Clinical management of ir patients in gonda

Clinical ManagementIR patients in the GOU

Justin McWilliams, M.D.

Assistant Professor of Radiology

UCLA

Intro to IR

General principles

IR procedures relevant to GOU Description of procedure Post-procedure management Complications

Case scenarios

Outline

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Interventional Radiology

What do we do?

4


What do we do?

“Minimally invasive procedures with imaging guidance”

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What do we do?

“Minimally invasive procedures with imaging guidance”

Whaaa?

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• Close things down• Tumor embolization• Bleeding• Fibroids• Varicose veins• Varicoceles


Open things up Thrombolysis TIPS Angioplasty and stenting Dialysis access

management

Put things in Venous access G and GJ tubes IVC filters Vertebroplasty Nerve blocks

Take things out Abscess drainage Nephrostomy Biliary drainage Foreign body retrieval

Diagnose things Angiography Cholangiography Needle biopsy Venous sampling

(and tumor ablation)

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Interventional RadiologyWhat is most relevant to GOU?

Embolization proceduresTACEUFE

Ablation proceduresRFAMWA

TACE and RFARationale and technique

Liver cancer treatments OLT

Treatment of choice for HCC, especially in cirrhotics Milan criteria: one lesion up to 5 cm, or up to 3 lesions, each up to 3 cm. No

vascular invasion or mets 5-year survival ~70%

Resection Treatment of choice for HCC in non-cirrhotics Any size lesion if limited to one lobe, PV invasion OK 5-year survival ~50%

RFA Treatment of choice in non-operative candidates with limited disease Effective in lesions up to 3-5 cm, up to 3 or 4 lesions 5-year survival ~40%

TACE Treatment of choice in non-operative candidates with intermediate stage HCC

(large or numerous tumors) Give chemotherapy-eluting particles directly into arteries feeding the tumor 5-year survival ~20%

Nexavar Treatment of choice in advanced HCC (extrahepatic spread or vascular

invasion) Tyrosine kinase inhibitor with proven survival benefit in RCT Median survival 10 months (vs 7 months with placebo)

Transarterial chemoembolizationRationale

HCC takes its blood supply almost exclusively from the hepatic artery

Surrounding normal liver has dual blood supply (with portal vein)

Chemotherapy + embolic agent administered into hepatic artery should selectively kill tumor while sparing normal liver

1. Conscious sedation2. Common femoral artery access3. Catheter to select hepatic artery4. Microcatheter to superselect tumor-bearing

artery5. Embolize to near-stasis or stasis

• Conventional TACE: Chemotherapy (doxorubicin, cisplatin, mitomycin C) with Lipiodol, followed by Gelfoam or Embospheres

• DEB-TACE: Doxorubicin-eluting LC beads

• Chemo elutes more slowly than with Lipiodol

• Reduced liver toxicity

• Less side effects

6. Arterial closure7. Overnight admission

TACETechnique

RCT of TACE vs. symptomatic treatment for unresectable HCC

Llovet: 112 patients

Lo: 80 patients

TACELlovet and Lo, 2002

3-year survival:29% with TACE17% with supportive care

3-year survival:26% with TACE3% with supportive care

“TACE is first-line non-curative therapy for non-surgical patients with large or multifocal HCC who do not have vascular invasion or extrahepatic spread (level I evidence).”

TACEConsensus statement

American Association for Study of Liver Diseases (AASLD) and European Association for the Study of the Liver (EASL).

RF current induces thermal coagulation necrosis around an electrode

• Complete ablation rates >80% for small to medium HCC

• Local recurrence uncommon (1-12%)

Disadvantages• Relies on thermal conduction

(limited ablation size) Best for tumors <3 cm

Increasing technical failure and local recurrence for tumors >3 cm

• Heat sink effect• Slow

McWilliams J, et al. Percutaneous ablation of hepatocellular carcinoma: current status. J Vasc Interv Radiol 2010;21:S204-S213.Hinshaw J. The role of image-guided tumor ablation in the management of liver cancer. Cancer News review article.

Radiofrequency ablationRationale

1. General anesthesia (usually)2. Ultrasound used to guide 1-3 needles into

tumor3. CT to confirm and/or adjust position4. Ablation performed (3-5 cm burn possible)5. Adjust needle position and repeat as

necessary6. Needle removal with tract cauterization7. Contrast CT to confirm adequate treatment8. MRI after anesthesia wears off9. Discharge same day (ideally)

RFATechnique

“Local ablation is safe and effective therapy for patients who cannot undergo resection, or as a bridge to transplantation.”

