Hepatic artery embolization

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Hepatic artery embolization
Other namesHAE, trans-arterial embolization, TAE
Specialty interventional radiology/oncology

Hepatic artery embolization, also known as trans-arterial embolization (TAE), is one of the several therapeutic methods to treat primary liver tumors or metastases to the liver. The embolization therapy can reduce the size of the tumor, and decrease the tumor's impact such its hormone production, effectively decreasing symptoms. The treatment was initially developed in the early 1970s. [1] The several types of hepatic artery treatments are based on the observation that tumor cells get nearly all their nutrients from the hepatic artery, while the normal cells of the liver get about 70-80 percent of their nutrients and 50% their oxygen supply from the portal vein, and thus can survive with the hepatic artery effectively blocked. [2] In practice, hepatic artery embolization occludes the blood flow to the tumors, [3] achieving significant tumor shrinkage in over 80% of people. [3] Shrinkage rates vary. [4] [5]

Contents

Background

The several types of hepatic artery treatments are based on the observation that tumor cells get nearly all their nutrients from the hepatic artery, while the normal cells of the liver get about 70-80 percent of their nutrients and 50% their oxygen supply from the portal vein, and thus can survive with the hepatic artery effectively blocked. [2] In practice, hepatic artery embolization is an option if the neoplastic growth is mainly within the liver. [6] By occluding the blood supply to the tumors, [3] achieving significant tumor shrinkage in over 80% of people. [3] Shrinkage rates vary. [4] The therapy can effectively decrease symptoms by reducing the size of the tumor, or by decreasing the tumor's impact, for example by decreasing the tumor's production of hormones. [7]

Primary liver tumors, metastatic neuroendocrine tumors to the liver [8] and other metastases to the liver [9] [10] may be considered for therapy directed via the hepatic artery.

Method

The percutaneous Seldinger technique introduces a catheter, which is a thin flexible tube made of medical grade material, into the hepatic artery under radiological control. [11] [12] This approach was developed for metastatic neuroendocrine tumors in the early 1970s. [1] Tumor cells get over 90% of their nutrients from the hepatic artery, [1] while the normal cells of the liver get about 70-80 percent of their nutrients and 50% their oxygen supply from the portal vein, and thus can survive with the hepatic artery effectively blocked. [1] [2] Once the catheter is carefully placed in the artery or in a selected branch, the blood flow can be occluded by injecting various items, such as plastic particles, glue, metal coils, foam, or by deploying a balloon. [11] Additional considerations and procedural details have been reviewed. [1] [13]

In hepatic artery chemotherapy (HAC), chemotherapy agents are given into the hepatic artery, often by steady infusion over hours or even days. Compared with systemic chemotherapy, a higher proportion of the chemotherapy agents is (in theory) delivered to the lesions in the liver. [14] [15]

Hepatic artery chemoembolization (HACE), sometimes called transarterial chemoembolization (TACE), combines hepatic artery embolization with hepatic artery chemo infusion. In one method, embospheres bound with chemotherapy agents injected into the hepatic artery, lodge in downstream capillaries. The spheres not only block blood flow to the lesions but by halting the chemotherapy agents in the neighborhood of the lesions, they provide a much better targeting leverage than chemo infusion provides.

See also

Related Research Articles

<span class="mw-page-title-main">Hepatocellular carcinoma</span> Medical condition

Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer in adults and is currently the most common cause of death in people with cirrhosis. HCC is the third leading cause of cancer-related deaths worldwide.

<span class="mw-page-title-main">Interventional radiology</span> Medical subspecialty

Interventional radiology (IR) is a medical specialty that performs various minimally-invasive procedures using medical imaging guidance, such as x-ray fluoroscopy, computed tomography, magnetic resonance imaging, or ultrasound. IR performs both diagnostic and therapeutic procedures through very small incisions or body orifices. Diagnostic IR procedures are those intended to help make a diagnosis or guide further medical treatment, and include image-guided biopsy of a tumor or injection of an imaging contrast agent into a hollow structure, such as a blood vessel or a duct. By contrast, therapeutic IR procedures provide direct treatment—they include catheter-based medicine delivery, medical device placement, and angioplasty of narrowed structures.

<span class="mw-page-title-main">Embolization</span> Passage and lodging of an embolus within the bloodstream

Embolization refers to the passage and lodging of an embolus within the bloodstream. It may be of natural origin (pathological), in which sense it is also called embolism, for example a pulmonary embolism; or it may be artificially induced (therapeutic), as a hemostatic treatment for bleeding or as a treatment for some types of cancer by deliberately blocking blood vessels to starve the tumor cells.

