Interventional Radiological Treatment of Liver Tumors (Contemporary Issues in Cancer Imaging)

Interventional radiological techniques are becoming increasingly important in the treatment of both primary and secondary malignant liver tumours. Surgery for liver tumours can be effective but carries considerable risks and new techniques have recently been developed. This volume provides an account of interventional radiological methods by some of the greatest experts in the field. It includes chapters on cryotherapy, chemoembolization and radiofrequency ablation and an extensive chapter on imaging techniques. The scientific background of these techniques, the pathology of the diseases involved and an analysis of more traditional surgical methods are also described. This text brings together the latest advances in this fast-developing field. Half-title 3 Title 5 Copyright 6 Contents 7 Contributors 9 Series foreword 13 Preface to Interventional Radiological Treatment of Liver Tumors 15 1 The clinical management of hepatic neoplasms 17 Introduction 17 Hepatocellular carcinoma 17 Epidemiology and etiology 17 Diagnosis 18 Screening 19 Staging and prognosis 20 Treatment options for HCC 20 Liver resection 20 Transplantation 21 Local ablation 22 Transarterial chemoembolization 22 Systemic therapies for HCC 24 Chemotherapy 24 Angiogenesis and hepatocellular carcinoma 25 Radiation therapy 28 Management of colorectal liver metastases 29 Surgical resection of liver metastases 29 Radiofrequency ablation for liver metastases 29 Systemic therapy for colorectal cancer 30 Inhibitors of EGF and VEGF in CRC 32 Downstaging of liver metastases 32 Conclusions 33 References 34 2 Pathology of hepatocellular carcinoma and hepatic metastases 41 Introduction 41 Pathology of hepatocellular carcinoma 41 Premalignant lesions of HCC 42 Dysplastic nodules 42 Early-stage well-differentiated HCC 43 Morphologic characteristics of small HCC of early stage 43 Evolution of HCC from early to advanced stage 46 Pathology of advanced HCC 47 Gross appearance 47 Histological findings 48 Variants of HCC 50 Angioarchitecture of advanced HCC 51 Arterial tumor vessels (unpaired arteries) 51 Venous tumor vessels 53 Portal veins 53 Sinusoid-like blood spaces 53 Pathology of metastatic liver cancers 53 Incidence 53 The frequency of hepatic metastases in cirrhotic and non-cirrhotic livers 54 Gross appearance of metastatic tumors 54 Biopsy diagnosis of hepatic metastasis 56 References 56 3 Diagnostic imaging pre- and post-ablation 60 Introduction 60 Imaging prior to liver ablation 61 Liver blood supply 61 Role of dynamic imaging 61 Pre-RFA evaluation of hepatic lesions 63 Screening for extrahepatic extension 77 Imaging following liver ablation 79 Post-RFA change in liver tissue 79 Imaging protocol for post-ablation follow-up 79 Imaging findings after liver ablation 81 Expected imaging (complete ablation) 81 Indeterminate imaging (needs follow-up) 85 Residual and recurrent imaging 88 Role of PET and PET/CT after RFA 90 Complications 92 Conclusions 93 References 94 4 Transarterial chemoembolization in the management of primary and secondary liver tumors 98 Introduction 98 Technique of chemoembolization 99 Pretreatment assessment 99 Embolization procedure 99 Post-procedure care 100 Embolic materials 100 Choice of embolic particles 100 Choice of chemotherapeutic agents 101 Choice of emulsion: transarterial oily chemoembolization 101 Efficacy of chemoembolization 102 Role of chemoembolization in unresectable hepatocellular carcinoma 102 Role of chemoembolization as a neoadjuvant therapy in HCC 104 Role of chemoembolization in colorectal metastases 106 Role of chemoembolization in neuroendocrine tumor metastases 106 Toxicity of chemoembolization 107 Post-embolization syndrome 108 Major complications 108 Patient selection 110 Selecting patients for optimum efficacy 110 Selecting patients for optimum tolerability 110 New developments in chemoembolization technology 111 Summary 111 References 112 5 High-intensity focused ultrasound (HIFU) treatment of liver cancer 116 Introduction 116 Principles of HIFU 116 Treatment devices and procedures 121 Liver cancer 123 HIFU in the treatment of liver tumors 125 Summary 128 Acknowledgement 128 References 128 6 Percutaneous ethanol injection of hepatocellular carcinoma 132 Introduction 132 Percutaneous ethanol injection 133 Techniques 134 Pretreatment assessments 134 Equipment 134 Procedure 136 Indications and contraindications 140 Complications 141 Evaluation of therapeutic effectiveness 141 Results 144 