1. Clinical Management
IR patients in the GOU
Justin McWilliams, M.D.
Assistant Professor of Radiology
UCLA
2. Outline
Intro to IR
General principles
IR procedures relevant to GOU
Description of procedure
Post-procedure management
Complications
Case scenarios
9. Liver cancer treatments
OLT
Treatment of choice for HCC, especially in cirrhotics
Milan criteria: one lesion up to 5 cm, or up to 3 lesions, each up to 3 cm. No vascular invasion or mets
5-year survival ~70%
Resection
Treatment of choice for HCC in non-cirrhotics
Any size lesion if limited to one lobe, PV invasion OK
5-year survival ~50%
RFA
Treatment of choice in non-operative candidates with limited disease
Effective in lesions up to 3-5 cm, up to 3 or 4 lesions
5-year survival ~40%
TACE
Treatment of choice in non-operative candidates with intermediate stage HCC (large or numerous tumors)
Give chemotherapy-eluting particles directly into arteries feeding the tumor
5-year survival ~20%
Nexavar
Treatment of choice in advanced HCC (extrahepatic spread or vascular invasion)
Tyrosine kinase inhibitor with proven survival benefit in RCT
Median survival 10 months (vs 7 months with placebo)
10. Transarterial chemoembolization
Rationale
HCC takes its blood supply almost
exclusively from the hepatic artery
Surrounding normal liver has dual
blood supply (with portal vein)
Chemotherapy + embolic agent
administered into hepatic artery
should selectively kill tumor while
sparing normal liver
11. TACE
Technique
1. Conscious sedation
2. Common femoral artery access
3. Catheter to select hepatic artery
4. Microcatheter to superselect tumor-bearing artery
5. Embolize to near-stasis or stasis
• Conventional TACE: Chemotherapy (doxorubicin, cisplatin,
mitomycin C) with Lipiodol, followed by Gelfoam or
Embospheres
• DEB-TACE: Doxorubicin-eluting LC beads
• Chemo elutes more slowly than with Lipiodol
• Reduced liver toxicity
• Less side effects
6. Arterial closure
7. Overnight admission
12. TACE
Llovet and Lo, 2002
RCT of TACE vs. symptomatic treatment for unresectable HCC
Llovet: 112 patients
3-year survival:
29% with TACE
17% with supportive care
Lo: 80 patients
3-year survival:
26% with TACE
3% with supportive care
13. TACE
Consensus statement
“TACE is first-line non-curative therapy for non-
surgical patients with large or multifocal HCC
who do not have vascular invasion or
extrahepatic spread (level I evidence).”
American Association for Study of Liver Diseases (AASLD) and European Association for the Study of the Liver (EASL).
14. Radiofrequency ablation
Rationale
RF current induces thermal
coagulation necrosis around an
electrode
• Complete ablation rates >80% for small
to medium HCC
• Local recurrence uncommon (1-12%)
Disadvantages
• Relies on thermal conduction (limited
ablation size)
Best for tumors <3 cm
Increasing technical failure and local
recurrence for tumors >3 cm
• Heat sink effect
• Slow
McWilliams J, et al. Percutaneous ablation of hepatocellular carcinoma: current status. J Vasc Interv Radiol 2010;21:S204-S213.
Hinshaw J. The role of image-guided tumor ablation in the management of liver cancer. Cancer News review article.
15. RFA
Technique
1. General anesthesia (usually)
2. Ultrasound used to guide 1-3 needles into tumor
3. CT to confirm and/or adjust position
4. Ablation performed (3-5 cm burn possible)
5. Adjust needle position and repeat as necessary
6. Needle removal with tract cauterization
7. Contrast CT to confirm adequate treatment
8. MRI after anesthesia wears off
9. Discharge same day (ideally)
16. Percutaneous ablation
Consensus statement
“Local ablation is safe and effective therapy for patients
who cannot undergo resection, or as a bridge to
transplantation.”
American Association for Study of Liver Diseases (AASLD) and European Association for the Study of the Liver (EASL).
