TREATMENT OF LIVER CANCER AND METASTASIS IN LYON
The liver is a vital organ.Treat tumors present on the liveris only possible if we manage to preserve its function. Theminimally invasive treatmentsoffer two possibilities:
- Destroy, through the skin, small primary cancers or liver metastases without surgery, while preserving maximum liver function, thanks to a miniature needle inserted under imaging control
- Inject anti-tumor treatments directly into liver tumors through the feeder arteries (chemotherapy, chemoembolization, internal radiotherapy, etc.) or through the skin using a needle.
For each of these gestures theinterventional radiologistwill confirm the possibility of aminimally invasive treatment, he will explain to you the course of thetreatment, and the indication will be confirmed in a multidisciplinary consultation meeting (RCP).
It can beprimary liver cancer(hepatocellular carcinoma or HCC, cholangiocarcinoma) ormetastasescolon cancer but also breast cancer, choroid melanoma, thyroid cancer, neuroendocrine carcinoma...
Percutaneous destruction of tumors by radiofrequency or microwave.
thetreatment of liver cancer in lyonis carried out using a needle containing an electrode, connected to a radio frequency wave generator (mono or multi bi-polar) or microwave.
While you sleep the needle is guided through the skin and guided into the tumor under ultrasound or CT scan. At the tip of the needle in the tumor, the waves will increase the temperature to more than 80°, thus allowing it to be destroyed. The burn must be a little larger than the tumor to take a little margin.
The needle is then withdrawn by coagulating the puncture path to prevent any bleeding.
Monitoring is 6 hours minimum on an outpatient basis or with one night of hospitalization, to detect any hematoma or pain following the procedure.
The pain is exceptional, 90% of people feel nothing, for the remaining 10% the pain is generally weak and well relieved in conjunction with a team of anesthetist.
You are seen again at 1 month with liver imaging to ensure that the lesion has been completely destroyed.
The tumor cells are replaced by scar tissue which will shrink over time.
The radiologist can then monitor you for several months in parallel with the oncologist to ensure that there is no later recurrence on images that are sometimes difficult to interpret, then follow-up is again provided solely by your oncologist.
Before confirming the treatment, the interventional radiologist will see you in consultation to make sure that the tumor is clearly visible and that nothing is in the way of performing this puncture, then cete burn.
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Chemoembolization
Chemoembolization or chemoembolization is aliver cancer treatment in Lyonminimally invasive allowing to deliver a treatment not in all the body but directly in the tumor of the liver while passing by the arteries.
The interventional radiologist will make a puncture on the artery of the leg or the wrist, then he will guide small catheters on guides to reach the arteries of the liver.
He will then identify the arteries feeding the or the tumors and inject the treatment, a product blocking the arteries of the tumor (embolization) associated with chemotherapy which will be blocked with. It is performed under sedation with an anesthesiologist because the injection of the treatment sometimes gives pain.
The chemotherapy used is different depending on the liver cancer or metastases (eg idarubicin in hepatocellular cancers). The fact that it is blocked directly in the tumor makes it possible to increase the concentration of intra-tumor chemotherapy and, conversely, to decrease the concentration in the rest of the body.
Embolization itself also has an important role because by being deprived of their arteries which feeds them, the tumors will become necrotic.
The main complication is the post embolization syndrome linked to the reaction of the liver and tumors just after the procedure, which occurs in about 20% of cases. An infusion before and for 2 days after the procedure helps to reduce the frequency and severity of this syndrome, which may include fever, fatigue, nausea and pain on the right side. A more serious complication is the insufficiency of liver function if it does not tolerate the treatment, this is why the treatment is never done on the whole liver in one session, but by half of the liver (lobe) in 2 sessions, in order to be certain of good tolerance. This treatment cannot therefore be carried out if the liver function is already too poor.
The objective is as for chemotherapy to control the disease, to stop it, to reduce the size of the nodules, and in the most favorable cases to make them disappear. After chemoembolization, all other liver cancer treatments can be offered and are discussed at each RCP depending on the evolution.
Radiation embolization (or SIRT selective internal irradiation)
Radiation embolization, or selective internal irradiation with Yttrium 90, is aliver cancer treatment in lyonminimally invasive drug delivered directly through the arteries in liver tumours. This involves delivering radiotherapy by the Y90, which is a B-ray emitter, directly from inside the body in contact with the tumour, without the rays passing through the skin. It will be performed in 2 stages under simple local anesthesia on an outpatient basis most of the time by a puncture of the wrist artery (radial route):
- first time of planning or Work up:
the interventional radiologist will carry out a precise mapping of the arteries of the liver by identifying those which supply the tumour(s). He thus decides which injection point(s) will be the most effective (the most tumor and the least amount of liver possible) by blocking small accessory arteries if necessary.
He will inject not the treatment but a marker (albumin) which will make it possible to verify on a nuclear medicine examination that the treatment targets the lesions, does not reach the organs outside the liver, and above all calculate with the radiophysicist and the radiopharmacist the dose of treatment to be injected in order to be effective without being harmful to liver function. This step is completely painless.
