Interventional Radiology for Liver Mets
A variety of interventional radiology therapies are available. These include: CryoAblation, Microwave Ablation, RadioFrequency, TACE, and SIRT. All of these procedures can be performed percutaneously (through the skin) by interventional radiologists (IR) or as an open surgical procedure by a surgeon who specializes in oncology. These procedures are generally safe and well tolerated. Medicare does provide coverage for these procedures.
What is Cryoablation?
Cryoablation uses extremely cold temperatures to destroy cancer cells.
How Does It Work?
Cryosurgery relies upon the process of producing extremely cold temperatures using liquid nitrogen or argon gas in order to destroy diseased or abnormal tissue. The freezing temperature results in the formation of ice crystals in the diseased tissue which causes abnormal cells to tear apart.
For external problems such as skin cancers, in particular, treatment is quick with usually few, if any, side effects. The liquid nitrogen is simply applied to the abnormal cells directly using either a swab or spraying device. In addition to smaller skin cancers and precancerous skin cells, it can also be used on things such as moles, warts and skin tags. The procedure deadens the skin which falls off later by itself.
Cryosurgery can also be used for internal abnormalities. These can include certain forms of liver tumors. For the liver, thee treatment is administered using an instrument which is inserted into the body to come into contact with the tumor. This is known as a cryoprobe.
It works by circulating argon gas or liquid nitrogen which results in a ball of ice crystals forming around the probe which then freezes the affected cells. After cryoablation has been completed, then eventually the frozen tissue thaws and it is then absorbed ty the body.
Although you can experience side effects as the result of undergoing cryoablation, they tend to be far less severe than other more conventional treatments. Side effects will also depend on where the tumor is located.
One of the key benefits of cryoablation is that it is far less invasive than other forms of treatments as well as producing fewer side effects. It is also far less expensive treatment to administer. Furthermore, it has started to gain increasing popularity for those whose medical conditions or a patient’s age means that they are not suitable for other traditional forms of surgery or treatment.
WHAT IS MICROWAVE ABLATION FOR LIVER TUMORS?
A microwave ablation system allows your doctor to destroy unresectable liver tumors in a minimally invasive way, using few or very small incisions. Your doctor will use ultrasound, CT, or MRI images to see your liver in real time while performing the ablation procedure. Guided by these images, your doctor will place the ablation antenna into the center of the non-resectable liver tumor. There, the antenna delivers thermal (heat) energy to destroy the non-resectable liver tumor(s) and some of the surrounding tissue.
Ablation can be combined with additional therapies (such as chemotherapy, radiation, or resection) so that you have another weapon in the battle for your liver.
HOW ABLATION WORKS
- Ablation targets the non-resectable liver tumor.
Guided by images of the liver, your doctor places the ablation antenna into the center of the non-resectable liver tumor.
- The tumor cells are destroyed.
The ablation antenna delivers thermal energy to destroy the tumor cells and some of the surrounding tissue.1
- Your tissues will heal. The dead tumor cells are gradually replaced by scar tissue that shrinks over time.2
WHO IS A CANDIDATE FOR LIVER TUMOR ABLATION?
For some patients, ablation may used for non-resectable liver tumors in addition to chemotherapy, radiation, or other therapies. Studies have shown that ablation is a good alternative therapy when the tumor(s) cannot be removed surgically.
Doctors generally make a decision to use ablation based on certain guidelines. For example, the non-resectable liver tumor and surrounding normal tissues need to be located where the doctor can reach them in a minimally invasive procedure.6 Also, ablation is generally more effective when used on non-resectable liver tumors that are less than 1.18 inches (3 centimeters) in size.
Microwave ablation procedures are not recommended for pregnant patients, patients with cardiac pacemaker, or other implanted electronic devices. Consult your health care professional and review the possibilities of risks.
WHAT TO EXPECT BEFORE YOUR ABLATION PROCEDURE
You may receive ablation as an outpatient procedure. It is performed in a hospital radiology suite or operating room. Here are some things to know before you have your ablation procedure:
- Ablation is typically performed under sedation or general anesthesia. Before your procedure, your healthcare team will determine the appropriate sedation for you.
- The length of the procedure varies from patient to patient.
