CHEMOEMBOLIZATION AND OTHER METHODS OF THE ADVANCED-STAGE CANCER TREATMENT – Prof Dr med Thomas Vogl

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Prof. Dr. med. Thomas Vogl is an outstanding radiologist who has devoted more than 40 years to X-ray diagnostics, interventional radiology, neuroradiology, and nuclear medicine. At the beginning of his career, Prof. Vogl mainly practiced diagnostic examinations, but now his medical team has developed and introduced into clinical practice many personalized treatment procedures that are used for benign and malignant conditions.

Prof. Vogl sees patients at the University Hospital Frankfurt am Main. For more than 20 years, he has been heading the Department of Adult and Pediatric Diagnostic, Interventional Radiology. In the interview, the professor tells us about the treatment of advanced stages of cancer, including stage four cancer, using chemoembolization, a minimally invasive procedure that can successfully fight primary tumors and multiple metastases in the liver, lungs, and other organs. You will find detailed information about the specialized hospitals that use chemoembolization and the average cost of treatment on the Booking Health website. 

Hello! Today we are at the University Hospital Frankfurt and we have an expert interview with the famous Prof. Dr. Vogl on the topic "Chemoembolization".

Prof. Vogl, thank you very much for agreeing to the interview! We are very happy to meet you! Could you please tell us about yourself?

My name is Thomas Vogl. I am an Ordinary Professor and Head of the Department of Radiology. I have been working at the University Hospital Frankfurt am Main for 23 years. Prior to that, I worked at the Charite University Hospital in Berlin and had my clinical training in Munich. I specialize in diagnostic imaging. We have also developed many procedures that are used to treat patients with certain diseases.

Prof. Vogl, for how many patients do you perform chemoembolization procedures every year? How many patients come to you from abroad? 

This is a rather difficult question. I will say: every day we perform about 8-10 regional chemotherapy procedures. Based on these figures, you can draw your own conclusions about the number of procedures per year. Chemoembolization is performed for tumors in the liver, lungs, and pelvic organs, as well as neoplasms in soft tissues and extremities. As for foreign patients, it is difficult for me to give specific figures. Certainly, before the coronavirus pandemic, more people came from abroad.

Today, we are gradually reaching the number of foreign patients that we had before the pandemic. The difference, however, still persists. I can say that 10-20% of patients come to us from abroad.

Could you please tell us more about the mechanism of action of chemoembolization?

The term "chemoembolization" is the injection of a chemotherapy drug into the human body, into an organ, or into a tumor, and the term "embolization" is the occlusion of blood vessels. The procedure is very complex. It combines a targeted effect on the tumor with chemotherapy drugs, followed by the injection of emboli that block the blood supply to the tumor.

We pursue three goals. First, unlike classical chemotherapy, we want to ensure the most targeted injection of chemotherapy drugs. To do this, before the procedure, a patient undergoes a comprehensive examination, which includes an MRI, CT scan, and angiography. These examinations also allow for the identification of the blood vessels supplying the tumor. That is, we know exactly how to deliver chemotherapy drugs to a malignant focus. Following the injection of chemotherapy drugs, the lumen of the blood vessel is closed with miniature balls (emboli). These provide embolization, due to which chemotherapy drugs act on the tumor for as long as possible and dissolve over time. Our goal is to help patients with cancer. For example, when a patient has many metastases in the liver, lungs, pelvis, or other organs, we try to reduce the tumor burden on the human body.

Prof. Vogl, what is the reason for the high efficiency of the procedure?

It is important to understand that there is no single procedure that would be 100% effective. We have extensive experience in the treatment of various tumors, and I am a qualified radiologist and oncologist, which is a distinctive feature of our center. And, of course, I have deep knowledge in the field of chemotherapy. We are also happy to cooperate with oncologists, specialized doctors, and many other of our colleagues.

Not a single regional therapy is carried out without the involvement of specialists from related medical fields. We always try to maintain contact with the hospital where a patient received primary care, regardless of which country they came to us from, as we strive to bring all the elements together. I am convinced that this is a very important point. A patient who has been diagnosed with oncopathology needs a person who will supervise the treatment process, the so-called "medical guide." And of course, the patient needs good and qualified specialists with extensive experience.