Percutaneous ablationConsensus statement

American Association for Study of Liver Diseases (AASLD) and European Association for the Study of the Liver (EASL).

Post-embo and post-ablation managementGeneral principles

Occurs in 80-90% of patients who undergo embolization (TACE, UFE, etc)

Within 24 hours of embolization, tissue and cell death begins, and breakdown products are released into the circulation

• Pain – At site of embolization, may be severe

• Nausea/vomiting – About 1/3 of patients

• Fever – 15-30% of patients, up to 104 degrees

• Leukocytosis – 15-30% of patients, can exceed WBC 20k

• Fatigue – Most patients, can last for weeks

Some or all of these symptoms may not manifest until after patient discharge

Post-ablation syndrome consists of the same symptoms, but is less frequent (<1/3 of patients)

Most symptoms resolve by 72 hours (except fatigue, and sometimes pain)

General PrinciplesPost-embolization syndrome (PES)

Can occur during the procedure, but often does not occur until post-procedure

Referred visceral pain from the liver is often found in the right shoulder

Opioid analgesia is treatment of choice for severe pain

• Dilaudid or morphine

• PCA is often best method of delivery

NSAIDs can be useful for minor pain, but generally avoid in liver patients

Tylenol is OK but limit to 1.5 grams/day in liver patients

General PrinciplesPain

Often multifactorial

• PES

• Chemotherapy

• Opioid use

Zofran works great (4 mg q4 or 8 mg q8)

Can add dexamethasone in non-diabetics (12 mg on day of treatment)

Compazine or droperidol for breakthrough nausea

General PrinciplesNausea

15-30% of patients develop fever after intervention

• Usually at 24-48 hours

• May be up to 104, but usually <102

Leukocytosis is normal

• Can exceed 20k

Low grade or moderate fever in first few days after treatment should not warrant fever work-up

Differentiating infection vs. PES is difficult

• Gas in embolized area on CT is normal, not abscess

• Fevers beyond 48 hours may require work-up

• Abscess usually occurs at 2-4 weeks

General PrinciplesFever

Extremely common after embolization, and to a lesser extent, ablation

Peaks several days after treatment

Can last for days or weeks

Risk factors

• Baseline fatigue

• High dose of chemo used

General PrinciplesFatigue

Post-embo and post-ablation managementThe specifics

Fluids/Diet

Activity

Pain control

Nausea control

Antibiotics

Puncture site

Labs

TACEPost-procedure management

Fluids/Diet• IV hydration NS ~250 cc/hr x 5 hours

• Advance diet as tolerated (do not start with Salisbury steak)

Activity

Pain control

Nausea control

Antibiotics

Puncture site

Labs


Fluids/Diet

Activity• Bed rest at least 2 hours (closure device)

• Bed rest at least 6 hours (manual compression)

• Bed rest overnight (higher risk patients)

Pain control

Nausea control

Antibiotics

Puncture site

Labs


Fluids/Diet

Activity

Pain control

• PCA (almost everyone)

• If pain stays controlled, switch to PO Vicodin/Percocet/Oxycodone the next AM

Nausea control

Antibiotics

Puncture site

Labs


Fluids/Diet

Activity

Pain control

Nausea control• Dexamethasone 6 hours post-procedure (if non-diabetic)

• Zofran (4 mg q4 hours, or 8 mg q8 hours)

• If ineffective, can use Phenergan or Droperidol or Reglan

Antibiotics

Puncture site

Labs


Fluids/Diet

Activity

Pain control

Nausea control

Antibiotics• No data prove their necessity or effectiveness post-TACE

• Used empirically by some operators, especially in higher risk patients

• Cipro +/- Flagyl x 7 days

Puncture site

Labs


Fluids/Diet

Activity

Pain control

Nausea control

Antibiotics

Puncture site

• First 2 hours post-procedure are critical

• Groin checks and vitals q15 min x 4, then q30 min x 2

• The most dangerous bleeds are not externally obvious

Labs


Fluids/Diet

Activity

Pain control

Nausea control

Antibiotics

Puncture site

Labs• AST and ALT

• Total bilirubin

• Creatinine

• Sodium


Liver failure

Bleeding

Nontarget embolization

Acute renal failure

Infection/abscess

TACEComplications

Liver failure• Risk factors: Child B/C, total bili >3.0, albumin <2.0, ECOG >2

• Mechanism: TACE-related injury to “normal” liver parenchyma (poor reserve in cirrhotic livers)

• Incidence: 13% of TACE patients suffer some degree of liver failure.

