
30:37
patients
30:38
not doing
30:39
well
30:39
afterwards
30:40
or feeling
30:40
really
30:40
sick,
30:41
that
30:41
kind of
30:42
disheartened
30:42
me.
30:42
So
30:43
the nice
30:44
thing about
30:44
the
30:44
hepzato kit
30:45
okay
30:45
procedure,
30:46
other than
30:47
the
30:47
recovery
30:47
from the
30:48
anesthesia,
30:48
the recovery
30:49
is actually
30:49
quite
30:50
rapid.
30:51
same thing
30:51
with the
30:51
radioembolzation
30:52
Same thing
30:53
with
30:53
thermal
30:53
ablation.
30:54
So
30:54
I foresee
30:56
that chemo
30:57
embolization
30:58
and immuno
30:59
embolization
31:00
will
31:01
probably
31:02
fall out
31:03
of favor
31:03
significantly.
31:05
as hepzato
31:06
kit becomes
31:08
more
31:08
widespread
31:09
use and
31:10
widely
31:10
available.
31:11
Perhaps it
31:12
might
31:12
be used
31:13
in those
31:14
patients
31:14
where,
31:15
the hepzato
31:16
kit
31:16
procedure
31:16
failed or,
31:17
you know,
31:18
patients
31:18
progressed
31:18
after it
31:19
and
31:19
they didn't
31:19
have
31:20
any other options.
31:21
and so
31:22
hopefully
31:22
we really
31:22
won't
31:23
see that
31:23
too often.
31:24
but I think
31:25
it's going
31:25
to be
31:25
relegated
31:26
to what
31:26
I would
31:27
say, the
31:27
salvage
31:28
setting.
31:29
Okay.
31:30
we've
31:30
talked
31:30
a little
31:31
about
31:31
the y90
31:31
and we
31:32
talked
31:32
about some
31:32
of these
31:32
kind
31:33
of like
31:33
maybe one
31:34
or like one
31:34
side of
31:35
the liver.
31:35
It really
31:35
just needs
31:36
a little
31:36
more
31:36
directed
31:37
treatment.
31:38
Hepzato
31:38
Kit, you've
31:39
said,
31:39
is a
31:39
little bit
31:40
more,
31:41
heavily
31:41
used
31:42
right now,
31:42
at least
31:43
when
31:43
you have
31:44
a larger
31:45
amount
31:45
of tumor
31:46
involvement
31:47
or liver
31:47
involvement.
31:47
let's
31:48
just say
31:48
I've got 2
31:49
or 3
31:49
moderate
31:50
sized
31:50
tumors
31:50
I can see
31:51
on the
31:51
imaging and
31:51
my doctor
31:52
is telling
31:52
me, oh,
31:53
there's
31:53
kind of
31:53
this
31:53
peppering
31:54
like
31:54
there's,
31:55
there's
31:55
like all
31:55
of these
31:56
little tiny
31:56
little
31:57
specks
31:57
everywhere
31:57
that we're
31:58
pretty
31:58
sure,
31:58
you know,
31:58
just
31:59
based on
31:59
how it
31:59
presents.
32:00
This is
32:01
more
32:01
cancer.
32:02
I'm
32:02
just kind
32:02
of breaking
32:02
this down
32:03
for
32:03
those of
32:03
you guys
32:03
listening,
32:04
just
32:04
so that
32:04
if you're
32:05
imagining
32:05
your scans,
32:05
you can
32:06
kind of
32:06
picture
32:06
what your
32:07
doctor
32:07
might be
32:07
saying.
32:08
what what
32:09
would this
32:09
look like
32:10
as far as
32:11
why
32:11
has auto
32:11
might be
32:12
a better
32:12
option?
32:13
That's
32:13
actually
32:14
a quite
32:14
a common
32:15
occurrence.
32:15
We see,
32:16
you know,
32:16
multiple
32:16
lesions,
32:17
but you see
32:17
a lot
32:17
of little
32:17
dots on
32:18
the MRI.
32:20
It's always
32:20
hard to
32:20
say what
32:21
those dots
32:21
are.
32:21
But
32:22
we kind of
32:22
know just
32:23
historically
32:24
that
32:24
those dots
32:25
are very
32:26
small
32:26
tumors
32:27
in its infancy.
