Embolization: To infinity and beyond

Embolization to infinity and beyond

Where we’ve been, where we’re going, and how the evolution has transformed IR. A summary from honorary GEST 2022 guest lecturer, Mike Darcy, Washington University School of Medicine.

The first documented embolization procedure appeared in JAMA in 1904. Since then, the technical aspects have evolved, new applications have been developed and IRs themselves have evolved. The challenges in the early days of embolization were found in large delivery catheters, crude embolic materials and basic imaging – all of which have advanced to enable more precise and increasingly smaller delivery.

All of these technological advancements along with innovative IRs that are using them have allowed us to move into almost every organ system and disease indication including bleeding at other sites beyond GI, devascularizing tissue, oncologic agent delivery, blocking abnormal channels, treating pain or inflammation, and treating medical conditions such as hyperthryoidism, obesity, and fertility among others.

Of all the advancements in the last 30 years, perhaps the most significant is embolization as a therapeutics delivery mechanism. Personalized medicine is becoming more and more important for targeting specific tumor types at specific regions with specific types of therapies. This makes embolization well adapted to play a major role in personalized medicine.

These advancements have also helped our development as a clinical specialty. Often times IRs are the only physicians treating the patient. We’ve become a vital part of a number of service lines (ex. trauma, transplant etc). Embolization (IO) has become the 4th pillar in oncology and IR embolization is often the court of last resort (ex. HCC, pelvic trauma, massive GI bleeding, and AVS that are unresectable with no medical options). The advancements in embolization have helped solidify our role as a clinician.

Even such, there is a ways to go and challenges ahead such as a better understanding of the field, competition from other specialties (TURF), and lack of support for clinical practice. The key going forward is to continue to provide a better product and service, determine the best indications for existing techniques, continue innovating, and elevate training and education. For that reason, it is conferences and communities like GEST that continue to provide the education and support, thereby advancing embolotherapy in IR.

“…the knowledge on the part of the patient that by this method he has one more chance, though all other plans have failed, and the growth beyond excision, restores his courage and cheerfulness and puts aside the imminence of despair. As a surgeon has phrased it, we substitute in such a case, instead of the certainty of death, once more the uncertainty of life.” Dawburn (1904) JAMA 43:792.

The way we see it…Embolization – to infinity and beyond!

The role of IR/IO in managing liver tumors.

Role of IR/IO in managing liver tumors

The role of Interventional Radiology (IR/IO) in the management of primary liver tumors, hepatocellular carcinoma, and liver mets – a summary from GEST 2022.

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the third most common cause of cancer related death. Resection, ablative therapies, transarterial chemoembolization (TACE), radioembolization, systemic, and immune therapies are all treatment options available and selection is dependent on tumor burden, location, and comorbidities.

Immunotherapy is an increasingly popular approach to cancer treatment. Data shows that the objective response rate in a multitude of cancers is low (between 20-30%). Why is this, what can be done about it, and why should IR/IO care?

A review of many exciting and potential immunotherapies show that while there is promise in preclinical and phase I and II clinical trials, there is a high failure rate in phase III, indicating the importance of effective delivery. If the drug works perfectly but can’t get into the tumor, it’s still not going to do anything. There is where IR comes in!

IR is the key stakeholder in any intratumoral immunotherapy program. The job of IR/IO is to get the therapy where it needs to be. Of course, it’s not as simple as that. There are many physical barriers to delivery. But there are many tools in the toolkit and many tricks up the IR sleeve.

"The abscopal effect is real and image-guided cancer therapies may be the key to unlocking an immunotherapy’s potential. IR/IO plays a key role in how, what, and where these are delivered. But as with any intervention, technique matters! Getting it right can make a positive difference, getting it wrong can have a negative influence on the immuno environment.”

Innovation and the Entrepreneurial IR

12 rules for physician entrepreneurs

Each year during the Annual GEST conference, we focus on innovation and how you push forward a new idea. Below is a summary from the Innovation sessions at GEST 2022.

Some of the most challenging clinical scenarios have paved the way for some of the landmark IR procedures. Recognizing a clinical unmet need is often where ideas start. So you have an idea – what are you going to do with it? What are the opportunities and what are the challenges in going from idea to implementing a new procedure, developing a new product, starting a new company, or commercializing a concept? How do you go from idea to equipment to proof to patients to payment to regulation?

GEST Innovation sessions focused on thinking outside the box when it comes to the Entrepreneurial IR. Guidance for who to collaborate with and when, the initial studies needed, developing a plan, finding the funding, taking the necessary steps to move it forward, getting new devices into humans, and protecting your IP. Of course, no session on innovation and entrepreneurship would be complete without covering hard lessons learned from the pioneers that have gone before us.

12 Rules for Physician Entrepreneurs presented by Dr. Lindsay Machan, University of British Columbia

  1. Know what you know…know what you don’t know
  2. Appropriately value the other skill sets needed to get across the goal line.
  3. Only do what only you know how to do.
  4. Bring on board members with knowledge and experience that the company needs and you don’t have.
  5. Hire for attitude and team-fit first and experience second
  6. Appropriately value the impact of timing on success.
  7. Bootstrap as long as you can.
  8. Know your critical path… always have a plan B.
  9. Everything takes twice as long and costs twice as much as you think it will.
  10. Be reasonable about your valuation… leave money on the table for all investment rounds.
  11. You have to be a salesman 24/7.
  12. No jerks…. ever!

Embolization for MSK and Sports Injuries

MSK at GEST 2022

Musculoskeletal pain is a leading cause of disability among aging patients in the U.S. Many with chronic pain are unable to get adequate relief from traditional pharmacologic therapies. Others may not be able to take them due to age or comorbidities. Attention has turned to embolotherapy as a safe and minimally invasive procedure to treat MSK pain.

MSK sessions at GEST 2022 were standing room only. Attendees were given an update on the research using embolotherapy for joint disease and MSK sports injuries.

With most IRs lacking in depth experience in MSK, there was high interest in the educational sessions which covered an overview of embolization techniques for OA, frozen shoulder, and sports injuries. Attendees also learned about patient selection and what outcomes resulted from these procedures as well as what future studies would need to encompass to receive acceptance by referring physicians.

Due to the popularity of these sessions and the need for IRs to understand how to examine and diagnose a patient to determine if they are a candidate for an interventional procedure, we are thrilled to announce our first focused Hot Topic Meeting on MSK.