Transcatheter arterial chemoembolization (TACE) is a minimally invasive procedure performed in interventional radiology to restrict a tumor's blood supply. Small embolic particles coated with chemotherapeutic drugs are injected selectively through a catheter into an artery directly supplying the tumor. These particles both block the blood supply and induce cytotoxicity, attacking the tumor in several ways.

<span class="mw-page-title-main">Carcinoid</span> A slow-growing type of neuroendocrine tumor

A carcinoid is a slow-growing type of neuroendocrine tumor originating in the cells of the neuroendocrine system. In some cases, metastasis may occur. Carcinoid tumors of the midgut are associated with carcinoid syndrome.

Carcinoid syndrome is a paraneoplastic syndrome comprising the signs and symptoms that occur secondary to neuroendocrine tumors. The syndrome is caused by neuroendocrine tumors most often found in the gut releasing biologically active substances into the blood causing symptoms such as flushing and diarrhea, and less frequently, heart failure, vomiting and bronchoconstriction.

<span class="mw-page-title-main">Neuroendocrine tumor</span> Medical condition

Neuroendocrine tumors (NETs) are neoplasms that arise from cells of the endocrine (hormonal) and nervous systems. They most commonly occur in the intestine, where they are often called carcinoid tumors, but they are also found in the pancreas, lung, and the rest of the body.

Percutaneous hepatic perfusion (PHP) is a regionalized, minimally-invasive approach to cancer treatment currently undergoing Phase II and Phase III clinical testing. PHP treats a variety of hepatic tumors by isolating the liver and exposing the organ to high-dose chemotherapy. As demonstrated in clinical trials, patients treated by PHP can tolerate much higher doses of chemotherapeutic agents than those receiving traditional systemic chemotherapy without increased toxicities.

Delcath Systems, Inc. is a publicly traded specialty pharmaceutical and medical device company, that develops percutaneous perfusion technologies for the targeted administration of high-dose chemotherapeutic agents to specific organs or regions of the body. Based in Queensbury, New York, the company has an intellectual property portfolio consisting of 28 patents worldwide. Delcath's Percutaneous Hepatic Perfusion (PHP) is currently undergoing Phase II and Phase III trials against tumors in the liver. Delcath has a Cooperative Research and Development Agreement (CRADA) with the National Cancer Institute and has received Fast Track and a Special Protocol Assessment from the Food and Drug Administration for its use of melphalan in treating unresectable liver tumors. PHP, also known as the Delcath System, is tested for the treatment of metastatic melanoma in the liver and for primary liver cancer and metastatic hepatic malignancies from neuroendocrine cancers and adenocarcinomas, as well as patients with melanoma who previously received isolated perfusion. Chemotherapy is usually delivered intravenously, although a number of agents can be administered orally.

Hepatic arterial infusion (HAI) is a medical procedure that delivers chemotherapy directly to the liver. The procedure, mostly used in combination with systemic chemotherapy, plays a role in the treatment of liver metastases in patients with colorectal cancer (CRC). Although surgical resection remains the standard of care for these liver metastases, majority of patients have lesions that are unresectable.

<span class="mw-page-title-main">Metastatic liver disease</span> Medical condition

A liver metastasis is a malignant tumor in the liver that has spread from another organ affected by cancer. The liver is a common site for metastatic disease because of its rich, dual blood supply. Metastatic tumors in the liver are 20 times more common than primary tumors. In 50% of all cases the primary tumor is of the gastrointestinal tract; other common sites include the breast, ovaries, bronchus and kidney. Patients with Colorectal cancer will develop liver metastases during the disease

<span class="mw-page-title-main">Selective internal radiation therapy</span>

Selective internal radiation therapy (SIRT), also known as transarterial radioembolization (TARE), radioembolization or intra-arterial microbrachytherapy is a form of radiation therapy used in interventional radiology to treat cancer. It is generally for selected patients with surgically unresectable cancers, especially hepatocellular carcinoma or metastasis to the liver. The treatment involves injecting tiny microspheres of radioactive material into the arteries that supply the tumor, where the spheres lodge in the small vessels of the tumor. Because this treatment combines radiotherapy with embolization, it is also called radioembolization. The chemotherapeutic analogue is called chemoembolization, of which transcatheter arterial chemoembolization (TACE) is the usual form.

In oncology, metastasectomy is the surgical removal of metastases, which are secondary cancerous growths that have spread from cancer originating in another organ in the body.

