In the past 20 years, interventional scholars at home and abroad have done a lot of work and achieved promising results in the interventional treatment of hepatocellular carcinoma, and explored many effective interventional treatment methods. They are broadly divided into two categories: percutaneous transvascular treatment techniques and percutaneous non-vascular treatment techniques.
1.Percutaneous transvascular treatment techniques
1）Hepatic artery embolization
Hepatic artery embolization was developed on the basis of super-selective hepatic arteriography, and the clinical application of this method was first reported abroad in 1976. In China, the clinical application of hepatic artery embolization for HCC was first reported in 1983. Later, with the development and application of various embolic agents, hepatic artery embolization has been used more and more widely in clinical practice for palliative treatment of inoperable or postoperative recurrent hepatocellular carcinoma cases, and has even become an optional method alongside with surgical resection. In recent years, based on the technology of TAE, many new embolization methods have been carried out and promoted clinically with good therapeutic effects, such as: combined hepatic artery-portal vein embolization, hepatic subsegmental embolization, etc.
(2) Combined hepatic artery-portal vein embolization
Hepatic artery embolization is performed simultaneously with percutaneous portal vein puncture to embolize the portal branch of the segment where the tumor is located, and this technique often uses real-time television fluoroscopy to monitor the placement of the tube. Experts reported that TAE combined with embolization of the portal vein branches of the corresponding segment, the necrosis rate of the main tumor, intrahepatic metastases and portal vein aneurysm embolization was higher than that of the hepatic artery embolization group.
3) Hepatic segmental and subsegmental embolization
It is also called hydromedication, i.e. super-selective intubation for LP-TAE. foreign experts believe that iodine oil exceeding a certain limit can return from the hepatic sinusoids to the small branches of the portal vein, which can serve the purpose of portal embolization. Experts believe that iodine oil mixed with anhydrous ethanol in a certain proportion of embolization can also achieve this purpose. Coaxial catheter method, drug-assisted method (such as vasoconstrictor) or direct super-selective catheter insertion method are often used. It is indicated in cases where the tumor is located in a single or a few hepatic segments or subsegments, with or without subfoci, or in patients who are not suitable for conventional hepatic artery embolization due to severe abnormal liver function.
(4) Hepatic artery chemoembolization after temporary blockade of hepatic vein
It is suitable for limited hepatic lobar and segmental tumors and those with arteriovenous fistula. The arteriogram under the blocked hepatic vein reveals an increase in the number of arteries in the visualization. This method can avoid embolic agent into the body circulation and make TAE treatment feasible for patients with arterio-hepatic venous fistula, while increasing the local chemotherapeutic drug concentration and acting as TAPVE.
5) Sandwich bread therapy
Embolization of the distal segment of the hepatic artery with drug-containing iodine oil, infusion of chemotherapeutic agents, and then embolization of the proximal artery. Clinical studies have shown that this method can lead to complete necrosis of small tumors and a significant decrease in AFP.
6）Multiple arterial perfusion embolization Hepatocellular carcinoma often has parasitic arteries or vagus arteries, embolization of these side branches while embolizing the hepatic artery can greatly improve the efficacy.
7) Permanent hepatic artery embolization Studies have shown that the internal diameter of arteries embolized by different embolic agents varies. The artery embolized by gelatin sponge particles is in the middle artery of 1200-1500μm; while microspheres and alcohol can enter the micro-artery of about 100μm in diameter and are not absorbed, some scholars call the embolization performed by such embolic agents permanent hepatic artery embolization.
8) Hepatic artery perfusion TAI technique was applied in the clinic before TAE. However, TAI alone has poor effect on the treatment of hepatocellular carcinoma, and it is rarely used alone in clinical application now. Some scholars use balloon to block blood flow for intra-arterial drug perfusion, which can improve the drug concentration in the tumor area (30 times), and the drug stays for a long time, and the effect is better than general perfusion. Experts have achieved better efficacy in treating liver cancer in rats by heating and reperfusion of chemotherapy drugs. Some scholars have also used arterial pressure boosting method to perfuse chemotherapeutic drugs by taking advantage of the poor response of tumor arteries to vasoactive substances.
(9) Implantable drug cartridge catheter system
The implantation of catheter and perfusion pump can be placed surgically through the abdomen or through the femoral or subclavian artery, and Pentecost suggested that the establishment of a pillbox catheter system can enable high local drug concentration in the liver. Experts applied this method to treat metastatic liver cancer and found that those with liver metastases from gastrointestinal cancer had better outcomes, with a median survival of 17.6 months and 1- and 2-year survival rates of 68.4% and 39.5%, respectively.
10）Intra-arterial embolization combined with internal radiation therapy
This method can not only completely embolize and block the blood supply of tumor, but also the internal radiation source can be uniformly distributed in tumor tissues in high concentration to implement radiation killing effect, which has low local radiation reaction. The 90Y glass microspheres and 32P glass microspheres made in China have been used in clinical practice and have achieved satisfactory efficacy. In addition, in order to block the parasitic blood vessels of hepatocellular carcinoma, Iwamoto used silicone rubber film implanted on the surface of liver, and then performed TAE and portal perfusion treatment, which prolonged the patient’s survival, and some people called this method as isolation therapy.