32:28
So
32:28
in that case,
32:29
when we see
32:30
that it
32:30
makes
32:31
more sense
32:31
to do
32:32
a more
32:32
whole liver
32:33
for global
32:34
approach.
32:35
And that's
32:35
where I do
32:36
think that
32:36
hepzato
32:37
kit, plays
32:37
a role.
32:38
In fact,
32:38
the last
32:39
two
32:39
patients
32:40
that we did
32:40
have
32:41
exactly
32:41
that
32:42
appearance.
32:43
the nice
32:44
thing
32:44
is that,
32:44
it really
32:46
does.
32:46
You know,
32:46
when we're
32:47
infusing
32:47
the chemo
32:48
with the
32:48
chemo,
32:48
keep in
32:48
mind, is
32:49
a liquid,
32:49
right?
32:49
Just like
32:50
turning on
32:51
that
32:51
faucet,
32:51
running it
32:52
through
32:52
that
32:52
sponge,
32:53
it'll
32:53
fill up
32:54
the whole sponge
32:54
so
32:55
the chemo
32:55
will
32:55
fill up
32:55
the whole liver.
32:56
So it'll
32:56
get to
32:57
all those
32:58
tiny
32:58
little dots
33:00
as well as
33:00
the
33:00
big tumors.
33:01
So that's
33:01
that's
33:02
really
33:02
the
33:02
advantage.
33:03
The second
33:03
advantage
33:04
is this,
33:05
when even
33:05
despite
33:06
doing a
33:06
whole liver
33:07
treatment
33:07
with the
33:07
hepzato kit
33:08
okay,
33:09
the risk
33:10
of liver
33:11
toxicity
33:12
or liver
33:13
damage
33:15
is
33:15
exceptionally
33:16
low
33:17
in all
33:18
the patients
33:18
that we
33:19
have
33:19
treated
33:19
so far,
33:20
we have
33:21
measured
33:21
all their
33:22
liver
33:22
enzymes,
33:23
immediately
33:24
prior
33:24
to the procedure
33:25
and then
33:25
afterwards
33:26
and then
33:26
even two
33:27
weeks
33:27
afterwards
33:28
and one
33:28
month
33:28
afterwards.
33:29
And not
33:30
a single
33:30
person
33:31
has had
33:32
elevation
33:33
of their
33:33
liver
33:33
function
33:34
tests.
33:35
So it's
33:36
quite
33:36
remarkable,
33:37
almost
33:37
surprising,
33:38
that we're
33:39
giving such
33:40
a high dose
33:40
of chemo
33:41
right
33:41
into their
33:42
liver.
33:43
And for
33:43
whatever
33:44
reason,
33:45
the
33:45
hepatocytes,
33:46
the normal
33:47
liver
33:47
cells,
33:48
are not
33:48
reacting
33:49
to it.
33:50
and so
33:50
the liver
33:51
function
33:51
remains
33:51
completely
33:52
preserved.
33:53
So
33:53
what does that
33:54
mean?
33:54
That means
33:54
also that
33:56
we can give
33:57
this
33:58
multiple
33:58
all times
33:59
if needed.
34:00
And we can
34:00
give this
34:01
with
34:01
immunotherapy
34:02
or
34:02
chemotherapy
34:03
or
34:04
tebentafusp
34:05
And there's
34:05
not going
34:05
to be
34:06
any
34:06
significant
34:07
interaction
34:08
that we are
34:08
aware of.
34:10
Oh that's
34:10
incredible.
34:10
So a really
34:11
sounds like
34:12
there's
34:12
a lot
34:12
of benefits
34:13
to the
34:14
treatment
34:14
landscape.
34:14
And just
34:15
kind of
34:15
what
34:15
you guys
34:16
creatively,
34:17
creatively
34:17
can do,
34:18
you know,
34:18
as doctors,
34:19
as
34:19
interventional
34:20
radiologists,
34:20
you've got
34:21
so much
34:21
more to
34:21
work with
34:22
when you
34:23
when you
34:23
can trust
34:24
that
34:24
the liver
34:24
is not
34:24
going to
34:25
be
34:25
compromised.
