Transcatheter intraarterial therapies have proved valuable in the battle against primary and secondary hepatic malignancies. The unique aspects of all such therapies are their reduced toxicity profiles and highly effective tumor responses. These unique characteristics coupled with their minimally invasive nature provide an attractive therapeutic option in patients who may have previously had few alternatives. The concept of all catheter-based intraarterial therapies is to selectively deliver anticancer treatment to tumor(s). These therapies, which include transarterial embolization, intraarterial chemoinfusion, transarterial chemoembolization with or without drug-eluting beads, and radioembolization with use of yttrium 90, inflict lethal insult to tumors while preserving normal hepatic parenchyma. This is possible because hepatic neoplasms preferentially derive their blood supply from an arterial source while the majority of noncancerous liver is supplied by the portal vein. As part of the interventional oncology review series, in this article we describe the rationale behind each of these transcatheter therapies and provide a review of the existing medical literature.
Worsening hepatic function is a well-known potential complication of chemoembolization and occurs in up to 58% of patients undergoing chemoembolization. Although liver function returns to baseline levels within 3–4 weeks in the majority of patients, fulminant liver failure and death occur with a reported frequency of ~2–10%. Poor performance status, portal vein obstruction, biliary obstruction, extensive tumor burden, and Child-Pugh status B or C are among factors predisposing to an increased risk of transient or fulminant hepatic failure, with Child-Pugh status being the most accurate. Unless the patient is a candidate for liver transplantation, treatment for hepatic failure is limited to supportive measures.
Hepatic arterial embolization (HAE) is a treatment used in the management of primary and some metastatic hepatic tumors. Complications of HAE are similar to those seen in other treatments, particularly transcatheter arterial chemoembolization (TACE), but without the possibility for chemotherapy related side effects. Particle reflux into the cystic artery is generally clinically occult but gallbladder ischemia severe enough to require cholecystostomy tube placement can occur. The authors discuss the case of a patient who underwent HAE and subsequently required a cholecystostomy tube due to development of acute cholecystitis.
Transarterial chemoembolization has proven benefit in the treatment of unresectable hepatocellular carcinoma (HCC). Commonly reported symptoms following chemoembolization with or without drug-eluting beads include abdominal pain, nausea, and low-grade fever, which typically limited resolve within a few days. A recent study comparing traditional chemoembolization versus chemoembolization with drug-eluting beads demonstrated similar survival between the two techniques, but improved tolerability when the drug-eluting beads were used. This case report describes a patient with unresectable HCC undergoing chemoembolization with drug-eluting beads. The postprocedure course was complicated by interstitial pneumonitis secondary to shunting of the drug-eluting beads containing doxorubicin to both lungs via tumor vasculature. This case highlights the relationship between the number and size of the tumors to be treated, arteriovenous shunting within the liver/tumors, and the size of the embolization particles.
Postembolization syndrome (PES) is a common complication after embolic procedures, and it is a frequent cause of extended inpatient hospital admissions. PES is a self-limited constellation of symptoms consisting of fevers, unremitting nausea, general malaise, loss of appetite, and variable abdominal pain following the procedure. Although a definite cause is unknown, this syndrome is thought to be a result of therapeutic cytotoxicity, tumor ischemia, and resulting intrahepatic and extrahepatic inflammation. The authors report a case of PES precipitated by transcatheter intrarterial chemoembolization of hepatic metastases.
Chemoembolization with drug-eluting beads is a type of locoregional therapy currently being used for the treatment of hepatocellular carcinoma and metastatic disease to the liver. This treatment has proven effectiveness in controlling tumor growth, extending survival time, and improving quality of life. Chemoembolization with drug-eluting beads have been shown to be safe, but like any other invasive procedure, can have associated complications. The authors present a case of intrahepatic biloma formation occurring as a result of treatment with drug-eluting beads.
