Q&A With CIO Course Director Ripal Gandhi, MD
Clinical Interventional Oncology Course Director Ripal Gandhi, MD, Miami Cardiac and Vascular Institute (MCVI), shared his thoughts on the 9th annual Symposium in Hollywood Florida, Feb. 4-5, 2017.
Tell us about the growing importance of IO and the opportunities for those interested in this practice area.
The exciting field of interventional oncology continues to evolve and has now transitioned from the innovative and early adopter phase to the more mainstream as the 4th pillar in the multidisciplinary care of cancer, in conjunction with medical oncology, surgical oncology, and radiation oncology. Minimally invasive, cutting-edge treatments offered by interventional oncology are often faster, safer, and less painful alternatives to more invasive surgical options. The majority of these treatments are performed on an outpatient basis. CIO is one of the largest scientific meetings in the world dedicated to minimally invasive treatment of cancer and is an excellent opportunity for those interested in this field to be exposed to the most up-to-date knowledge and techniques from national and international leaders in the field.
Describe the CIO experience for someone who has not previously participated.
CIO is a cutting-edge meeting that is different from many other IO meetings in that education is provided in a very practical and interactive approach. The goal is for practitioners to walk away from the meeting with useful clinical information that affects their daily practice. It is valuable to those who are new to the space as well as to seasoned physicians who want to fine-tune their IO expertise. It allows for multidisciplinary discussion of complex cases in a tumor board type setting.
What was exciting about this year’s program?
The Tumor Bootcamp was particularly new and exciting. It provided a multidisciplinary approach to various clinical scenarios, and helped interventional radiologists be prepared to participate in their own tumor boards. We also had a session entitled “Occasional and Exotics,” which exposed attendees to some newer and innovative therapies. The focused year in review sessions, were especially excellent as well as the tips and tricks, and "Must Know" sessions, to name a few.
What are a couple of the newer developments presented at CIO 2017?
SIR-Spheres yttrium-90 (Y-90) resin microspheres
To illustrate the most significant advances established at CIO 2017, the SIR-Spheres yttrium-90 (Y-90) resin microspheres have been included as a category 2A recommended treatment in the latest National Comprehensive Cancer Network (NCCN) clinical practice guidelines in oncology for metastatic colon and rectal cancer to the liver. This designation indicates that there is uniform consensus among the NCCN panel that Y90 radioembolization is an appropriate option in patients with liver-dominant, chemotherapy-resistant metastatic colorectal cancer (mCRC). This recommendation places radioembolization at the same designation as systemic chemotherapy.
We eagerly await the overall survival results from the combination of the SIRFLOX, FOXFIRE, and FOXFIRE global results for patients with colorectal cancer with liver metastatic disease treated with radioembolization in a first line setting. These results will be available this year and will surely be a focus for significant discussion during CIO next year.
Peptide receptor radionucline therapy (PRRT)
Additionally, peptide receptor radionucline therapy (PRRT) is going to have a significant role in the treatment of metastatic neuroendocrine tumor to the liver. In the Phase 3 Trial of Lu-Dotatate for Midgut Neuroendocrine Tumors published in the New-England Journal of Medicine in January, there was markedly improved progression-free survival (PFS) in the treatment group. In this study, 229 patients with well-differentiated, metastatic midgut neuroendocrine tumor, received 7.4 GBq of 177-Lu-Dotatate every 8 weeks with 4 intravenous infusions, + 30 mg of octreotide LAR VERSUS octeotide LAR 60 mg alone for 4 weeks.
Results showed that PFS at month 20 was 65.2% in the PRRT VS 10.8% in the control group; the response rate in the treated group was 18% versus 3% in the control group. Fourteen deaths occurred in PRRT versus 26 in the control group. Grade 3 or 4 neutropenia, thrombocytopenia and lymphopenia occurred in 1%, 2%, and 9% respectively in the experimental group only. The study concluded that PRRT resulted in markedly greater PFS and response rate than with octreotide LAR alone. There was a clinically significant myelosuppression in <10% of the PRRT group. Even though overall survival (OS) data is not yet available, this will likely show improved OS. This will change how we treat these patients altogether. I predict that many of these patients will be treated with first line PRRT, and liver directed locoregional therapies such as bland embolization, chemoembolization, and radioembolization will be reserved for progression after PRRT. Future clinical trials combining PRRT with liver directed therapies will be helpful in determining if patients would ideally benefit from combination therapy. It is impossible to review all the new data presented at CIO 2017 in this short summary, but the above illustrate some of the recent significant advances in interventional oncology, the now estabished 4th pillar in the treatment of cancer.