What is Interventional Oncology?
Interventional Oncology is a subspecialty of interventional radiology and is considered one of the four main specialties involved in comprehensive cancer treatment and treatment of cancer related disorders. The others include medical oncology, surgical oncology, and radiation oncology.
Interventional oncology procedures provide minimally invasive, targeted treatment of cancer. Most procedures are provided on an outpatient basis or may require a single overnight hospital stay.
The major types of cancer that are treated include: Liver cancer (hepatocellular carcinoma), Metastatic Liver cancer (colorectal cancer and others), Kidney cancer (renal cell carcinoma), Lung cancer (bronchogenic carcinoma), and Bone cancer (bone metastases from other cancers as well as multiple myeloma).
These cancers can be treated with either arterially directed therapies (chemoembolization) or heat based therapies (microwave ablation or cryoablation).
In general, these techniques are reserved for patients whose cancer cannot be surgically removed or effectively treated with systemic chemotherapy. However, there are some instances in which the best first line treatment for a given cancer is interventional oncology based. These procedures are also frequently used in combination with other therapies provided by other members of the cancer team.
What should I expect during my visit?
Once you schedule your appointment, you will undergo a consultation with one of our experienced interventional radiologists. Following a thorough history and physical, additional testing such as blood work and imaging may be required.
Based on your type and stage of cancer, minimally invasive treatment may be offered. Your interventional radiologist will discuss the treatment options, including the risks, benefits and alternative treatment strategies before proceeding.
Liver Cancer Treatment & Chemoembolization
Surgical removal of liver tumor or liver transplantation offers the best chance for a cure. Unfortunately, the majority of liver tumors are inoperable because the tumor may be too large, or has grown into major blood vessels or other vital structures. Sometimes, many small tumors are spread throughout the liver, making surgery too risky or impractical. Surgical removal is not possible for more than two-thirds of primary liver cancer patients and 90 percent of patients with secondary liver cancer. Historically, chemotherapy drugs have been ineffective at curing liver cancer.
There are two major types of liver cancer:
Primary Liver cancer
About 18,500 cases of primary liver cancer are diagnosed each year. The most common form of primary liver cancer is hepatocellular carcinoma (HCC). Primary liver cancer is twice as common in men as in women.
HCC most frequently occurs in those who have a form of liver disease called cirrhosis. Cirrhosis occurs when the liver becomes diseased and develops scarring, usually over a period of years. The liver attempts to repair, or regenerate itself. This process can lead to the formation of tumors. In the United States, the most common causes of cirrhosis are alcohol abuse and chronic infection with hepatitis B or C.
Metastatic Liver cancer
Cancer may spread from any part of the body to the liver. There the cancer cells may grow for months or years before they are detected. One of the most common sources of metastatic liver cancer is from tumors of the colon and rectum. About one in 10 of these patients will have a chance for a cure by having the liver tumors removed surgically.
Patients with other types of cancer are also at risk for liver cancer. The liver serves as a way-station for cancer cells that circulate through the bloodstream. These cells may grow and form tumors in the liver. It is estimated that as many as 70 percent of all people with uncontrolled cancer will eventually develop secondary liver tumors, or metastases.
Diagnosing Liver Cancer
There are a number of tests that can help in the diagnosis of cancer, including blood tests, physical examination and a variety of imaging techniques including X-rays (e.g., chest X-rays and mammograms); computed tomography (CT); magnetic resonance (MR) and ultrasound. Usually, however, the final diagnosis cannot be made until a biopsy is performed. In a biopsy, a sample of tissue from the tumor or other abnormality is obtained and examined by a pathologist.
Needle biopsy, also called image-guided biopsy, is usually performed using a live-moving X-ray technique (fluoroscopy) computed tomography (CT) or ultrasound to guide the procedure. In many cases, needle biopsies are performed with the aid of equipment that creates a computer-generated image and allows radiologists to see an area inside the body from various angles. This "stereotactic" equipment helps them pinpoint the exact location of the abnormal tissue.
