Chemoembolization

What is Chemoembolization?

Chemoembolization is a treatment option for patients who have cancer that involves the liver. It is used for tumors that cannot be removed by surgery because of the location or the number of tumors present. Both tumors that have originated in the liver (primary liver cancer) and tumors that have spread (“metastasized”) from other sites (ie, colon, breast, etc) can be treated with this procedure. This is a palliative, not a curative-treatment. However, it can be extremely effective in treating liver cancers, especially when combined with other therapies.

The liver is unique because it has two blood supplies. The portal vein provides 75 percent of the liver’s blood supply and the hepatic artery supplies the remaining 25 percent. Tumors that grow in the liver typically receive their blood supply from the hepatic artery making chemoembolization possible.

There are different ways of performing chemoembolization of the liver. For most cases we soak microscopic beads in the chemotherapy medication. Later, these beads are then injected directly into the blood vessels feeding the tumor using a tiny catheter.

Chemoembolization with these beads offers several advantages over traditional systemic chemotherapy:

The medication stays in contact with the tumor for up to one month.
The medication is delivered only to the tumor, rather than administered throughout the patient’s bloodstream. Healthy tissues are spared from side effects, allowing doctors to administer dosages up to 200 times greater than those used in conventional “systemic” chemotherapy.
The beads that are part of the injected mixture not only hold the medication in place, but also block the blood supply to the tumor. This deprives the tumor of oxygen and nutrients, halting its growth.

This treatment can be repeated (every 4-8 weeks) or used in combination with other types of therapy to control the tumor or tumors in your liver.

Why is it done?

Chemoembolization is a palliative treatment for patients who are not candidates for curative treatments like surgery or percutaneous ablation. This means it is done to control the disease, not cure it. In some instances, after chemoembolization, the tumor may decrease in size to the point where other curative therapies like surgery or ablation may not be feasible.

What are the risks?

As with any interventional procedure, there is a small risk of bleeding at the catheter insertion site. Most of the time we use a small plug to avoid this problem and thankfully the overall risk is small.

The goal of the procedure is to kill the tumor. The resulting necrotic material releases inflammatory chemicals into the bloodstream. This can cause something called tumor embolization syndrome. It is usually manifested with symptoms of fever, pain, nausea and vomiting, but tends to resolve spontaneously. Another potential complication of chemoembolization is the development of an infection or abscess within the necrotic tumor.

There is also a small chance of the embolization material or particles becoming lodged in the wrong place depriving normal tissue of its blood supply. This could lead to gastric ulcers or even bowel perforations. However, with the use of modern imaging equipment and techniques, this is exceedingly rare.

There is a small chance of allergic reaction to the contrast material used to view your blood vessels with X-ray. There is also a risk for kidney damage, especially for patients with diabetes or pre-existing kidney disease. The effects from the contrast vary for every patient. Medications and IV fluids are given to help prevent or relieve most of these side effects. Also, steps can be taken before the procedure to prevent allergic reactions to contrast and lessen the chance of kidney damage for those at risk.

Reasons to avoid this procedure?

Chemoembolization is not for every patient with liver tumors. This treatment may not be appropriate for patients who have blockages of the vessels that supply blood to the liver, cirrhosis of the liver, or blockage of the bile ducts. Patients who have liver failure, usually manifested by jaundice, are also not good candidates.

How will you prepare?

Usually this procedure is performed with IV sedation called moderate, or “twilight” sedation, and local anesthesia. You will need to be fasting for 8 hours before the procedure. We recommend no eating or drinking after midnight before the procedure. Generally, you should take your daily morning medications with a small sip of water.

If you take blood thinners you will need to stop before the procedure. Please refer to pre-procedure instructions for detailed instructions about your medications.

Please leave all valuables such as jewelry, credit cards and money at home on the day of the procedure. Family members may wish to bring a magazine or book to read during the wait time.

After checking in at Patient Registration, you will be directed to the Short Stay pre-procedure unit on 2B. Once in the department, a nurse will prepare you for the procedure. This preparation will include changing into a gown, a nurse taking your vital signs, starting an IV in your arm, lab tests, and giving you IV fluids and IV medications (antibiotics, anti-nausea, etc).

How is the procedure done?

The procedure is performed in the catheterization laboratory, also called “cath lab”. An entire team will be taking care of you during the procedure including 2 nurses, a radiology technologist and the physician. In the procedure room, the nurse will help you lay on an exam table. You will be connected to heart rate, oxygen saturation and blood pressure monitors. IV medicine then will be given to relax you (moderate sedation). Your groin area will be shaved and washed with a special soap and covered with sterile sheets. Local anesthetic medicine is injected into the area. You will feel some burning as the medicine is given. Once it takes effect, the area will be numb. The procedure time varies, but usually takes 1 to 2 hours. Throughout the procedure, medication is given through your IV to keep you comfortable. Your oxygen saturation, blood pressure and pulse are checked closely during and after the procedure.

A small catheter will be inserted through the groin into the femoral artery. Using x-rays the interventional radiologist will be able to advance the catheter in the artery into the specific artery supplying the liver. Through this catheter the interventional radiologist performs an arteriogram to identify the branches of the hepatic artery supplying the tumor(s) and then threads smaller catheters into these branches. This is done to maximize the chemotherapeutic dose that is delivered to the tumor.

Once the catheter is positioned in the desired location, the drug eluting beads are injected under x-ray guidance, making sure they go to the exact location of the tumor. The total chemotherapeutic dose may be given in one vessel’s distribution, or it may be divided among several vessels supplying the tumor(s). After the treatment is administered, the catheter is withdrawn. Usually a special “plug” is applied to the puncture site in the artery to avoid bleeding.

What can you expect after the procedure?

After the procedure you will be taken to the recovery area for about 2 hours. Your nurse will monitor your blood pressure, oxygen saturation and heart rate. They will also check your groin site, where the catheter was placed and removed for bleeding or bruising and check the pulses in your feet. It is important to lie flat during this time and keep your leg straight and motionless. This prevents bleeding at the groin site. Most patients need to be on bed rest for only 2 hours. However, in some situations, you may be on bed rest and required to lie flat for up to 6 hours. In these cases you may be admitted to the hospital for observation and pain management.

After the procedure some patients may have the following:

Fever (short-term in 10% of patients)
Nausea/vomiting (nausea can last up to 2 weeks, vomiting for a couple of days)
Fatigue
Upper right abdominal discomfort (can last from a couple days up to a week)
A small, firm lump on the groin where the catheter was. (can last a few weeks)
Bruising at the procedure site.

If necessary, pain medicine is given through your IV on the post procedure unit. You will receive IV antibiotics before and after the procedure. Follow up blood tests are done to see how your liver is tolerating the treatment. Most patients will be discharged the same day or morning after the procedure if admitted for observation.

How long does it take to recover?

Usually you will feel really tired for about 2 weeks. After that you will probably be able to resume all of your normal activities.

Follow up?

You should follow up with the interventional radiologist 1-2 weeks after the procedure for a check up.

Repeat CT/MRI and/or PET scans may be ordered along with blood tests 4 weeks after the procedure. After these are completed, another follow up appointment (4-5 weeks after initial treatment) should be made with the interventional radiologist to review the studies.

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