- The doctors performing your procedure will use imaging scans to help them monitor the area of ablation.
- After the procedure, you will go to recovery where doctors will monitor you.
- Your doctor will discuss the results of the procedure with you. If necessary, your doctor will help you determine any further steps to take.
- The most common complication patients experience after an ablation procedure is some slight pain and discomfort.
- Serious complications, such as bleeding and infection, are uncommon. Your doctor will discuss your risk for specific complications.
- Please consult with your doctor for a complete list of indications, warnings, precautions, adverse events, clinical results, and other important medical information about ablation.
What should I expect after the Microwave ablation?
- Often a one night stay in the hospital is required post procedure for observation and pain control.
- Pain post procedure may last up to 5-7 days, tapering in intensity. This usually does not require more than a few days of prescription pain medicine and many patients only use over the counter pain medication.
- Do not plan anything active or requiring your close attention for the first few days following discharge from the hospital. If you work, you may return as soon as you feel able. Most patients do not need more than 2-3 days away from work.
- There are no dietary restrictions specifically due to this procedure. If you had restrictions prior due to other treatments or diseases such as diabetes, cardiovascular disease, or renal disease, continue with these.
- Bathing & Wound Care: It is okay to shower 24 hours after the procedure. Gently wash the catheter insertion site with soap and water, do not scrub only after 3 days post procedure. Do not bathe or soak in water for 3 days following the procedure.
Follow-up visit information:
Call your primary doctor after discharge for a follow-up appointment if you don’t already have one. Follow up with Interventional Radiology is not routinely necessary with follow up imaging depending on the targeted region. Occasionally, a situation will require prompt attention and an emergency room visit is necessary:
- Jaundice (yellowing eyes and skin)
- Severe, worsening abdominal pain
- Sudden shortness of breath
- You have shaking chills or a temperature over 102°F
- Your treatment site starts bleeding and will not stop after 10 minutes of firm pressure.
If you received Conscious Sedation (IV sedation) or General Anesthesia:
- You must have someone drive you home when you leave the hospital if it is less than 24 hours post procedure.
- For 24 hours after your procedure, do not do anything where you need to be mentally alert. This includes making important decisions, operating machinery, signing important papers, etc.
- Eat light for the first 24 hours, and then start eating more as you are able. Drink plenty of fluids.
- Sore throat or mild “hang over” type feeling for a day or two from the general anesthesia. This may include mild nausea.
If you are taking pain medications:
- Take as directed
- Do not drink alcohol while taking narcotic pain medication
- Do not drive
- If you are constipated, drink more fluids and eat more fiber. You can also use an over-the-counter stool softener.
What is RFA?
Radiofrequency ablation (RFA) is a minimally invasive procedure that destroys cancerous tumors. Pulses of radiofrequency energy are sent through a catheter (a long, thin tube) to heat and destroy diseased tissue. Currently, RFA is a standard treatment for patients with inoperable liver tumors. It is being increasingly used for other cancers, such as lung cancers, kidney (renal), and certain benign and malignant bone tumors, and is being tested for other types of cancer. RFA does not cure cancer, but it can effectively destroy cancer cells, possibly in a similar way to surgical removal, relieve pain and suffering, and may prolong life.
Radiofrequency ablation (RFA) is a local treatment for cancer that delivers radiation directly to a tumor.
Radiofrequency energy comes from electric and magnetic energy and is absorbed by the body as heat. In RFA, the physician inserts a metal probe through the skin into a tumor. This heat destroys the cancerous cells but spares healthy tissue.
RFA may increase longevity and relieve pain, but it does not cure cancer.
RFA has fewer complications, is less risky, and causes fewer side effects than surgery to remove a tumor.
RFA may be used with other interventional cancer therapies, such as chemoembolization, and traditional cancer treatments, for example, chemotherapy.
WHEN IS IT INDICATED?
RFA is indicated in patients who have liver cancer for whom surgery is not possible. RFA may also be used to shrink large liver tumors before surgery.
Before treating cancer, the physician will order tests to determine the location, type, and severity of the cancer. These tests include:
- Blood tests
- Computed tomography (CT) scan
- Liver function test
- Magnetic resonance imaging (MRI)
- Spiral CT scan
The night before the procedure, the patient is not allowed to eat. However, water is usually allowed up to 2 hours before the procedure.