<span class="mw-page-title-main">Metastatic breast cancer</span> Type of cancer

Metastatic breast cancer, also referred to as metastases, advanced breast cancer, secondary tumors, secondaries or stage IV breast cancer, is a stage of breast cancer where the breast cancer cells have spread to distant sites beyond the axillary lymph nodes. There is no cure for metastatic breast cancer; there is no stage after IV.

<span class="mw-page-title-main">Pancreatic neuroendocrine tumor</span> Medical condition

Pancreatic neuroendocrine tumours, often referred to as "islet cell tumours", or "pancreatic endocrine tumours" are neuroendocrine neoplasms that arise from cells of the endocrine (hormonal) and nervous system within the pancreas.

Interventional oncology is a subspecialty field of interventional radiology that deals with the diagnosis and treatment of cancer and cancer-related problems using targeted minimally invasive procedures performed under image guidance. Interventional oncology has developed to a separate pillar of modern oncology and it employs X-ray, ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI) to help guide miniaturized instruments to allow targeted and precise treatment of solid tumours located in various organs of the human body, including but not limited to the liver, kidneys, lungs, and bones. Interventional oncology treatments are routinely carried out by interventional radiologists in appropriate settings and facilities.

Portal vein embolization (PVE) is a preoperative procedure performed in interventional radiology to initiate hypertrophy of the anticipated future liver remnant a couple weeks prior to a major liver resection procedure. The procedure involves injecting the right or left portal vein with embolic material to occlude portal blood flow. By occluding the blood flow to areas of the liver that will be resected away, the blood is diverted to healthy parts of the liver and induces hyperplasia. This may allow for a more extensive resection or stage bilateral resections that would otherwise be contraindicated resulting in better oncological treatment outcomes.

Radiation lobectomy is a form of radiation therapy used in interventional radiology to treat liver cancer. It is performed in patients that would be surgical candidates for resection, but cannot undergo surgery due to insufficient remaining liver tissue. It consists of injecting small radioactive beads loaded with yttrium-90 into the hepatic artery feeding the hepatic lobe in which the tumor is located. This is done with the intent of inducing growth in the contralateral hepatic lobe, not dissimilarly from portal vein embolization (PVE).

Transarterial bland embolization is a catheter-based tumor treatment of the liver. In this procedure, a variety of embolizing agents can be delivered through the tumor’s feeding artery in order to completely occlude the tumor’s blood supply. The anti-tumor effects are solely based on tumor ischemia and infarction of tumor tissue, as no chemotherapeutic agents are administered. The rationale for the use of bland embolization for hepatocellular carcinoma(HCC) and/or other hyper-vascular tumors is based on the fact that normal liver receives a dual blood supply from the hepatic artery (25%) and the portal vein (75%). As the tumor grows, it becomes increasingly dependent on the hepatic artery for blood supply. Once a tumor nodule reaches a diameter of 2 cm or more, most of the blood supply is derived from the hepatic artery. Therefore, bland embolization and transarterial chemoembolization (TACE) consist of the selective angiographic occlusion of the tumor arterial blood supply with a variety of embolizing agents, with or without the precedence of local chemotherapy infusion. The occlusion by embolic particles results in tumor hypoxia and necrosis, without affecting the normal hepatic parenchyma.

<span class="mw-page-title-main">Liver angiosarcoma</span> Medical condition

Liver angiosarcoma also known as angiosarcoma of the liver or hepatic angiosarcoma is a rare and rapidly fatal cancer arising from endothelial that line the blood vessels of the liver. It is a type of angiosarcoma. Although very rare with around 200 cases diagnosed each year, it is still considered the third most common primary liver cancer, making up around 2% of all primary liver cancers. Liver angiosarcoma can be primary, meaning it arose in the liver, or secondary, meaning the angiosarcoma arose elsewhere and metastasized to the liver. This article covers PHA, however much is also applicable to secondary tumors.

