The David H. Koch Center for Cancer Care at MSK houses a dedicated floor for interventional radiology procedures.
Treating liver cancer and liver metastases — cancer that has spread to the liver from elsewhere in the body — is challenging. Most patients are not candidates for surgery because there are many tumors or because the tumors are in difficult locations.
In some cases, however, tightly focused, minimally invasive therapies can treat liver tumors effectively. With this approach, called interventional radiology (IR), doctors use imaging guidance paired with tools such as needles and catheters to pinpoint the exact area for treatment.
At Memorial Sloan Kettering Cancer Center (MSK), interventional radiologists do nearly 24,000 procedures of all types each year, including more than 800 annually to treat liver tumors. Imaging techniques such as CT scans, ultrasound, PET, and MRI allow interventional radiologists to target tumors and destroy them without using a knife.
“For certain types of cancer, IR techniques are less invasive and can be a lot easier for patients to tolerate than surgery,” says MSK interventional radiologist Anne Covey, MD. “Patients tend to have fewer complications and a faster recovery. Often, our patients go home the same day or the day after a procedure.”
“The IR team treats both primary and metastatic liver cancers,” says MSK interventional radiologist Constantinos Sofocleous, MD, PhD. “The most common primary liver cancers are hepatocellular carcinoma, which arises in the liver, and cholangiocarcinoma, which starts in the bile duct. The vast majority of liver metastases we treat come from colon cancer.”
There are many benefits to IR compared with other treatments:
- Surgery may be unsafe due to cirrhosis [scarring], which is common in people with liver cancer.
- Systemic therapy like chemotherapy affects the entire body and causes many side effects.
- IR lets doctors limit the treatment to only the tumor and to avoid healthy tissues.
- IR treatments are minimally invasive and targeted, allowing for high success and very low complication rates.
Embolization Blocks the Tumor Blood Supply
The most commonly used IR approach at MSK for liver tumors is embolization. This involves injecting microscopic beads — with diameters roughly the width of a human hair — into the blood vessels that feed the liver tumors. Sometimes the goal is simply to choke off the blood supply to the tumor and kill it, a technique called bland embolization. Primary liver tumors and neuroendocrine tumors are especially dependent on an ample blood supply, so bland embolization can be particularly effective.
Interventional radiologist Anne Covey
The beads can also be filled with chemotherapy to shrink or kill the tumor, but Dr. Covey says MSK has not used the approach much for liver tumors. “This approach is used more for other types of cancer,” she explains.
After receiving embolization, patients are monitored closely with CT or MRI scans every three to six months for the next five years. If the cancer grows back, the procedure can be repeated safely in most patients.
Adding Radiation Improves Embolization for Liver Metastases
Unlike primary liver cancer, metastatic liver tumors often do not respond to embolization alone. For these cases, IR specialists may add a radioactive substance to the beads. This treatment is known as radioembolization or selective internal radiation therapy (SIRT).
Interventional radiologist Constantinos Sofocleous
“This form of radiation is delivered through the hepatic artery, the main blood vessel that gives nutrients to the tumor in the liver,” Dr. Sofocleous says. “We often use radioactive spheres containing the isotope Yttrium-90 to treat the liver tumors.”
With SIRT, the radioactive spheres can deliver a much higher dose of radiation than what is possible with external beam radiation. At the same time, it causes minimal if any injury to the healthy parts of the liver.
“This treatment can be used in combination with chemotherapy to provide longer control of liver disease,” Dr. Sofocleous adds. “It may also allow us to use less chemotherapy or may be used while patients are having a break from chemotherapy.”
This treatment may be used in patients with a rare cancer called pancreatic neuroendocrine tumor who have had an operation called a Whipple procedure. The beads may reduce the risk of infections.
Ablation Destroys Liver Tumors
The other main IR approach for liver tumors is ablation. This involves placing a specialized needle, or probe, into the tumor and destroying it. Because it can completely destroy the tumor, ablation has cure rates that are similar to surgery. However, it is limited to liver tumors that are small in both size and number.
Several ablation techniques are available:
- Freezing (cryoablation)
- Heat (thermal ablation)
- Radio waves (radiofrequency ablation)
- Microwaves (microwave ablation)
- Chemicals such as ethanol (percutaneous ethanol injection)
- Electrical currents (irreversible electroporation)
- Acoustic energy (histotripsy)
Thermal ablation is the preferred and more established method of ablation, however it cannot be used in all cases.
For liver tumors that are too near bile ducts or blood vessels, irreversible electroporation may be the best option. This technique, which punches holes in cancer cell membranes, is done with an instrument called a NanoKnife®.
Histotripsy Is a New Treatment for Liver Tumors
Histotripsy is a newer method for killing liver tumors. It uses acoustic energy to make tiny bubbles inside tumors. The bubbles grow fast and pop, breaking the tumors into tiny pieces that the body naturally clears away. This method may be used when thermal ablation is not an option — because the tumor is too close to structures that maybe damaged by the heat.
“Because histotripsy does not use heat or radiation, it is much less likely to harm healthy tissue around the tumor. Most people have little or no pain after treatment, and their recovery time is much shorter than recovery from surgery or ablation,” Dr. Sofocleous says. “MSK’s recent acquisition of a histotripsy device adds to the long list of tools we can use to provide the best cancer care to our patients.”
MSK Helps Patients With Liver Tumors Recover Quickly
Dr. Covey says IR is just one component of MSK’s collaborative process, which ensures every patient receives the best treatment for their specific case. “I can’t think of any person with liver cancer who is managed by only one MSK specialist,” she says. “There’s always an entire team evaluating their case and guiding them through treatment. It makes an enormous difference in their treatment and outcome.”
Another advantage is the state-of-the-art facilities that make these collaborations possible. Most IR procedures are done in MSK’s Center for Image Guided Intervention (CIGI) in Memorial Hospital or at the David H. Koch Center for Cancer Care at MSK, where there is a dedicated IR floor that offers full anesthesia support and an inpatient floor for IR patients who need to stay overnight.
“The IR and radiology teams at MSK have been frontrunners in the development of new treatments for liver cancer, including through leadership in a number of international clinical trials,” Dr. Sofocleous says. “These approaches offer highly effective treatments with minimal complications and downtime. Many of our patients are discharged the same day, and most of them can expect to be back to their normal lives soon after treatment.”
