Tumor Embolization

Every tumor needs an artery. Embolization blocks it from the inside, through a catheter the width of a strand of spaghetti.

A liver tumor the surgeon cannot remove. A kidney tumor that will bleed heavily on the operating table. A metastasis in the spine that has to come out, and a cancer that is bleeding and will not stop. Each of these has an artery feeding it, and embolization is the treatment that reaches that artery from inside the body and blocks it, with particles, with chemotherapy-loaded beads, or with radioactive microspheres, delivered through a catheter threaded from the wrist or the groin under X-ray guidance. For liver cancer the evidence is old and firm. In the Barcelona trial published in the Lancet in 2002, chemoembolization raised two-year survival from 27 percent to 63 percent, and a Hong Kong trial the same year found the same direction. For single liver tumors up to 8 centimeters, radioembolization with yttrium-90 produced a response in 88 percent of patients in the LEGACY study, and a third of them went on to a transplant or an operation. This page explains the four kinds of embolization, which tumors they suit, what the week after feels like, and how to plan a stay of a few days in Istanbul.

Starving a tumor of blood

Tumor Embolization is a treatment in which the blood supply to a tumor is blocked from within the artery that feeds it. No cut anywhere. A catheter enters an artery at the wrist or the groin, is steered under X-ray to the branch that supplies the tumor, and delivers something that stops the flow. Tumor tissue dies within days for want of oxygen, while the organ around it, fed by other branches, carries on.

Three reasons make it work in the liver above all. A healthy liver takes three quarters of its blood from the portal vein and only a quarter from the hepatic artery, while a liver tumor draws nearly all of its supply from the artery. Blocking the artery therefore hits the tumor and spares the liver. And the same catheter that blocks the artery can leave chemotherapy or radiation behind, concentrated in the tumor at doses the rest of the body never sees.

The tumor lives on the artery. The liver lives on the vein. That asymmetry underlies the whole of liver embolization. It explains why the treatment has held its place for forty years.

Four kinds of embolization

Liver cancer and chemoembolization

Hepatocellular carcinoma, the cancer that arises in a liver already damaged by hepatitis or cirrhosis, is the disease that made embolization standard. Two randomized trials, both published in 2002, set the figures.

Two facts in those trials still shape practice. Both selected patients whose liver was working well, and in the Hong Kong trial death from liver failure was commoner in the treated group, which is why the liver tests decide eligibility as much as the scan does. And both repeated the treatment, since a single session rarely finishes the job.

Chemoembolization today uses drug-eluting beads in most centers, which release the drug over days and put less of it into the bloodstream. Guidelines make it the standard for intermediate-stage liver cancer, several tumors confined to the liver in a patient who is well. It also holds a tumor still while a patient waits on the transplant list.

Radioembolization with yttrium-90

Radioembolization delivers radiation from inside the tumor. Millions of microspheres, each thinner than a hair and carrying yttrium-90, lodge in the smallest arteries of the tumor and irradiate it from a range of a few millimeters for about two weeks. The dose reaching the tumor can be many times what an external beam could safely give.

A radioembolization has two visits a week or two apart. On the first, a mapping angiogram studies the arteries, blocks with coils any branch that leads to the stomach or bowel, and injects a test dose of harmless particles that a scan then traces to measure how much would leak to the lungs. On the second comes the treatment itself. The microsphere dose is calculated from that scan.

Before an operation, and for bleeding tumors

Who is a candidate

For liver embolization the answer has three parts, and the scan answers only one of them.

Metastases in the liver from bowel, breast, neuroendocrine and other cancers are treated with embolization when drugs have stopped working or as an addition to them, and the choice between chemoembolization, radioembolization and ablation is made by the tumor board from the number, size and position of the deposits.

Preparation

Preparation fills a week with small tasks. The blood tests carry the most weight.

The procedure

Five steps, one to two hours in the room.

1. Access. A local anesthetic at the wrist or the groin, and a sheath the width of a drinking straw placed in the artery.
2. Mapping. A catheter is steered to the liver, the kidney or the tumor in question, and contrast is injected to show every artery feeding it and every branch that must be protected.
3. Selection. A microcatheter, thinner than a strand of spaghetti, is advanced into the branch or branches that feed the tumor alone, as far from healthy tissue as the anatomy allows.
4. Delivery. Particles, drug-loaded beads or microspheres are injected slowly until the flow to the tumor stops or the planned dose has gone in. For radioembolization the injection takes minutes, and the room is cleared of everyone not needed.
5. Closure. The catheter and sheath come out, and the artery is sealed with a closure device or with pressure. At the wrist a small band does it, and at the groin you lie flat for two to four hours while the puncture seals.