Hepatic abscess following transarterial chemoembolization is an uncommon complication. The authors describe a case of liver abscess after transarterial chemoembolization for neuroendocrine liver metastases, including risk factors, prophylaxis, treatment, and outcomes.
Nontarget embolization during transarterial chemoembolization, although infrequent, can be a serious complication. The authors describe a case of nontarget gastric embolization to the stomach after transarterial chemoembolization and describe the published incidence of nontarget embolization to various organs, its diagnosis, treatment, and possible outcomes.
Transarterial chemoembolization (TACE) was first introduced in 1977 by Dr. Yamada, who exploited hepatocellular carcinoma’s (HCC) preferential blood supply from the hepatic artery for the delivery of antitumor therapy. His findings on an initial cohort of 120 patients were published in the English literature in 1983 [1].
Objective: To prospectively evaluate the safety and short-term therapeutic efficacy of switching monopolar radiofrequency ablation (RFA) with multiple electrodes to treat medium-sized (3.1-5.0 cm), hepatocellular carcinomas (HCC).
Background. Hepatic arterial therapy (HAT) has been proven to be effective at palliation of hormonal symptoms of metastatic neuroendocrine tumors (NETs), as well as a means of cytoreduction. Recently, the newer modalities of yttrium-90 and drug-eluting beads with doxorubicin (DEBDOX) have been reported to be effective in the treatment of metastatic NETs. The aim of this study was to compare the safety, efficacy, and cost of selective internal radiation with DEB therapy.
Minimally invasive techniques used in the evaluation and treatment of colorectal liver metastases (CRLMs) include ultrasonography (US), computed tomography, magnetic resonance imaging, percutaneous and operative ablation therapy, standard laparoscopic techniques, robotic techniques, and experimental techniques of natural orifice endoscopic surgery. Laparoscopic techniques range from simple staging laparoscopy with or without laparoscopic intraoperative US, through intermediate techniques including simple liver resections (LRs), to advanced techniques such as major hepatectomies. Hereins, we review minimally invasive evaluation and treatment of CRLM, focusing on a comparison of open LR (OLR) and minimally invasive LR (MILR). Although there are no randomized trials comparing OLR and MILR, nonrandomized data suggest that MILR compares favorably with OLR regarding morbidity, mortality, LOS, and cost, although significant selection bias exists. The future of MILR will likely include expanding criteria for resectability of CRLM and should include both a patient registry and a formalized process for surgeon training and credentialing.
Hepatocellular carcinoma (HCC) is one of the most common malignancies, ranking the sixth in the world, with 55% of cases occurring in China. Usually, patients with HCC did not present until the late stage of the disease, thus limiting their therapeutic options. Although surgical resection is a potentially curative modality for HCC, most patients with intermediate-advanced HCC are not suitable candidates. The current therapeutic modalities for intermediate-advanced HCC include: (1) surgical procedures, such as radical resection, palliative resection, intraoperative radiofrequency ablation or cryosurgical ablation, intraoperative hepatic artery and portal vein chemotherapeutic pump placement, two-stage hepatectomy and liver transplantation; (2) interventional treatment, such as transcatheter arterial chemoembolization, portal vein embolization and image-guided locoregional therapies; and (3) molecularly targeted therapies. So far, how to choose the therapeutic modalities remains controversial. Surgeons are faced with the challenge of providing the most appropriate treatment for patients with intermediate-advanced HCC. This review focuses on the optional therapeutic modalities for intermediate-advanced HCC.
To compare the survival outcomes between hepatic resection and transarterial lipiodol chemoembolization (TACE) used as the initial treatment in patients with large (5 cm), multiple, and resectable hepatocellular carcinomas. Radiology: Volume 259: Number 1—April 2011. Copyright RSNA, 2011.
AIM: To evaluate the efficacy and safety of combination therapy with recombinant adenovirus p53 injection (rAdp53) and transcatheter hepatic arterial chemoembolization (TACE) for advanced hepatocellular carcinoma (HCC).
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