SIR RFS IO Service Line
Created by: Colin Burke
10-22-13
Images from:
Vascular and Biliary Variants in the Liver: Implications for Liver Surgery: Radiographics March-April 2008 28:2 359-378
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www.deltagen.com
www.wikipedia.org
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 5th most common cancer
 Fastest growing cause of cancer mortality
 Risk Factors
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HBV
HCV
Cirrhosis
Alcoholism
Biliary cirrhosis
Hemochromatosis
NAFLD
Aflatoxins- Esp. in Asian population
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 Multifactorial, exact
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mechanism unclear
Inflammation, necrosis,
fibrosis, regeneration of
cirrhotic liver
Environmental toxins
Mistakes in regenerative
pathway
Gene mutations: p53, B catenin
Main Theory
 Repeated necrosis &
www.livingwithcancerinternational.com
regeneration + genetic
material in viral hepatitis =
mutations & abnormal cell
proliferation
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 Jaundice, pruritis
 Ascites,
 Abdominal Pain
 Variceal bleed
 Encephalopathy
 Paraneoplastic syndromes
 Unintentional weight loss
Image from: http://www.mcemcourses.org/wpcontent/uploads/case9picture.jpg
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 Chronic Liver Disease: Screen with US every 6 months
 AASLD Guidelines
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Asian men over 40 & Asian woman over 50
Patients with HBV & Cirrhosis
African & North American Blacks
Patients with a family history of HCC
 US results
 Nodule < 1 cm
 Usually not HCC, monitor every 3 months until they disappear
 Nodules > 1 cm
 Evaluate with CT/MRI
 Biopsy only if unable to diagnose on imaging findings
 Lab Studies
 Nonspecific:
 Anemia, thrombocytopenia, increased LFTs,
 AFP
 Raises concern, especially when over 200 mg/dl
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 US
 Small hypo-echoic lesion
 Heterogenous (fibrosis,
fatty change &
calcifications)
 Hard to distinguish from
cirrhosis
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 CT
 Focal, multifocal diffuse, infiltrative or atypical
 Hypervascularity in arterial phase, washout in portal and delayed
phases
 Focal necrosis and calcification (10%)
 Capsule (24%)
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 MRI
 T1
 Variable
 Isointense or hyperintense
compared to surrounding
liver
 T2
 Variable, typically
hyperintense
 Post-gadolinium
 Arterial-phase enhancement
+/- discrete feeder vessels
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 Unresectable: mortality within 3-6 months
 Resectable: partial hepatectomy curative due to
regenerative nature of liver
 2/3 of the liver can be resected
 Role of portal vein embolization prior to partial
hepactectomy
 IR embolizes the right portal vein, stimulating
hypertrophy of noninvolved lobe & can qualify the
patient for resection or bridging to Tx
 5 year survival if resectable: 37-56%
 Only 10-20% are completely resectable
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 Medical Therapy
 Minimally responsive to
chemotherapy
 Sorafenib (tyr-kinase inhib) used
for advanced cases
 Mainly Palliative
 Lactulose titrated to 2-3 loose
stools/day to control
encephalopathy in cirrhosis.
 Diuretics to control ascites
 Antibiotic prophylaxis to prevent
SBP
 Surgical Therapy
 Liver transplant
 Resection
 Small lesions may be cured under
RFA done by IR
http://www.ppdictionary.com/viruses/carcinoma_hepatitis_
b.jpg
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 Unresectable tumors
 Increase survival, improve
quality of life, currently not
intended for cure
 Slows progression and is
palliative. Also used to help
patient’s survive partial
hepatectomy or act as a bridge
to transplant.
 Terminology
 Transarterial
Chemoembolization: TACE
 Radiofrequency Ablation:
RFA
 Selective Internal Radiation
Therapy: SIRT
 Portal Vein Embolization:
PVE
http://www.anes.ucla.edu/images/news/large/DSC02293.jpg
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 Percutaneous transhepatic
approach
 Embolization of portal vein
supplying lobe of liver with the
tumor
 Compensatory hypertrophy of
surviving lobe can qualify patient
for resection
 Patients initially unresectable due
to insufficient remaining normal
parenchyma may qualify
 Post resection morbidity
decreased
Right PVE:
http://radiographics.rsna.org/content/22/5/1063/F13.
expansion.html
 Serve as a bridge to transplant
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 Selective injection of antineoplastic agent
with a radiopaque contrast agent (lipiodol)
and embolic agent (gelfoam)
 Higher dose of chemotherapy due to
decreased systemic exposure
 Post Procedure
 Post Embolization Syndrome
 Hospital stay of 1-3 days
 Decreased energy in the following 2
months
 Abominal Pain, transaminitis
 Follow up CT several weeks later to check
for tumor response
 Repeat TACE
 Only 2% of patients have complete
response from 1 procedure
 Considered non-curative (unlike RFA)
 Base repeat treatment on tumor response
and hepatic reserve
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 Destroys tumor using
thermal energy from high
frequency radio waves
 Usually used for small
tumors (< 3cm)
 US guided percutaneous
approach
 Post Procedure
 Follow up CT/MRI several
weeks later to check for
tumor response. Can also
follow AFP
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 Similar to chemoembolization
 Uses radioactive microspheres
 Radioactive isotope Yttrium (Y-90) incorporated into
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radioactive spheres
Spheres selectively injected and get lodged in tumor
capillaries and proximal vascular supply
Localized brachytherapy
Combined radiation and ischemia results in cell
death.
