動脈化學灌注治療 IntraAterial Infusion Chemotherapy

大綱 肝臟解剖 HCC與為何做IAIC的原因 IAIC的起源 IAIC&TAE的比較 適應症 禁忌症 材料 檢查流程 Case討論

肝臟 肝臟是人體的最大器官，重約1.5公斤 肝臟被鐮狀韌帶分成左右兩葉，右葉是左葉的六倍大 右葉可再分為右葉本部、尾葉、方葉 方葉的右方為膽囊，左方為圓韌帶 尾葉的右側為下腔靜脈，左方為靜脈韌帶

肝臟之分節 S2 S3 S4 S5 S6 S7 S8 S1 肝圓靭帶 門脈右支 IVC 門脈左支 右肝靜脈 中肝靜脈 左肝靜脈 臍靜脈部

肝癌的治療方式 肝癌的治療方式 手術療法 開刀&肝臟移植 局部注射療法 腫瘤內注射冰醋酸 調溫療法 冷凍 微波 阻斷血流療法 肝動脈栓塞 化學療法 經動脈灌注化學療法 其他 基因 偏方 混合

HCC one of the most common cancers HCC were classified into nodular type, massive type, and diffuse type surgical resection 、 liver transplantation low resection rate due to advanced tumors, poor liver reserve, and high recurrence rate following resection bother clinicians. Limited donors also decrease the number of liver transplants

Treatment transcatheter arterial embolization(TAE) with/or without chemotherapeutic agents Local injection with pure alcohol microwave coagulation therapy and radiofrequency tumor ablation

Why use chemotherapy not suitable for patients with bulky tumors、main vessel invasion or multiple tumors involving both lobes of the liver

Introduction iaic 1950, Klopp firstly reported the results of the intra-arterial infusion chemotherapy (IAIC) for HCC. we evaluated the therapeutic effects of IAIC using a combination of 5-FU, mitomycin-C, cisplatin, and leucovorin in patients with unresectable advanced HCC

IAIC TAE IAIC與TAE比較 血管攝影 治療肝癌使用化療藥 Portal vein 正常與否無關 治療腫瘤使用栓塞物質 相同 不同

What we choice IAIC Intravenous systemic chemotherapy Intra-arterial infusion chemotherapy compared with systemic chemotherapy, IAIC shows an increased concentration of chemotherapeutic agents locally, and less systemic side effects. tumor itself、severity of hepatic dysfunction

INDICATIONS Portal vein throbosis TACE 沒有療效的病人 Liver function

Contraindication serum bilirubin > 3 mg/dL, serum creatinine > 3 mg/dL white cell count (WBC) < 2500/cumm, platelet count < 60,000/cumm

材料

材料

材料

材料

檢查流程 請病人上檢查台並放置手板 使用超音波掃描所需要的血管 消毒並麻醉 用穿刺針並配合超音波掃描血管 將打化療藥的管子放置目的地 照相並留存

上檢查台 請病人上檢查台並放置手板 使用超音波掃描所需要的血管 消毒並麻醉 用穿刺針並配合超音波掃描血管 將打化療藥的管子放置目的地 照相並留存

Left subclavicular artery 請病人上檢查台並放置手板 使用超音波掃描所需要的血管 消毒並麻醉 用穿刺針並配合超音波掃描血管 將打化療藥的管子放置目的地 照相並留存 Left subclavical artery

麻醉 消毒並麻醉 打LOCO IM 請病人上檢查台並放置手板 使用超音波掃描所需要的血管 消毒並麻醉 用穿刺針並配合超音波掃描血管 將打化療藥的管子放置目的地 照相並留存 消毒並麻醉 打LOCO IM

穿刺 請病人上檢查台並放置手板 使用超音波掃描所需要的血管 消毒並麻醉 用穿刺針並配合超音波掃描血管 將打化療藥的管子放置目的地 照相並留存

Seldinger technique 薛林格爾穿刺法 30-45度角 Seldinger technique 薛林格爾穿刺法

注射 會在找到celiac trunk時打一組顯影劑

找尋血管的路徑 導管經由Left subclavicular artery→ Thoracic aorta→celiac trunk→common hepatic artery →proper hepatic artery

放置管子 管子 請病人上檢查台並放置手板 使用超音波掃描所需要的血管 消毒並麻醉 用穿刺針並配合超音波掃描血管 將打化療藥的管子放置目的地 照相並留存 管子

對照 請病人上檢查台並放置手板 使用超音波掃描所需要的血管 消毒並麻醉 用穿刺針並配合超音波掃描血管 將打化療藥的管子放置目的地 照相並留存

術後注意事項 Continuous infusion of 5000 units (5 cc) heparin solution daily was filled in the catheter for prevention of occlusion by thrombosis.

Course of chemotherapy Each course of treatment was 5 days. Cisplatin (10 mg/M2) and mitomycin-C (2 mg/M2) were dissolved in 50 mL isotonic sodium chloride solution which was infused for 20 to 30 minutes each time and continued for 5 days. 100 mg/M2 of 5-Fluorouracil (5-FU), dissolved in 250 mL of isotonic sodium chloride solution, was administered for 24 hours by infusion pump for 5 days Leucovorin (15 mg/M2) was given daily to improve the efficacy of 5-FU during IAIC.

Complications Gastrointestinal side effects, such as anorexia,nausea or vomiting Hematological toxicities such as leukopenia and thrombocytopenia, as well as liver and renal function impairment occurred occasionally and recovered spontaneously without specific treatment about 1 to 2 weeks after treatment in most of the patients

術後注意事項 每天下來follow 管子有嚴重滲漏時，不可自行拔管 要通知放射師 管子有移位時，會利用guidewire把管子放到正確位置

Ex 1

Case討論

Case 1 Tumor

Case 1 tumor

Case 1 tumor

Case 1

Case 1

Case 1

Case 1

Case 2

Case 2

Case 2 Tumor tumor

Case 2

Case 2

Remove canal 五天後拔管 會再補充lipidol+Adriamycin 化學藥劑劑量會依照腫瘤大小所評估

結論 HCC是一個普遍且死亡率很高的癌症，雖然說治療方式有很多種，但是portal vein 阻塞、肝功能不好甚至是年齡都使的一些手術或局部手術(ex TAE)而無法執行 IAIC雖然只有其他治療方式療效的3成，但是卻可以延長病患壽命，甚至能更進一步的做治療，而並不會增加癌症的合併症，所以IAIC開啟了另一種治療的機會

METHODS Patients with advanced HCC who were not eligible for surgical resection or other local treatment were evaluated using ultrasound (US), computed tomogram (CT) scanning

Result The maximum tumor reduction rate at the third month and/or the sixth month after chemotherapy was used to evaluate the efficacy Tumor volume reduction rate (%)= (Product before chemotherapy - Product after chemotherapy)* 100% / Product before chemotherapy

complete response (CR) partial response (PR) minor response (MR) no change (NC) progressive disease (PD)

What is IAIC advantage Eleven of the 53 patients underwent additional local therapies (10 patients: TAE, 1 patient: percutaneous acetic acid injection). These 11 patients got more promising responses following additional local therapies. Tumor shrinkage was found in responders, but persistent viable tumor could not be eradicated by chemotherapy only.

Case 4 8/10 IAIC

Case 4 11/27 IAIC