18. General Principles
Post-embolization syndrome (PES)
Occurs in 80-90% of patients who undergo embolization (TACE, UFE, etc)
Within 24 hours of embolization, tissue and cell death begins, and breakdown
products are released into the circulation
• Pain – At site of embolization, may be severe
• Nausea/vomiting – About 1/3 of patients
• Fever – 15-30% of patients, up to 104 degrees
• Leukocytosis – 15-30% of patients, can exceed WBC 20k
• Fatigue – Most patients, can last for weeks
Some or all of these symptoms may not manifest until after patient discharge
Post-ablation syndrome consists of the same symptoms, but is less frequent
(<1/3 of patients)
Most symptoms resolve by 72 hours (except fatigue, and sometimes pain)
19. General Principles
Pain
Can occur during the procedure, but often does not
occur until post-procedure
Referred visceral pain from the liver is often found in
the right shoulder
Opioid analgesia is treatment of choice for severe pain
• Dilaudid or morphine
• PCA is often best method of delivery
NSAIDs can be useful for minor pain, but generally
avoid in liver patients
Tylenol is OK but limit to 1.5 grams/day in liver patients
20. General Principles
Nausea
Often multifactorial
• PES
• Chemotherapy
• Opioid use
Zofran works great (4 mg q4 or 8 mg q8)
Can add dexamethasone in non-diabetics (12 mg on day of
treatment)
Compazine or droperidol for breakthrough nausea
21. General Principles
Fever
15-30% of patients develop fever after intervention
• Usually at 24-48 hours
• May be up to 104, but usually <102
Leukocytosis is normal
• Can exceed 20k
Low grade or moderate fever in first few days after
treatment should not warrant fever work-up
Differentiating infection vs. PES is difficult
• Gas in embolized area on CT is normal, not abscess
• Fevers beyond 48 hours may require work-up
• Abscess usually occurs at 2-4 weeks
22. General Principles
Fatigue
Extremely common after embolization, and to a lesser
extent, ablation
Peaks several days after treatment
Can last for days or weeks
Risk factors
• Baseline fatigue
• High dose of chemo used
25. TACE
Post-procedure management
Fluids/Diet
• IV hydration NS ~250 cc/hr x 5 hours
• Advance diet as tolerated (do not start with Salisbury steak)
Activity
Pain control
Nausea control
Antibiotics
Puncture site
Labs
26. TACE
Post-procedure management
Fluids/Diet
Activity
• Bed rest at least 2 hours (closure device)
• Bed rest at least 6 hours (manual compression)
• Bed rest overnight (higher risk patients)
Pain control
Nausea control
Antibiotics
Puncture site
Labs
33. TACE
Complications
Liver failure
• Risk factors: Child B/C, total bili >3.0, albumin <2.0, ECOG >2
• Mechanism: TACE-related injury to “normal” liver parenchyma (poor reserve in
cirrhotic livers)
• Incidence: 13% of TACE patients suffer some degree of liver failure.
• Diagnosis: Elevated bilirubin/INR, jaundice, itchiness, dark urine, light stool
• Avoidance strategy: Superselective embo
• Treatment: Supportive care
• Outcome: Most recover. 30-day TACE-related mortality from liver failure is 2%
34. TACE
Complications
Bleeding (puncture site)
• Risk factors: Low platelets, high INR, obesity, closure device failure, uncooperative patient
• Mechanism: Platelet plug does not form or dislodges
• Incidence: Minor groin hematoma <10%. Major intramuscular or retroperitoneal bleed is rare but
devastating.
• Diagnosis: Groin swelling/pain (not if retroperitoneal), tachycardia, hypotension, orthostasis, pallor,
dizziness, lightheadedness, weakness
• Avoidance strategy: Careful access and closure, bed rest with leg straight
• Treatment: Pressure. IVF. Stat type/cross and transfuse. Stat CT. Consider angio.
• Outcome: Depends on blood loss.
35. TACE
Complications
Bleeding (variceal)
• Risk factors: Presence of varices, previous variceal bleed, low platelets, high INR
• Mechanism: Increased portal HTN in setting of periprocedural liver insult (varices)
• Incidence: <1%, anecdotal
• Diagnosis: Hematemesis, shock
• Avoidance strategy: Pre-TACE banding? Superselective TACE
• Treatment: IVF. Type/cross and transfuse. Immediate endoscopy with banding. Consider
emergent TIPS if no other options.
• Outcome: High mortality rate.
36. TACE
Complications
Nontarget embolization
• Risk factors: Lobar (nonselective) treatment
• Mechanism: Embolic material passes into gallbladder, stomach or intestine
• Incidence: <<10%
• Diagnosis: Ulceration, perforation, pain, bleeding
• Avoidance strategy: Superselective embo
• Treatment: NPO. Hydration. PPI. Prolonged observation. Consider surgery if bowel necrosis.
• Outcome: Most recover with supportive care alone.