Post Procedure
 Post embolization syndrome with fatigue,
constitutional symptoms, and abdominal pain
 Follow up CT/MRI several weeks later to check tumor
response. Can also follow AFP. Return to IR if AFP
remains increased. Monitor for variceal bleeds and
assessment of underlying liver function.
http://www.rwjuh.edu/images/cancer/sirt
image2.jpg
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TACE
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Post Embolization Syndrome
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Liver Failure
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Post Embolization Syndrome
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20-55%
Hepatic Dysfunction
RFA
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3-5%
Non target embolization into left gastric
SIRT
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Dependent on preprocedure liver function
20% of patients, irreversible in 6%
Gastroduoenal ulceration
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60-80% of patients
Fatigue, constitutional symptoms, abdominal pain
Symptoms last 3-4 days, full recovery in 7-10
Complications are rare but include abscess formation, subcapsular hematoma and tract seeding
If HCC is not treated
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TNM staging:
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5 year survival 55%, 37% and 16% for stage I, II, III respectively
Okuda system: tumor size and degree of cirrhosis
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8.3, 2.0 and 0.7 months for stage I, II, and III respectively
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 HCC: Relatively poor prognosis including both high
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morbidity and mortality
Main risk factors are chronic liver disease such as HBV,
HCV, and cirrhosis
Patients often present with decompensation of chronic
liver disease
Medical management generally palliative, aimed at
reducing liver disease symptoms, chemotherapy is
traditionally ineffective
Surgical resection and transplant can be curative
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Screen high risk patients with US, f/u with CT/MRI
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IR procedures traditionally palliative for
unresectable tumors and those patients who are not
yet candidates for liver transplant
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Growing evidence suggesting increased role for IO
therapies
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Smaller (<4cm) or solitary lesions managed with
RFA
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Large or multifocal tumors = TACE or SIRT
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Insufficient data for combination RFA and TACE
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Efficacy (complicated and conflicting data)
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TACE: Objective response: 6-60%. Most studies show
increased survival vs conservative treatment
SIRT: Comparable to TACE
RFA: can be curative. 80-90% response for tumors<3
cm
Common complications: Post embolization
syndrome and hepatic dysfunction
www.barrieronline.com
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
Catalano OA, Singh AH, Uppot RN, Hahn PF, Ferrone CR, Sahani DV.Vascular and Biliary Variants in the Liver: Implications for Liver
Surgery: Radiographics March-April 2008 28:2 359-378

Furuta T, Maeda E, Akai H, Hanaoka S, Yoshioka N, Akahane M, Watadani T, Ohtomo K.. Hepatic Segments and Vasculature: Projecting CT
Anatomy onto Angiograms. Radiographics. November 2009 Nov;29(7):1-22.
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Madoff DC, Hicks ME, Vauthey JN, Charnsangavej C, Morello FA Jr, Ahrar K, Wallace MJ, Gupta S. Transhepatic portal vein embolization:
anatomy, indications, and technical considerations. Radiographics. 2002 Sep-Oct;22(5):1063-76
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Yang ZF, Poon RT. Vascular changes in hepatocellular carcinoma. Anat Rec (Hoboken). 2008 Jun;291(6):721-34
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Roche SP, Kobos R. Jaundice in the adult patient. Am Fam Physician. 2004 Jan 15;69(2):299-304
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Uptodate
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Clinical features and diagnosis of primary hepatocellular carcinoma. http://www.uptodate.com/contents/clinical-features-anddiagnosis-of-primary-hepatocellular-carcinoma?source=see_link. Last Updated Sept 23, 2013. Accessed October 20th 2013.
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Epidemiology and etiologic associations of hepatocellular carcinoma http://www.uptodate.com/contents/epidemiology-and-etiologicassociations-of-hepatocellular-carcinoma?source=see_link. Last Updated August 30 2013. Accessed October 21, 2013
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Prevention of hepatocellular carcinoma and recommendations for surveillance in adults with chronic liver disease.
http://www.uptodate.com/contents/prevention-of-hepatocellular-carcinoma-and-recommendations-for-surveillance-in-adults-withchronic-liver-disease?source=see_link. Last Updated July 12, 2013. Accessed October 20, 2013
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Surgical management of potentially resectable hepatocellular carcinoma. http://www.uptodate.com/contents/surgical-managementof-potentially-resectable-hepatocellular-carcinoma?source=preview&anchor=H1061867819&selectedTitle=2~150#H1061867819 . Last
Updated May 22, 2013. Accessed October 23, 2013
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Nonsurgical therapies for localized hepatocellular carcinoma: Transarterial embolization, radiotherapy, and radioembolization
http://www.uptodate.com/contents/nonsurgical-therapies-for-localized-hepatocellular-carcinoma-transarterial-embolizationradiotherapy-and-radioembolization?source=preview&anchor=H1248650314&selectedTitle=1~16#H1248650342 . Last Updated Sept 6
2013. Accessed October 23,2013
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Inteventional Radiology Treatments for Liver Cancer. http://www.sirweb.org/patients/liver-cancer/. Accessed October 2014
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Anatomy of Liver Segments. http://www.radiologyassistant.nl/en/p4375bb8dc241d/anatomy-of-the-liver-segments.html Accessed October
2013
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Image addapted from: http://www.utmb.edu/surgicalpathology/picts/photo_of_the_month_2006_2007/pom_aug_06.jpg
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