34:26
Yeah.
34:26
It gives us
34:27
a lot more,
34:29
it gives us
34:29
a lot
34:30
more
34:30
latitude
34:31
in what
34:31
we can do.
34:32
And I would
34:33
say even
34:34
with this
34:34
procedure,
34:35
we're
34:35
still just
34:35
starting
34:36
out.
34:36
so far,
34:37
the procedures
34:38
have gone
34:38
extremely
34:39
smoothly.
34:40
the
34:40
procedure
34:41
time
34:41
ranging
34:42
from 2.5
34:43
hours
34:44
to three
34:45
hours.
34:46
Patients
34:46
all getting
34:47
discharged
34:48
at the end
34:48
of the day
34:49
or the
34:49
next morning.
34:50
But I
34:51
actually
34:51
foresee
34:52
several
34:53
technical
34:53
improvements
34:54
for the
34:54
procedure
34:54
over
34:55
the next
34:55
two years
34:56
where
34:56
we can
34:56
make it
34:56
even more
34:58
efficient
34:59
as we share
35:00
and learn
35:01
our ideas.
35:02
I'll
35:03
give you
35:03
one
35:03
example.
35:04
initially
35:05
the procedure
35:05
was done
35:06
in a
35:06
clinical
35:06
trial
35:07
where
35:07
the all
35:07
these
35:07
catheters
35:08
and sheaths
35:10
were left
35:10
in place
35:11
and
35:11
in coming
35:12
out
35:12
of the body
35:13
while they
35:14
were
35:14
recovering
35:14
in the ICU.
35:16
and what we
35:17
did is one
35:18
small
35:18
adaptation
35:19
that we did
35:19
is before
35:20
they even wake
35:20
up, we
35:20
remove
35:21
them.
35:21
We use
35:22
something
35:22
called
35:22
a closure
35:23
device
35:23
to close
35:24
the
35:24
arteries
35:24
and veins.
35:25
and
35:25
then they
35:26
get a band
35:26
aid
35:26
afterwards.
35:27
So now
35:28
it's nice
35:29
that
35:29
you wake
35:29
up.
35:30
You don't have
35:31
anything
35:31
sticking
35:31
out
35:31
of your body
35:32
except just
35:32
maybe
35:33
in your hand.
35:34
and so
35:34
that's just
35:35
a small
35:35
technical
35:36
improvement
35:36
that
35:36
we did.
35:37
And I
35:37
foresee
35:37
several
35:38
improvements,
35:39
that will
35:39
occur over
35:40
the next
35:40
two years.
35:42
Well,
35:42
and I
35:42
think
35:42
that's,
35:43
you know,
35:43
that's
35:43
the beauty
35:44
of medicine
35:44
is when
35:44
we have
35:45
modern
35:45
medicine
35:46
and it's
35:46
really been
35:47
some
35:47
established
35:48
care
35:48
of some
35:48
kind, like
35:49
there is so
35:49
much
35:50
more room
35:50
for rapid
35:51
improvements.
35:51
And,
35:52
and I know
35:52
you guys
35:52
as doctors,
35:53
that's
35:53
your goal.
35:53
Like
35:54
your goal
35:54
is to
35:54
make sure
35:55
patients
35:55
have
35:56
as good
35:56
of an
35:56
experience
35:57
as possible
35:57
and can get
35:58
back to
35:59
regular,
35:59
you know,
36:00
regular
36:00
life
36:00
programing,
36:01
so to
36:01
speak.
36:02
Yeah,
36:02
absolutely.
36:02
And that's
36:03
something
36:03
that we
36:03
always have
36:04
in the back
36:04
of our
36:04
minds.
36:05
And
36:05
any time
36:06
let's say
36:06
I do this
36:07
or any
36:07
other
36:07
procedure,
36:08
we do
36:09
a, sit down
36:10
consultation,
36:10
either
36:11
in person
36:11
or via
36:12
video
36:12
or
36:12
whatever,
36:13
you know,
36:13
the
36:13
patient's
36:13
preferences.
36:14
And
36:14
we go over
36:15
their
36:15
goals,
36:15
we go over,
36:16
you know,
36:16
their needs
36:17
and what
36:17
their wants,
36:18
and
36:19
you know
36:20
how
36:20
aggressive
36:21
they want
36:21
to be.
