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208 K.J. Kolbeck and J.A. Kaufman
• Contraindications to embolization: limited residual liver function, risk of induc-
ing liver failure.
• Relative contraindications: portal vein thrombosis, biliary obstruction, and tumor
burden greater than 50% of the f unctioning liver.
Specific Complications
• Arterial access: as previously described in this book.
• Non-target embolization: symptoms depend upon embolic material as well as
organ embolized.
• Complex/distorted hepatic arterial anatomy: can severely limit catheter access
and make catheterization extremely difficult.
• Carcinoid reaction/crisis: sudden hormone/neurotransmitter release during con-
trast injections, embolization, or with tumor necrosis.
• Premedication with 500 μg octreotide IV helps block receptors, reducing side
effects.
• Steroids, anti-histamines, anti-asthmatic agents, anti-hypertensives, as well as
adrenergic blockers (alpha and beta), may be required pending individual patient
reactions.
Vascular Anatomy
• All the variations of hepatic arterial anatomy are possible.
• Bulky liver disease frequently results in extremely distorted anatomy.
• Hypervascular lesions occasionally parasitize adjacent, non-hepatic arteries (e.g.,
phrenic artery).
Equipment
Catheters
• Non-selective catheters: aortic flush run rarely used to identify aberrant ves-
sels. Vessel origins for selective catheterization and evaluation can frequently
be identified on previous cross-sectional imaging.
• Selective catheters: anatomy dependent, frequently able to selectively catheter-
ize target vessels with 5Fr celiac catheter and microcatheter. Other selective catheters include cobra, Simmons, Omni Select, with superselection via
microcatheters.
• High-flow microcatheters: often used to diminish risk of catheter occlusion with
particulate embolics.
• Guide catheter/sheath: if catheter changes are expected a 5 Fr common femoral
sheath is recommended.
21 Liver Tumors: Neuroendocrine Hepatic Metastases 209
Embolic Agents
• Bland embolization (iodinated oil emulsion or particles)
• Chemoembolization (oil emulsions mixed with doxorubicin alone or the three
drug combination—cisplatin, doxorubicin, and mitomycin C)
• Multiple embolic agents (gel foam slurry, polyvinyl alcohol suspensions, as well
as engineered copolymer embolic agents)
• Drug-eluting bead co-polymers
• Resin and glass Yttrium-90 microspheres
Medications
• Routine chemoembolization premedication regimen include an anti-
inflammatory (e.g., ketorolac, 30 mg IV), steroid (e.g., 20 mg dexamethasone),
antibiotic (e.g., 1 g cefotaxime), and anti-emetic (e.g., ondansetron 8 mg IV).
• Intra-procedural medications include midazolam and fentanyl for moderate
sedation.
• Intravenous octreotide (500 μg) prior to treatment/infusion of iodinated contrast
is recommended to reduce the risk of carcinoid crisis.
• In the event of carcinoid crisis, additional doses of octreotide as well as symp-
tomatic control (oxygen, volume support for hypotension, anti-hypertensives,
anti-emetics, and anti-histamines) may be required. Note that epinephrine may
induce/provoke attacks rather than alleviate symptoms. Dopamine infusion is
recommended as the primary vasopressor in the event of a hemodynamic
collapse.
• Bolus administration of an additional 500 μg IV octreotide and/or a titrated con-
tinuous IV infusion of octreotide may be required for symptom control. Infusion
doses of 100–500 μg/hour may be required. Monitoring for bradycardia and
arrhythmias is recommended with octreotide infusions.
IR Evaluation
Access
• Common femoral artery, most commonly right, related to physician
preference.
Arteriography
• Frequently, hypervascular tumors require high volume injections and high flow
rates to adequately assess the vasculature.
210 K.J. Kolbeck and J.A. Kaufman
Assessing the Lesions
• Due to hypervascular tendencies, evaluation with a 4–5Fr catheter is recom-
mended. Microcatheters frequently do not allow enough contrast volume/flow
to adequately asses the entire vascular distribution.
• Once adequate arteriographic evaluation has been obtained, further selection and
embolization with a microcatheter is frequently required.
Fig. 21.3 The Superior
mesentric arteriogram (from
thesamepatientinFig. 21.1
and 21.2) demonstrates a
replaced right hepatic artery
with multiple hypervascular
lesions in an enlarged right
lobe of the liver
Fig. 21.4 Celiac axis arteriogram in the same patient as Fig. 21.3 demonstrates a steep caudal
shift to the common and proper hepatic arteries with a significant (approximately 150
direction) change of both medial and lateral segmental left lobe arterial supply
◦
reversal in
21 Liver Tumors: Neuroendocrine Hepatic Metastases 211
Fig. 21.5 Parenchymal phase arteriogram of the same patient as Figs. 21.3 and 21.4 demon-
strates hypervascular lesions from the celiac axis injection. Note the right lobe lesions are partially
supplied via intrahepatic collaterals from the left lobe arterial supply
Angiographic Appearance
• The majority of neuroendocrine tumors are hypervascular with an intense arterial
blush and slow washout relative to the hepatic parenchymal phase.