What are the main differences between chemoembolization and systemic chemotherapy?

It is necessary to understand which tumor is the primary one. There are tumors, the localization of which does not change throughout the entire period of the tumor's "life", so to speak. For example, the tumor is localized in the liver and does not spread to other organs. In this case, local chemotherapy is perfect for treatment because the tumor is localized only in the liver, so this organ is the main target.

Unfortunately, there are more complex cancers, for example, colon cancer with metastases or breast cancer. Breast cancer is always a systemic disease. This means that patients with breast cancer or prostate cancer always have malignant cells in other organs. In such cases, a patient needs to undergo a course of therapy that affects the entire body. This may be chemotherapy or immunotherapy, which is now an advanced treatment method. Even after such therapy, large malignant foci may remain in the liver, lungs, and other organs. In such a situation, we can definitely help the patient destroy neoplasms in these organs.

This is a complex process that largely depends on the treatment performed.

I have to say that chemoembolization and systemic chemotherapy complement each other well. For many of our patients, we also prescribe additional oral chemotherapy drugs. They are well tolerated at low doses.

We use this approach because we always believe that we can achieve a good result with regional therapy, but there is a risk that new oncological foci may appear over time. Such cases become a huge disappointment for us.

Prof. Vogl, how different is the effectiveness of chemoembolization from systemic chemotherapy?

The advantage of systemic chemotherapy is its effect on almost all organs in the human body. However, there is one organ protected by its own barrier, and that is the brain. Most chemotherapy drugs do not penetrate the brain, so other methods are needed to kill cancer cells in this organ. Thus, the advantage of systemic chemotherapy is that, with its help, the doctor can destroy cancer cells throughout the body. The advantage of regional chemotherapy, or chemoembolization, is that it allows for the destruction of the metastases that develop in many patients in the liver, lungs, bones, and soft tissues. In such cases, systemic chemotherapy is not particularly effective because the chemotherapy drugs are distributed throughout the body. If, when assessing the results of systemic chemotherapy, the attending physician comes to the conclusion that the oncological focus is not decreasing or the patient has new metastases, for example, in the liver, then local therapeutic procedures will be discussed. This is the advantage of chemoembolization.

Metastases in what organs can be suppressed by chemoembolization?

First of all, these are liver metastases, which pose a serious threat to the patient's life. These are liver metastases that are the main cause of death. The spread of metastases from breast, colon, pancreatic, or uterine cancer to the liver is one of the causes of death. This explains our specialization: up to 70% of clinical cases in our work involve chemoembolization due to oncological processes in the liver.

The second most common type of cancer in our practice is lung cancer. As a rule, lung neoplasms do not cause any pain, but the presence of multiple lung metastases also worsens the patient's prognosis. However, we have effective procedures for such patients. Bone metastases are treated with chemotherapy combined with radiation therapy or surgery. This approach is somewhat different but still allows for good outcomes, for example, in the treatment of metastases in the pelvic bones.

Prof. Vogl, how does chemoembolization work, for example, for liver metastases?

Treatment begins like this: a patient who wants to undergo chemoembolization comes to us, or the patient's oncologist informs us that liver metastases continue their growth after a course of systemic chemotherapy. What are we doing? First of all, we perform 3D imaging and assess the anatomy of the patient's vascular system to see if chemoembolization is technically possible.

This is the main part of the scanner that allows for performing rotational movements at different levels. A patient takes a lying position on the table of the device, after which a 3D body scan is made (see video).

CHEMOEMBOLIZATION IN GERMANY - Prof. Thomas Vogl

After the intervention, the patient, depending on their condition, either stays in our department or continues treatment in a day clinic located on the top floor. The intervention is relatively simple, so the patient either stays here for about an hour or is transferred to the day clinic for treatment. It is good that everything in the hospital is in close proximity, and we always have the opportunity to monitor the condition of patients.

The purpose of the procedure is to achieve a high concentration of chemotherapy drugs in the oncological focus. We have determined that, for example, when using Cisplatin during chemoembolization, we can achieve a dose of the drug up to 15 times higher than with systemic chemotherapy. We can say that local chemotherapy is the destruction of the tumor with "poison." I always tell patients that this is quite a toxic treatment.