36:23
you know,
36:23
and I
36:24
try to
36:24
get a
36:25
very good
36:25
gauge
36:26
of their
36:26
current
36:27
physical
36:27
status.
36:28
In
36:28
other words,
36:29
are you
36:29
sitting on
36:29
your couch
36:30
all day?
36:30
Are you
36:30
in bed
36:31
all day?
36:31
Are you
36:32
working
36:32
out?
36:33
The last person
36:34
I treated,
36:34
he was
36:35
in the gym
36:36
lifting
36:36
weights
36:37
two hours
36:37
a day
36:37
before
36:37
the procedure.
36:38
And
36:38
fortunately
36:39
it two
36:39
weeks later
36:39
he was back at it.
36:42
and so
36:42
we want to
36:43
get that
36:43
gauge
36:43
because I
36:44
want to
36:44
return
36:44
people back
36:46
to their
36:47
previous
36:47
lifestyle.
36:49
Yeah.
36:49
It's just
36:49
I mean,
36:50
I know
36:50
that's
36:50
something
36:51
that's so
36:51
important
36:51
to me
36:51
personally,
36:52
and I hope
36:52
you guys
36:53
like, can
36:53
maybe
36:54
you can
36:54
relate
36:54
that.
36:54
Like,
36:54
you don't
36:55
want cancer
36:55
to take
36:56
anything
36:56
more
36:56
from you
36:57
than it
36:57
has to.
36:58
And so it's
36:58
so it's
36:59
so
36:59
validating.
37:00
I think, to
37:00
hear that
37:01
doctors
37:01
are
37:01
understanding
37:02
that
37:02
they're
37:02
value
37:02
in that
37:03
and that,
37:04
you know,
37:04
that we
37:04
have
37:04
professionals
37:05
like you
37:05
who are
37:06
looking for
37:06
how do I make
37:07
sure
37:07
my patients
37:08
have
37:08
the best
37:08
quality
37:09
of life
37:09
and
37:09
the most
37:10
longevity,
37:11
like,
37:11
you know,
37:11
as they're
37:12
dealing
37:12
with
37:12
metastatic
37:12
disease?
37:14
you know.
37:14
I would say
37:14
that's
37:15
not done.
37:15
I
37:15
unfortunately,
37:16
it's
37:16
not universal.
37:17
I think
37:18
especially
37:18
in our field,
37:19
it tends
37:19
to be much
37:20
more
37:20
common.
37:21
I know
37:21
I've had,
37:22
family
37:23
members
37:23
who have,
37:24
gone
37:24
through
37:25
some pretty
37:25
tough times
37:26
in terms
37:26
of their
37:27
cancer
37:27
care,
37:28
and had,
37:29
you know,
37:29
I still
37:30
still
37:30
remember
37:30
my
37:31
grandmother
37:31
who had
37:32
chemotherapy
37:33
for breast
37:33
cancer
37:33
at 85.
37:34
And it
37:35
you know,
37:35
it took
37:35
a very
37:36
vital
37:37
person
37:37
and
37:37
basically
37:38
put her
37:39
into bed,
37:39
you know,
37:40
within weeks.
37:40
And she
37:41
really
37:41
never
37:41
kind of
37:42
came out
37:42
of that.
37:43
And that's
37:43
still
37:44
that was
37:44
ten years
37:45
ago.
37:45
That still
37:45
sticks in
37:46
my head.
37:47
And I think
37:49
not only
37:49
myself,
37:50
but I think
37:50
most in the
37:51
radiology
37:51
community,
37:52
actually,
37:53
most ocular
37:54
melanoma
37:54
oncologists
37:55
I work
37:55
with, feel
37:55
the same
37:56
way.
37:56
We're
37:56
trying to
37:57
avoid that,
37:58
and trying
37:59
to preserve
37:59
people's
38:00
quality
38:00
of life
38:01
as much
38:01
as possible.
38:02
and I think
38:03
that's,
38:03
you know,
38:04
an equal
38:04
goal in
38:05
terms of,
38:06
comparing
38:06
to quantity
38:07
of life
38:07
as well.
