Interventional Radiology in Liver Cancer. Nakarin Inmutto MD

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1 Interventional Radiology in Liver Cancer Nakarin Inmutto MD

2 Liver cancer Primary liver cancer Hepatocellular carcinoma Cholangiocarcinoma Metastasis

3 Interventional Radiologist Diagnosis Imaging US / CT / MRI Tissue diagnosis FNA / Core biopsy Treatment

4 Hepatocellular carcinoma

5 AASLD Every 6 months 1 modality 1 cm No Bx No AFP

6 Hepatoma

7 Hepatoma

8 Hepatoma

9 Arterial phase Portal phase Classic enhancement pattern 24% in tumor size < 1 cm 28% in tumor size 1-2 cm 47% in tumor size > 2 cm

10 MRI

11 Treatment options

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15 Barcelona Clinic Liver Cancer (BCLC) Radiologic tumor extent Liver function Patient s performance status Best chance of predicting patient survival

16 ECOG : PS

17 Child-Pugh Score

18 Interventional Radiologits

19 Local ablation

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21 Ethanol Dehydration Coagulation necrosis Small vessel thrombosis Low cost /Treat in critical site Multiple sessions / Local recurrent

22 PEI

23 PEI

24 RFA Radiofrequency ablation Localised treatment Heat the tumor tissue Temperatures exceeds 60c Imaging guidance: US / CT

25 RFA

26 RFA Alternating current of radio frequency waves Changes in the direction of ions Ionic agitation and frictional heating Coagulative necrosis

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31 Meta-analysis: RFa VS Sx No difference in 1-y and 3-y recurrences

32 TACE

33 TACE

34 TACE TransArterial ChemoEmbolization TOCE TransArterial Oily Chemoembolization Drug + Oil

35 ctace Chemotherapy drug + Lipiodol Selective retained within the tumor Raising the exposure of neoplastic cell to chemotherapy Hepatic artery is occluded

36 ctace ctace Chemotherapy Drug Lipiodol Embolization +

37 Lipiodol Ethiodized or iodized oil (Lipiodol, Guerbet) Iodinated ester derived from poppy seed oil

38 TACE Selectively deliver therapeutic agents to the arterial supply of a tumor Increased concentration of the chemotherapy reaches the tumor To achieve complete tumor necrosis while minimising ischemia to the surrounding liver parenchyma

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41 Performing TACE Catheterization into the most distal portion Lipiodol + drug injection with slight force until overflowing into the portal vein in the embolized area Gelatin sponge slurry injection to completely obstruct the tumor feeding branch

42 Indication Intermediate-stage HCC; Large Multinodular HCC Pre-transplant setting Early HCC in patients unsuitable to curative therapy

43 Contraindication Decompensated cirrhosis Child-Pugh B8 Total bilirubin > 3 Extensive tumor with massive replacement of both entire lobe Severely reduced portal vein flow Main portal vein thrombosis Reverse flow Extrahepatic metastasis

44 Patient preparation NPO 6-8 hr IV fluid LEFT side Clean and shave perineum Foley catheter Inform consent

45 Patient preparation CBC plt PLT > 50, ,000 Coagulation INR < 1.5 LFT TB<3 BUN, Cr

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47 Type a quote here. Johnny Appleseed

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56 Gelfoam slurry

57 Post-procedure care Bed rest Observe bleeding / hematoma / pulse Post-embolization syndrome Pain / NV / fever / leukocytosis Medical treatment

58 End-point Complete necrosis / no viable HCC Progression of disease No response after 2 sessions Metastasis Contraindication for TACE Child-Pugh / LFT

59 Result: HCC Barcelona-Clinic Liver Cancer Group J Hepatology 2003;37: Meta-analysis Results-2 year Survival TREATED 41% [19-63%] UNTREATED 27% [11-50%]

60 Result: HCC CR rate = % 5-year survival rate 26% Matui O, et al. J Hepatobiliary Pancreat Sci 17:407-9, 2010

61 Result: HCC OS = 3.3 years 5-year survival = 34% Takayasu, et al. J Hepatology; 2012

62 Cholangiocarcinoma

63 Interventional Radiologist Diagnosis US / CT FNA / Biopsy Treatment PTBD Preoperative Palliative

64 Diagnosis: CT scan

65 Diagnosis: CT scan

66 Aspiration for cytology

67 Core needle biopsy

68 PTBD

69 PTBD Percutaneous biliary drainage External drainage

70 Indication Biliary obstruction Malignancy Stricture Cholangitis or infected bile Bile duct injury or bile leak

71 Contraindication Uncorrectable coagulopathy Multisegmental obstruction Massive ascites

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76 Catheter care Dressing every 3 days at home or hospital Exchange PTBD every 3 months Irrigate / check when Bile leak Decreased about of bile Increased jaundice Ascites leak