Summary 147 References 147 7 The role of surgery in the treatment of hepatocellular carcinoma and hepatic metastases 151 Introduction 151 Recent reports demonstrating increasing safety of hepatectomy for cancer 151 The role of surgery in the treatment of hepatocellular carcinoma 153 The role of surgery in the treatment of hepatic metastases 156 Surgical treatment of hepatic metastases from colorectal cancer 157 Surgical treatment of hepatic metastases from neuroendocrine tumors 160 Surgical treatment of hepatic metastases from non-colorectal and non-neuroendocrine tumors 163 Summary 165 References 165 8 Image-guided radiofrequency ablation: techniques and results 172 Introduction 172 Eligibility criteria 172 Technique 174 Imaging 177 Clinical outcomes 181 Treatment of hepatocellular carcinoma 181 Treatment of colorectal hepatic metastases 184 Complications 186 Summary 186 References 187 9 Radiofrequency equipment and scientific basis for radiofrequency ablation 191 Introduction 191 Basic principles of radiofrequency ablation 191 Goals of minimally invasive tumor ablation 191 Radiofrequency induction of coagulation necrosis 192 Radiofrequency ablation techniques and equipment 193 Principles of the bioheat equation 193 Creating clinically meaningful volumes of ablation 194 Modification of electrode design 194 Multitine arrays 194 Bipolar/multipolar arrays 195 Internally cooled electrodes 195 Perfused electrodes 195 RF algorithms for effective heating 196 Modulating tissue characteristics 196 Altered tissue thermal conductivity 197 Altered tissue electrical conductivity 197 Modulating tissue blood flow 197 Minimizing heat sink 198 Tissue perfusion 198 Synergistic therapies 198 Thermal ablation with chemotherapy 199 Thermal ablation with radiation therapy 199 Conclusion 200 References 200 10 Cryotherapy of the liver 205 Introduction 205 Work-up and patient selection 206 Hepatocellular carcinoma 206 Metastatic disease 207 Technique 209 Probe placement 209 Monitoring of the ablation zone 212 Periprocedural sedation and pain control 215 Post-procedure patient management 216 Complications 216 Hemorrhage 216 Abscess 217 Tumor lysis syndrome (cryoshock) 218 Tumor seeding 218 Post-ablation syndrome 218 Biliary complications 219 Follow-up 219 Conclusion 221 References 222 11 Considerations in setting up a radiofrequency ablation service: how we do it 227 Introduction 227 Training for the radiologist in ablation 228 Hospital admitting privileges 229 Setting up a clinic 229 Professional team 230 Billing team 231 Marketing and building referrals 231 Communication 232 Patient management 233 Post-procedural follow-up 234 Summary 235 References 235 Index 237 Half-title......Page 3 Title......Page 5 Copyright......Page 6 Contents......Page 7 Contributors......Page 9 Series foreword......Page 13 Preface to Interventional Radiological Treatment of Liver Tumors......Page 15 Epidemiology and etiology......Page 17 Diagnosis......Page 18 Screening......Page 19 Liver resection......Page 20 Transplantation......Page 21 Transarterial chemoembolization......Page 22 Chemotherapy......Page 24 Angiogenesis and hepatocellular carcinoma......Page 25 Radiation therapy......Page 28 Radiofrequency ablation for liver metastases......Page 29 Systemic therapy for colorectal cancer......Page 30 Downstaging of liver metastases......Page 32 Conclusions......Page 33 References......Page 34 Pathology of hepatocellular carcinoma......Page 41 Dysplastic nodules......Page 42 Morphologic characteristics of small HCC of early stage......Page 43 Evolution of HCC from early to advanced stage......Page 46 Gross appearance......Page 47 Histological findings......Page 48 Variants of HCC......Page 50 Arterial tumor vessels (unpaired arteries)......Page 51 Incidence......Page 53 Gross appearance of metastatic tumors......Page 54 References......Page 56 Introduction......Page 60 Role of dynamic imaging......Page 61 Pre-RFA evaluation of hepatic lesions......Page 63 Screening for extrahepatic extension......Page 77 Imaging protocol for post-ablation follow-up......Page 79 Expected imaging (complete ablation)......Page 81 Indeterminate imaging (needs follow-up)......Page 85 Residual and recurrent imaging......Page 88 Role of PET and PET/CT after RFA......Page 90 Complications......Page 92 Conclusions......Page 93 References......Page 94 Introduction......Page 98 Embolization procedure......Page 99 Choice of embolic particles......Page 100 Choice of emulsion: transarterial oily chemoembolization......Page 101 Role of chemoembolization in