• Diagnosis: Elevated bilirubin/INR, jaundice, itchiness, dark urine, light stool

• Avoidance strategy: Superselective embo

• Treatment: Supportive care

• Outcome: Most recover. 30-day TACE-related mortality from liver failure is 2%

TACEComplications

Bleeding (puncture site)• Risk factors: Low platelets, high INR, obesity, closure device failure, uncooperative patient

• Mechanism: Platelet plug does not form or dislodges

• Incidence: Minor groin hematoma <10%. Major intramuscular or retroperitoneal bleed is rare but devastating.

• Diagnosis: Groin swelling/pain (not if retroperitoneal), tachycardia, hypotension, orthostasis, pallor, dizziness, lightheadedness, weakness

• Avoidance strategy: Careful access and closure, bed rest with leg straight

• Treatment: Pressure. IVF. Stat type/cross and transfuse. Stat CT. Consider angio.

• Outcome: Depends on blood loss.

TACEComplications

Bleeding (variceal)• Risk factors: Presence of varices, previous variceal bleed, low platelets, high INR

• Mechanism: Increased portal HTN in setting of periprocedural liver insult (varices)

• Incidence: <1%, anecdotal

• Diagnosis: Hematemesis, shock

• Avoidance strategy: Pre-TACE banding? Superselective TACE

• Treatment: IVF. Type/cross and transfuse. Immediate endoscopy with banding. Consider emergent TIPS if no other options.

• Outcome: High mortality rate.

TACEComplications

Nontarget embolization• Risk factors: Lobar (nonselective) treatment

• Mechanism: Embolic material passes into gallbladder, stomach or intestine

• Incidence: <<10%

• Diagnosis: Ulceration, perforation, pain, bleeding

• Avoidance strategy: Superselective embo

• Treatment: NPO. Hydration. PPI. Prolonged observation. Consider surgery if bowel necrosis.

• Outcome: Most recover with supportive care alone.

TACEComplications

Acute renal failure• Risk factors: High baseline creatinine (CRI), diabetes, dehydration

• Mechanism: Nephrotoxic contrast, nephrotoxic chemotherapy, tumor lysis syndrome

• Incidence: <1-8%

• Diagnosis: Rising creatinine, peaking 2-3 days after insult; oliguria

• Avoidance strategy: IV hydration. Minimize contrast. Bicarbonate/Mucomyst.

• Treatment: IV hydration. Temporary dialysis if necessary.

• Outcome: 1/3 require permanent dialysis. 2/3 recover.

TACEComplications

Fluids/Diet

Activity

Pain control

Nausea control

Antibiotics

Puncture site

Labs

RFA/MWAPost-procedure management

Fluids/Diet

• IVF (gentle)

• Advance as tolerated (most had general anesthesia)

Activity

Pain control

Nausea control

Antibiotics

Puncture site

Labs


Fluids/Diet

Activity• Ad lib

Pain control

Nausea control

Antibiotics

Puncture site

Labs


Fluids/Diet

Activity

Pain control

• Usually PO narcotics suffice (Vicodin, Percocet)

• PCA or IV morphine/dilaudid if pain is severe

Nausea control

Antibiotics

Puncture site

Labs


Fluids/Diet

Activity

Pain control

Nausea control

• Rarely needed

• Zofran

Antibiotics

Puncture site

Labs


Fluids/Diet

Activity

Pain control

Nausea control

Antibiotics

• Little evidene to support its use in routine ablation

• Cipro +/- Flagyl if chance of biliary/bowel injury or high risk patient

Puncture site

Labs


Fluids/Diet

Activity

Pain control

Nausea control

Antibiotics

Puncture site

• Usually nothing to see

• Rare skin burns

Labs


Fluids/Diet

Activity

Pain control

Nausea control

Antibiotics

Puncture site

Labs

• Hemoglobin, Total Bilirubin, AST/ALT, sodium


Hemorrhage

Liver failure

Nontarget ablation

Infection

Tumor seeding

RFA/MWAComplications

Hemorrhage• Risk factors: Low platelets, high INR, multiple needle placements, ascites

• Mechanism: Arterial injury by needle, or persistent oozing from liver puncture

• Incidence: ~1% clinically significant hemorrhage rate

• Diagnosis: Hypotension, tachycardia, pallor, pain, dizziness, orthostasis

• Avoidance strategy: Tract cauterization, FFP/platelet support

• Treatment: IVF resuscitation. Transfuse. Stat CTA (look for active extravasation). Hepatic angiography and embolization.