References

  1. 1 2 3 4 5 Del Prete, Michela; Fiore, Francesco; Modica, Roberta; Marotta, Vincenzo; Marciello, Francesca; Ramundo, Valeria; Di Sarno, Antonella; Carratù, Annachiara; Di Roseto, Chiara; Tafuto, Salvatore; Tatangelo, Fabiana; Baldelli, Robero; Colao, Annamaria; Faggiano, Antongiulio (2014). "Hepatic arterial embolization in patients with neuroendocrine tumors". Journal of Experimental & Clinical Cancer Research. 33 (1): 43. doi: 10.1186/1756-9966-33-43 . PMC   4038067 . PMID   24887262.
  2. 1 2 3 Pommier R. 2003. The role of surgery and chemoembolization in the management of carcinoid. California Carcinoid Fighters Conference. October 25, http://www.carcinoid.org/content/role-surgery-and-chemoembolization-management-carcinoid
  3. 1 2 3 4 Kvols LK. 2002. Carcinoid Tumors and the Carcinoid Syndrome: What's New in the Therapeutic Pipeline. (The Carcinoid Cancer Foundation: Carcinoid Symposium 2002)http://www.carcinoid.org/content/carcinoid-tumors-and-carcinoid-syndrome-whats-new-therapeutic-pipeline
  4. 1 2 Gu, Ping; Wu, Jennifer; Newman, Elliot; Muggia, Franco (2012). "Treatment of Liver Metastases in Patients with Neuroendocrine Tumors of Gastroesophageal and Pancreatic Origin". International Journal of Hepatology. 2012: 1–8. doi: 10.1155/2012/131659 . PMC   3299245 . PMID   22518318.
  5. ↑ Lewis, M. A; Jaramillo, S; Roberts, L; Fleming, C. J; Rubin, J; Grothey, A (2012). "Hepatic Artery Embolization for Neuroendocrine Tumors: Postprocedural Management and Complications". The Oncologist. 17 (5): 725–31. doi:10.1634/theoncologist.2011-0372. PMC   3360912 . PMID   22511263.
  6. ↑ Chan, Jennifer A; Kulke, Matthew H (2011). "New Treatment Options for Patients with Advanced Neuroendocrine Tumors". Current Treatment Options in Oncology. 12 (2): 136–48. doi:10.1007/s11864-011-0148-2. PMID   21437592. S2CID   40007214.
  7. ↑ Strosberg, J. R; Choi, J; Cantor, A. B; Kvols, L. K (2006). "Selective hepatic artery embolization for treatment of patients with metastatic carcinoid and pancreatic endocrine tumors" (PDF). Cancer Control. 13 (1): 72–8. doi: 10.1177/107327480601300110 . PMID   16508629.
  8. ↑ Castellano, Daniel; Grande, Enrique; Valle, Juan; Capdevila, Jaume; Reidy-Lagunes, Diane; o'Connor, Juan Manuel; Raymond, Eric (2014). "Expert consensus for the management of advanced or metastatic pancreatic neuroendocrine and carcinoid tumors". Cancer Chemotherapy and Pharmacology. 75 (6): 1099–114. doi:10.1007/s00280-014-2642-2. PMID   25480314. S2CID   39434924.
  9. ↑ Swierz, Mateusz J.; Storman, Dawid; Riemsma, Robert P.; Wolff, Robert; Mitus, Jerzy W.; Pedziwiatr, Michal; Kleijnen, Jos; Bala, Malgorzata M. (12 March 2020). "Transarterial (chemo)embolisation versus no intervention or placebo for liver metastases". The Cochrane Database of Systematic Reviews. 2020 (3): CD009498. doi:10.1002/14651858.CD009498.pub4. ISSN   1469-493X. PMC   7066934 . PMID   32163181.
  10. ↑ Lodh, Suhrid; Maher, Richard; Guminski, Alexander (2014). "Intra-arterial infusion and chemo-embolization for melanoma liver metastases". Journal of Surgical Oncology. 109 (4): 376–82. doi:10.1002/jso.23551. PMID   24500702. S2CID   22508186.
  11. 1 2 MedlinePlus. Endovascular embolization. MedlinePlus, a service of the U.S. National Library of Medicine
  12. ↑ Catheter Embolization. Radiological Society of North America and American College of Radiology
  13. ↑ Brown, Daniel B; Cardella, John F; Sacks, David; Goldberg, S. Nahum; Gervais, Debra A; Rajan, Dheeraj K; Vedantham, Suresh; Miller, Donald L; Brountzos, Elias N; Grassi, Clement J; Towbin, Richard B (2009). "Quality Improvement Guidelines for Transhepatic Arterial Chemoembolization, Embolization, and Chemotherapeutic Infusion for Hepatic Malignancy". Journal of Vascular and Interventional Radiology. 20 (7): S219–S226, S226.e1–10. doi:10.1016/j.jvir.2009.04.033. PMID   19560002.
  14. ↑ Fong, T and Schoenfield LJ. Arterial Chemotherapy Infusion of the Liver (and) Chemoembolization of the Liver (TACE)).
  15. ↑ Leal, Julie N; Kingham, T. Peter (2015). "Hepatic Artery Infusion Chemotherapy for Liver Malignancy". Surgical Oncology Clinics of North America. 24 (1): 121–48. doi:10.1016/j.soc.2014.09.005. PMID   25444472.
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