TACE-Interventional embolization chemotherapy for hepatocellular carcinoma
Reprinted from Cui Hong, Department of Hepatobiliary and Pancreatic Surgery, Henan Cancer Hospital
Tags: Miscellaneous
The indications and contraindications are listed below, which are extracted from the Ministry of Health’s 2011 Standard for the Treatment of Primary Liver Cancer
Indications
(1) The main indications for TACE are middle and advanced HCC that cannot be surgically resected without severe liver and kidney dysfunction, including.
(i) Macroscopic hepatocellular carcinoma: tumor occupying <70% of the entire liver.
② multiple nodular hepatocellular carcinoma.
③ portal vein trunk not completely obstructed, or although completely obstructed but compensatory collateral vessel formation between hepatic artery and portal vein.
④ those with failed surgical procedures or postoperative recurrence.
⑤ liver function classification (Child-Pugh) grade A or B, ECOG score 0-2.
(6) Bleeding from liver tumor rupture and portal hypertension caused by hepatic artery-portal artery shunt.
(2) Preoperative application for liver tumor resection, which can shrink the tumor and facilitate second-stage resection, as well as clarify the number of lesions.
(3) Small hepatocellular carcinoma, but not suitable for or unwilling to undergo surgery, local radiofrequency or microwave ablation treatment.
(4) Control of local pain and bleeding as well as embolization of arteriovenous impotence.
(5) After resection of hepatocellular carcinoma to prevent recurrence.
4. Contraindications.
(1) Severe impairment of liver function (Child-Pugh grade C).
(2) Severely impaired coagulation function, which cannot be corrected.
(3) The main trunk of the portal vein is completely embolized by the cancer, and there is little formation of collateral vessels.
(4) Combined with active infection and cannot be treated simultaneously.
(5) Extensive distant metastases with estimated survival <3 months
(6) those who have malignant fluid or multiple organ failure.
(7) tumors accounting for ≥70% of the whole liver; if liver function is basically normal, a small amount of iodine oil emulsion may be considered for fractional embolization.
(8) Significant reduction in peripheral blood leukocytes and platelets, with leukocytes <3.0×109/L (not an absolute contraindication, such as those with hypersplenism, which is different from chemotherapeutic leukopenia) and platelets <60×109/L.
Indications and contraindications for hepatic artery chemotherapy (HAI) and hepatic artery embolization (HAE)
Indications
Contraindications
hepatic artery
chemotherapy
n Primary or secondary hepatocellular carcinoma that has been lost to surgery
n Poor hepatic function or difficulty with super-selective cannulation
n Recurrence of hepatocellular carcinoma after surgery or postoperative prophylactic hepatic artery infusion chemotherapy
n Severely impaired liver function
n Large amount of ascites
n Systemic failure
n Significant reduction in white blood cells and platelets
Hepatic artery
Embolization
n Pre-operative application for liver tumor resection can shrink the tumor and facilitate resection. It can also clarify the number of lesions and control metastasis
n No serious liver or kidney dysfunction, no complete obstruction of the main portal vein, and tumor occupancy less than 70%
n Those who failed in surgical operation or recurred after resection
n Control of pain, bleeding and arteriovenous fistula
Prophylactic hepatic artery chemoembolization after hepatectomy for hepatocellular carcinoma
n Recurrence of hepatocellular carcinoma after liver transplantation
n Severe hepatic dysfunction, Child-Pugh class C
n Severely impaired coagulation that cannot be corrected
portal hypertension with reverse flow and complete obstruction of the main portal vein with little collateral vessel formation (super-selective catheter technique can be used to embolize the tumor target vessels in a fraction of the time if liver function is basically normal)
n Infection, such as liver abscess
n Extensive metastases throughout the body, where treatment is not expected to prolong the patient’s survival
n Systemic failure
n cancer occupying 70% or more of the whole liver (if liver function is basically normal, fractional embolization with a small amount of iodine oil can be used)
Hepatic artery embolization chemotherapy (TACE): Hepatic artery infusion chemotherapy (TAI) and hepatic artery embolization (TAE) are performed simultaneously to improve the efficacy of the treatment. TACE can effectively block the arterial blood supply of hepatocellular carcinoma, while releasing high concentrations of chemotherapeutic drugs to combat the tumor, causing ischemic necrosis and shrinkage, with less impact on normal liver tissue. Evidence-based medical evidence has shown that TACE can effectively control the growth of hepatocellular carcinoma, significantly prolong the survival of patients, and benefit patients with hepatocellular carcinoma, which has become the first and most effective treatment method for middle and advanced hepatocellular carcinoma that cannot be surgically resected.
