Imaging based Hepatology with Jeffrey Weinreb

Transcript

• 00:19Welcome back to the Yale
• 00:22Liver Diamond Jubilee.
• 00:24This session is being recorded.
• 00:26The Q&A for these sessions will
• 00:28happen at 5:15. Thank you.
• 00:32So this is the final session of
• 00:34the afternoon. I'm rob Goodman.
• 00:36I'm chair of radiology at
• 00:37Yale and it's my pleasure to
• 00:38introduce our first speaker.
• 00:40My colleague Jeff Weinreb,
• 00:41who is a professor of radiology
• 00:42and biomedical imaging and national
• 00:44authority on liver imaging,
• 00:45and helped define the Lie RADS
• 00:48classification criteria, Jeff.
• 00:59Oh
• 01:02not opening.
• 01:06You can't see my screen Canyon.
• 01:09You see, you've not just slides.
• 01:11Not yet. I'm hitting.
• 01:13I'm hitting, let's see desktop share.
• 01:18Open system preferences is
• 01:19what I'm getting, what's that?
• 01:25We can pull them up for you, Jeff
• 01:27no well, the slides are different
• 01:28than what you have, unfortunately.
• 01:32Why is it not opening here?
• 01:43Thanks share screen,
• 01:45share screen and then I'm getting
• 01:47open allow zoom to share your screen
• 01:49open system preferences is the.
• 01:54And then nothing's happening.
• 01:58Are you on? You're on a Mac or a PC.
• 02:02I'm on a Mac on a Chrome.
• 02:07And never had this
• 02:07problem before. Well,
• 02:09you know what I'll just wing it.
• 02:11Just bring up those slides,
• 02:12but I'll it's going to be a mess
• 02:14because they're not the ones that
• 02:16I wanted to use.
• 02:18Alright thanks, OK sorry about that.
• 02:22I'm gonna talk about.
• 02:25Image based hepatology.
• 02:27I'm going to focus on only one
• 02:30thing because this is a very broad
• 02:32topic and I thought it'd be more
• 02:34useful to just focus on one thing.
• 02:36I'll also tell you that the slides
• 02:38I'm using are not the ones I.
• 02:41Prepared, so I'm going to be jumping around,
• 02:43skipping some slides and I'm going to
• 02:46focus mainly on using imaging CT and Mr.
• 02:50Four. It's not advancing.
• 02:51You want to advance it for me.
• 02:54Yeah, you have to. This is going to be tough.
• 02:57OK, I have no disclosures.
• 02:58I'm gonna focus on HCC.
• 02:59Go ahead next.
• 03:03So I think everybody who's participating
• 03:05in this conference knows that imaging
• 03:07plays a pivotal role in the diagnosis
• 03:10and staging and management of patients
• 03:11with or at risk for HCC and you've
• 03:14all in the past gotten reports.
• 03:17Those of you who are clinicians
• 03:19from radiologists that are just a
• 03:22mess and unintelligible in dealing
• 03:24with this difficult disease.
• 03:25So in 2008, Claude Sirlin from UCSD
• 03:28contacted me and a few other people,
• 03:31and we talked about standardizing.
• 03:34The acquisition, interpretation,
• 03:35and reporting of these reports,
• 03:38and this is the origin of Lyra's.
• 03:40Next slide, please.
• 03:44So Lyrans has been developed
• 03:46and refined over many years.
• 03:48Have been many contributors,
• 03:49including Mario,
• 03:50Strassen, Bosco and next.
• 03:56The most recent version is
• 03:58version 2018 and this isn't very
• 04:00important because up to this point,
• 04:02myriads and the ASLD had somewhat
• 04:06divergent criteria for diagnosing
• 04:09HCC on imaging and through
• 04:12collaboration from both organizations.
• 04:15The ACR and ASLD they came
• 04:17up with a unified guidance,
• 04:19and this is what we're using today next.
• 04:24And this has been translated
• 04:25into many languages now,
• 04:27so it's being used widely around the world.
• 04:29With a few exceptions. In Europe,
• 04:31they've developed their own guidelines,
• 04:34which are performance wise,
• 04:36apparently equivalent to LYRANS,
• 04:38but it probably be useful if
• 04:41everybody used the same ones.
• 04:42We're not there yet next.