38:08
Yeah.
38:09
Well,
38:10
and you
38:10
mentioned
38:10
too
38:11
that like,
38:11
this is
38:11
the kind
38:11
of
38:12
treatment
38:12
that you
38:12
can have
38:13
multiple
38:13
times.
38:14
So like
38:14
let's just,
38:15
you know,
38:15
let's
38:15
just say
38:16
I've got
38:16
this, this,
38:16
you know,
38:17
this, this,
38:18
this
38:18
presentation
38:19
of all of
38:19
these
38:19
tumors
38:20
in my
38:20
liver.
38:20
It's
38:20
obviously
38:21
super
38:21
concerning.
38:22
and you're
38:22
telling me
38:23
about,
38:23
okay, it's
38:23
a
38:23
really good
38:24
option.
38:24
So how many
38:25
treatments
38:26
could
38:26
I
38:26
realistically
38:26
have,
38:27
you know,
38:27
without it
38:28
producing
38:29
side
38:29
effects
38:30
or things
38:30
like that?
38:31
Okay.
38:31
So great
38:32
question.
38:32
So I think
38:33
right now
38:34
we don't
38:34
truly know.
38:35
But in
38:36
general
38:36
we're
38:37
looking at
38:37
around six.
38:38
So
38:38
what does
38:39
six
38:39
treatments
38:39
mean.
38:40
We do
38:40
these in
38:41
groups
38:41
of two.
38:42
So
38:42
we do one.
38:43
And then
38:43
we do
38:43
another one
38:44
6 to 8
38:44
weeks
38:44
later.
38:45
And then
38:46
we get
38:46
imaging
38:47
afterwards.
38:48
In general
38:49
it tends
38:50
to be
38:51
more more
38:51
tolerated
38:52
with each
38:53
treatment.
38:54
As an
38:54
example,
38:55
I saw
38:55
somebody
38:56
last week
38:56
in
38:56
the office
38:57
after
38:58
they
38:58
received
38:58
their first
38:59
two
38:59
treatments,
39:01
their
39:01
tumors
39:02
shrunk
39:02
considerably.
39:04
So
39:04
I sat down
39:05
with them.
39:05
I said,
39:06
look, here
39:06
are your options.
39:07
We can
39:08
either just
39:09
you can
39:09
continue
39:10
your
39:10
immunotherapy.
39:11
You can get
39:11
scans every
39:12
few months,
39:13
or I can do
39:14
rounds
39:15
three
39:15
and four.
39:16
I've have
39:16
decided to
39:17
shrink them
39:17
even
39:18
further.
39:19
It really
39:20
depends on
39:21
how you did
39:21
after
39:22
the last
39:22
two.
39:22
If you
39:23
didn't
39:23
tolerate
39:23
the last two,
39:24
I probably
39:24
would
39:24
hold off.
39:25
If you tolerated
39:25
the last
39:26
two,
39:26
I'd go
39:27
for it.
39:27
He's like,
39:28
well,
39:28
the last one
39:29
I had on
39:29
a
39:29
Wednesday.
39:30
I was back
39:30
at work
39:30
Monday
39:31
morning.
39:31
I don't
39:31
really feel
39:32
any different,
39:33
so let's
39:34
just do it.
39:35
So he's
39:35
going
39:35
to get
39:36
scheduled
39:36
for rounds
39:37
three
39:37
and four
39:39
because
39:39
he's
39:39
totally up
39:40
for it.
39:41
there are certain
39:42
other
39:43
considerations.
39:43
We want
39:44
to make
39:44
sure that
39:44
they
39:45
continue
39:45
to not have
39:46
heart
39:46
disease or
39:46
develop it.
39:47
the one
39:48
main side
39:49
effect of
39:50
the Hepsato
39:50
kit
39:50
okay,
39:50
procedure
39:51
is that it
39:52
can lower
39:53
one of
39:53
your blood
39:54
counts.
39:55
That's
39:55
called the
39:55
white blood
39:56
cell count.
39:57
So we want
39:58
to make
39:58
sure your
39:58
white blood
39:59
cell count
39:59
is within
40:00
an normal
40:01
range.