WHO IS ELIGIBLE?
Eligible patients have liver cancer or cancer that has spread to the liver. Additionally, patients with small kidney tumors, lung tumors, or bone cancer may be eligible.
Patients with large or multiple liver tumors may be ineligible for RFA. RFA may not be as successful for liver metastases as for primary liver tumors.
WHAT TO EXPECT
RFA is frequently performed as an outpatient procedure by an interventional radiologist. In most cases, only a mild sedative and a local anesthetic are needed.
Interventional procedures are generally painless. Because there are no nerve endings inside the arteries, people cannot feel the catheters (long, thin tubes) as they move through their body.
The interventional radiologist will locate the tumor using imaging tests and choose an insertion point above a blood vessel for the catheter. Through this catheter, the physician inserts a probe with electrodes that transmit radiofrequency energy.
The interventional radiologist guides the probe to the site of the tumor while watching real-time images on a monitor. The patient may need to lie still or hold his or her breath as the probe is placed into the tumor. A generator sends radiofrequency energy through the probe. Heat kills the cancer cells surrounding the probe. This portion of the procedure typically takes 10 to 30 minutes.
When treatment is complete, the physician slowly removes the probe and places a small bandage over the site of the insertion. The entire procedure takes 1 to 3 hours.
POST-TREATMENT GUIDELINES AND CARE
The physician takes CT or MR images to ensure that the treatment has destroyed the tumor. If necessary, the procedure may be repeated.
For the first 2 to 3 hours after the procedure, the patient is placed on bed rest and his or her vital signs are monitored. Painkillers may be given. Patients stay in the hospital overnight.
For 24 hours following the procedure, the patient should avoid driving a car, exercising strenuously, or making important decisions if they have been given sedatives. Otherwise, patients can resume normal activities immediately.
Patients receiving RFA return for follow-up imaging tests. If the tumors have not shrunk, some patients may need additional treatments.
POSSIBLE SIDE EFFECTS
In general, RFA is safe and has a low rate of minor side effects, including:
- Low-grade fever
If a tumor in the liver or upper kidney is being treated, there is a small risk of lung collapse during the insertion of the probe.
Recurrence rates of liver tumors treated with RFA range from 1.8 percent to 28 percent. Long-term results of the procedure are not yet known.
SIRT is what YES is all about!!!
Selective internal radiation therapy (SIRT) or Yttrium 90 Microspheres is a relatively new treatment suitable for use even in patients with extensive liver involvement. Radioactive spheres (SIR-Spheres or Therasphere) are injected into an artery in the liver. The spheres are very tiny radioactive seeds. After they are iinjected through the liver artery, they travel into smaller arteries that feed the tumor. Once “the little magic beads” are in the tumor, they give off radiation for about three days. The radioactivity causes damage to cancer cells with little damage to the healthy liver tissue. Radioembolization is a highly effective and well-tolerated regional treatment for liver tumors. This treatment is covered by Medicare.
What is Selective Internal Radiation Therapy?
SIRT is a revolutionary treatment for cancers of the liver that uses new technology to deliver radiation directly to the site of the tumor. SIRT delivers millions of microscopic radioactive spheres, called SIR-Spheres or Therasphere, directly to the site of the liver tumors, where they selectively irradiate the tumors. The targeted nature of SIRT lets doctors deliver up to 40 times more radiation to the liver tumors than would be possible using conventional radiotherapy.
What to expect before, during, and after treatment
Selective Internal Radiation Therapy is known by a number of names that include: SIRT, Sir-spheres, Therasphere, radioembolization, Yttrium 90, Y90, brachytherapy, and has been coined by YES co-founder as “little magic beads.” We understand that being diagnosed with liver cancer or metastases to the liver from other cancer is terrifying, to say the least. Exploring the treatment options available and choosing the one best suited for your individual condition is an important decision. Your physician and loved ones need to be included in this process.
“What to expect” before, during, and after SIRT as described below may vary depending on the individual hospital and your specific disease burden and physical condition. The following is provided to give you a general idea of what you might experience while undergoing and recovering from SIRT. Patients who have previously undergone treatment with Y-90 therapy have contributed their voice of experience to help you make more informed choices regarding SIRT. Hopefully, this will help to make your experience easier and more comfortable.
