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28 - Vascular access: Venous and arterial ports
- from Section X - Specialized interventional techniques in cancer care
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- By Thierry de Baère, Institut de Cancérologie, Eric Desruennes, Institut de Cancérologie
- Edited by Jean-Francois H. Geschwind, Michael C. Soulen
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- Book:
- Interventional Oncology
- Published online:
- 05 September 2016
- Print publication:
- 22 September 2016, pp 283-293
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Summary
Hepatic intra-arterial port
Indications
Because hepatic artery infusion chemotherapy (HAIC) is a local treatment, it is most often used in case of liver cancer without extrahepatic disease, or in patients with predominant hepatic disease. Such treatment has been used mostly as salvage therapies after failure of intravenous (IV) standard-of-care therapies for metastases, and because response rate remains interesting even when using the same drug that was or became inefficient with IV administration. Due to the high response rate of HAIC, there are some recent reports and ongoing study using such therapies in first line. The goal of such therapies in first line, as a so-called induction treatment, is to obtain as early as possible in the disease the highest response possible in order to downstage a non-surgical candidate to a surgical candidate. Indeed, it has been demonstrated that the increase in response rate of colorectal liver-only metastases (CRLM) to treatment is linearly correlated with an increase in resection rate, and consequently with an increased chance of cure. Such induction chemotherapy targeting specifically the liver is obviously even more interesting in patients with liver-limited disease which demonstrated a steeper slope of the linear correlation between response and downstaging from non-operable to surgical candidates. HAIC used in an adjuvant setting after liver resection has been demonstrated to increase survival.
For primary tumors, and namely hepatocellular carcinoma, the use of HAIC is less common due to the high efficacy of transarterial chemoembolization (TACE). Indications are probably in patients not responding to TACE or not candidates for TACE due to portal vein thrombosis or advanced liver insufficiency.
HAIC is technically more challenging than systemic chemotherapy, because it requires the implantation of an indwelling catheter in the hepatic artery that is connected to a subcutaneous port for the administration of repeated courses of HAIC. The main drawbacks that hampered the use of HAIC were that, until recently, the implantation of such a device required a laparotomy, and additionally, frequent catheter dysfunction led to discontinued treatment. For example, in a randomized controlled study comparing HAIC with 5-fluorouracil (5-FU) to systemic 5-FU in 290 cases, 50 (37%) patients allocated to HAIC did not start their treatment, and another 39 (29%) had to stop before receiving six cycles of treatment because of catheter failure. Only 33% of patients received at least six courses of HAIC vs. 78% for the IV route.
26 - Interventional Radiology for the Treatment of Liver Metastases from Neuroendocrine Tumors
- from PART III - ORGAN-SPECIFIC CANCERS
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- By Thierry de Baère, Professor, Department of Interventional Radiology Institut Gustave Roussy Villejuif, France
- Edited by Jean-François H. Geschwind, The Johns Hopkins University School of Medicine, Michael C. Soulen, University of Pennsylvania School of Medicine
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- Book:
- Interventional Oncology
- Published online:
- 18 May 2010
- Print publication:
- 15 September 2008, pp 301-310
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Summary
Neuroendocrine gut and pancreatic tumors are rather rare malignant diseases, but development of new diagnostic tools (somatostatin receptor scintigraphy) and therapeutic options (somatostatin analogs, radioactive-labeled octreotide, transarterial therapy, radiofrequency ablation) make them of great interest to the medical community. The term neuroendocrine tumor encompasses a variety of relatively different diseases:
Carcinoid tumors, which are the most common, with an incidence of about 3 per 100,000 persons
Islet cell carcinomas, also called pancreatic endocrine tumors, with an incidence of about 0.3 per 100,000 persons
Carcinoid tumors arise most often from the small bowel, sometimes from pancreas, lung and bronchi, and more rarely from other organs such salivary glands or uterus but can arise from nearly everywhere due to the widespread diffusion of neuroendocrine cells, which give rise to the disease. Most often, they induce high levels of serotonin or chromogranin A. Islet cell carcinomas or pancreatic endocrine tumors arise from the pancreas and can produce insulin, glucagons, or vasoactive intestinal peptide (VIP). Production of various systemic hormones associated with specific immunohistochemical markers such as neurospecific enolase (NSE), synaptophysin, cytokeratin, chromogranin and CD 56 allows the diagnosis of these neuroendocrine tumors. For clinical considerations, the histopathologic grade of the tumor is an even more important factor than the histopathologic type. The grade obtained from the number of mitoses per microscope high-power field is linked to the aggressiveness of the disease and thus will influence therapeutic choices. Tumors with two or fewer mitoses are classified as low grade.
42 - Vascular Access: Venous and Arterial Ports
- from PART IV - SPECIALIZED INTERVENTIONAL TECHNIQUES IN CANCER CARE
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- By Thierry de Baère, Professor, Department of Interventional Radiology Institut Gustave Roussy Villejuif, France, Eric Desruennes, Department of Interventional Radiology Institut Gustave Roussy Villejuif, France
- Edited by Jean-François H. Geschwind, The Johns Hopkins University School of Medicine, Michael C. Soulen, University of Pennsylvania School of Medicine
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- Book:
- Interventional Oncology
- Published online:
- 18 May 2010
- Print publication:
- 15 September 2008, pp 533-543
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Summary
Externalized central venous catheters and totally implantable central venous access port systems are widely used to improve venous access reliability in patients receiving prolonged courses of cytotoxic therapy, anti-infectious chemotherapy or long-term parenteral nutrition. Totally implantable venous access port systems have several advantages over externalized catheters, including reliable venous access, low incidence of infection, absence of maintenance and fewer restrictions on activities such as bathing and sports. Ports are usually inserted by surgeons, anesthesiologists or radiologists in order to gain direct access to the central circulation as well as the hepatic artery to deliver cytotoxic drug directly to the liver. At the current time, minimally invasive techniques provided by interventional radiologists allow placement of catheter or port systems for intra-arterial hepatic chemotherapy (IAHC) without the need for open surgery or repeated catheterization.
Other directed intra-arterial therapies have been used, namely in the pelvis, but will not be described in this chapter, which will deal with central venous catheter and port placement for hepatic intra-arterial therapy.
VENOUS PORTS
Description
These devices consist of a port made of titanium or plastic with a self-sealing septum, accessible by percutaneous needle puncture, and a radiopaque catheter usually made in a well-tolerated long-term substance – silicone or polyurethane. Most ports are single lumen, but there are others with two lumens for separate administration of incompatible drugs. The connection between the catheter and the port can either be sealed during the manufacturing process or made at the time of placement.
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