Interventional Treatment of Liver Cancer
Prevalence
The most common form of liver cancer is hepatocellular carcinoma (HCC), which originates in the main cells of the liver. Approximately 18,500 patients are diagnosed with liver cancer each year. Patients with a liver disease called Cirrhosis are most frequently diagnosed with liver cancer. Cirrhosis is often caused by alcohol abuse and chronic infection from Hepatitis B or C.
Risk Factors
- Men are more likely to develop Liver Cancer than women
- Chronic infection of Hepatitis B or Hepatitis C
- Cirrhosis
- Other Liver diseases
- Diabetes
- Obesity
- Excessive alcohol consumption
Symptoms
- Upper Abdominal pain
- Unexplained weight loss
- Loss of appetite
- Nausea & vomiting
- General weakness or fatigue
- Enlarged Liver
- Abdominal swelling
- Yellow discoloration of your skin or the whites of your eyes (Jaundice)
Diagnosis
Physicians use a variety of tests to aid in the diagnosis of cancer, including physical examination, blood tests, and imaging (CT, MRI, ultrasound, and x-ray), but final diagnosis cannot be determined until a biopsy is performed. A biopsy provides a sample of tissue for a pathologist to examine, which will help determine the type of cancer and its growth rate. Upon gathering this information, physicians can determine the best treatment for the patient.
Needle Biopsy
This biopsy technique, also called an image-guided biopsy, utilizes imaging, such as fluoroscopy, CT, ultrasound, or MRI, to guide the procedure. This imaging allows the Interventional Radiologist to guide the needle to the tissue to obtain an accurate biopsy sample.
Needle biopsy is usually an outpatient procedure and patients return to normal activities after the procedure. This technique very rarely produces complications and has several advantages:
- Image-guidance allows the physician to see and avoid blood vessels and vital organs while obtaining the biopsy sample.
- Recovery time is short and patients usually return to normal activities immediately.
- Pain and scarring is greatly reduced and there is no need for stitches.
Treatment
While surgical removal of cancerous liver tumors is the best treatment, many patients are not surgical candidates for one of several reasons. Tumors may be too large or grown into a major blood vessel or other vital structure. Multiple tumors may have manifested and would make surgical intervention impractical or risky. Chemotherapy has also proven to be mostly ineffective for treating liver cancer. Patients with other forms of cancer, such as colon or rectal cancer, may form metastatic liver cancer when tumors spread to the liver.
Treatment for liver cancer is meant to relieve the symptoms of the cancer, rather than reverse or cure the disease. These treatments can improve the quality of life for the patient.
Radiofrequency Ablation
Radiofrequency Ablation (RFA) is a preferred nonsurgical procedure because it is delivers targeted, localized treatment, which uses heat to kill the targeted tissue while leaving healthy tissue intact. This procedure does not have any systematic side effects and does not affect the overall health of the patient. It is also easier on the patient and more effective than systematic therapy. Most patients return to normal activities within a few days of the procedure.
Hepatocellular carcinoma in liver (arrow). CAT scan shows ablation probe in place.
Radiofrequency Ablation is used to treat liver cancer and may be a viable option for patients who:
- Have liver tumors that do not respond to chemotherapy.
- Are not good candidates for surgery due to any of several reasons, such as large tumors, many tumors that are spread out, or older age.
- Have liver tumors that have recurred after being removed.
To perform the procedure, the Interventional Radiologist guides a small needle into the tumor using medical imaging. Through the needle, radiofrequency energy is transmitted into the targeted tissue to kill the tumor by heating it, causing the dead tumor tissue to shrink.
How to Prepare for Radiofrequency Ablation
Prior to your procedure, you will receive specific instructions for how to properly prepare for your procedure. The following information is a general guideline for what you might expect, but always follow the instructions given to you by your physician.
- Be sure to tell your doctor about all medications you are taking and any allergies you may have.
- You may be advised to stop taking blood thinners or nonsteroidal anti-inflammatory drugs (NSAIDs) for a specified period of time prior to your treatment.
- If you will be given sedation, you may be asked to fast (not eating or drinking anything) for several hours prior to your procedure.
- Blood tests may be ordered to determine how well your liver and kidneys are functioning and to see how your blood clots.
- Female patients should always inform their physician if they are or if there is a possibility that they are pregnant.
- Shower or bathe the night before your procedure.
- Remove jewelry, nail polish/artificial nails and hairpins, but please wear the following items to the procedure if you use them:
- Eye Glasses
- Dentures
- Hearing Aid(s)
- You should plan to have a relative or friend drive you home following your procedure.
What to Expect During & After Radiofrequency Ablation
- You will be positioned on the examining table and be connected to monitors that track your heart rate, blood pressure and pulse during the procedure, and a nurse or technologist will insert an intravenous (IV) line into a vein in your hand to deliver sedation medication.
- The physician will discuss the procedure with you and answer questions you may have. You will also read and sign a consent form.
- The area where the electrodes are to be inserted will be sterilized and draped with a surgical drape before the physician numbs the area with a local anesthetic.