40:02
So
40:02
sometimes
40:03
we'll wait
40:03
another
40:04
few months
40:04
to make
40:05
sure it
40:05
comes back
40:06
to normal
40:06
range.
40:07
It tends
40:07
to not be a
40:08
significant
40:09
problem.
40:10
so we want
40:10
to
40:10
make sure
40:10
that you're
40:11
still safe
40:11
for
40:11
the procedure.
40:12
And I
40:13
basically
40:13
I ask them
40:14
if they're up
40:15
for it,
40:16
and they
40:16
want to
40:16
go ahead.
40:18
Okay.
40:18
Well, I
40:19
mean,
40:19
I think
40:19
that's
40:19
fair.
40:19
And I
40:20
think it's
40:20
so
40:20
important
40:21
that we,
40:21
as patients
40:22
have the
40:22
opportunity
40:22
to be
40:23
involved in
40:24
the
40:24
decision
40:24
making of like,
40:25
what do I want?
40:26
so I think
40:27
that's a
40:27
that's a
40:27
really
40:27
good thing
40:28
to find for
40:28
you guys.
40:30
okay.
40:30
So around
40:32
six
40:32
treatments
40:33
in
40:33
groups of two.
40:34
And then
40:34
you
40:34
mentioned
40:35
that I
40:35
could
40:35
still have
40:36
my systemic
40:36
therapy.
40:37
Yeah.
40:37
So
40:38
the kind of
40:38
main
40:39
options
40:39
we've
40:39
got for
40:40
the
40:40
systemic
40:40
therapy are
40:41
ipi nivo,
40:42
which is
40:42
generally
40:43
for anyone
40:43
but we know
40:44
doesn't
40:44
have or
40:45
historically
40:45
hasn't
40:46
had the
40:46
best
40:46
response
40:47
rate as far
40:47
as I know.
40:48
And then
40:48
we also
40:49
have the
40:49
HLA
40:49
dependent
40:50
Kimmtrack
40:50
for, for
40:51
anybody
40:51
who,
40:52
you know,
40:52
maybe
40:52
you're
40:52
confused
40:53
about
40:53
Kimmtrack
40:54
versus tebn
40:54
They are
40:55
the same thing.
40:56
so let's
40:56
just say
40:57
I am I'm
40:57
hla
40:57
positive
40:58
I can have
40:58
Kimmtrack.
40:59
or I can
41:00
have ipi
41:00
nivo like,
41:02
how soon do
41:02
I have to
41:03
kind of
41:04
pause
41:04
my
41:04
immunotherapy
41:05
before
41:06
I can
41:07
have one
41:07
of the
41:07
hepzato
41:08
treatments,
41:08
or vice
41:09
versa?
41:10
From what
41:11
we can
41:11
tell, you
41:12
don't
41:12
need to
41:12
pause it
41:12
at all.
41:13
we have treated
41:14
patients
41:15
both on
41:15
Kimmtrack,
41:16
and we have
41:17
treated
41:17
patients
41:18
both on
41:19
nivolumab
41:19
We've also
41:20
treated
41:20
patients
41:21
on other
41:21
third line,
41:22
immuno
41:23
agents
41:23
as well.
41:25
there does
41:25
not seem
41:26
to be
41:26
any cross
41:27
reaction
41:28
in terms of
41:28
the side
41:29
effects.
41:30
and so
41:32
we have
41:33
recommended
41:34
that you
41:35
do not stop
41:36
or even
41:37
temporarily
41:38
discontinue
41:39
your systemic
41:40
therapy.
41:41
That's
41:42
kind of
41:42
the nice
41:42
thing
41:42
about this.
41:43
There's
41:43
no
41:43
it doesn't,
41:44
you know,
41:44
add to
41:45
the side
41:45
effect
41:46
profile
41:46
of what
41:47
you already have.
41:49
So I don't
41:49
really
41:49
foresee
41:50
any reason,
41:52
to stop
41:53
your
41:53
systemic
41:54
therapy
41:54
at this
41:55
time.
41:56
There is
41:56
an ongoing
41:57
trial
41:58
in Europe
41:58
called
41:58
a Chopin
41:59
trial of
42:00
hepzato kit
42:00
plus
42:02
immunotherapy.
