Here Dr Graham Plant, Consultant Interventional Radiologist at Hampshire Hospitals NHS Foundation Trust, explains treatment options provided by interventional radiologists*:
In addition to high quality classical surgical techniques, including open and laparoscopic approaches, we employ a variety of other methods to either help with these approaches, or to treat tumours directly. Many of these are performed using some kind of imaging (X-Ray) guidance to allow us to precisely target the effects. These procedures are performed by Interventional Radiologists, in the X-ray department, in either their dedicated Interventional theatre suite or in the CT scanner dedicated to these cases.
By using these additional options we are able to widen the group of patients that we are able to help – allowing us to include those who are too unwell for a conventional operation, where the tumours are inaccessible, or where the operation would carry unacceptable risks.
These approaches include:
- Thermal ablation (MTA)
- Precision Trans-Arterial Chemo-Embolization (TACE)
- Portal Vein Embolization (PVE)
- Biliary drainage and stenting
- Hepatic artery embolization
- Biopsy and drainage
Thermal ablation (MTA)
Thermal ablation is the treatment of tumours by heating them, in place, via a needle directly placed into the tumour, using a scanner for guidance of the needle. When we started treating patients with this technique, over twelve years ago, we used Radio-Frequency for the ablation (RFA), but we have switched over to using a needle carrying microwaves in the last few years. We feel that this technique, Microwave thermal Ablation (MTA), has advantages over RFA for the patients we treat, and we use it for both primary and secondary tumours of liver and lung. This operation is carried out under a general anaesthetic.
Precision Trans-Arterial Chemo-Embolization (TACE)
There are some tumours that are unsuitable for surgery, for a variety of reasons, and some of these may be treated using chemotherapy delivered directly into the tumour and surrounding liver, via the blood stream. This technique, TACE, involves a catheter being guided along the arteries, from the top of the leg, to the appropriate positions in the liver under X-ray guidance, and then tiny plastic beads, which contain a chemotherapeutic agent, usually Doxorubicin or Irinotecan, are injected. These beads fill the arteries to the tumour, blocking off the blood supply to the tumour, and then release the chemotherapy, in high concentration, just where it’s needed, minimizing the dose to the rest of the body. This procedure is often undertaken in a number of stages, often weeks or months apart, to give a sustained dose to the tumour(s).
Portal Vein Embolization (PVE)
In some patients the size or positions of the tumours means that to remove them successfully a large amount of liver must be taken out with the tumour. In these cases we are concerned that the remaining amount of liver will not be able to cope with all the work being imposed on it, particularly immediately after a major operation. In these cases we employ PVE to block off some of the blood supply to the part of the liver that we plan to remove approximately a month prior to the operation. The rest of the liver will take up the load after the PVE, it will increase in size and, more importantly, will become more efficient at all of its processes so that when the surgery is undertaken, the patient will have a better, safer and shorter post-operative period.
Biliary drainage and stenting
The biliary tree provides the route out of the liver for bile and digestive enzymes. These allow us to process and digest food in the gut. If the biliary tree is blocked, by gallstones, infection or tumours, patients become jaundiced and unwell, and are unable to digest food properly.
In these cases it may be possible to bypass the blockage by the insertion of plastic tubes, or expanding metal springs (stents) to allow recovery. These may be inserted from above, through the liver, by Interventional Radiologists, or from below, via the gut, a technique known as Endoscopic Retrograde Cholangio-Pancreatography (ERCP) which in this hospital is performed by our gastroenterologist colleagues.
Hepatic artery embolization
If patients bleed into the liver, (or indeed elsewhere in the body), due to a tumour, trauma or other causes, we may employ embolization. This technique, carried out under X-Ray guidance in our radiological operating theatre, involves a catheter being manipulated along the arteries from the top of the leg, to the bleeding points and the artery at the point of bleeding being blocked by a variety of plugs. This very effective treatment may be performed under sedation and local anaesthetic only, as it causes very little discomfort. It may however be the fastest way to stop some kinds of bleeding, particularly in inaccessible parts of the body, or in very sick patients, who may be unable to withstand a general anaesthetic and open surgical procedure.
Biopsy & drainage
From time to time it may be necessary to obtain tissue from a tumour, to allow us to plan the appropriate treatment. There are a variety of ways to do this, and one is an image guided biopsy, where a fine needle is placed in a tumour, using X-ray or ultrasound guidance, under local anaesthetic. We are very selective on whom we do this, because we know there is a risk of spreading the tumour by seeding along the track of the biopsy. However, in appropriate, selected, cases we undertake these simple procedures.
In some patients we discover a collection of fluid, possibly blood, infection or bile in the abdomen. These are best treated in the majority of cases by placing a thin flexible drainage tube into the fluid and allowing it to drain out of the body into a closed bag. We perform these procedures in the same way, using a scanner to guide us, and under sedation and local anaesthetic. The tube can be left for a few days until the fluid stops being produced and then it is removed.
The use of these interventional and operative procedures also allows much greater flexibility in the way we manage patients, and allows us to react to some of the more complex and unpredictable ways that disease and especially cancer affects us.
In addition to all the procedures undertaken in the X-ray department by Interventional Radiologists, most patients will also be helped by the expert care of our diagnostic Radiological colleagues. Indeed the vast majority of patients will have far greater contact with, and experience of, the diagnostic side of our work, as they will have a variety of body scans and x-rays to allow us all to identify disease, pinpoint its location, plan the best treatment for it and then follow up the results.
Graham Plant
August 2011
*Please note that this applies to Basingstoke practice. If you have questions or concerns about your specific diagnosis and treatment, you should talk to your specialist nurse.