Before TACE, we should analyze the imaging performance, clarify the tumor site, size, number and blood supplying artery, and then super-select the cannula to the right hepatic artery and left hepatic artery to give perfusion chemotherapy respectively. The head end of the catheter should cross the gallbladder, the right gastric artery and the gastroretinal artery and other vessels. In most HCC, more than 95% of the blood supply comes from the hepatic artery, which is characterized by thickened blood supply arteries, abundant tumor vessels and dense tumor staining. Embolization should be performed after perfusion chemotherapy. It is advocated that super-liquefied ethyl iodide oil and chemotherapeutic drugs should be fully mixed to form an emulsion, and the mixture should be slowly injected into the target vessel through a microcatheter super-selectively inserted into the blood supplying arterial branch of the tumor. Embolization should be performed to avoid embolization of normal liver tissue or into non-target organs. For patients with hepatocellular carcinoma with markedly thickened blood supply arteries, it is usually advisable to add granular embolic agents (e.g. gelatin sponge or microspheres) after the iodine oil emulsion embolization. Embolization should try to embolize all the feeding vessels of the tumor in order to de-vascularize the tumor. Care should be taken not to completely occlude the intrinsic hepatic artery to facilitate re-TACE treatment.
The main factors affecting the long-term efficacy of TACE include the degree of cirrhosis, the functional status of the liver and the tumor condition (size, grade, pathological type, portal vein carcinoma thrombus, and arteriovenous fistula). In addition, TACE treatment itself has certain limitations, which are mainly manifested as.
(i) TACE is often difficult to achieve pathologically complete necrosis of the tumor due to incomplete embolization and establishment of tumor collateral vessels.
②After TACE treatment, due to ischemia and hypoxia of tumor tissues, the level of hypoxia-inducible factor (HIF) in residual tumors increases, which leads to high expression of vascular endothelial growth factor (VEGF). These factors can lead to intrahepatic tumor recurrence and distant metastasis.
Adverse effects are common after TACE.
Post-embolization syndrome is the most common adverse effect of TACE treatment, mainly manifested as fever, pain, nausea and vomiting. Fever and pain occur due to local tissue ischemia and necrosis caused by embolization of the hepatic artery, while nausea and vomiting are mainly related to chemotherapy drugs. In addition, there are other common adverse effects such as bleeding at the puncture site, white blood cell drop, transient liver function abnormalities, renal function impairment and difficulty in urination. Generally, adverse reactions after interventional procedures last for 5-7 days and most patients can fully recover after symptomatic treatment.
Follow-up and treatment interval.
It is generally recommended to review CT and/or MRI etc. at 4-6 weeks after the first hepatic artery intervention; as for the follow-up review, it can be 1-3 months apart depending on the patient’s condition. The frequency of intervention should depend on the follow-up results. If the imaging shows dense iodine oil deposits in the liver at 4-6 weeks after the intervention, necrosis of the tumor tissue and no enlargement or new lesions, no further intervention should be done for the time being. The interval between the initial 2-3 interventions can be short. Thereafter, the treatment interval should be prolonged in the absence of tumor progression to ensure the recovery of liver function. During the treatment interval, the survival of liver tumor can be evaluated using CT and/or MRI dynamic enhancement scans to decide whether another interventional treatment is needed. If the tumor continues to progress after several interventions, switching to or combining with other treatments, such as surgery, local ablation and systemic therapy, should be considered.
Operating procedures
Dressing, hand washing, disinfection
Prepare two 50ml waies, prepare contrast agent or saline
Prepare a large curved tray with built-in saline, puncture needle, super-slip catheter, arterial sheath, black mudskipper, and liver tube
Treat the arterial sheath tube, pigtail with tee or liver tube, and super-slip catheter with saline.
Puncture point: two transverse fingers below the midpoint of the inguinal ligament, the point of strongest femoral artery pulsation.
After subcutaneous infiltration anesthesia, the skin is cut and punctured at an angle (about 30 degrees) toward the pulsation point under the fingers (holding the last end of the needle), and after seeing the return of blood at the last end of the fixed needle while entering the sheath tube inward, the needle core is basically pulled out relatively.
After seeing good arterial blood flow, enter the guidewire (there should be no resistance), and after confirming the position of the guidewire under fluoroscopy (except for circling and entrapment), enter the arterial sheath.
Enter the contrast catheter (connected to a tee), located at the level of the inferior border of the 12th lumbar vertebra. Contrast.
Into the RH tube (connect to the tee), taking care not to disrupt the bend of the RH tube too much when feeding the tube. (Under fluoroscopy) The tube is usually entered to the aortic arch, pushed upward to shape the tube, and the tube is lightly dragged downward, with the RH tube positioned left and right and the bend facing upward, usually at the level of the first lumbar vertebra into the abdominal trunk. The RH tube is entered into the common hepatic by advancing and retreating, rotating (left and pulling back, which can be done with a guidewire), etc. Contrast confirmation. Superselection available with SP catheter.
Chemotherapy with 5-FU, epi-amycin. Chemotherapeutic agents are diluted with saline.
Cisplatin is diluted with iodine oil and pushed slowly in pulses under fluoroscopy, taking care to prevent reflux.
Morphine may be given intraoperatively for pain relief. Routine postoperative analgesia, antiemetic, hydration, hepatoprotection, and acid control.
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