42:03
The results
42:03
should
42:04
there's
42:04
some prelim
42:05
results
42:05
right now,
42:06
but they're
42:06
very,
42:06
very prelim
42:07
and
42:07
the final
42:08
results
42:08
should be out.
42:09
I would say
42:10
shortly,
42:10
perhaps,
42:11
you know,
42:11
later
42:12
this year,
42:13
which will
42:13
confirm,
42:14
hopefully
42:15
confirm
42:15
the safety
42:16
of,
42:17
let's say
42:17
Nebo
42:18
and ipi
42:18
with
42:19
hepzato
42:19
kit.
42:19
Enough.
42:20
But
42:20
honestly,
42:20
I don't
42:20
foresee
42:21
any issues.
42:22
Okay.
42:22
Awesome.
42:23
and just
42:24
just for,
42:24
you know,
42:25
brief
42:25
reference
42:26
for anybody
42:26
who's
42:26
looking
42:27
for, like,
42:27
the data
42:27
and the
42:28
studies
42:28
around
42:28
Hepzato
42:29
kit itself
42:29
and like,
42:30
the efficacy
42:30
and how
42:31
well it
42:31
works.
42:32
what where
42:33
where could
42:33
somebody
42:34
find some
42:34
of that
42:34
good data
42:35
on, on
42:36
hepzato kit
42:37
So the best
42:37
data is a
42:38
recently
42:39
released
42:39
trial
42:39
that was
42:40
published
42:41
in the
42:41
Journal of
42:41
Surgical
42:42
Oncology,
42:43
in this
42:43
past
42:44
spring.
42:45
It is
42:45
called the
42:46
Focus
42:47
trial.
42:48
efficacy U.
42:49
S
42:50
and
42:50
the first
42:51
author is
42:52
Doctor
42:52
Zager
42:53
z a g e r
42:55
who is a
42:55
surgical
42:56
oncologist
42:56
at of
42:57
Moffitt
42:57
in Florida.
42:58
So he led
42:59
he was the
43:00
primary
43:00
investigator
43:01
on this
43:01
multicenter,
43:02
international
43:03
trial,
43:04
of hepzato
43:05
kit.
43:05
This is the trial
43:06
that was
43:07
presented
43:08
at a
43:09
oncology
43:09
conference
43:10
in 2023,
43:11
which then
43:12
resulted in
43:13
the FDA
43:14
approval
43:15
in the
43:15
United States.
43:16
And that's
43:17
amazing.
43:17
Okay.
43:17
Well,
43:18
we'll
43:18
make sure
43:18
that we
43:18
link that
43:19
and we'll
43:19
share that
43:20
in
43:20
the focus
43:20
trial.
43:21
just
43:21
so that
43:21
you guys
43:22
can see
43:22
the
43:22
breakdown,
43:23
because
43:23
it's
43:23
amazing
43:24
how like,
43:24
just how
43:25
much
43:25
stronger of
43:26
an efficacy
43:26
that happens
43:27
out. Okay.
43:27
It shows
43:28
in the focus
43:28
trial.
43:28
So
43:29
just as we
43:29
end,
43:30
doctor,
43:30
doctor
43:31
Polya,
43:31
where do
43:32
you see
43:32
the future
43:32
going
43:33
for out?
43:33
Okay,
43:33
now
43:34
that we're
43:34
just a
43:34
year out
43:35
from FDA
43:35
approval
43:35
from last
43:36
summer.
43:38
So I see
43:39
a couple
43:39
of things.
43:39
Number one,
43:40
in
43:40
the short
43:41
term,
43:41
I see
43:41
several
43:42
technical
43:42
improvements,
43:43
that we can
43:44
potentially
43:44
make,
43:45
to make
43:46
the
43:46
procedure
43:47
easier and
43:48
faster and,
43:49
more
43:50
adaptable
43:50
to other
43:51
institutions
43:52
as well.
43:53
One of
43:53
the
43:53
things
43:53
I didn't
43:53
mention is
43:54
it does
43:54
take a
43:55
good amount
43:55
of
43:55
coordination
43:56
between
43:57
intervention,
43:57
radiology,
43:58
anesthesia
43:59
and a
44:00
perfusion
44:00
team which
44:01
handles
44:02
the
44:02
filtration
44:03
of
44:03
the medication.