It is impossible to know in advance which dose will be optimal. We therefore simply deliver the highest possible dose of chemotherapy drug to the target area in order to destroy as many tumor cells as possible.

How is treatment usually planned for patients with liver cancer?

Speaking of liver cancer, one should distinguish between secondary (metastatic) liver tumors due to other types of cancer and primary liver tumors. There are two main primary types of liver cancer: one occurs due to fatty liver disease and alcoholic liver disease, and the other is due to a bile duct tumor against the background of chronic inflammation. After we determine which of these types of cancer the patient has, we meet with colleagues and discuss further treatment tactics.

Special liver tumor boards are held in our department. At such tumor boards, we discuss the patient's clinical case with the surgeon. I ask the surgeon if he can get the best results with surgery. In rare cases, it is also possible to perform a liver transplant, which is a major and complex surgical procedure but, at the same time, offers a real chance of curing certain types of cancer. I discuss with oncologists the possibility of systemic chemotherapy or immunotherapy. Only then can regional chemotherapy be considered.

Prof. Vogl, can chemoembolization be considered a treatment for lung cancer?

The approach to treating lung cancer with chemoembolization is the same as that for liver cancer. If classical chemotherapy does not work and immunotherapy does not give the desired result, we can perform regional administration of chemotherapy drugs. We developed this treatment method and conducted our own research on its effectiveness, the results of which we use. Research results show that chemoembolization can stop tumor growth and achieve a certain tumor shrinkage.

It is extremely important to understand that regional chemotherapy cannot completely cure lung cancer, although this is already known to everyone. There are patients who will live for ten years after such treatment. In such cases, we can talk about a cure for cancer. I would say that it is a miracle, but, of course, miracles do happen.

What results can patients with stage 4 cancer and multiple organ involvement expect?

Here, everything again depends on what kind of cancer the patient is diagnosed with. For example, women with even stage 4 breast cancer are in relatively good health for a long period of time. In the case of stage 4 colon cancer, things are much worse. For patients with pancreatic cancer, there is practically no chance of recovery, but it is still worth trying to undergo treatment. There are patients who struggle. They receive many concomitant therapies and immunotherapies. Many of them also resort to the methods of complementary medicine. Personally, I don't particularly support the latter, but I think there's nothing wrong with it. Of course, a person thus prolongs their lives because they have faith and hopes for recovery, unlike those who give up. Once, I worked under the supervision of the head physician, a very well-known oncologist and radiologist. He always said, "You must look into the patient's eyes." Of course, if I cannot see any fire in the patient's eyes and he has no motivation, then, in my opinion, it is better not to take up his treatment at all. This is where motivation plays an important role. In addition, it should not be the motivation of children who want their father to live a few more months but the fire in the patient's eyes and his desire to fight. It is also worth thinking about side effects and the fact that therapy may be unsuccessful or cause complications. The patient may die, as there is a risk of death during the operation, although this happens extremely rarely. I believe that communication with the patient is very important. And I will also say this: having a conversation with the patient is one thing, but when he comes into my office and I look into his eyes, I understand whether he has a chance for a cure or not.

Prof. Vogl, are there any contraindications for chemoembolization?

Yes, there are. And what is more, contraindications are quite serious. If we talk about liver cancer, first of all, it is worth considering that patients may have jaundice. With elevated liver enzymes, no matter how elevated the concentration of one or another enzyme, the patient needs appropriate treatment. Patients with lung cancer have other problems, among which are difficulty breathing and shortness of breath. For example, chemoembolization is difficult to perform in women with breast cancer that has metastasized to the lungs. However, every effort must be made to help the patient.

Is there any control examination before the intervention?

Yes, there is. We always conduct it so no patient can lie on the table of the CT scanner for treatment before imaging studies are made. This is because we want to rule out any contraindications for chemoembolization and assess the size of the neoplasm. The examination before the procedure allows us to find out if the patient has inflammatory processes, contraindications to regional chemotherapy, or thrombosis. Perhaps the secret of our successful clinical practice is that no patient can lie on the table of the CT scanner for treatment until imaging studies have been completed.

