[Anesthesiological and postinterventional management in percutaneous hepatic melphalan perfusion (chemosaturation)]

Percutaneous hepatic melphalan perfusion (PHMP) is a last-line treatment of inoperable primary or secondary liver tumors. Selective perfusion and saturation (chemosaturation) of the liver with the chemotherapeutic agent melphalan is performed via catheterization of the hepatic artery without affecting the rest of the body with its cytotoxic properties. Using an extracorporeal circulation and balloon occlusion of the inferior vena cava, the venous hepatic blood is filtered and returned using a bypass procedure. During the procedure, considerable circulatory depression and coagulopathy are frequent. The purpose of this article is to review the anesthesiological and postprocedural management of patients undergoing PHMP with consideration of the pitfalls and special circumstances.

Analysis of patient’s X-ray exposure in hepatic chemosaturation procedures: a single center experience

Background

Hepatic chemosaturation is a technique in which a high dose of the chemotherapeutic agent melphalan is administered directly into the liver while limiting systemic side effects. We reviewed our institutional experience regarding patient’s X-ray exposure caused by the procedure.

Methods

Fifty-five procedures, performed between 2016 and 2020 in 18 patients by three interventional radiologists (radiologist), were analyzed regarding the patient’s exposure to radiation. Dose-area-product (DAP) and fluoroscopy time (FT) were correlated with the experience of the radiologist and whether the preprocedural evaluation (CS-EVA) and the procedure were performed by the same radiologist. Additionally, the impact of previous liver surgery on DAP/FT was analyzed.

Results

Experienced radiologist require less DAP/FT (50 ± 18 Gy*cm²/13.2 ± 3.84 min vs. 69 ± 20 Gy*cm²/15.77 ± 7.82 min; p < 0.001). Chemosaturations performed by the same radiologist who performed CS-EVA required less DAP/FT (41 ± 12 Gy*cm²/11.46 ± 4.41 min vs. 62 ± 11 Gy*cm²/15.55 ± 7.91 min; p < 0.001). Chemosaturations in patients with prior liver surgery with involvement of the inferior cava vein required significantly higher DAP/FT (153 ± 27 Gy*cm²/25.43 ± 4.57 min vs. 56 ± 25 Gy*cm²/14.44 ± 7.55 min; p < 0.001).

Conclusion

There is a significant learning curve regarding the procedure of hepatic chemosaturation. Due to dose reduction the evaluation and chemosaturation therapy should be performed by the same radiologist. Procedures in patients with previous liver surgery require higher DAP/FT.

Thrombotischer Verschluss der extrakorporalen Zirkulation während hepatischer Chemosaturation trotz zielgerechter Antikoagulation

Die perkutane hepatische Chemosaturation ist eine Behandlungsoption bei nichtresektablen primären oder sekundären Lebertumoren. Dabei wird der Bereich der Lebervenenmündung der Vena cava inferior (VCI) mittels 2 Ballons von der Zirkulation isoliert, sodass die systemische Verteilung des über die Leberarterie applizierten Chemotherapeutikums Melphalan verhindert wird. Nach Passage der Leber und venöser Drainage aus der retrohepatischen VCI durchläuft das chemosaturierte Blut 2 parallel geschaltete extrakorporale Filter. Anschließend wird das gereinigte Blut jugulär rückgeführt. Das Verfahren geht oft mit einer ausgeprägten hämodynamischen Instabilität einher, deren Ursache nicht abschließend geklärt ist. Zusätzlich stellt das Gerinnungsmanagement eine Herausforderung dar. Die Autoren berichten von einem Fall, bei dem sich trotz ausreichender „activated clotting time“ (ACT) ein Thrombus im rückführenden Schenkel der extrakorporalen Zirkulation bildete. Gezielte Problemsuche und -lösung waren parallel zur hämodynamischen Stabilisierung und interdisziplinären Zusammenarbeit notwendig, um die Intervention erfolgreich durchzuführen und der Patientin eine sichere Therapie zukommen zu lassen.