47. RFA/MWA
Complications
Hemorrhage
• Risk factors: Low platelets, high INR, multiple needle placements, ascites
• Mechanism: Arterial injury by needle, or persistent oozing from liver puncture
• Incidence: ~1% clinically significant hemorrhage rate
• Diagnosis: Hypotension, tachycardia, pallor, pain, dizziness, orthostasis
• Avoidance strategy: Tract cauterization, FFP/platelet support
• Treatment: IVF resuscitation. Transfuse. Stat CTA (look for active extravasation).
Hepatic angiography and embolization.
• Outcome: Depends on blood loss.
48. RFA/MWA
Complications
Liver failure
• Risk factors: Child B/C, total bili >3.0, albumin <2.0, ECOG >2, large ablation zone, multiple
ablations
• Mechanism: Ablation of “normal” liver parenchyma (poor reserve in cirrhotic livers)
• Incidence: 12% risk of death from liver failure in ablation of Child C patients; <1% risk for
Child A or B
• Diagnosis: Elevated bilirubin/INR, jaundice, itchiness, dark urine, light stool
• Avoidance strategy: Staged ablation
• Treatment: Supportive care
• Outcome: Recovery is less likely than in TACE as liver is permanently damaged with ablation
49. RFA/MWA
Complications
Nontarget ablation
• Risk factors: Target tumor near stomach, bowel, bile ducts, gallbladder
• Mechanism: Nontarget tissues lie within ablation zone
• Incidence: 2%
• Diagnosis: Bowel or gallbladder perforation, bile leak or obstruction
• Avoidance strategy: Hydrodissection, positioning
• Treatment: Surgery or supportive care
• Outcome: Mortality is high for bowel injury in this population
50. RFA/MWA
Complications
Infection/abscess
• Risk factors: Hepatojejunostomy, biliary drainage tube
• Mechanism: Colonized biliary system seeds the necrotic treated ablation zone
• Incidence: <5% with normal sphincter of Oddi; 30-80% if compromised
• Diagnosis: Pain, fever
• Avoidance strategy: Periprocedural antibiotics, bowel prep
• Treatment: Antibiotics and drainage
• Outcome: Most recover
51. RFA/MWA
Complications
Tumor seeding
• Risk factors: Multiple needle insertions, concomitant biopsy
• Mechanism: Tumor cells on needle seed tract as needle is removed
• Incidence: <1%
• Diagnosis: Imaging
• Avoidance strategy: Tract ablation/cauterization with needle removal
• Treatment: Ablation or surgery
• Outcome: Most are detected on follow up and treated
52. TG
39 y/o female
Fibrolamellar HCC diagnosed in 2001
Left lobe resection of 9 x 11 cm mass in 2001
Recurrence 2007 with partial right lobe
resection
CT 4/9/2010: At least
Presents with multifocal recurrence 2/2010 10 hypervascular liver
masses
Not a surgical or transplant candidate
Presented at tumor board and referred for
locoregional therapy
53. TACE 5/3/2010 100 mg doxorubicin on
LC beads
2 weeks later, returns
with fevers, RUQ pain
54. CT 5/19/2010: near- complete
tumor necrosis
Prolonged CT 8/6/2010: Biloma
Percutaneous biloma catheter resolved, but
drainage drainage intrahepatic recurrence
and new lung nodule.
To study drug
57. Fibrolamellar hepatocellular carcinoma
Status post left lobectomy and partial right lobectomy
No longer a surgical candidate
OLT?
RFA?
TACE?
Chemotherapy?
58. Liver cancer treatments
OLT
Treatment of choice for HCC, especially in cirrhotics
Milan criteria: one lesion up to 5 cm in size, or up to 3 lesions, each up to 3 cm in
size. No vascular invasion and no mets.
RFA
Place ablation needle into lesion (under CT/US guidance) and cook it
Effective in lesions up to 3 cm (sometimes larger), up to 3 or 4 lesions
Damage to adjacent bile ducts or bowel can be a concern
TACE
CFA access, catheterize hepatic artery and subselect tumor feeders
Give chemotherapy-eluting particles
Block blood flow
Release tumoricidal chemotherapy
Targeted chemotherapy
Nexavar (tyrosine kinase inhibitor) – extends survival in advanced HCC
Avastin (monoclonal VEGF inhibitor) – promising but unproven
59. Liver cancer treatments
OLT
Too many lesions to qualify (outside Milan criteria)
Can consider Milan exception if we can decrease her disease burden
RFA
Too many lesions to effectively treat, and marginal location increases risk for
bowel/stomach injury
TACE
Suitable
Targeted chemotherapy
Suitable, if TACE fails
60.
61.
62. Status post 100 mg doxorubicin on 100-300 and 300-500 micron LC beads
63. Discharged home the next day, doing well
2 weeks later, having persistent high fevers to 103 and night sweats
