Interventional Radiology in Liver Cancer Nakarin Inmutto MD
Liver cancer Primary liver cancer Hepatocellular carcinoma Cholangiocarcinoma Metastasis
Interventional Radiologist Diagnosis Imaging US / CT / MRI Tissue diagnosis FNA / Core biopsy Treatment
Hepatocellular carcinoma
AASLD Every 6 months 1 modality 1 cm No Bx No AFP
Hepatoma
Hepatoma
Hepatoma
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
MRI
Treatment options
Barcelona Clinic Liver Cancer (BCLC) Radiologic tumor extent Liver function Patient s performance status Best chance of predicting patient survival
ECOG : PS
Child-Pugh Score
Interventional Radiologits
Local ablation
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Ethanol Dehydration Coagulation necrosis Small vessel thrombosis Low cost /Treat in critical site Multiple sessions / Local recurrent
PEI
PEI
RFA Radiofrequency ablation Localised treatment Heat the tumor tissue Temperatures exceeds 60c Imaging guidance: US / CT
RFA
RFA Alternating current of radio frequency waves Changes in the direction of ions Ionic agitation and frictional heating Coagulative necrosis
Meta-analysis: RFa VS Sx No difference in 1-y and 3-y recurrences
TACE
TACE
TACE TransArterial ChemoEmbolization TOCE TransArterial Oily Chemoembolization Drug + Oil
ctace Chemotherapy drug + Lipiodol Selective retained within the tumor Raising the exposure of neoplastic cell to chemotherapy Hepatic artery is occluded
ctace ctace Chemotherapy Drug Lipiodol Embolization +
Lipiodol Ethiodized or iodized oil (Lipiodol, Guerbet) Iodinated ester derived from poppy seed oil
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
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
Indication Intermediate-stage HCC; Large Multinodular HCC Pre-transplant setting Early HCC in patients unsuitable to curative therapy
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
Patient preparation NPO 6-8 hr IV fluid LEFT side Clean and shave perineum Foley catheter Inform consent
Patient preparation CBC plt PLT > 50,000-100,000 Coagulation INR < 1.5 LFT TB<3 BUN, Cr
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Gelfoam slurry
Post-procedure care Bed rest Observe bleeding / hematoma / pulse Post-embolization syndrome Pain / NV / fever / leukocytosis Medical treatment
End-point Complete necrosis / no viable HCC Progression of disease No response after 2 sessions Metastasis Contraindication for TACE Child-Pugh / LFT
Result: HCC Barcelona-Clinic Liver Cancer Group J Hepatology 2003;37:429-442 Meta-analysis Results-2 year Survival TREATED 41% [19-63%] UNTREATED 27% [11-50%]
Result: HCC CR rate = 30-60 % 5-year survival rate 26% Matui O, et al. J Hepatobiliary Pancreat Sci 17:407-9, 2010
Result: HCC OS = 3.3 years 5-year survival = 34% Takayasu, et al. J Hepatology; 2012
Cholangiocarcinoma
Interventional Radiologist Diagnosis US / CT FNA / Biopsy Treatment PTBD Preoperative Palliative
Diagnosis: CT scan
Diagnosis: CT scan
Aspiration for cytology
Core needle biopsy
PTBD
PTBD Percutaneous biliary drainage External drainage
Indication Biliary obstruction Malignancy Stricture Cholangitis or infected bile Bile duct injury or bile leak
Contraindication Uncorrectable coagulopathy Multisegmental obstruction Massive ascites
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