• 04:47Well, this is the basic algorithm for lyrae's
• 04:51for diagnosing and management debate.
• 04:54CC and it starts with ultrasound and if
• 04:56there's a finding on ultrasound then
• 04:59the patients would go on to a contrast,
• 05:02enhance them are or see T and based
• 05:04on what the findings are and in
• 05:07lyrids have called observations,
• 05:09they're categorized from one to
• 05:12five based on the probability that
• 05:15it represents an HCC.
• 05:17Is also a category for non
• 05:20HCC malignancies. Next
• 05:25next again, I'm going to
• 05:28have to skip over slides.
• 05:30Just jump ahead, keep going.
• 05:31You're gonna have to jump ahead
• 05:32a lot here, and I apologize I.
• 05:36I'm not sure why this doesn't work.
• 05:37Keep going, keep going.
• 05:40Keep going.
• 05:42You don't have time for these,
• 05:43keep going.
• 05:46Keep going. Keep going.
• 05:51OK, stop there.
• 05:53Oops, go back. OK, so.
• 05:57Actually go to the next slide.
• 05:58Sorry about that.
• 05:59Go to the next slide.
• 06:01So I'm going to rather than
• 06:02trying to cover everything,
• 06:04I'm going to just point out
• 06:06A5 areas where I think image
• 06:09being based hepatology is
• 06:11going decently HCC next.
• 06:16So the first you already
• 06:18heard about up till now.
• 06:22Lie Rads and ASLD guidelines are the same,
• 06:27but OP TN uses somewhat different guidelines
• 06:30and this results in some problems.
• 06:32So as you heard from David Mulligan,
• 06:35there's now an effort to harmonize
• 06:37OPT N with liraz and that'll be
• 06:40very useful going forward next.
• 06:45Next, let's talk about surveillance.
• 06:48Currently, HCC surveillance and at risk
• 06:51populations is done with ultrasound semi
• 06:54annually and part of the reason for
• 06:56this is that you know ultrasound works,
• 06:59but it's also very widely available
• 07:02and relatively inexpensive.
• 07:04But we all know that ultrasound is limited
• 07:07sensitivity for earlier small HCC's,
• 07:09especially in patients with advanced
• 07:12cirrhosis and conditions such as a.
• 07:15Obesity and steatosis,
• 07:16in other words, in Americans next.
• 07:22So there's very good data showing that
• 07:25CT and MRI have significantly higher
• 07:28sensitivity for HCC then ultrasound,
• 07:31but we do have these concerns
• 07:33about cost and availability next.
• 07:37So one of the future directions
• 07:41for imaging of HCC is to narrow the
• 07:45cost and availability gaps using
• 07:48abbreviated MRI techniques or protocols,
• 07:52and these have been developed
• 07:53over the last few years.
• 07:55They're still undergoing some testing,
• 07:57but there's a fair amount
• 07:59of data out there on this,
• 08:00and the idea here is that instead of
• 08:03the exam taking about 1/2 hour or so.
• 08:07Or longer that the patient gets
• 08:09injected with a hepatobiliary agent
• 08:12outside the MRI room and then at
• 08:14your leisure you put the patient
• 08:16in the scanner and do a limited
• 08:18number of imaging pulse sequences
• 08:21so that the total scan time is
• 08:24down to about 5 minutes rather than
• 08:27what we are currently using.
• 08:29And not only could this in theory,
• 08:31at least in a in a health system
• 08:35where you're rewarded for.
• 08:37Or or where you can actually
• 08:39cut the reimburse payment,
• 08:41which we don't have now.
• 08:44A less expensive exam,
• 08:45but equally as important
• 08:47by doing shorter exams,
• 08:48we increase the accessibility
• 08:50of the availability of MRI.
• 08:52Now this will probably work in
• 08:57places like the United States and
• 08:59parts of Europe and Asia where
• 09:02there's an abundance of MRI scanners.
• 09:04Probably not going to be that
• 09:06useful in those parts of the world.
• 09:08But you don't have a lot of MRI scanners,
• 09:12and probably what we're going to end
• 09:14up with is some kind of a refined algorithm,
• 09:17hopefully based on data that
• 09:18will get in the future.
• 09:20That indicates which patients
• 09:22should undergo surveillance with
• 09:24ultrasound and which patients
• 09:26should go directly to MRI or CT.