• Outcome: Depends on blood loss.


Liver failure• Risk factors: Child B/C, total bili >3.0, albumin <2.0, ECOG >2, large ablation zone,

multiple ablations

• Mechanism: Ablation of “normal” liver parenchyma (poor reserve in cirrhotic livers)

• Incidence: 12% risk of death from liver failure in ablation of Child C patients; <1% risk for Child A or B

• Diagnosis: Elevated bilirubin/INR, jaundice, itchiness, dark urine, light stool

• Avoidance strategy: Staged ablation

• Treatment: Supportive care

• Outcome: Recovery is less likely than in TACE as liver is permanently damaged with ablation


Nontarget ablation• Risk factors: Target tumor near stomach, bowel, bile ducts, gallbladder

• Mechanism: Nontarget tissues lie within ablation zone

• Incidence: 2%

• Diagnosis: Bowel or gallbladder perforation, bile leak or obstruction

• Avoidance strategy: Hydrodissection, positioning

• Treatment: Surgery or supportive care

• Outcome: Mortality is high for bowel injury in this population


Infection/abscess• Risk factors: Hepatojejunostomy, biliary drainage tube

• Mechanism: Colonized biliary system seeds the necrotic treated ablation zone

• Incidence: <5% with normal sphincter of Oddi; 30-80% if compromised

• Diagnosis: Pain, fever

• Avoidance strategy: Periprocedural antibiotics, bowel prep

• Treatment: Antibiotics and drainage

• Outcome: Most recover


Tumor seeding• Risk factors: Multiple needle insertions, concomitant biopsy

• Mechanism: Tumor cells on needle seed tract as needle is removed

• Incidence: <1%

• Diagnosis: Imaging

• Avoidance strategy: Tract ablation/cauterization with needle removal

• Treatment: Ablation or surgery

• Outcome: Most are detected on follow up and treated


TG

39 y/o female

Fibrolamellar HCC diagnosed in 2001

Left lobe resection of 9 x 11 cm mass in 2001

Recurrence 2007 with partial right lobe resection

Presents with multifocal recurrence 2/2010

Not a surgical or transplant candidate

Presented at tumor board and referred for locoregional therapy

CT 4/9/2010: At least 10 hypervascular liver

masses

100 mg doxorubicin on LC beads

TACE 5/3/2010

2 weeks later, returns with fevers, RUQ pain

Percutaneous biloma drainage

CT 5/19/2010: near- complete tumor necrosis

CT 8/6/2010: Biloma resolved, but

intrahepatic recurrence and new lung nodule.

To study drug

Prolonged catheter drainage

Four

39 year old female

Fibrolamellar hepatocellular carcinoma

Status post left lobectomy and partial right lobectomy

No longer a surgical candidate OLT? RFA? TACE? Chemotherapy?

OLT Treatment of choice for HCC, especially in cirrhotics Milan criteria: one lesion up to 5 cm in size, or up to 3 lesions, each

up to 3 cm in size. No vascular invasion and no mets.

RFA Place ablation needle into lesion (under CT/US guidance) and cook it Effective in lesions up to 3 cm (sometimes larger), up to 3 or 4 lesions Damage to adjacent bile ducts or bowel can be a concern

TACE CFA access, catheterize hepatic artery and subselect tumor feeders Give chemotherapy-eluting particles

Block blood flow

Release tumoricidal chemotherapy

Targeted chemotherapy Nexavar (tyrosine kinase inhibitor) – extends survival in advanced HCC Avastin (monoclonal VEGF inhibitor) – promising but unproven

Liver cancer treatments

OLT Too many lesions to qualify (outside Milan criteria)

Can consider Milan exception if we can decrease her disease burden

RFA Too many lesions to effectively treat, and marginal location increases

risk for bowel/stomach injury

TACE Suitable

Targeted chemotherapy Suitable, if TACE fails

Liver cancer treatments

Status post 100 mg doxorubicin on 100-300 and 300-500 micron LC beads

Discharged home the next day, doing well

2 weeks later, having persistent high fevers to 103 and night sweats

Abscess?

Biloma?

Necrotic tumor?

10F drain placed under ultrasound

One week later Output 150-200 cc/day

Biloma with continued leak Drain upsized to 12 French Contrast injection – no obvious communication Improved with 6 weeks of drainage

Clinical management of ir patients in gonda

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