Clinical Scenarios
Treatment Plan and Technique
• Primary goal is usually symptomatic relief or control of bulk disease. These
patient populations frequently require multiple treatments to multiple liver
lesions prior to attaining symptom control. Due to the number of treatments
required, embolization goals/endpoints should allow for multiple treatments of
thesameareaoftheliver.
• Note that symptom control is likely related to hormone release. Unfortunately,
hormone release is not necessarily related to lesion size. Once adequately treated,
the active hormone should no longer be released, and the clinical symptoms
should improve.
• Plan to treat the liver lesions in stages. Start with a specific lesion if it is sus-
pected of releasing the majority of the active hormone (by Octreoscan, PET, or
biopsy characteristics). Otherwise treat the large/dominant lesions first, followed
212 K.J. Kolbeck and J.A. Kaufman
by secondary lesions after a 4–6-week recovery period. Each lesion may require
two to three treatments prior to symptom control.
• Embolization to stasis may reduce the ability to treat future lesions in the same
area of the liver and is not recommended.
Aftercare
Usually admitted to the hospital for overnight observation for both intravenous
nausea and pain control. Majority of patients are discharged on post procedure day 1.
Arterial Access Site
Given the high probability of multiple procedures in this patient population, manual compression is recommended in most cases. Arterial access with a 5Fr sheath
requires bed rest for a 4–6 h period. If closure devices are used, then the bedrest
time may be shortened.
Post-embolization
Post-embolization syndrome (pain, nausea, vomiting, fatigue, low-grade fevers,
mild/moderate elevation of white blood cell count, and other liver-specific blood
tests) may occur and frequently subsides within 7–10 days.
Follow-Up
Post-procedure (7–14 days) clinic visit: to evaluate arterial access site, assess
degree of post-embolization syndrome, and discuss the results of the procedure
and plan upcoming procedures. After all liver lesions have been treated and symptoms have improved, clinic visits every 6–12 months assist in planning future
treatments.
Keypoints
1. Diffuse hepatic metastases frequently alter/distort hepatic arterial supply.
Understanding the arterial anatomy assists in complete therapy.
2. Symptomatic control is the dominant goal of embolization therapy.
21 Liver Tumors: Neuroendocrine Hepatic Metastases 213
3. Multiple treatments will likely be required; therefore, attempt to preserve patency of dominant hepatic arterial vessels and minimize impact at
common femoral arterial access site.
4. Carcinoid crisis may require urgent/emergent control even with preprocedure prophylactic IV octreotide.
Suggested Reading/References
Clancy TE, Sengupta TP, Paulus J, Ahmed F, Duh MS, Kulke, MH. Alkaline Phosphatase Predicts
Survival I Patients with Metastatic Neuroendocrine Tumors. Dig Dis Sci 2006; 51:877–884.
de Baere T. Interventional Radiology for the Treatment of Liver Metastases from Neuroendocrine
Tumors. In: Geschwind JFH and Soulen MC, eds. Interventional Oncology Principles and
Practice, pp. 301–310. New York, NY: Cambridge University Press, 2008.
Garrot C, Stuart K. Liver-Directed Therapies for Metastatic Neuroendocrine Tumors. Hematol
Oncol Clin N Am 2007; 21:545–560.
Ho AS, Picus J, Darcy MD et al. Long-Term Outcome After Chemoembolization and Embolization
of Hepatic Metastatic Lesions from Neuroendocrine Tumors. Am J Roentgenol 2007; 188:
1201–1207.
Kulke MH, Mayer RJ. Carcinoid Tumors. N Engl J Med 1999; 340:858–868.
Murthy R, Kamat P, Nunez R, et al. Yttrium-90 Microsphere Radioembolotherapy of Hepatic
Metastastic Neuroendocrine Carcinomas after Hepatic Arterial Embolization. J Vasc Interv
Radiol 2008; 19:145–151.
Ruutianen AT, Soulen MC, Tuite CM, et al. Chemoembolization and Bland Embolization of
Neuroendocrine Tumor Metastases to the Liver. J Vasc Interv Radiol 2007; 18:847–855.
Rhee TK, Lewandowski RJ, Liu DM, et al.
Liver Tumors: Preliminary Results from a Multi-Institutional Experience. Ann Surg 2008;
247:1029–1035.
Warner RRP, Kim MK. Carcinoid and Related Neuroendocrine Tumors. In: Geschwind JFH and
Soulen MC, eds. Interventional Oncology Principles and Practice, pp. 290–300. New York, NY:
Cambridge University Press, 2008.
90
Y Radioembolization for Metastatic Neuroendocrine
Chapter 22
Embolization of Benign and Malignant Renal Tumors
David O. Kessel
Clinical Features
• Renal tumor embolization can be required as an elective or emergency procedure.
