Regional Chemotherapy for Liver Tumors

Used to treat either primary or secondary liver tumors. This type of therapy may be intraarterial or intraportal, depending on the specific disease.

Intraarterial chemotherapy

The use of this technique is based on the knowledge that liver tumors, especially metastatic tumors, are supplied by arterial blood vessels. This technique favors then, the concentration of antimitotic agents in the tumor(s), sparing the healthy liver and the rest of the organism. It has been demostrated that 5-fluorouracil concentration is 5 to 20 times higher in the tumor than in the rest of the liver parenchyma with this technique.

The advantage is that the body is spared of the toxicity of these agents, but the liver tumors are not, letting physicians augment the dosage of the antimitotics. Therapy can be delivered either in a discontinued or continued basis.
A preoperative angiography is mandatory to familiarize with the patient's vascular anatomy.

Implantation technique

Laparotomy: Dissection of the hepatoduodenal ligament, and of the gastroduodenal artery (GD) is performed. The pyloric artery is systematically ligated to prevent a chemotherapy induced ulcer. A complete devascularization of the duodeno-pyloric region is performed for the same reason.

Then the anterior face of the head of the pancreas is exposed and 2-3 cm of the gastroduodenal artery are dissected, up to its origin at the level of the common hepatic artery. The GD artery is exposed and freed in all of its circumference, the distal part is ligated and clamped carefully at its origin. A small arteriotomy is performed and the catheter is introduced.
The catheter should not be placed neither, too far away into the common hepatic artery, nor in a way that it floats in the arterial lumen, because these are causes of arterial thrombosis. Two monofilaments, should tighten lightly the cathether.

A routine cholecystectomy should be performed to avoid an acute, chemo-induced inflammation (20-30%).
Finally a perfusion test should be done with indocyanine or methylene blue to confirm liver perfusion and not duodenal or pyloric perfusion. The catheter is rinsed afterwards with a heparinized solution (500 U/ml).

Postoperative confirmation

Always perform a technetium scintigraphy before initiating therapy. On a number of cases, extrahepatic perfusion is evident, and this contraindicates the usage of intraarterial chemotherapy.
This is usually due to a small arterial branch to the pancreas or duodenum that was not evident and therefore not ligated during laparotomy. This artery could be ligated or embolized before starting the treatment, to prevent complications such a duodenal ulcer.

Other techniques

Percutaneous placement

Used specially by radiologists. Femoral, humeral, axillary and thoracoacromial trunk can be used to access the celiac trunk, then the gastroduodenal artery is embolized and a catheter is placed in the hepatic artery.
Complications are more frequent with this approach than with the laparotomy approach. Some of them are: displacement (10-40%) and migration (15%).



Intercostal approach

As described by Castaing, the tenth intercostal left artery is used to access the celiac trunk and place the catheter in the hepatic artery.

Intraportal Chemotherapy

Its goal is merely preventive. This is because liver micrometastases have a portal supply, so this is a way of sterilizing the liver of microscopic and subclinical metastases not evident to the surgeon or the radiologist.

Technique

Multiple venous accesses can be used for this purpose.

Repermeabilization of the umbilical vein

The round ligament is sectioned and a small catheter is used to repermealize the umbilical vein until blood reflux is seen. A catheter is then placed to the left portal vein. Usually with this technique, liver perfusion is not homogeneous and the left liver is usually preferentially perfused.

Henle’s Gastrocolic trunk

Dissection of this trunk and isolation of the right gastroepiploic vein and right superior colic vein. Henle’s trunk and the right border of the superios mesenteric vein are dissected also. The catheter is placed in the right superior colic vein after ligation of the distal part of Henle’s trunk.

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