Needle biopsy is typically an outpatient procedure with very infrequent complications; less than 1 percent of patients develop bleeding or infection. In about 90 percent of patients, needle biopsy provides enough tissue for the pathologist to determine the cause of the abnormality.
Advantages of needle biopsy include:
- With image guidance, the abnormality can be biopsied while important nearby structures such as blood vessels and vital organs can be seen and avoided.
- The patient is spared the pain, scarring and complications associated with open surgery.
- Recovery times are usually shorter and patients can more quickly resume normal activities.
Chemoembolization, Ablation, and other Liver Cancer Treatments
As vascular experts, interventional radiologists are uniquely skilled in using the vascular system to deliver targeted treatments via catheter throughout the body. In treating cancer patients, interventional radiologists can attack the cancer tumor from inside the body without medicating or affecting other parts of the body.
Tumors need a blood supply, which they actively generate, to feed themselves and grow. Interventional radiologists can attack the cancer tumor from inside the body without medicating or affecting other parts of the body by using embolization and heat based therapies.
Embolization is a well-established interventional radiology technique that is used to treat trauma victims with massive bleeding, to control hemorrhage after childbirth, to decrease blood loss prior to surgery and to treat tumors. In treating cancer patients, interventional radiologists use embolization to cut off the blood supply to the tumor (embolization or chemoembolization), deliver radiation to a tumor (radioembolization), or combine this technique with chemotherapy to deliver the cancer drug directly to the tumor (chemoembolization).
Additionally, interventional radiologists can use imaging to guide them directly to the tumor through the skin to administer radiofrequency heat to "cook" and kill the cancer cells (radiofrequency ablation), microwave ablation, or cyroablation to freeze the tumor.
Chemoembolization is a minimally invasive treatment for liver cancer that can be used when there is too much tumor to treat surgically or through heat based methods such as RFA, microwave ablation or cryoablation. Sometimes, this may be used in combination with RFA, microwave ablation or other treatments.
Chemoembolization delivers a high dose of cancer-killing drug (chemotherapy) directly to the organ while depriving the tumor of its blood supply by blocking, or embolizing, the arteries feeding the tumor. The interventional radiologist threads a catheter up the femoral artery in the groin into the blood vessels supplying the liver tumor. By blocking the blood flow to the tumor, a higher dose of chemotherapy drug can be used. This allows less of the drug to circulate to the healthy cells in the body. An overnight hospital stay is required and most patients can go home the following morning. Patients typically have lower than normal energy levels for about a week or two afterwards.
Chemoembolization is a palliative, not a curative, treatment. It can be extremely effective in treating primary liver cancers, especially when combined with other therapies. Chemoembolization has also shown promising results with some types of metastatic tumors.
A catheter is positioned in the hepatic artery and X-ray dye injected showing the large liver tumor at the top right of the image. The Interventional Radiologist will block the blood supply and deliver high dose chemotherapy at the same time to kill the tumor.
Radiofrequency and Microwave Ablation
For inoperable liver tumors, radiofrequency ablation (RFA) or microwave ablation offers a nonsurgical targeted treatment that kills the tumor cells with heat, while sparing the majority of healthy liver tissue. This treatment is usually easier on the patient than systemic therapy.
In this procedure, the interventional radiologist guides a small needle through the skin into the tumor. From the tip of the needle, energy is transmitted to the tip of the needle, where it heats the tissues. This eventually kills the tumor tissue. This treatment is FDA approved for killing certain solid organ tumors and can be curative.
BEFORE – Bright spot on right side of image is the viable “alive” liver tumor
AFTER – Bright spot is now a dark hole indicating necrosis or “dead” tumor
For more information about Microwave Ablation, please click here +
Y90 Radioembolization (SIRT)
Yttrium-90 Microsphere Radioembolization
Radioembolization also known as selective internal radiation therapy (SIRT), is a form of internal radiation therapy used to selected patients who are not candidates for surgery due to the location of their tumors or their performance (health) status.
