Hepatocellular Carcinoma (HCC) Chemoembolization

What is hepatocellular carcinoma (HCC)?

Hepatocellular carcinoma is a malignant tumor of the liver. It accounts for 80 to 90% of all liver cancers. The cause of liver cancer is unknown, but contributing factors include chronic liver disease, viral hepatitis, hemochromatosis, known liver carcinogens, and toxins.

What is chemoembolization?

Chemoembolization is a palliative treatment for liver cancer. This can be a cancer originating in the liver or a cancer that has spread ("metastasized") to the liver from other areas in the body. Chemoembolization only treats tumors in the liver and will have little or no effect on any other cancer in the body. The following liver cancers may be treated by Chemoembolization:

• Hepatoma (primary liver cancer)
• Metastasis* to the liver from:
• colon cancer
• carcinoid
• ocular melanoma
• sarcomas
*The transfer of disease from one organ or part to another.

How is the chemoembolization performed?

Several days prior to the procedure you will be given instructions from the Interventional Radiologist's office staff on how to prepare for the procedure including modification of your medications if necessary. You will need to have blood drawn at the hospital or a local clinic for testing. You may also need to have several pre-procedure evaluation tests, including liver function tests, and a CT scan or an MRI of your liver. The Interventional Radiologist needs to check these test results to make sure you do not have any blockage of the portal vein or bile ducts, or liver cirrhosis (hardening of the liver). If you have any of these conditions, the Interventional Radiologist may determine that chemoembolization is not the best treatment for you.

The procedure is performed in the interventional radiology suite. First, the nurse will give you a sedative through the intravenous line, which will be placed in your arm. You will feel relaxed and sleepy, but you will be awake throughout the procedure. The Interventional Radiologist will numb an area of your groin with a local anesthetic. He/she will then place a small, thin tube called a catheter into the femoral artery which is a large artery in the groin. You will not feel any discomfort when he places the catheter, but you may initially feel some slight pressure. The Interventional Radiologist will then advance the catheter through the hepatic artery to the tumor in the liver. An angiogram, which an x-ray procedure that studies the arteries or veins, will then be performed to determine the best catheter position for the chemotherapy injection. Because blood vessels cannot be seen under x-ray, contrast media (x-ray dye) is used to visualize the vessels under x-ray.

Once the catheter is properly positioned, the chemotherapy drugs are injected directly into the artery that supplies blood to the tumor in the liver. The artery is then blocked off ("embolized") with a mixture of oil and/or embolic materials. The embolic materials used may vary. The most common materials include polyvinyl alcohol (PVA) particles, Embospheres®, and Gelfoam®. PVA looks like finely ground, white grains of sand. These particles become wedged in the blood vessels when injected through the catheters. Embospheres® are clear acrylic microspheres that are compressible, allowing easy passage through catheters and into the vessels. Gelfoam® is a gelatin sponge that is cut into small pieces and injected through the catheter into the vessels.

The chemoembolization procedure is approximately three hours in length, and involves an overnight hospital stay. It is performed repeatedly on a monthly basis, with a treatment regimen of approximately 1 to 3 sessions.

Chemoembolization deprives the tumor of oxygen and nutrients, while infusing the tumor with high doses of chemotherapy (without the normal dilution that occurs with a standard intravenous infusion). Because the hepatic artery is blocked, no blood can wash through the tumor. Therefore, the chemotherapy drugs can remain in the tumor for up to one month with little or no side affects usually seen with chemotherapy. This technique can slow or stop tumor growth, and in some cases, may result in tumor shrinkage.

Chemoembolization is effective without causing liver damage because although the hepatic artery is central to the tumor's survival, it provides only 25 percent of the liver's blood supply. The liver is unique in that it has two blood supplies - a hepatic artery as well as a large portal vein that furnishes ample blood flow.

Patient Discharge and Follow-up Instructions:

Before discharge from the hospital, the nurse will review the discharge instructions with you and give you a copy to take home. Instructions include:

• Take pain medications as directed. Report pain that is not controlled with medications.
• Rest remainder of the day
• Limit activity for next 2 days
• You may drive 24 hours after discharge
• You may resume your normal diet after any nausea goes away
• Schedule an appointment with the Interventional Radiologist 2 – 3 weeks after the procedure. To schedule the   appointment, call the office at (305) 932-7800.
• The office staff will assist you in scheduling follow-up tests including a tumor marker blood test (2 – 3 weeks after   each treatment) and CT or MRI (6 – 8 weeks after each treatment).

Will Chemoembolization help me?

Remember this is a treatment, not a cure. Approximately 70% of the patients will see improvement in the liver and, depending on the type of liver cancer, it may improve your survival.

What are the possible side effects and complications?

Following the procedure you may experience the following side effects:

• Nausea and/or vomiting lasting 1-2 weeks, which can be controlled with medications
• Abdominal pain/discomfort for 1-2 weeks, which can be controlled with medications
• Hiccups and a low grade fever that may be due to tumor shrinkage
• A decrease in energy level for 2-4 weeks
Possible complications include:
• Death or decay of gallbladder
• Liver abscess or infection due to tumor decay
• Bleeding in the stomach or bowel
• Liver toxicity

These complications should be discussed with the Interventional Radiologist prior to the procedure.