unresectable hepatocellular carcinoma......Page 102 Role of chemoembolization as a neoadjuvant therapy in HCC......Page 104 Role of chemoembolization in neuroendocrine tumor metastases......Page 106 Toxicity of chemoembolization......Page 107 Major complications......Page 108 Selecting patients for optimum tolerability......Page 110 Summary......Page 111 References......Page 112 Principles of HIFU......Page 116 Treatment devices and procedures......Page 121 Liver cancer......Page 123 HIFU in the treatment of liver tumors......Page 125 References......Page 128 Introduction......Page 132 Percutaneous ethanol injection......Page 133 Equipment......Page 134 Procedure......Page 136 Indications and contraindications......Page 140 Evaluation of therapeutic effectiveness......Page 141 Results......Page 144 References......Page 147 Recent reports demonstrating increasing safety of hepatectomy for cancer......Page 151 The role of surgery in the treatment of hepatocellular carcinoma......Page 153 The role of surgery in the treatment of hepatic metastases......Page 156 Surgical treatment of hepatic metastases from colorectal cancer......Page 157 Surgical treatment of hepatic metastases from neuroendocrine tumors......Page 160 Surgical treatment of hepatic metastases from non-colorectal and non-neuroendocrine tumors......Page 163 References......Page 165 Eligibility criteria......Page 172 Technique......Page 174 Imaging......Page 177 Treatment of hepatocellular carcinoma......Page 181 Treatment of colorectal hepatic metastases......Page 184 Summary......Page 186 References......Page 187 Goals of minimally invasive tumor ablation......Page 191 Radiofrequency induction of coagulation necrosis......Page 192 Principles of the bioheat equation......Page 193 Multitine arrays......Page 194 Perfused electrodes......Page 195 Modulating tissue characteristics......Page 196 Modulating tissue blood flow......Page 197 Synergistic therapies......Page 198 Thermal ablation with radiation therapy......Page 199 References......Page 200 Introduction......Page 205 Hepatocellular carcinoma......Page 206 Metastatic disease......Page 207 Probe placement......Page 209 Monitoring of the ablation zone......Page 212 Periprocedural sedation and pain control......Page 215 Hemorrhage......Page 216 Abscess......Page 217 Post-ablation syndrome......Page 218 Follow-up......Page 219 Conclusion......Page 221 References......Page 222 Introduction......Page 227 Training for the radiologist in ablation......Page 228 Setting up a clinic......Page 229 Professional team......Page 230 Marketing and building referrals......Page 231 Communication......Page 232 Patient management......Page 233 Post-procedural follow-up......Page 234 References......Page 235 Index......Page 237 Clinical Management Of Hepatic Neoplasms -- Pathology Of Hepatocellular Carcinoma And Hepatic Metastases -- Diagnostic Imaging Pre- And Post-ablation -- Transarterial Chemoembolization In The Management Of Primary And Secondary Liver Tumors -- High-intensity Focused Ultrasound (hifu) Treatment Of Liver Cancer -- Percutaneous Ethanol Injection Of Hepatocellular Carcinoma -- Role Of Surgery In The Treatment Of Hepatocellular Carcinoma And Hepatic Metastases -- Image-guided Radiofrequency Ablation: Techniques And Results -- Radiofrequency Equipment And Scientific Basis For Radiofrequency Ablation -- Cryotherapy Of The Liver -- Considerations In Setting Up A Radiofrequency Ablation Service: How We Do It. Edited By Andy Adam, Peter R. Mueller. Includes Bibliographical References And Index. "Intervention radiological techniques are becoming increasingly important in the treatment of both primary and secondary malignant liver tumors." "This volume provides an account of interventional radiological methods by some of the greatest experts in the field. It includes chapters on cryotherapy, chemoembolization, and radiofrequency ablation, and an extensive chapter on imaging techniques. The scientific background of these techniques, the pathology of the diseases involved, and more traditional surgical methods of treatment are also described. This text brings together the latest advances in this fast-developing field."--BOOK JACKET Surgery for liver tumours can be effective but carries considerable risks. New techniques have been developed recently, involving the insertion of needle-like instruments which destroy these tumours by freezing, heating or injection of chemicals. This book describes these methods and how they can transform the treatment of this life-threatening condition.