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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3892_Библиотеки_им_академика_М_И_Перельмана
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417
How is performance
status classified?
The ECOG (Eastern Cooperative
Oncology Group) performance status
is utilized to further classify patients
into the appropriate treatment option
based on the following scale (ECOG
0–2 is required for most interventional
treatments):
ECOG 0 → Fully active
ECOG 1 → Restricted in physically
strenuous activity. Able to do light
house or office work
ECOG 2 → Self-care okay. No
work. Up/about >50% of waking
hours
ECOG 3 → Limited self-care,
confined to bed or chair >50% of
waking hours
ECOG 4 → Completely disabled.
No self-care. Confined to bed or
chair
ECOG 5 → Dead
What is the BCLC
staging system?
The Barcelona Clinic Liver Cancer
(BCLC) staging system is a guideline
created for the staging of HCC,
considering the ECOG performance
status (PS), Child-Pugh (CP) staging,
and radiologic extent of disease.
What is the standard
preprocedural imaging
that should be performed
before liver-directed
therapy?
Three- or four-phase liver CT or
MRI to assess anatomy, extrahepatic
tumoral supply, and presence of
ascites. Additional imaging may be
performed to exclude extrahepatic
disease.
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High Yield History
What are the major
risk factors for the
development of HCC?
Hepatitis B, hepatitis C, alcohol use,
NASH, hereditary liver diseases (e.g.,
hemochromatosis), and primary biliary
cirrhosis
What is the latency
period of HCC?
1–3 decades
What is the 3-year
survival of HCC if
untreated?
28%
After imaging
evaluation is performed
confirming HCC or
hepatic metastases,
which parties determine
the appropriate
treatment?
A multidisciplinary team or tumor
board consisting of hepatobiliary
surgery, interventional radiology,
diagnostic radiology, radiation
oncology, hepatology, medical
oncology, and other specialties may be
involved in such cases.
Indications/Contraindications
What are the Milan
criteria for liver
transplantation?
1 tumor ≤ 5cm, or up to 3 tumors ≤ 3cm
No vascular invasion
No extrahepatic extension
What are the UCSF
criteria?
Higher threshold for transplantation
than Milan criteria
1 tumor ≤ 6.5cm or 2 lesions ≤ 4.5cm
with a total tumor diameter ≤ 8cm
What are the main
indications for
percutaneous ablation?
Favored for small isolated HCC (BCLC
0 and BCLC A disease).
Data shows equivalent survival for
thermal ablation and surgical resection
in this group.
Resection is often preferred if tumor
is in a location difficult to get good
ablative margins (e.g., hepatic dome).
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What are the common
reasons to perform
ablation over hepatic
resection?
Thermal and/or radiative ablation
is often utilized if mass is deemed
unresectable and there are poor liver
function, multifocal disease/metastases,
or comorbidities negating surgical
treatment.
Ablation is less invasive, causes less
pain, and results in less complications, as
well as a shorter hospital stay.
Ablation can be performed as a bridge
to transplantation.
What areas are
generally avoided in
percutaneous ablation?
< 1cm to a central bile duct, hepatic
dome or anterior exophytic lesions,
adjacent to large high flow blood
vessels, near gastric and bowel tissue, or
near the gallbladder fossa
When is TACE utilized
in the treatment of
HCC?
Treatment of unresectable disease,
including large tumors and multinodular
disease without evidence of vascular
invasion or extrahepatic spread
What are the common
indications for TARE?
Advanced unresectable HCC with life
expectancy > 3months.
HCC with portal vein thrombosis.
Downstaging patients to resectable
disease (similar to TACE), particularly
in bilobar or multinodular disease
(> 5 tumors).
Increase functional liver reserve with
the goal of contralateral hypertrophy
prior to resection.
Radiation segmentectomy in early stage
disease.
Increasing use outside of HCC for
hepatic metastatic disease.
What are the
contraindications of
TARE?
Child-Pugh C disease with marginal
hepatic reserve (serum bilirubin greater
than 3mg/dL (except for segmental
injection)) and ECOG > 2
(continued)
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When is TACE
preferred over TARE?
TARE not universally available in the
USA or worldwide
Patients susceptible to
radioembolization-induced liver disease
(REILD) or with hyperbilirubinemia
Tumor staining for thermal ablation
What is the benefit
of adding TACE to
ablation?