• 09:29Informally, that's already happening,
• 09:31but it's not written into
• 09:33really any guidelines next.
• 09:39And as far as the costs go,
• 09:42the the reimbursement for MRI has been
• 09:45steadily going down over the years.
• 09:48It's actually not a whole lot more than a
• 09:51CT scan or even ultrasound at this point,
• 09:54at least from Medicare.
• 09:55And there are now some early studies
• 09:58showing that by various measures,
• 10:01including quality adjusted life years,
• 10:04that MRI can be cost effective for
• 10:06surveillance in the high and intermediate.
• 10:09This patience but more work
• 10:11needs to be done on this,
• 10:12but I think we're headed in this
• 10:14direction in some instances next.
• 10:19Another thing has to do with assessing
• 10:22the biology and behavior and prognosis.
• 10:24So you've already heard that
• 10:26HC's are heterogeneous neoplasm,
• 10:29they have different molecular profiles and it
• 10:33would be nice to use imaging biomarkers to.
• 10:38Determine to differentiate between
• 10:40different types of HDCP and that
• 10:43would help us know have a better
• 10:46idea about prognosis and management.
• 10:49Ideas next.
• 10:51And it turns out there actually are.
• 10:52You can go to the next one too,
• 10:53but we don't have time to go into this.
• 10:55That there actually is some early research
• 10:58showing that with MRI the research in
• 11:01features that do indicate to us what
• 11:03the aggression of the HCC is and what
• 11:07the prognosis is for that type of HCC.
• 11:11This is a developing field,
• 11:13but it's making a lot of progress next.
• 11:17Lyra so of course imaging has a role
• 11:20in treatment response and we all know
• 11:22that CT and MRI play a central role
• 11:24in assessing treatment response next.
• 11:29So there is now a lyres treatment response.
• 11:35Algorithm and these are the categories
• 11:38that you see and we were a little
• 11:40late in adapting this at Yale,
• 11:42but we've been using it now
• 11:44since January and it seems to
• 11:46be working fairly well next.
• 11:49But of course there's a lot of
• 11:52different therapies for HCC,
• 11:54and even as you already heard from
• 11:56a Dave Medoff that there's a lot
• 11:59of local regional therapies next,
• 12:01and what we're learning is that.
• 12:05Assessment of treatment response for each
• 12:08one of these therapies may be different.
• 12:11They may have different criteria.
• 12:13Next so for and and you can
• 12:18go to the next one also.
• 12:20And so this is a paper that just came
• 12:24out which is talking about using.
• 12:27Lira has criteria for stereotactic
• 12:29body radiation therapy assessment
• 12:31and it turns out that the criteria
• 12:33are going to be different than what
• 12:35we're using for other therapies.
• 12:37Now we were really struggling right
• 12:39now is with things like transarterial,
• 12:42Y-90, radioembolization.
• 12:43Lyres just doesn't work there,
• 12:46so we're probably in the future
• 12:48going to have different criteria for
• 12:51assessment of response to each of these
• 12:54different types of treatments next.
• 12:59And finally, and this is a theme that
• 13:02you've already heard during this symposium.
• 13:07This is gonna be get to be very complicated
• 13:09and most of us have limited neurons.
• 13:11It's going to be very hard to put
• 13:14this all together without the help of
• 13:16a deep learning and and and the AI.
• 13:19And so I think this is going to play
• 13:21a really big role going on into the
• 13:24future and you'll hear more about this
• 13:26from one of the following speakers.
• 13:28Julia Shapiro next.
• 13:32So in summary, imaging based
• 13:34hepatology has a great future.
• 13:37I didn't talk about any of
• 13:39the technological advances.
• 13:40I didn't talk about the advances
• 13:42we're seeing in ultrasound,
• 13:43nuclear medicine, contrast agents,
• 13:45photon counting, ECT.
• 13:47Faster and more motion free
• 13:50MRI and improved assessment of
• 13:53metabolic diseases metastases.
• 13:55Colangelo carcinoma all of
• 13:57these things are happening and
• 13:59so just keep paying attention.
• 14:02Thanks.
• 14:13After one share the screen,
• 14:14can you one share the screen for me?
• 14:19It's not sharing anymore.