Chemoembolization therapy

Sumi, S., Yamashita, Y., Mitsuzaki, K., Yamamoto, H., Urata, J., Nishi-haru, T., Takahashi, M. Power Doppler Sonography assessment of tumor recurrence after chemoembolization therapy for hepatocellular carcinoma. Amer. J. Roentgenol. 1999 172 67—71... 

Kabayashi S, Nakamura Y, Terada T et al (1993) Postmortem survey of bile duct necrosis and biloma in hepatocellular carcinoma alter transcatheter arterial chemoembolization therapy relevant to microvascular damages of peribiliary capillary plexus. Am J Gastroenterol 88 1410-1415... 

Sasaki Y et al. (1987) A new approach to chemoembolization therapy for hepatoma using ethiodized oil cisplatin and gelatin sponge. Cancer 60 1194 1203 Schlumberger MJ (1998) Papillary and follicular thyroid carcinoma- N Engl J Med 338 297 306 Schteingart D (2000) Neoplasms of the adrenal cortex. In Bast RC, Kufe DW, Pollock RE, Weichselbaum RR, Holland JF, Frei III E (eds) Cancer medicine, 5th edn. BC Decker, Hamilton, pp 1115 1120... 

Choi BI, Kim HC, Han JK, Park JH, Kim Yl, Kim ST, Lee HS, Kim CY, Han MC (1992) Therapeutic effect of transcatheter oily chemoembolization therapy for encapsulated nodular hepatocellular carcinoma CT and pathologic findings. Radiology 182 709-713 Chung JW, Park JH, Im JG, Han JK, Han MC (1993) Pulmonary oil embolism after transcatheter oily chemoembolization of hepatocellular carcinoma. Radiology 187 689-693... 

Salman HS, Cynamon J, Jagust M, Bakal C, Rozenblit A, Kaleya R, Negassa A, Wadler S (2002) Randomized phase II trial of embolization therapy versus chemoembolization therapy in previously treated patients with colorectal carcinoma metastatic to the liver. Clin Colorectal Cancer 2 173-179... 

Li X, Feng GS, et al. (2004) Expression of plasma vascular endothelial growth factor in patients with hepatocellular carcinoma and effect of transcatheter arterial chemoembolization therapy on plasma vascular endothelial growth factor level. World J Gastroenterol 10 2878-2882... 

Chemoembolization therapy is one of the improved methods of TAE, whereby anticancer agents delivered to the tumorous cells (Nishioka et al., 1993). The use of drug carriers can often enhance the efficiencies of antitumor agents (Ohnishi et al., 1984). 

Patients with hepatic-predominant disease whose disease progresses with systemic therapy may be candidates for hepatic-directed therapies such as chemoembolization, cryotherapy, or radiofrequency ablation. 

Kato T, Saito Y, Niwa M, Ishiguro J, Ogoshi K. Combination therapy of transcatheter chemoembolization and percutaneous ethanol injection therapy for imresectable hepatocellular carcinoma. Cancer Chemother Pharmacol 1994 33(Suppl) S115-18. 

Hepatocellular carcinoma (HCC) represents one of the most common types of cancer, with more than 1 million new cases worldwide and a dramatic increase in the western world. In most cases, HCC is detected at an advanced stage and frequently liver cirrhosis as an underlying disease is present. Therefore, therapeutic options are limited. Beside resection, liver transplantation is regarded the only curative therapy [4]. However, only 10%-15% of patients are candidates for curative surgery - especially due to the shortage of liver donors. There are no effective systemic treatments [4] to date for these patients and transarterial chemoembolization or RE are therefore the only palliative therapies. 

Presently, numerous palliative hepatic-directed therapies are available for the treatment of non-resectable liver tumors, including conformal radiation therapy, microsphere brachytherapy, hepatic arterial infusion chemotherapy, transarte-rial chemoembolization, radiofrequency ablation and combinations of these treatments. 

Hepatic arterial bland and chemo-embolization have also been utilized. This therapy is based on the anatomic vascular distribution of the blood supply for hepatic tumors. The hepatic artery serves tumors in the liver almost exclusively while the portal vein serves normal hepatic parenchyma. There is some crossover but it is only approximately 10%. Bland embolization uses particles placed in the hepatic artery only while chemoembolization mixes these particles with a variety of chemotherapeutic agents and lipiodol, an iodinated poppy seed oil, which has been shown to increase the uptake into the cell via a pump in the cell wall. This therapy has been utilized for the last 20 years but eventual re-growth and recurrence have also uniformly occurred. Repeated embolizations are necessary to keep the disease in check and to palliate the patient s symptoms. The mean response to embolization is approximately 12-18 months with eventual occlusion of the hepatic arterial supply to the tumor after multiple embolizations. Response to embolotherapy has been dramatic for palliation of symptoms, with 63% of patients reporting a reduction in symptoms and an objective response seen on CT to be 76% either partial or minimal response, with an additional 16% reporting stable disease [4]. The embolotherapy will rid the patient of much of their tumor burden but isolated islets of viable tumor will remain after the procedure, accounting for the resurgence of disease. 