Added TACE to ablation in lesions
larger than 3cm, satellite tumors,
those in precarious location, poorly
encapsulated, or not well visualized on
US or CT can improve outcomes.
Tumor staining with Ethiodol improves
targeting for ablation.
Pre-ablation TACE increases ablation
zones by diminishing heat sink effect.
Results in overall improved survival in
tumors >5cm.
Can targeted
therapies be used for
colorectal cancer liver
metastases?
TARE is considered the best initial
intra-arterial locoregional therapy in
treating CRC metastases. Drug-eluting
beads loaded with irinotecan (DEBIRI)
have also demonstrated improved
overall survival.
What is radiation
segmentectomy?
Selective transcatheter delivery of Y-90
is delivered to two segments or less,
with ablative intent
Relevant Anatomy
Why can arterial
embolization procedures
be performed largely
without causing liver
necrosis and liver failure?
This is due to differences in the blood
supply to normal liver versus tumors.
80% of tumors are supplied by the
hepatic artery. 70–75% of normal
liver parenchyma is supplied by the
portal vein.
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How is nontarget
anatomy protected during
percutaneous ablation?
Patient positioning, general
anesthesia with a paralytic to
control breathing, chilled fluids
through biliary system, intentional
pneumothorax, intraperitoneal gas,
fluid, or balloons
Describe the normal
hepatic arterial branch
pattern from celiac trunk.
Approximately what
percentage of people have
this anatomy?
The celiac trunk normally trifurcates
into splenic, left gastric, and common
hepatic arteries. The common hepatic
artery then bifurcates into the
gastroduodenal artery and proper
hepatic artery. The proper hepatic
artery then gives rise to the left and
right hepatic arteries. The middle
hepatic artery, which supplies the
caudate lobe, most commonly arises
from either the left or right hepatic
artery, although in 10% of cases may
originate directly from the proper
hepatic artery.
(continued)
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What are the most
frequently observed
hepatic artery variants?
“Replaced” means the hepatic artery
in its entirely arises from the variant
origin, whereas “accessory” means
the hepatic artery is duplicated in
that there is a branch arising from the
normal origin, as well as an accessory
branch that arises from the aberrant
origin.
Common hepatic artery off aorta
or SMA, or trifurcation into right
hepatic, left hepatic, and GDA
Replaced left hepatic artery from left
gastric artery
Accessory left hepatic artery from
left gastric artery
Replaced right hepatic artery from
the SMA, celiac trunk, or aorta
Accessory right hepatic artery from
the SMA
A replaced or accessory right hepatic
artery typically originates from the
superior mesenteric artery, whereas
a replaced or accessory left hepatic
artery typically originates from the
left gastric artery.
Combinations of these variants occur,
for instance a patient may have
both replaced left and right hepatic
arteries, or may have a replaced
artery on one side and an accessory
artery on the other, although these
cases are exceedingly rare (<5%).
After multiple TACE
procedures, what
anatomical considerations
are important to
consider?
Development of extrahepatic
collateral vessels (i.e., right and
left internal mammary, right and
left inferior phrenic, right and left
gastric arteries) is common (~25% of
TACE).
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How is cone-beam CT
(CBCT) utilized during
hepatic arterial oncologic
interventions?
Accurate anatomic localization of
tumor-feeding arteries, following
delivery of chemoembolic agent to
ensure adequate territorial coverage,
and to calculate of liver treatment
volumes for TARE
Why is mapping
procedure required
prior to Y-90
radioembolization?
The mapping procedure is performed
to delineate tumoral blood supply.
Both celiac and SMA arteriograms
are performed, as well as selective
injections with or without the use of
cone-beam CT.Once the treatment
territory is confirmed, Tc99-MAA
is delivered via the microcatheter.
After the procedure, planar nuclear
imaging is performed to calculate
lung shunt fraction. SPECT/CT is
sometimes performed, and can be
used to assess for nontarget delivery
in the abdomen/pelvis.
What are the essential
vessels to identify during
the mapping procedure?
Cystic artery, right gastric
artery, gastroduodenal artery,
pancreaticoduodenal arcade,
falciform artery, and any additional
feeders to hepatic tumors (i.e.,
inferior phrenic artery)
Relevant Materials
When is percutaneous
ethanol ablation
employed?