It is essential to understand the implications of treatment of such an important end
organ.
• Renal cell cancer (RCC): 80–90% of malignant renal tumors, peaks in 6th–7th
decade, mean age 55, hypervascular with AV shunting.
• Angiomyolipoma (AML): contains blood vessels, smooth muscle and fat, 60%
asymptomatic, F:M, 4:1 in isolated AML, 20% are associated with tuberous
sclerosis. AMLs are prone to aneurysm formation and hemorrhage.
Diagnostic Evaluation
Laboratory
Beware of renal impairment and ensure adequate hydration; consult renal physicians
if necessary.
Imaging: never start renal embolization until you have formally reviewed the
pre-procedure imaging.
Use contrast-enhanced CT/MRI (Fig. 22.1) for the following:
• To verify the condition of the contralateral kidney.
• To demonstrate the location of the tumor and any local and distant spread that
may affect treatment.
• To identify renal blood supply.
• To assess tumor vascularity and look for the presence of arteriovenous
shunting.
• Target treatment.
• In angiomyolipoma, target the largest tumor or the one with the hematoma.
• Extension of tumor to renal vein/IVC.
Transcatheter Embolization and Therapy,
Techniques in Interventional Radiology, DOI 10.1007/978-1-84800-897-7_22,
C
Springer-Verlag London Limited 2010
215
216 D.O. Kessel
a
Fig. 22.1 (a) Pre-embolization CT. (b) Angiogram showing vascular large right renal cancer (yel-
low arrowheads) with IVC tumor thrombus (white arrowhead). Note extensive shunting through
multiple large retroperitoneal veins (red arrowheads). (c) Post-embolization with spongestan: the
arterial and venous flow has been abolished. Coils were subsequently deployed distal to the adrenal
artery
b
c
Indications
These include the following:
• Symptomatic relief for inoperable or hemorrhagic RCC.
• Reduced blood loss at nephrectomy for RCC.
• Definitive therapy for hemorrhagic AML.
• Prophylactic treatment for AMLs >4 cm.
Contraindications
• As always, the contraindications are relative and relate to the indication; thus
there is little that will prevent emergency embolization for hemorrhage from a
tumor.
• Renal insufficiency. Patients with tuberous sclerosis will often have diffuse
involvement of both kidneys and preservation of renal function can be an issue.
• Extensive collateral supply increases the risk of non-target embolization and may
limit effectiveness of proximal embolization. Beware supply to spinal cord and
bowel.
• Massive arteriovenous shunts increase risk of pulmonary embolization.
Anatomy
Assess the vascular supply on the pre-procedural imaging. Multiple vessels supplying the tumor indicate that the case will take longer to perform.
22 Embolization of Benign and Malignant Renal Tumors 217
Normal Anatomy
• Accessory renal arteries arise from a variety of positions on the aorta and iliac
arteries.
• Inferior adrenal artery typically arises from the proximal renal artery.
• Capsular arteries typically arise from the proximal renal artery.
Aberrant Anatomy
Collateral supply (Fig. 22.2) arises from the following:
• Lumbar arteries.
• Adrenal arteries.
• Capsular arteries.
• Phrenic arteries.
• Occasionally mesenteric vessels.
• Ectopic kidneys and horseshoe kidneys may have very unusual arterial
supplies.
• Large tumors may be very vascular with extensive abnormal draining veins; this
can be associated with arteriovenous shunting which affects the choice of embolic
agent.
ab
Fig. 22.2 (a) Large right renal tumor supplied from the right renal artery (white arrowheads).
(b) Flush aortography reveals the true extent of the tumor (white arrowheads) with extensive collateral supply from the L2–L4 lumbar arteries and also a large unnamed collateral vessel (white
arrow)
218 D.O. Kessel
Equipment
• Non-selective catheters: pigtail or straight catheter if flush aortogram is
necessary.
• Selective catheters: cobra, renal double curve, sidewinder. Microcatheter for
selective embolization.
• Guide catheter with detachable hemostatic valve if using Amplatzer vascular
plugs (AVP).
Embolic Agents
The choice of agent depends on the clinical context.
• Pre-operative: gelfoam and coils or AVP
• Selective: polyvinyl alcohol particles 350–500 μm unless shunting or very large
vascular tumor; microcoils
• Hemorrhage: PVA (350–700 μm)/coils
Medication
Renal tumor embolization is often painful and post-embolization syndrome is
common.
• Pain control: prophylactic anti-inflammatory strong analgesia is often
needed and should be given early. Patient-controlled analgesia should be
established.
• Infection control: broad spectrum antibiotics are recommended as tissue necrosis
is likely.
• Sickness control: anti-emetics should be given prophylactically.
• Hydration: intravenous normal saline.
Procedure
Access
• Plan according to the pre-operative imaging.
• >90% approached from the femoral artery.
• The approach may have to be altered with ectopic kidneys.