Repeated percutaneous hepatic perfusion with melphalan can maintain long-term response in patients with liver cancers

Chemosaturation (CS; CHEMOSAT®, Delcath Systems Inc.) temporarily administers melphalan into the liver by percutaneous hepatic perfusion (PHP). CS-PHP can effectively control growth in liver tumors, but efficacy and tolerability of sequential treatments are unclear. We analyzed outcomes of sequential CS-PHP treatment. Patients with either unresectable intrahepatic metastases of ocular melanoma (OM, n = 9), cholangiocarcinoma (CCA, n = 3), or hepatocellular carcinoma (HCC, n = 1) were recruited retrospectively. Response was assessed by tomography imaging. Ten patients (mean age 60 years) with more than one CS-PHP treatment were included. CS-PHP was administered 2-6 times in the OM patients, 3 times in the CCA, and the HCC patient received 6 treatments. Overall response rate (ORR) to CS-PHP was 80%, and stable disease was achieved in one patient. Median hepatic progression-free survival (hPFS) was 336 days (range 0-354) for OM, 251 days for the CCA patient, and 256 days for the HCC patient. At the end of observation (153-701 days after first CS-PHP), 6/10 patients were still alive (5/9 with OM, 0 with CCA, and 1 with HCC). Death cases were not related to CS-PHP. Adverse events were mostly hematologic, grade I-IV, and self-resolving. The liver function was not deteriorated by CS-PHP. We conclude that repeated CS-PHP treatments were effective and well tolerated in the long term.

Radial Artery Access for Hepatic Chemosaturation: The First Description of Technical Feasibility

Chemosaturation with percutaneous hepatic perfusion (CS-PHP; Hepatic CHEMOSAT® Delivery System, Delcath Systems Inc, Wilmington, Delaware) is an interventional radiology procedure that delivers high doses of melphalan, a chemotherapeutic agent, directly to the liver in patients with unresectable primary and secondary liver tumours.

Traditionally, CS-PHP is delivered by arterial access via the femoral artery. However, there can be many risks and adverse effects associated with femoral artery punctures, such as retroperitoneal haemorrhage and haematoma formation. The monitoring and bed rest required following the removal of a femoral arterial catheter may also cause significant distress to patients as they remain immobile, potentially prolonging their stay in hospital. The radial artery is an alternative access point, with fewer reported adverse events and increased patient tolerance when compared with femoral access.

This case report details the first reported use of Hepatic CHEMOSAT® therapy being delivered via the radial artery. Two patients received hepatic chemosaturation with no reported complications. This report demonstrates that access via the radial artery is a feasible alternative for the delivery of chemotherapy, which may reduce morbidity and the risks usually associated with femoral access.

Over 12 Years Single Institutional Experience Performing Percutaneous Hepatic Perfusion for Unresectable Liver Metastases

Patients with unresectable hepatic metastases, from uveal or ocular melanoma, are challenging to treat with an overall poor prognosis. Although over the past decade significant advances in systemic therapies have been made, metastatic disease to the liver, especially from uveal melanoma, continues to be a poor prognosis. Percutaneous hepatic perfusion (PHP) is a safe, viable treatment option for these patients. PHP utilizes high dose chemotherapy delivered directly to the liver while minimizing systemic exposure and can be repeated up to 6 times. Isolation of the hepatic vasculature with a double-balloon catheter allows for high concentration cytotoxic therapy to be administered with minimal systemic adverse effects. A detailed description of the multidisciplinary treatment protocol used at an institution with over 12 years of experience is discussed and recommendations are given. A dedicated team of a surgical or medical oncology, interventional radiology, anesthesiology and a perfusionist allows PHP to be repeatedly performed as a safe treatment strategy for unresectable hepatic metastases.

Embolization of variant hepatic arteries in patients undergoing percutaneous hepatic perfusion for unresectable liver metastases from ocular melanoma

PURPOSE

In patients undergoing percutaneous liver perfusion with melphalan (M-PHP), the presence of variant hepatic arteries (HAs) may require catheter repositioning and thus prolong procedure time. Coil-embolization of variant HAs may enable M-PHP with a single catheter position as occlusion of variant HAs results in redistribution of flow through preexisting intrahepatic arterial collaterals. We aimed to evaluate whether redistribution of flow has any negative effect on therapeutic response in ocular melanoma patients undergoing M-PHP.

METHODS

We retrospectively analyzed pretreatment angiograms in all 32 patients that underwent M-PHP between January 2014 and March 2017 for unresectable liver metastases from ocular melanoma. Patients that underwent embolization of a variant left HA (LHA) or middle HA (MHA) during pretreatment angiography followed by at least one technically successful M-PHP were included for further analysis. Redistribution of arterial flow was evaluated on angiography and cone-beam computed tomography (CBCT) images. In each patient, tumor response in liver segments with redistributed blood flow was evaluated using RECIST 1.1 and mRECIST, and then compared with tumor response in segments without flow redistribution. Follow-up scans were reviewed to evaluate progression of liver metastases.