This historical agent is an inexpensive
option utilized for smaller tumors near
heat-sensitive organs.
(continued)
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How does
radiofrequency
ablation (RFA) treat
tumors and what are
its limitations?
RFA is a widely utilized method of
thermal ablation that induces coagulative
necrosis. Its survival benefit versus
ethanol ablation is most pronounced
in tumors larger than 2cm, and can be
used for tumors up to 3cm. It has fallen
out of favor in some institutions due
to limitations of heat sink effect from
nearby vessels and the availability of
microwave ablation.
What is microwave
ablation and what are
its benefits?
Microwave ablation produces oscillation
of water molecules, friction, and thus
very high temperatures, resulting in
coagulative necrosis in tumoral tissue. It
has replaced RFA in many institutions
because it can heat tissue faster, multiple
probes can be utilized simultaneously to
achieve larger ablation zones, and it is
less susceptible to heat sink effect.
How does
cryoablation work
and what are its
advantages?
Cycles of freezing and thawing disrupt
cell membranes of tumor cells (lysis)
inducing cell death. It is less painful
for patients than microwave ablation,
though it is less commonly utilized for
liver-directed therapy. The ablation zone
(ice ball) can be actively visualized on
intraprocedural imaging, helping to
confirm adequate coverage of the desired
treatment target.
What is a dreaded
complication of
cryoablation?
Cryoshock is an extremely rare
complication of cryoablation caused
by cytokine release, which can lead to
disseminated intravascular coagulation
(DIC) and multi-organ failure.
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What is irreversible
electroporation
(IRE) and when is it
utilized?
This is a nonthermal technique utilizing
high-energy electrical pulses to disrupt
cell membranes and cause cell death.
IRE must be performed under anesthesia
with a neuromuscular blocking agent
and cardiac monitor to avoid muscle
contractions and arrhythmias. The benefit
is the ability to safely be utilized for
small tumors near blood vessels and bile
ducts due to its nonthermal mechanism
and lack of heat sink effect.
What is “bland
embolization”?
Mechanical obstruction using
embolic agent without the use of a
chemotherapeutic agent
What is ethiodized
oil and why is it
effective?
Embolic agent also utilized as a carrier
of chemotherapeutics
Contains iodine, easily identified on
imaging
Attaches to the cancer cell membrane
of liver tumors and travels via the
peribiliary capillary plexus to the portal
branches, thereby depleting nutrient
supply to potential nonimaged satellite
lesions.
What is the typical
chemotherapeutic
dosing for
conventional TACE?
Variable; single or multiple drug
regimens may be used. A common
regimen includes 50–100mg cisplatin,
50–75mg doxorubicin, and 10mg
mitomycin C.The drugs are mixed with
contrast to improve visualization on
imaging and to stabilize the drug/oil
emulsion.
How much ethiodized
oil should be
administered in
TACE?
The ratio of volume of drug to oil should
be 1:2.
Ethiodized oil volume is tumor
dependent, typically less than 15mL per
session.
(continued)
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What should be
administered intra-
arterially after
chemotherapeutic/
ethiodized oil
emulsion?
Embolic material such as particles or gel
foam prevents washout of ethiodized oil
from the treated zone.
What is DEB-TACE
and what are its
purported benefits
over conventional
TACE?
Drug-eluting beads lodge in small
tumoral arterioles, delivering a sustained
release of chemotherapy.
Reduced liver toxicity and potential
systemic uptake.
Consistency and reproducibility of
treatment.
General Step by Step
What preprocedural
imaging should
ideally be performed
prior to ablation
procedures?
CT or MRI within 2weeks for colorectal
cancer metastases and 2–4months for
HCC
What intraprocedural
imaging is performed
for ablation?
CT and ultrasound are most frequently
utilized for both probe/applicator
placement and monitoring the ablation
zone. MRI can also be utilized if available
and probes are compatible. Ultrasound
and CT can be utilized to monitor ice ball
formation during cryoablation. After the
procedure, contrast-enhanced CT, MRI,
or ultrasound is performed to confirm
adequate ablation zone.
What are acceptable
ablative margins for
HCC and for liver
metastases?
Circumferential ablation zone of 0.5cm
for HCC and 1.0cm for metastases
S. I. Stein
https://t.me/med1917
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