2. Percutaneous non-vascular treatment techniques.
(1) Percutaneous anhydrous ethanol injection therapy
In 1983, the treatment of experimental mice with liver cancer foci by injection of anhydrous ethanol was successful. After Livraghi reported the clinical application of anhydrous ethanol in the treatment of small liver cancer in 1983, this method was gradually promoted. Domestic experts have also done clinical research reports on such cases. In addition, some scholars have shown that the injection of anhydrous ethanol at 60℃～70℃ can induce tumor necrosis, which is called HOT PEI. the ideal indication for PEI is tumor diameter ≤3cm and no more than 3 nodes. Its main disadvantages are that it requires multiple punctures, multiple courses of treatment and multiple amounts of anhydrous ethanol, and it cannot kill tumors that cannot be detected by current imaging, and it is not ideal for blood-rich type and giant hepatocellular carcinoma.
2) Percutaneous acetic acid injection therapy
The puncture technique, treatment method and mechanism of action are similar to those of PEI, but the dose and number of treatments used are significantly reduced. The quantitative analysis of tumor necrosis was 90%-100% and 64%-90% for Walkar-256 rat liver cancer treated with 50% acetic acid compared with anhydrous ethanol, suggesting that 50% acetic acid can replace anhydrous ethanol to achieve better efficacy.
(3) Direct injection of transdermal chemotherapeutic agents
Some scholars advocate the addition of ultrasound-guided DICT after TAI/TAE, which is considered to have a higher survival rate than single treatment, but there is no large group of cases reported.
Advantages of interventional treatment for hepatocellular carcinoma.
1. Definite efficacy. Successful treatment can see rapid decrease of AFP, shrinkage of mass and pain relief.
2. Mechanistic science: the local drug concentration of interventional therapy is tens of times higher than that of systemic chemotherapy, and the blood supply of tumor is blocked, so the two-pronged treatment is effective and less toxic than systemic chemotherapy.
3. Simple and easy to operate, safe and reliable.
4.It can be performed even for the old and weak and those with certain diseases, without general anesthesia and keeping awake.
5.The cost is relatively low.
6.It can be repeatedly performed, and the diagnostic imaging is clear and easy to compare.
7.For some hepatocellular carcinoma, it can be reduced in size and then resected in two steps.
8.It can be used as one of the important means of comprehensive treatment for advanced tumors.
Disadvantages of liver cancer interventional therapy.
1.The main blood supply of hepatocellular carcinoma depends on hepatic artery, but there is portal vein blood supply around the cancer mass, so the cancer cells can “live in peace”.
The catheter should be super-selected to enter the blood supplying artery for better efficacy, but sometimes it is difficult to enter the hepatic artery. Some hepatocellular carcinoma can have multiple blood vessels.
3. Despite the super-selective access, there are still obvious side effects, and our hospital data analysis shows that there are most reactions in the digestive tract.
4.People with existing portal vein cancer thrombus must consider or remove the cancer thrombus as appropriate.
5.Even if the operation is carried out smoothly with super selection, it may cause misembolism, shunt and inevitable micro-metastasis due to high pressure injection and other reasons.
6.It may still damage normal liver cells, and a few patients may even suffer from hepatic insufficiency.
7.The efficacy is not satisfactory for those with large cancer masses.
8.Some patients may have blockage of blood vessels after one treatment, which makes it difficult to operate again.
Adverse effects of hepatocellular carcinoma interventional therapy care.
1. Fever: Fever is caused by necrosis, shedding and absorption of tumor tissues, and the incidence varies from 10% to 100%. According to the observation of patients in our hospital, most of them have different degrees of fever after surgery. Generally, it appears on the 2nd day after surgery, and the body temperature is between 37.5-38℃ and lasts for 5-7 days, and the body temperature of individual patients is above 38.5℃ and lasts for 9-14 days. Changes in body temperature should be routinely observed after surgery, and body temperature should be measured 4 times a day. If the body temperature is >38℃, the patient should be given physical cooling and told to drink more water; if the physical cooling is ineffective or the body temperature exceeds 38.5℃, the patient should report to the doctor and be given medication.
2, gastrointestinal reactions: is the drug treatment caused by the digestive system reactions, manifested as nausea, vomiting, lack of appetite, etc., the incidence of 44.8% ~ 83%. In this group, there are different degrees of gastrointestinal reactions after surgery, and most patients cannot tolerate them. The patients were instructed to eat an easily digestible, light, less greasy, high vitamin diet and to hydrate more; for those with vomiting, the patients were instructed to choose to eat less and eat more between vomiting periods; in case of severe vomiting, intravenous rehydration was reported to the doctor, and the color and nature of the vomitus were observed. If vomiting is serious, report to the doctor for intravenous rehydration treatment and observe the color and nature of the vomit.