- second treatment time:
the radiologist will simply inject the calculated treatment dose at the planned location. Good targeting is again confirmed by a PET scanner. This treatment is very well tolerated, pain or complications are rare, but patients present in 30% of cases with significant fatigue several days later. The real complication is the insufficiency of liver function if the dose of irradiation delivered to the liver is too high (REILD syndrome), especially if it already had an impaired function before. To do this, the team must respect a certain liver dose threshold that must not be exceeded, and the interventional radiologist must favor as many injection points as possible targeting the arteries of the tumor and not the healthy liver, which is not always possible depending on anatomy.
If the dose delivered to the tumor has been substantial, there will be a real tumor necrosis. If the dose is not optimized the disease will simply be slowed down. This technique can be used to completely destroy a segment or lobe of the liver (segmentectomy and radiation lobectomy) or to prepare for surgery (contralateral compensatory hypertrophy).
The interventional radiologist will see you in follow-up at 3 months to judge the effectiveness of the treatment and ensure that there are no complications.
Chemotherapy by hepatic intra-arterial catheter
Another way totreat liver cancer and metastases in Lyondirectly is to insert a hepatic arterial catheter, in order to be able to carry out bi-monthly chemotherapy cures directly in the arteries of the liver
The placement of the hepatic catheter is a complex and long procedure (1 hour) performed by a trained interventional radiologist. It is perfectly painless and is performed under local anesthesia with premedication.
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Why intra arterial hepatic chemotherapy?
Hepatic cancer metastases have a preponderant arterial vascularization. The use of chemotherapy directly intra-arterially has the advantage of being able to deliver higher concentrations within the tumors than via the venous route, where the product reaches the liver in a more dilute form. Conversely, after the hepatic arterial passage, the venous concentration of chemotherapy is lower than by the venous route, with therefore fewer side effects. In practice, hepatic intra-arterial chemotherapy (HAIC) is used to intensify the treatment of primary cancer or liver metastases. The aim is to obtain more patients who can be operated on secondarily, or to prolong life expectancy under chemotherapy alone.
CIAH's decision is made jointly with the various specialists during a multidisciplinary consultation meeting. The patient is seen in consultation by the oncologist and the interventional radiologist in order to explain the expected benefits and possible complications.
2. How is the liver catheter inserted?
The installation is done during a 24-hour hospitalization in a radiology block according to the following steps:
• Local anesthesia and puncture of the right femoral artery. Placement of a probe in the hepatic artery.
• Proximal identification and occlusion of arterial branches arising from the hepatic artery with an extrahepatic destination (digestive or pancreatic) using a microcatheter and metallic microspirals.
• Study of the number and origin of arteries supplying the liver:
- a single hepatic artery: the CIAH catheter can be inserted;
- several hepatic arteries: the CIAH catheter will be in the one with the largest caliber, and the others will be occluded proximally to allow a redistribution of the arterial flow to the whole of the liver from the only artery kept permeable (mono- pediculization of the liver).
• Intraoperative verification by rotational angiography or angio-CT of the complete and only hepatic nature of the infusion
• Insertion of the CIAH catheter:
- blocked in the gastroduodenal artery with a lateral hole in the hepatic artery, then micro-catheter occlusion of the gastroduodenal artery, in parallel and around the CIAH catheter already in place, by metal coils.
- free in the hepatic artery if blocked insertion impossible.
• Placement of the implantable port in the right iliac fossa
_cc781905-5cde-3194 -bb3b-136bad5cf58d_3. Once the catheter is in place, how do you use it?
The catheter will be used as an implantable venous port with some exceptions.
Chemotherapy can begin immediately after the installation. Every 15 days the catheter is checked before the chemotherapy to ensure that it is correctly positioned and that there are no new arteries to be embolized.
Chemotherapy can sometimes give stomach pains during the infusion which are controlled by slowing down the flow and by painkillers.
This technique has shown quite promising results and is a validated option in patients with liver metastases from colorectal cancer. It is being evaluated more precisely in clinical trials to know when exactly it should be offered to patients in comparison with other treatments. Dr. Charles Mastier is an investigator for these clinical trials, do not hesitate to ask him for details.
Isolation Liver perfusion
Hepatic perfusion isolation is aliver cancer treatmentcarried out by team since carried out jointly by interventional radiology, resuscitator anesthetist and seasoned perfusionist. Under general anesthesia, the interventional radiologist will first place a catheter in the right heart and the vena cava, blocking the blood flow returning from the liver with two balloons. This same catheter will draw blood from the liver and direct it outside the patient so that it is filtered of any product before returning to the patient's neck vein. Once this circuit has been completed, the radiologist will be able to enter the arteries of the patient's liver and inject very high doses of chemotherapy, since this chemotherapy will then be recovered from the venous blood of the liver and filtered in the circuit outside the patient. .
The risks of the procedure are cardiac and anesthesiologists because when the venous return to the heart is blocked, there is a significant drop in blood pressure which will be compensated by the anesthesiologist-resuscitator. There is also a risk of not filtering out all the chemotherapy with a drop in blood cells (aplasia) which will be monitored for 3 weeks. The treatment requires 2 nights of hospitalization.
This treatment is used in several countries for all liver cancer, but in France it is currently only available in the context of clinical trials such as the FOCUS trial which assesses its effectiveness for ocular melanoma metastases. Dr. Charles Mastier was an investigator for this trial at the Léon Berard Center (the only French center for this international study), do not hesitate to ask him your questions.
References:
You want to know more?
Here are some useful links
Explanatory video of hepatic RF by Gustave Roussy's team
Explanatory animation of Radioembolization by Sirtex
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