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Stambo et al. LC Bead embolization of hepatic neoplasms

to endovascular treatment did poorly. The irinotecan Many times peripheral located liver masses that
treated colorectal metastasis patients had poor appear successfully embolized can return with
response rate at 3 months with no reduction in tumor increasing size and persistent tumor enhancement
size or tumor enhancement compared to pre-procedural on follow-up imaging. Repeat angiograms can
images. The 3 months interval time frame was long demonstrate peripheral tumor vascular recruitment
enough to account for the post treatment inflammation from extrahepatic collateral suppliers prohibiting
and edema caused by chemoembolization on the effective control of the tumor. These angiographic
hepatic tumors. Doxorubicin and irinotecan were findings were more commonly seen in advanced
selected due to the chemotherapy data at that time. stages of metastatic liver disease. Those collateral
arterial feeders should be separately embolized at that
Fiorentini et al. [17] described an 80% response rate time. Fortunately, a complete vascular assessment
following drug eluting bead embolization using during the initial selective angiography eliminated the
irinotecan. However, they used twice the dose of need for repeat studies attempting to search for new
inrinotecan (100 mg/mL) compared to this study. collaterals each time.
Furthermore, their patients were treated once every 3
weeks and subsequently demonstrated improvement There was no intraprocedural discomfort described
in contrast enhancement on all responding patients. by the patients during the doxorubicin eluted bead
In comparison, this article used the standard dosage embolization. However, we found 10/12 (83%) of the
which may not have been concentrated enough and/ irinotecan patients described immediate right upper
or the treatment time may not have been long enough quadrant pain during intraprocedureal bead delivery.
for the embolization to obtain this type of response. This phenomenon was rapid in onset, resolved quickly
Also in their study, the embolization treatments were and did not recur following the procedure. This clinical
stopped if findings of progressive disease were noted response does not occur with doxorubicin eluted bead
and subsequently those patients were excluded from placement. If needed, patients were given intravenous
the study. On the other hand, our study included all the analgesia intra-procedurally but no premedication
patients treated with one session of irinotecan bead protocol was developed during this study. It may relate
embolization and none were excluded from the study to the faster elution of the irinotecan (approximately 4
despite the results. days) from the beads as compared to doxorubicin. [21]
Also, the amount of liver parenchyma being treated
Along with chemoembolization, combination therapies during the embolization frequently is more extensive
including radiofrequency ablation, microwave ablation due to the nature of colonic metastasis.
and cryoablation can be used in conjunction with
synergistic effects. [18] The idea of combination therapies The study investigators routinely embolized the
is to both embolize the larger tumors decreasing the gastroduodenal artery (GDA) to prevent the embolics
size with the DEB and then percutaneously ablate from refluxing into the arterial pathways leading into
the remaining tumor. The DEB treatment prior to the duodenum and pancreas. In this study, there was
percutaneous ablation devascularizes the surface of no non target duodenal, gallbladder or pancreatic
the tumor which reduces the heat-sink making ablation embolization complications. At this institution, GDA
more effective. Percutaneous ablation of the center embolization is performed in every case because
of the tumor mass results in a sub lethal temperature of that small chance of complications related to
experienced at the periphery of the tumor masses embolization of non target vascularity. We understand
allowing these cells to be less resistant to the high that gastroduodenal artery embolization is not the
concentration of drug. [18] standard of practice in many centers despite the use
of microcatheters for delivery of the embolic material.
The major disadvantage of conventional TACE However, we believe that preserving the gallbladder,
procedures is the rapid washout of the duodenum and pancreas from preventable non target
chemotherapeutic out of the tumor into the embolization is crucial. GDA embolization is a quick
systemic circulation. On the other hand, LC Bead and technically easy procedure to perform prior to LC
chemoembolization has 2 major advantages over Bead chemoembolization not adding much procedure
conventional TACE. First, the drug is continuously time to the case.
released over a 10-12 days window providing a higher
overall intratumoral drug dose over a longer time. [14] The study is a retrospective investigation of this
Secondly, with the continuous slow release of drug, institution’s LC Bead chemoembolization practice and
there is less systemic toxicity and therefore less post there are several study limitations. First, doxorubicin
embolization syndrome. [10,19,20] was the only chemotherapeutic agent used on HCC.
146 Hepatoma Research ¦ Volume 3 ¦ July 12, 2017