RESULTS

A total of 12 patients were included. Replaced LHA embolization resulted in redistribution of flow to segment(s) 2 (n=3), 2 and 3 (n=5), and 2, 3 and 4 (n=2). MHA embolization resulted in redistribution of flow to segment 4 (n=2). Successful redistribution was confirmed by angiography and/or CBCT in all patients. Tumor response was similar for redistributed and non-redistributed liver segments in 8 out of 9 patients (89%) according to RECIST 1.1, and in 7 out of 8 patients (88%) according to mRECIST. In three patients, tumor response was not evaluable according to RECIST 1.1 or mRECIST as metastases were too small to be categorized as target lesions (n=1), or target lesions were confined to non-redistributed segments (n=2). In one patient, tumor response was not evaluable according to mRECIST as target lesions in the redistributed segments were hypovascular. After a median follow-up time of 17.1 months (range, 9.1-38.5 months), hepatic progression was seen in 9 out of 12 patients with a median time to progression of 9.9 months (range, 2.5-17.7 months). Progression of liver metastases was never seen only in the redistributed liver segments.

CONCLUSION

Flow redistribution in liver segments by coil-embolization of variant HAs is a feasible technique that does not seem to compromise tumor response in patients undergoing M-PHP.

Endovascular Ion Exchange Chemofiltration Device Reduces Off-Target Doxorubicin Exposure in a Hepatic Intra-arterial Chemotherapy Model

Purpose

To determine if endovascular chemofiltration with an ionic device (ChemoFilter [CF]) can be used to reduce systemic exposure and off-target biodistribution of doxorubicin (DOX) during hepatic intra-arterial chemotherapy (IAC) in a preclinical model.

Materials and Methods

Hepatic IAC infusions were performed in six pigs with normal livers. Animals underwent two 10-minute intra-arterial infusions of DOX (200 mg) into the common hepatic artery. Both the treatment group and the control group received initial IAC at 0 minutes and a second dose at 200 minutes. Prior to the second dose, CF devices were deployed in and adjacent to the hepatic venous outflow tract of treatment animals. Systemic exposure to DOX was monitored via blood samples taken during IAC procedures. After euthanasia, organ tissue DOX concentrations were analyzed. Alterations in systemic DOX exposure and biodistribution were compared by using one-tailed t tests.

Results

CF devices were well tolerated, and no hemodynamic, thrombotic, or immunologic complications were observed. Animals treated with a CF device had a significant reduction in systemic exposure when compared with systemic exposure in the control group (P <.009). Treatment with a CF device caused a significant decrease in peak DOX concentration (31%, P <.01) and increased the time to maximum concentration (P <.03). Tissue analysis was used to confirm significant reduction in DOX accumulation in the heart and kidneys (P <.001 and P <.022, respectively). Mean tissue concentrations in the heart, kidneys, and liver of animals treated with CF compared with those in control animals were 14.2 μg/g ± 1.9 (standard deviation) versus 26.0 μg/g ± 1.8, 46.4 μg/g ± 4.6 versus 172.6 μg/g ± 40.2, and 217.0 μg/g ± 5.1 versus 236.8 μg/g ± 9.0, respectively. Fluorescence imaging was used to confirm in vivo DOX binding to CF devices.

Conclusion

Reduced systemic exposure and heart bioaccumulation of DOX during local-regional chemotherapy to the liver can be achieved through in situ adsorption by minimally invasive image-guided CF devices.© RSNA, 2019.

Hepatic artery infusion of melphalan in patients with liver metastases from ocular melanoma

BACKGROUND AND OBJECTIVES

Ocular melanoma has a predilection for liver metastases. Systemic treatment is ineffective and the optimal regional therapy approach is poorly defined. Isolated hepatic perfusion (IHP) with melphalan has emerged as a viable treatment option, however a subset of patients are not candidates for this treatment. We therefore sought to determine if melphalan could be safely administered via the hepatic artery for these patients.

METHODS

A retrospective review of patients treated with hepatic artery infusion (HAI) of melphalan was undertaken. All patients had contraindications to IHP and were without other therapy options. Melphalan infusion was repeated every four weeks with consideration for dose escalation in the absence of toxicity or significant disease progression.

RESULTS

Fourteen patients were treated with HAI of melphalan from 2010 to 2015. All patients had hepatic dysfunction or prohibitive tumor volume precluding IHP. There were no procedure-related complications. Three patients (21%) died within 30 days and the median survival was 2.9 months. Elevated baseline bilirubin > 2.5 mg/dL was associated with worse overall survival (0.93 vs 6.3 months, P < 0.05).

CONCLUSION

HAI of melphalan is safe and feasible for patients with metastatic ocular melanoma. Further study to determine the optimal utilization of this treatment approach is warranted.