Most patients with primary liver cancer are not indicated for surgery when they are found, and only 28% of them can be surgically resected. The average survival of patients with inoperable intermediate to advanced hepatocellular carcinoma is only 3-6 months. Although hepatic artery infusion chemotherapy (HAI) and embolization (HAE) have achieved good results in the treatment of inoperable intermediate and advanced hepatocellular carcinoma and have been recognized as the first choice of non-surgical treatment for hepatocellular carcinoma, the long-term efficacy is not satisfactory, and the survival rate of ≥5 years is only 9.0%-16.2%. Although interventional treatment for hepatocellular carcinoma has been carried out in China for more than 20 years, it is not yet fully standardized, such as the mastering of indications for interventional treatment is not consistent, which not only affects the efficacy, but also causes unnecessary waste of drugs.
Strictly grasp the indications for interventional treatment of hepatocellular carcinoma.
1. Indications for hepatic artery chemotherapy (HAI).
① primary or secondary hepatocellular carcinoma that has lost the opportunity of surgery; ② poor liver function or difficulty in super-selective cannulation; ③ recurrence of hepatocellular carcinoma after surgery or postoperative prophylactic hepatic artery infusion chemotherapy.
2.Contraindications to HAI.
There is no absolute contraindication, but it should be contraindicated for those with systemic failure, severe liver dysfunction, massive ascites, severe jaundice and white blood cells <3000.
3.hepatic artery embolization (HAE) indications.
① application before hepatic tumor resection can shrink the tumor and facilitate resection, and at the same time can clarify the number of lesions and control metastasis; ② middle and advanced hepatocellular carcinoma that cannot be surgically resected, without severe liver and kidney dysfunction, without complete obstruction of the main trunk of the portal vein, and with tumor occupancy <70%; ③ small hepatocellular carcinoma; ④ failure of sexual surgery or recurrence after resection; ⑤ control of pain, bleeding and arterial fistula; ⑥ prophylaxis after hepatectomy Hepatic artery chemoembolization.
4.HAE contraindications.
①Severe liver dysfunction, such as: severe yellow pox [bilirubin>51μmol/L, ALT>120U (depending on the size of the tumor)], hypocoagulability, etc. massive ascites or severe cirrhosis, liver function is Child C; ② portal hypertension with reverse blood flow and complete obstruction of the main trunk of the portal vein, with little formation of collateral vessels; ③ infection, such as liver abscess; ④ cancer accounting for 70% or more of the whole liver (if the liver function is basically normal, or a small amount of iodine oil embolization); ⑤ white blood cells <3000; ⑥ extensive metastases have occurred throughout the body; ⑦ systemic conditions (vii) systemic failure.
5.Hepatic artery chemoembolization operation procedure.
Seldinger’s method is used, the catheter is inserted through the femoral artery puncture, and the catheter is placed in the common hepatic artery for imaging, the total amount of contrast is 30-40% ml, and the flow rate is 4-6 ml. If a region of the liver is found to be sparsely vascularized or lacking, other vessels should be explored (selective superior mesenteric artery angiography is often required) to detect ectopic origins of the hepatic artery or collateral feeding vessels. After careful analysis of the angiographic features, the site, size, number and arteries supplying the tumor are clarified, and then superselective infusion chemotherapy is administered to the intrinsic hepatic artery or right or left hepatic artery branches.
The chemotherapeutic drug should be diluted to 150~200ml with saline and slowly injected into the target vessel. Then, inject iodine oil emulsion and/or gelatin sponge embolization. It is advocated that super-liquidated ethyl iodine oil and chemotherapeutic drugs should be fully mixed into emulsion and slowly injected through catheter. The amount of iodine oil should be flexible according to the size of the tumor, the blood supply and the number of tumor blood supplying arteries, and the limit of iodine oil deposition should be 10-20ml under fluoroscopy according to whether the tumor area is dense or not, and whether there is a small branching shadow of portal vein around the tumor. If there is hepatic artery-portal vein fistula and/or hepatic artery-hepatic vein fistula, gelatin sponge particles and/or a small amount of anhydrous ethanol can be mixed with iodized oil first, and then injected slowly.
Principles of TAE treatment for hepatocellular carcinoma: ①Peripheral embolization with terminal type embolization agent first, then central embolization. ②The amount of iodized oil should be sufficient, especially in the first embolization. ③Do not completely occlude the intrinsic hepatic artery for re-TAE, with the exception of obvious hepatic artery-portal vein fistula. ④If there are 2 or more arteries supplying the hepatic tumor, each artery should be embolized one by one in order to de-vascularize the tumor. ⑤Iodine oil embolization can still be used for small hepatic artery-portal fistulas, but should be done with caution. (6) Try to avoid embolization agent entering non-target organs.
After embolization, hepatic arteriogram is performed again to understand the embolization of hepatic artery, and the tube is removed after satisfaction. The puncture site is compressed for 10`~15 min to stop bleeding, and local pressure bandage is applied. After the intervention, the limb on the puncture side should be braked and bedridden for 8-12h to observe the vital signs, whether there is bleeding at the puncture site and dorsalis pedis artery pulsation of both lower limbs.
6. Precautions for hepatocellular carcinoma intervention.
① Iodine oil embolization should always be monitored under fluoroscopy. If the flow of iodine oil in the blood vessel is very slow, the injection should be suspended and heparin saline should be slowly pushed to flush, and iodine oil should be injected again after the iodine oil in the blood vessel disappears. If the injection of heparin saline still cannot make the iodine oil move forward, the iodine oil in the blood vessel should be pumped back into the syringe. Do not forcibly inject, so as not to accidentally tether the non-target site.
In the process of injecting iodine oil, the patient may have different degrees of dullness in the liver area and epigastric pain, which can be relieved by injecting 2% lidocaine through the catheter, usually with a total amount of 100-500 mg. A few patients may have a slower heart rate (<50 times/min), chest tightness, or even a drop in blood pressure, so stop the operation and give the patient oxygen in time. After the heart rate and blood pressure return to normal, the patient should be treated as appropriate.
③ For elderly patients with hepatocellular carcinoma (≥65 years old), patients with more severe cirrhosis, but not accompanied by portal vein trunk or large branch cancer emboli, normal or mild abnormal liver function indexes, and no or little ascites, super-selective cannulation in the tumor feeding artery and simple chemoembolization (e.g., MMC 10mg, EADM 40-60mg, with super-liquidated ethyl iodide oil 5-15ml mixed with horse emulsion) can be given, followed by 2 to 3 short gelatin sponge embolization. If there is a portal vein injection trunk or large branch cancer embolus, the use of iodine oil emulsion gelatin sponge should be cautious.
④ Search for collateral vessels for embolization of hepatocellular carcinoma (after multiple hepatic artery embolization, there is no original of hepatocellular carcinoma.)