There will be several specialists involved during your microspheres experience. They may include an interventional radiologist, your oncologist, radiation therapist, and nurse among others. With your spheres team working together you will receive the highest quality of care because all aspects of your treatment and recovery will be covered.
Most important, you can be matched with other patients who have undergone SIRT. Through speaking with other patients, you can gain important knowledge about what to expect as well as receive emotional support before and after treatment.
For more information on selective internal radiation therapy (SIRT) and the patient treatment process, please visit their websites at the following:
www.sirtex.com or www.therasphere.com
The Screening Process
Many patients learn about Yttrium 90 microspheres therapy through their own research. Quite often, the treating oncologist will know very little about the procedure. Finding an interventional radiologist near you that is specially trained to administer the spheres will be your first step toward the screening process. You may be able to send your records and medical history for an opinion. If it appears that you may indeed be a candidate an appointment for evaluation will be set.
For a list of treatment centers near you, please refer to the list we have provided on our web-site or consult with either Sirtex or Boston Scietific.
At this point, you know there is a good chance that you qualify for SIRT and the evaluation is the next step. You might find that you are anxious about this visit and the possibility that it holds. This experience will be much like the actual implantation of microspheres. In essence, it is a dress rehearsal. You may want to arrive at the hospital with a book to read, music to listen to, or something else that requires little movement but will occupy your time. It is always nice to bring a family member or friend to keep you company before and after the procedure.
You will be asked not to eat for a specific amount of time before your evaluation. You will bring lab-work and recent scans for review. You will be prepped for the procedure and your interventional radiologist will make a tiny incision in your leg and carefully place a small but long, flexible plastic tube called a catheter into the femoral artery (which is the major blood vessel in the leg). He/she will use an x-ray that allows him to view the inside of the body on the screen as he guides the catheter through the blood vessels to the hepatic artery (which is one of two blood vessels that feed the liver). He will ease the tube into the branch of the hepatic artery that feeds the cancerous tumor(s) in your liver. This process will ensure that the microspheres are going to be distributed appropriately. It will also indicate whether or not they will be likely to go into areas that could be dangerous – such as the lung or abdominal cavity. Sometimes blood flow will have to be redirected. You will be awake for the procedure and can even watch the monitors if you so choose. You may feel some pressure but should not feel pain. Once the procedure is complete, the catheter will be carefully removed and pressure will be applied to the incision. You will have to lie flat for several hours to ensure that bleeding does not occur. If all goes well and Yttrium 90 Microspheres therapy is possible, then a date for the procedure will be set and you should be able to return home shortly after the evaluation.
On the day of your scheduled SIRT you will need to check in at the facility and will be directed to the radiology suite. Wear loose, comfortable clothing. Again, you may also want to bring a newspaper/magazine to read or headphones and a CD for any waiting time before your treatment. It is always nice to bring a family member or friend to keep you company before and after the procedure.
Just as with the evaluation, you will be asked not to eat for a specific amount of time before the procedure. You will be prepped for the treatment and the same actions that were required for your evaluation will be performed. Your interventional radiologist will make a tiny incision in your leg and carefully places a small but long, flexible plastic tube called a catheter into the femoral artery (which is the major blood vessel in the leg). He/she will use and x-ray that allows him to view the inside of the body on the screen as he guides the catheter through the blood vessels to the hepatic artery (which is one of two blood vessels that feed the liver). He will ease the tube into the branch of the hepatic artery that feeds the cancerous tumor(s) in your liver and “the little magic beads” will be infused. Once the procedure is complete, the catheter will be carefully removed and pressure will applied to the incision. You will have to lie flat for several hours to ensure that bleeding will not occur. If the treatment goes as planned, return to home with a few simple precautions will be allowed within 24 hours. The wait for results begins……
After the implantation of the microspheres, some simple precautions must be taken for a week following the procedure. These include:
No close physical contact with others for longer than 2 hours
No contact with anyone who is pregnant
No contact with young children
No public transportation
Pets should not sit on the patien’ts lap
The patient should sleep in bed alone
Generally, there are few side effects from treatment. Most patients will feel only flu-like symptoms. We talked to patients that experienced these along with a slight fever. Some had abdominal cramping that ranged from low to intense. Most complained that fatigue was the biggest factor and that very little activity was accomplished in the days following the treatment. Severe side effects rarely occur, but can.
