Chemoembolization of Liver Tumors

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Chemoembolization of Liver Tumors
R. Torrance Andrews, M.D.
UW Department of Radiology

I. Overview

Chemoembolization is a targeted treatment for liver cancer. It combats cancer in two ways. First, it gives a high dose of chemotherapy directly to the tumor. Second, it cuts off the tumor’s blood supply, a process known as “embolization.”

Liver cancer can be primary or metastatic. Primary liver cancers are those that originate in the liver. They are significantly more likely to affect patients with liver scarring (cirrhosis). Cirrhosis usually appears in patients with alcoholism or chronic hepatitis B or C infections. Metastatic liver cancers are those that originate in another organ—such as the colon, bowel, pancreas, or skin—and spread to the liver.

The first line of treatment for the most common type of primary liver cancer is a transplant. However, transplants are only feasible when the cancer is caught early; if there is any chance that the cancer has spread beyond the liver, transplantation is not an effective therapy. Because liver cancers cause few symptoms until later stages, they are often not diagnosed until the opportunity for a transplant has passed. To be eligible for a transplant, a patient must have fewer than four tumors, with no single tumor greater than three centimeters in diameter, and must have had no cancer outside the liver in the last six years.

The second line of treatment for primary liver cancer is surgical removal (resection) of the cancerous part of the organ. However, if the cancer is not caught early, there may not be enough non-cancerous tissue left to maintain liver function after a resection. Only one in four liver cancers is caught early enough for surgery to be effective.

When transplant or resection is not possible, chemoembolization and radio-frequency ablation are the treatments of choice. These therapies can be applied singly or together. In chemoembolization, the physician inserts a catheter into an artery in the groin. Using X-ray imaging as a guide, the doctor moves the catheter into the hepatic artery, which supplies the tumor with blood. He or she then releases a combination of medications from the end of the catheter. These medications include an agent that blocks the flow of blood to the tumor, cutting off its supply of oxygen and nutrients, and a chemotherapy drug (or drugs) that poison the tumor. Because these agents are applied only at the tumor site, and because non-cancerous liver tissue does not rely on the hepatic artery as its main source of oxygenated blood, healthy tissue remains unaffected by this treatment.

Patients with liver tumors that have spread from other organs are not transplant candidates because the risk of post-transplant tumors developing elsewhere in the body is too high. Instead, these patients are treated by removal of the original tumor (where the metastasis originated) and systemic (whole-body) chemotherapy. If the liver tumors fail to respond to this approach, or if they cause pain or other symptoms, they are targeted by local therapies. Surgical resection is preferred, but may not be possible on the basis of tumor size, location, or involvement of other structures. In these cases, chemoembolization and radio-frequency ablation are the first-line treatments.

Chemoembolization takes 30 to 45 minutes and requires only mild sedation. Usually the patient stays in the hospital overnight for observation. The most common side effect is pain near the site of the tumor. Oral pain medications can minimize this discomfort. Fever, fatigue, loss of appetite, and (depending upon the chemotherapy agent used) nausea are other side effects. Fever may occur for up to a week after the procedure, and loss of appetite and fatigue for up to two weeks. These side effects are usually mild and are a normal part of the recovery. Most patients are well enough to go back to work two days after the procedure is performed. The treatment is repeated two more times over the next two months, for a total of three treatments.

II. Medications

Adriamycin (also called doxorubicin) is the main chemotherapy drug used for primary liver cancer. If the cancer is metastatic instead of primary, mitomycin and cisplatin are added. This last drug accounts for many of the side effects, such as pain and nausea. Other, non-chemotherapy drugs may be prescribed to minimize these side effects.

III. Considerations

Patients who are not eligible for a transplant or surgical resection should consider this treatment. Determining which treatment is right for an individual patient is a complex process requiring consultation with many different specialists. UW Medical Center’s Liver Tumor Clinic provides comprehensive evaluation by specialists from seven different disciplines in a single appointment.

IV. Effectiveness

Left untreated, patients with primary liver cancer who are ineligible for transplant or surgical resection have a life expectancy of three to six months. For those with metastatic liver cancer, life expectancy is similar, but depends partly on the spread of cancer elsewhere. Even when chemoembolization eliminates existing tumors in the liver, new ones may appear. For these reasons, chemoembolization provides a permanent cure in only a small percentage of patients with liver cancer. However, the treatment has been shown to increase life expectancy up to three times, compared to no treatment.

In one study, 57 percent of patients with primary liver cancer who received chemoembolization were alive after one year, compared to 32 percent in a control group receiving no treatment. After three years, 26 percent of treated patients were alive, compared to 3 percent of untreated ones. Chemoembolization and radio-frequency ablation often work well in combination. (Chemoembolization is most effective on the outside of tumors, while radio-frequency ablation works best in the center.) One study showed only a 2 percent recurrence of primary liver tumors one year after such a combination therapy.

V. Risks of Treatment

In addition to the mild side effects mentioned earlier (fever, fatigue, loss of appetite), chemoembolization can produce transient changes in liver function. As with any surgical procedure, there is a small risk of infection. Hair loss, bone marrow suppression, and other side effects often seen with whole-body chemotherapy are very unusual with chemoembolization.

VI. Risks of No Treatment

Depending upon tumor type, patients with liver cancer who do not receive treatment have life expectancies ranging from less than one year to around three years. With treatment, their life expectancy may be improved.

VII. Urgency

Liver cancer should be treated as soon as possible.

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