- A very small nick in the skin is made where the physician inserts a needle electrode and uses medical imaging to guide it to the tumor site.
- Radiofrequency energy is applied to the tumor. The electrode may need to be repositioned for large tumors.
- After the treatment, the needle electrode is removed and pressure is applied to stop any bleeding. The small opening is covered with a dressing (no stitches are needed).
- Any discomfort, pain or nausea you experience will be controlled by medication.
- The entire procedure usually takes one to three hours to complete.
- Following the procedure, you will spend about six hours in a recovery room to allow the puncture site to heal before you are allowed to move. You will not be allowed out of bed and will need to use a bedpan or urinal.
- In recovery, a nurse will regularly check your blood pressure, foot pulses, and the puncture site. You will be allowed to eat and drink unless you are going into surgery.
- Very few patients still have pain a week following treatment.
- Your physician’s staff will schedule a follow up CT, PET or MRI and a clinic appointment. The physician will review the imaging and discuss the results of the procedure with you at this appointment.
Benefits
- May be performed under conscious sedation or general anesthesia
- Only a small nick in the skin is made, which does not require sutures
- Can be repeated if necessary
- May be combined with other treatments
- It has no effect on blood pressure
- Can relieve pain for many cancer patients
- It is a very safe procedure with low complication rates
Chemoembolization
Tumors grow when they have access to a blood supply. Chemoembolization aims to cut off the blood flow to the tumor, which will cause the tumor to shrink, while delivering a cancer drug directly to the tumor. Chemoembolization, formally known as transhepatic arterial chemoembolization, or TACE, is typically used for the treatment of hepatocellular carcinoma but can also be useful in the treatment of metastatic tumor to liver. It can be used alone if the tumor is too large in size or in a poor location to allow other treatment options. It can also be used in conjunction with surgery to shrink tumor prior to surgical removal, or with radiofrequency ablation to affect better cell death in the treated tumor.
For this procedure, an Interventional Radiologist uses medical imaging to guide a catheter through an artery at the groin to the liver tumor. The physician then delivers a high dose of cancer-killing drug and embolizing agent (blocks the blood flow) to the tumor. Because of the embolizing agent, the dose of medicine stays in the tumor without spreading to or damaging nearby healthy tissue and allows for a higher dose of the drug. This treatment usually requires a short hospital stay of one to three nights.
Hepatocellular carcinoma in liver before and after embolization with chemotherapy mixture.
How to Prepare for Chemoembolization
Prior to your procedure, you will receive specific instructions for how to properly prepare for your procedure. The following information is a general guideline for what you might expect, but always follow the instructions given to you by your physician.
- Be sure to tell your doctor about all medications you are taking and any allergies you may have.
- You may be advised to stop taking blood thinners or nonsteroidal anti-inflammatory drugs (NSAIDs) for a specified period of time prior to your treatment.
- If you will be given sedation, you may be asked to fast (not eating or drinking anything) for several hours prior to your procedure.
- Blood tests may be ordered to determine how well your liver and kidneys are functioning and to see how your blood clots.
- Female patients should always inform their physician if they are or if there is a possibility that they are pregnant.
- Shower or bathe the night before your procedure.
- Remove jewelry, nail polish/artificial nails and hairpins, but please wear the following items to the procedure if you use them:
- Eye Glasses
- Dentures
- Hearing Aid(s)
- You should plan to stay overnight in the hospital and have a relative or friend drive you home upon discharge.
What to Expect During & After Chemoembolization
- You will be positioned on the examining table and be connected to monitors that track your heart rate, blood pressure and pulse during the procedure and a nurse or technologist will insert an intravenous (IV) line into a vein in your hand to deliver sedation medication.
- The physician will discuss the procedure with you and answer questions you may have. You will also read and sign a consent form.
- The area where the catheter is to be inserted will be sterilized and draped with a surgical drape before the physician numbs the area with a local anesthetic.
- A very small nick in the skin is made where the physician inserts a catheter into the femoral artery near the groin and uses medical imaging to guide it to the liver.
- Contrast material (“x-ray dye”) is injected through the IV, x-rays are taken and the catheter is placed in the proper position.
- The physician then injects the anti-cancer drugs and embolic agent and x-rays will be taken again to confirm that the tumor has been properly treated.
- After the treatment, the catheter is removed and pressure is applied to stop any bleeding. The small opening is covered with a dressing (no stitches are needed).
- Any discomfort, pain or nausea you experience will be controlled by medication.
- The entire procedure usually takes about 90 minutes to complete.
- Following the procedure, you will spend the night in a recovery room to allow the puncture site to heal before you are allowed to move. You will not be allowed out of bed and will need to use a bedpan or urinal.
- In recovery, a nurse will regularly check your blood pressure, foot pulses, and the puncture site. You will be allowed to eat and drink unless you are going into surgery.
- This procedure may require a 1-3 night stay in the hospital.
- Your physician’s staff will schedule a follow up CT, PET or MRI and a clinic appointment. The physician will review the imaging and discuss the results of the procedure with you at this appointment.