Follow-up appointments are very important as they will determine your response to treatment. Be sure you do not miss any! Your tumors or lesions will need to be monitored periodically for progress.
**Be aware that scans often show inflammation of tumors for a period of up to three months post procedure and may be alarming to someone who has not evaluated the after effects of SIRT. A good discussion from a previous webinar conducted by Dr. Charles Nutting can be replayed.
For more information on the SIRT, please contact either Sirtex by phone at 1(888)474-7839 or through their web-site at www.sirtex.com or Boston Scientific by phone at 1-888-272-1001 or through their web-site at www.therasphere.com.
TACE (Transarterial Chemoembolization)
What is Chemoembolization?
Chemoembolization is a procedure in which chemotherapy drugs and embolic agents are delivered directly to a tumor via a long, thin tube called a catheter. Tiny particles in the embolic agents block the blood vessels leading to the tumor, which deprives it of blood flow. Embolic agents also increase the concentration and toxicity of the chemotherapy drugs.
Chemoembolization kills cancer tumors but spares healthy tissue, minimizing the side effects of conventional chemotherapy, such as hair loss and nausea.
Currently, the procedure is mainly used to treat patients with primary liver cancer or other types of cancer that have spread to the liver.
Chemoembolization cannot cure cancer, but it can increase the length and quality of life. Chemoembolization is often used with other interventional cancer therapies, including radiofrequency ablation, cryoablation, chemical ablation, and some intravenous chemotherapies.
WHEN IS IT INDICATED?
Chemoembolization is indicated in patients who have liver cancer and are candidates for the procedure.
Chemoembolization may also be used to shrink liver tumors while the patient awaits a donor organ.
The physician will order tests to determine the location, type, and severity of the cancer. These tests may include:
- Blood tests
- Computed tomography (CT) scan
- Liver function tests
- Spiral CT scan
The night before the procedure, the patient is not usually allowed to eat. However, water is often allowed up to 2 hours before the procedure.
Patients may be given one or more of the following drugs the day of the procedure:
- Antinausea drugs;
- Sedatives; and
- Intravenous fluids.
WHO IS ELIGIBLE?
Eligible patients have primary or secondary liver cancer.
Patients who have severe cirrhosis may be ineligible for chemoembolization.
The following conditions increase the risk of complications from the procedure:
- A blockage in the portal vein in the liver
- A tumor that is greater than 50 percent of the liver volume
- Bile duct obstruction
- Diabetes mellitus
If disease outside the liver (such as colon cancer) is the main source of symptoms, other treatments should be considered because chemoembolization only treats the liver
Poor kidney function
Poor liver function
WHAT TO EXPECT
The physician will locate the tumor using arteriography and choose an insertion point for the catheter, usually above the femoral artery in the groin.
Interventional procedures are generally painless. Because there are no nerve endings inside the arteries, people cannot feel the catheters as they move through their body.
Using an imaging technique called fluoroscopy, the physician steers the catheter through the arteries to the tumor, administers chemotherapy and embolic agents, and removes the catheter.
Once treatment is complete, pressure is applied on the insertion site for 15 to 30 minutes to prevent bleeding.
POST-TREATMENT GUIDELINES AND CARE
The patient’s vital signs are monitored for the first 5 to 6 hours after the procedure. Initially, some patients may experience abdominal pain. Antibiotics and antinausea drugs are administered as needed.
Chemoembolization typically requires an overnight hospital stay.
Patients can usually resume normal activities within 1 week. Chemoembolization patients typically have lower energy levels for 2 to 3 weeks following the procedure.
Patients return for follow-up CT scan, MRI, or blood tests. A second treatment, if needed, is usually performed 1 to 2 months after the first.
In general, chemoembolization is safe and commonly associated with only minor side effects including:
Allergic reaction to the contrast material used in arteriography;
- Hemorrhage, or bleeding.
- Injury to the liver;
- Liver abscess; and
- Low-grade fever;
- Nausea; and