Prior to the intervention, I analyze the patient's scans, so after chemoembolization, I can assess whether the size of the tumor has increased or decreased, what the tumor looks like, whether the patient has ascites, etc. Perhaps this is the advantage of regional chemotherapy over a classical one. Imaging tests are carried out regularly: first every two weeks and then every three months.

Just four weeks after chemoembolization, I can tell if the procedure was effective. If the procedure did not give the desired result, I have two further options: stop the course of treatment or change the chemotherapy drug. With the latest scans in hand, I can act much faster. The treatment process is simplified by the fact that I am a radiologist and have all the necessary resources.

Can chemoembolization be combined with other treatments?

It is important that chemoembolization, microwave ablation, or laser treatments are not used independently but as part of a comprehensive cancer treatment regimen. Today, oncology is based on four pillars, the first of which is surgery, if possible. This is followed by chemotherapy and immunotherapy, as well as radiation therapy or interventional oncology methods.

These four areas of treatment must be used in combination. This is the principle we use on our tumor boards when discussing a clinical case. For example, the surgeon raises his hand and says that he can resect the tumor today, I suggest microwave ablation, the oncologist says that he can carry out chemotherapy, and the radiation therapist offers irradiation. The final choice is up to the patient.

What do we offer in our department? For example, when a patient seeks help and does not know what treatment he wants to receive, he will receive offers in all four areas of cancer treatment. And the advantage of Germany is that the patient can decide for himself what kind of treatment he will undergo. In other countries, such as the UK, things are different. During the tumor board, doctors determine what kind of treatment will be provided and carry it out, or there is no tumor board at all.

During treatment in Germany, the patient can communicate with the doctors participating in the tumor board. For example, the patient may go to the surgeon and, looking into his eyes, ask if he can really perform the operation, or he may come up to me and, looking into my eyes, ask me whether I can really carry out a chemoembolization procedure.

We only have one life, so deciding on treatment is a very challenging task. However, I am convinced that the ability to make a decision on your own is a great advantage for the patient. And it is great that there is always the opportunity to choose in our center. For example, if a surgeon performs an operation to resect a tumor but cannot remove the entire tumor mass, I can help the patient with chemoembolization. If I am not able to achieve the desired result, there is always the possibility of performing another surgery. In addition, the advantage of the University Hospital Frankfurt am Main is that all medical fields are represented here. For example, a patient suddenly has an acute allergic reaction. In a small clinic, he would be in danger, and our hospital has specialized experts in all areas of medicine. We have the ability to carry out any necessary activities that save the patient's life, while in a small clinic, resources are limited and it would be very difficult to help him.

Prof. Vogl, what advice would you give to patients who have been fighting cancer for a long time and are already disappointed in the treatment?

It can be said unequivocally that psycho-oncologists can help such patients. Psycho-oncological consultations always have a positive impact on patients. And of course, it is worth looking for a doctor who can inspire hope because, without the hope of recovery, nothing will work. For example, in countries such as the Netherlands, Belgium, or Denmark, there are departments that you can go to, and, according to their statistics, if a patient has T3-N1 stage cancer as of December, then the probability that in a year they will still be alive is 50%. This information is actually of no use because you don't know if you are among the 50% of patients who can live another year or more. What I can say for sure is that my team and I are involved in the research activities, and so far we have performed about 9,000-10,000 chemoembolization procedures and 4,000 laser procedures and microwave ablation procedures.

In my opinion, it is impossible to predict how long the patient will live. And I always say that every patient who comes to us is a part of a "scientific study" because they are treated at the university hospital. We therefore have a dual interest: firstly, as a doctor, of course, I want to maximally prolong the patient's life, but, on the other hand, it is also important for me to achieve good results from a scientific point of view. The longer the patient lives, the better. At the same time, research activities allow us to get closer to this goal.

Today I also admitted new patients. I told them that I was ready to take up their treatment. We have mutual interests with them because they want to live as long as possible and, at the same time, have a decent quality of life, and I want to have good statistics on treatment indicators.

Prof. Vogl, thank you very much for the informative interview!

Contact Booking Health

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