Radioembolization with yttrium-90 ( Y) microspheres represents an innovative approach that has gained increasing awareness and clinical use over the past 5-10 years. The minimal toxicity of radioembolization and the ability to discharge the patient on an outpatient basis make the therapy an attractive alternative in the treatment of primary and metastatic liver malignancies. Patients are able to resume normal activities shortly following treatment, with minimal side effects, in contrast to the post-embolization syndrome often associated with current chemoembolic techniques. 

Geschwind JF, Kaushik S, Ramsey DE, Choti MA, Fishman EK, Kobeiter H (2002) Influence of a new prophylactic antibiotic therapy on the incidence of liver abscesses after chemoembolization treatment of liver tumors. J Vase Interv Radiol 13 1163-1166... 

Biologic Response However, monitoring the size of the tumor is often impractical for several types of minimally invasive regional therapy such as embolization, intraarterial infusion, chemoembolization, or tumor... 

Combination Therapy Chemoembolization and Transportal Ethanol Injection Yamakodo et al. (1999) reported the long-term efficacy of TACE combined with transportal ethanol injection (TPEl) in patients with HCC > 2 cm in diameter. Transhepatic portal access was performed 2-6 weeks subsequent to TACE and ethanol (10-65 ml) was injected into the portal vein branch supplying the involved segment. Technical success was achieved in all patients, but hepatic failure developed in two (8%) patients. The 1- to 6-year survival rates were 87%, 72%, 72%, 63%, 51%, and 51%, respectively. 

Chemoembolization Moertel et al. (1994) have chronicled their 10 year experience in 111 patients with neuroendocrine hepatic metastases, usually hypervascular, receiving vascular occlusion therapy by a variety of methods. A total of 71 patients also received subsequent alternating chemotherapy regimens (dacarbazine + doxorubicin and streptozotocin + 5-fluorouracil). Objective regression rates of 60% with vascular occlusion alone and 80% with sequential therapy of vascular occlusion and chemotherapy were observed. A median survival time of 37 months was experienced in patients with islet cell carcinoma and 49 months with carcinoid hepatic metastases. Repeated embolizations were preferred. 

Chemoembolization In a series of 17 patients, Yayoi et al. (1995) compared intraarterial hepatic chemoembolization (n=9) of Adriamycin and lipiodolwith hepatic artery infusion (n=8) with Adriamycin. All intraarterial therapies were followed by endocrine therapy consisting of medroxyprogesterone acetate. There was no significant difference in rates of... 

Pajkos G et al. (1998) Combined therapy of metastatic liver neoplasms intrahepatic chemoembolization and systemic chemotherapy. Orv Hetil 139 1013-1017 Parkin DM et al. (1999) Estimates of the worldwide incidence of 25 major cancers in 1990. Int J Cancer 80 827-841 Patt YZ et al. (1994) Hepatic arterial infusion of floxuridine, leucovorin, doxorubicin, and cisplatin for hepatocellular carcinoma effects of hepatitis B and C viral infection on drug toxicity and patient survival. J Clin Oncol 12 1204-1211... 

Besides endovascular treatments in the brain, C-arm CT is also well suited to support abdominal apphca-tions. In fact, C-arm CT has aheady received considerable attention for tiimimaUy invasive liver tumor treatments. Innovative therapeutic approaches, such as local chemotherapy, chemoembolization, or selective internal radiation therapy (SIRT), may aU benefit. 

Regional liver therapies are considerably more common now than they were a decade ago. Kato et al. described in 1981 the first arterial chemoembolization with a microencapsulated anticancer drug in different organs (Kato et al. 1981). 

Tellez and colleges showed that chemoembolization is a feasible treatment modality in patients with liver metastasis from CRC who have experienced failure with other systemic treatments. It results in high response rates with transient mild-to-moder-ate toxicity. Patients who are able to undergo repetitive chemoembolization procedures may receive the most clinical benefit (Tellez et al. 1998). Salman et al. (2002) resumed that embolization of the liver as second-line therapy in patients with liver-predominant metastases is safe and effective. Median survivals are comparable to those following other second-line therapies. 

Transarterial chemoembolization (TACE) has widely been proposed as the palliative treatment of choice. However, most data indicate a limited benefit from TACE in patients with advanced liver cirrhosis (Llovet et al. 2003). In the past percutaneous tumor ablation by radiofrequency (RFA) or laser-induced thermo therapy (LITT) has supplemented ethanol injection. Any of these methods has hmitations with respect to tumor size, perfusion and localization, as described above. 

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