One to two nights in hospital for liver embolization. Same-day discharge for many preoperative and radioembolization procedures.

The first week

Patients feel the treatment more than they felt the procedure. What they feel has a name.

Radioembolization gives a quieter first week, and then the second and third weeks bring tiredness that lasts a month, with loss of appetite for a few weeks. Preoperative embolization has no week of its own. Its symptoms belong to the operation that follows.

Risks

Six things can go wrong, and the first is the one the blood tests exist to prevent.

Death within 30 days of a liver embolization done in a patient who met the criteria is rare, in the low single figures per hundred. Nearly all of it comes from liver failure in patients whose function was borderline.

Results, and repeating the treatment

The scan tells the story.

Four to six weeks after chemoembolization it shows how much of the tumor has died. Dead tumor takes up no contrast. Living tumor at the edge is treated again, and chemoembolization is repeated as needed, every two to three months, until the tumor no longer responds or the liver can no longer tolerate it. Two to four sessions in a year is the usual count.

With radioembolization the scan waits three months, since the response develops slowly, and a treated segment of liver shrinks over the following year while the rest grows to compensate. A second radioembolization to the other lobe is possible when the first was tolerated.

A tumor that shrinks enough may become removable, or small enough for ablation, or stable enough to keep a patient on the transplant list. Liver surgery, ablation, radiotherapy on an Elekta Versa HD linear accelerator and medical oncology are all delivered at Biruni Hospital on the same site, so the next step after a good response is a change of room rather than a change of hospital.

Days in Istanbul

A chemoembolization session takes four to five days in Istanbul. Consultation and blood tests on the first day, the procedure and one to two nights in hospital on the second and third, rest on the fourth, and the flight on the fifth. Radioembolization takes two visits of three days each, one to two weeks apart, or a single stay of ten to twelve days that covers the mapping and the treatment. Preoperative embolization sits inside the surgical stay and adds one day before the operation.

Flying home after chemoembolization waits until the fever and pain of the first days have settled, which for the majority is three to four days after the procedure.

Radioembolization sets no such limit. The radiation in the liver is too weak and too short-ranged to affect anyone nearby, so no precautions apply on the flight, and a patient who wants the second lobe treated later or a chemoembolization repeated can have it on a later visit or from an interventional radiologist at home on the protocol we write.

What a quote contains

No figure appears on this page, because the four kinds of embolization differ from each other more than most treatments differ from their alternatives.

Packages published by Turkish hospitals and medical travel agencies for liver embolization cover the consultation, one session, one to two nights in hospital, an interpreter and transfers, and leave out repeat sessions, flights, insurance, accommodation and the treatment of any complication.

A quote you can compare names the kind of embolization, the number of sessions it assumes, whether the mapping visit is inside the figure for radioembolization, and the number of hospital nights. It follows the free review.

Coordinator, language, companion

Language

Biruni Hospital gives every international patient one coordinator from the first message, reachable on the same WhatsApp number afterwards, and the international patients team works in English, Arabic, French, Russian, Serbian, Romanian and Spanish with interpreters arranged for other languages. For this treatment the interpreter matters at two points, the consultation where the kind of embolization is chosen and the reasons explained, and the discharge, when the symptoms of the week ahead are gone through so that a fever on day two does not send the family to an emergency department.

Companion and paperwork

Bring a companion for the days after the procedure. The office books accommodation close to the hospital, arranges airport transfers and the car to the hospital, and issues an appointment confirmation and invitation letter for a visa ten days or so before travel. Patient rooms have a companion bed. The hospital kitchen prepares halal, vegetarian and diabetic meals, and follows the low-salt diet a liver patient is prescribed. A prayer room is on site, and a female physician is arranged where the rota allows for anyone who asks in the first message.

Follow-up at home

Once you get back home, the procedure report with the arteries treated and the dose given, the images, the blood tests at discharge and the follow-up calendar go to your own oncologist or liver specialist.

• Liver blood tests and alpha-fetoprotein at four weeks, then every three months
• Contrast CT or MRI at four to six weeks after chemoembolization, at three months after radioembolization, then every three months in the first year
• Blood thinners restarted on the date written on the discharge note
• Any scan sent to the coordinator for comparison with the treatment images at no charge, and a recommendation on whether another session is due

Fever above 38 degrees beyond the first week, pain that gets worse instead of better, yellowing of the skin or eyes, confusion, swelling of the abdomen, or black stools go to a local emergency department the same day, with the discharge note in hand.

Tumor Embolization FAQ