3, liver function damage: most of the liver function damage is due to the cytotoxicity of chemotherapy drugs, embolic agents and the absorption of necrotic tissue after treatment. Some literature reports that the mechanical stimulation of intubation can also trigger liver function damage H, the incidence of 7% to 100%. In our group, 59% showed transient hepatic impairment, which usually occurred within 1 week after the procedure. The main manifestation is an increase in alanine aminotransferase (ALT). After surgery, patients should be advised to rest in bed, eat high-quality low-protein, low-fat, high-calorie, multivitamin and easy-to-digest food, ensure sufficient sleep, and keep indoor air circulation. Prevent cold and flu. Give routine hepatoprotective treatment, such as reducing glutathione (Alto Moran) 1.2g in 5% glucose 250ml intravenously once a day. Generally, the liver function gradually returns to normal after 1O-15 days of treatment. During the treatment period, the patient should be closely observed for changes in consciousness, changes in skin, sclera and color of urine and stool.
4, leukopenia: leukopenia is due to the suppression of bone marrow by chemotherapy drugs, the incidence is 25% to 30%. In this group, 30% of the patients had different degrees of leukocyte decline, which usually occurred within 2 weeks after surgery. It can be normalized by using leukocyte-raising drugs. If leukocytes drop below 1.0×10/L, protective isolation measures should be taken. Laminar flow clean room is available. Closely observe the patient’s body temperature, skin, mucous membrane, excretion and the tendency of bleeding.
5, epigastric pain: epigastric pain is caused by local ischemia of the liver after embolization, resulting in local vascular swelling of the liver to stimulate the liver envelope or direct stimulation of contrast and embolic agents, with an incidence of 3O% to l00%, generally occurring within 24 hours after surgery, with varying degrees of epigastric pain or discomfort. After the operation, attention should be paid to identify the nature, cause, location and duration of abdominal pain, and ultrasound examination should be performed if necessary. In our group, 11 cases had different degrees of epigastric pain on the second postoperative day, which was relieved by rectal administration of indomethacin pessary. If there is moderate or severe pain, 100mg of brucine or 10mg of morphine can be administered intramuscularly.
6, puncture site injury: the cause of puncture site injury is mostly due to the patient’s coagulation mechanism disorder, intraoperative application of heparin, the operation itself or excessive postoperative hemostatic pressure. The main manifestations are puncture local bleeding, hematoma, arterial and venous spasm, thrombosis or embolism, with an incidence of 2% to 13%. In our group, two cases showed postoperative weakness of dorsalis pedis artery pulsation, which improved after adjusting the compression band. Within 12 hours after surgery, the puncture site should be observed every hour for hematoma and blood leakage from the dressing, and pulse rate and blood pressure should be measured every 2 hours. If local hematoma appears, report it to the doctor immediately for timely treatment. The patient should be asked to lie flat for 24 hours after the operation, and the limb on the puncture side should be stretched flat for 6-8 hours, and the puncture site should be compressed with a sandbag for 6 hours to prevent bleeding. Also pay attention to the dorsalis pedis artery pulsation and blood circulation of the distal limb on that side. If the skin temperature of the punctured limb is lower than that of the opposite side or the limb is painful, pale, and the pulsation of the dorsalis pedis artery is weakened, it indicates arterial vasospasm, and while reporting to the doctor, check whether the compression bandage is too tight and adjust the compression band in time.
7.Post-embolization syndrome: Post-embolization syndrome is a common complication of interventional treatment, mainly manifested as fever, nausea, vomiting and abdominal pain. The incidence is reported to be 10% in the literature. After the operation, the patient’s vital signs should be closely observed, cardiac and blood pressure monitoring should be performed within 24 hours, body temperature and respiration should be measured 4 times a day, and body temperature, pulse, respiration and blood pressure should be measured after 24 hours and the vital signs are stable according to the level of care. If the body temperature is below 38.5℃, there is no need for drug treatment, and the patient should drink more water and gradually return to normal in 5-7 days; if the body temperature exceeds 38.5℃, the patient should be alerted to the occurrence of infection and care according to the routine requirements of hyperthermia care
8, psychological rehabilitation guidance: psychological rehabilitation guidance is the key to whether the patient can successfully complete interventional treatment. First of all, the nurse should understand the patient’s degree of awareness of the disease, psychological reaction and family economic status, so that the patient can be taught according to his or her needs and the corresponding nursing plan can be formulated. For patients who are informed and active in treatment, they should introduce in detail the whole process of treatment, possible adverse reactions, how to protect themselves, treatment principles and treatment effects, so as to eliminate the fear of treatment and accept treatment with an optimistic attitude. For patients who are unaware of the disease, we should communicate with the patient’s family and doctor and unify the content of the information according to the actual situation of the patient. During the recovery period of surgery, patients should be instructed to have a reasonable diet, quit smoking and alcohol, take appropriate exercise according to their physical condition, enhance their resistance to disease and prevent colds. Follow the doctor’s instructions to review regularly, take medication on time, maintain a good mood, and increase confidence in overcoming the disease.