44:03
So a large
44:04
part of us
44:05
setting
44:05
this up
44:06
at our center
44:06
at UCLA,
44:07
we spent
44:08
about
44:08
six months
44:08
prepping
44:09
this,
44:10
between
44:10
the three teams
44:11
so we could
44:11
work,
44:12
seamlessly
44:13
in the room
44:14
and the
44:15
room.
44:15
For
44:15
example,
44:15
there's
44:16
about 10 to
44:17
12
44:17
different
44:17
personnel,
44:18
working
44:19
on this
44:19
one
44:19
patient.
44:20
And so
44:20
we want
44:21
to make
44:21
sure that
44:22
everything
44:22
goes well,
44:23
seamlessly,
44:24
especially
44:24
from a
44:25
communication
44:25
standpoint.
44:27
so I think
44:27
that we
44:27
can make
44:28
a lot
44:28
of
44:28
improvements
44:29
in that,
44:29
in terms
44:30
of the
44:30
technical
44:30
know how
44:31
and
44:31
capabilities
44:32
of the
44:32
procedure.
44:33
there's
44:33
probably
44:33
some
44:34
improvements
44:34
we can make
44:34
in
44:35
the filter
44:35
as well
44:36
to change
44:37
or vary
44:38
how much of
44:39
the chemo
44:40
gets
44:40
withdrawn.
44:41
we need to
44:43
further
44:43
refine the
44:44
patient
44:45
population.
44:46
I would
44:46
love to
44:47
figure out
44:48
in the next
44:49
3
44:49
to 4 years
44:51
who it's
44:51
going to
44:51
work in
44:52
and
44:52
who it's not,
44:53
because
44:53
what
44:53
I would
44:53
like to do
44:54
is see
44:55
this person
44:56
in
44:56
my office
44:57
before
44:57
the
44:57
procedure
44:58
and say,
44:59
this is
44:59
going to
44:59
work
45:00
in you,
45:00
or even
45:01
conversely,
45:02
this is not
45:03
going to
45:03
work
45:03
in you.
45:04
I want to
45:04
offer
45:04
something
45:05
else.
45:05
right now,
45:07
we kind of
45:08
offer this
45:08
in all
45:09
patients
45:09
with
45:10
multifocal
45:11
tumors
45:11
throughout
45:12
their
45:12
liver.
45:13
It doesn't
45:14
work in
45:14
everyone.
45:14
And
45:15
we would love
45:15
I
45:15
would love
45:16
to figure
45:16
this out
45:17
as to
45:17
who it's
45:17
going
45:18
to work
45:18
in, who
45:18
it's not
45:19
in a way
45:20
similar to
45:21
tebentafusp
45:22
in a
45:22
certain
45:22
HLA
45:23
subtype.
45:23
We know
45:24
it works
45:24
in those
45:24
patients.
45:25
It does not
45:25
work in
45:26
the other
45:26
HLA
45:27
subtype.
45:27
So,
45:28
if I could
45:28
figure out
45:29
a marker
45:29
or
45:30
some kind
45:31
of way
45:33
to
45:33
prognosticate
45:35
people
45:35
to say that
45:36
it's
45:36
going to be
45:37
a success
45:37
or it's
45:38
not going
45:38
to be
45:38
a success,
45:39
I think
45:40
that's the
45:40
next option
45:42
or the
45:43
next,
45:43
advancement
45:44
for this
45:45
therapy.
45:46
Now, I
45:46
love that.
45:48
Well,
45:48
Doctor
45:48
padia
45:49
this has
45:49
been
45:49
incredible.
45:50
Thank you
45:50
so much
45:51
for joining
45:51
us today.
45:52
And
45:52
those of
45:52
you who are
45:52
listening,
45:53
please
45:53
make sure
45:53
to
45:54
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45:54
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45:55
newsletter.
45:55
If you
45:55
go to
45:56
our website
45:56
at
45:56
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45:57
.
45:58
And,
45:58
just a huge
45:59
thank you
45:59
to our
45:59
sponsors,
46:00
Castle
46:01
Biosciences
46:01
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46:03
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46:03
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46:09
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46:10
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