Radioembolization is currently used by the interventional radiologist to treat primary liver cancer (HCC) and metastatic cancer (liver metastases). The most common type of cancer being treated for this is colorectal cancer, however it may also be used for breast, pancreatic, neuroendocrine tumors, and others.
The treatment involves injecting tiny microspheres with low levels of radioactive material into the arteries that supply the tumor. The radioactivity destroys the liver tumor without significantly affecting or radiating other parts of the body, thus minimizing exposure to healthy tissue. In the procedure, the radiologist inserts a catheter which deposits radioactive particles to the area of the tumor.
Microspheres target liver tumors by taking advantage of the liver's hypervascularity. For example, metastatic liver tumors greater than 3 mm receive in excess of 80% of their blood supply from the hepatic artery whereas normal liver tissue is predominantly fed by the portal vein.
The microspheres are delivered via fluoroscopy (live x-ray). Millions of 30-micron beads are infused through a catheter into the hepatic artery, and become embedded in the liver. Over a period of two weeks, the therapeutic dose is delivered. The beads contain yttrium-90 (Y90). Y90 is a beta-emitting radionuclide that acts locally at the tumor site. This is the beta particles travel at most 11 mm in the liver due to their relatively low energy. This allows the beads to embed into and irradiate the tumor while healthy liver tissue is spared.Additionally, given the low distance it travels, there are minimal, if any, necessary radiation safety precautions following treatment.
Overall the treatment is very well tolerated with minimal side effects. The most common side effect is fatigue, which lasts about 2 weeks. Schedule a consultation with one of our interventional radiologists to discuss in further detail.
Additional information can be found at the following links:
Frequently Asked Questions
What are SIR-Spheres microspheres?
SIR-Spheres microspheres are microscopic resin beads that contain the radioactive isotope Yttrium-90 (Y-90) and emit radiation to kill cancer cells. Due to their small size (1/3 the width of a human hair) and similar density to blood cells, the microspheres travel easily with the bloodstream directly to the liver tumors. The microspheres become lodged inside the tumor and kill the cancer cells through radiation. Selective Internal Radiation Therapy (SIRT) with SIR-Spheres microspheres is considered a well-tolerated and effective method of using radiation to treat colorectal cancer that has spread to the liver and is often used in conjunction with chemotherapy. SIR-Spheres microspheres are manufactured by Sirtex Medical Limited which is headquartered in Australia and has U.S. operations in Woburn, Massachusetts.
What do SIR-Spheres microspheres treat?
SIR-Spheres microspheres are approved to treat colon and rectal cancer which has spread to the liver. In the United States, colorectal cancer is the second leading cause of death by cancer. The liver is the most common site for the spread of this cancer.
Can you describe the SIR-Spheres microspheres procedure?
The SIR-Spheres microspheres treatment is performed as an outpatient procedure by specially trained physicians called interventional radiologists. Using the liver's unique blood supply, millions of tiny resin microspheres loaded with Yttrium-90 (Y-90) are released into the liver blood circulation. The radioactive microspheres lodge in the blood supply of the tumor, where they emit radiation for about two weeks.
The treatment normally takes about 60 to 90 minutes, with most patients returning home four to six hours later. Patients are carefully monitored throughout and after the procedure. The most commonly reported side effects are flu-like symptoms over one to three weeks. The procedure can be performed in combination with chemotherapy or by itself.
How effective is the treatment?
Clinical studies have shown that SIRT with SIR-Spheres microspheres increases the length of time that the cancer is stable and not growing without adversely affecting the patient's quality of life.1,2,3 In clinical studies, the SIRT procedure has been combined with chemotherapy, given as a single procedure during a chemotherapy holiday or after chemotherapy options have failed.
Who is eligible for treatment with SIR-Spheres microspheres?
SIR-Spheres microspheres are the only fully FDA PMA-approved Y-90 microspheres for colorectal cancer that has spread to the liver.4 The treatment offers hope for patients who have one or more colorectal liver tumors which cannot be treated by surgical resection or ablation.
Where is the procedure performed?
The procedure is performed at a hospital or clinic on an outpatient basis by highly trained physicians called interventional radiologists.
How are SIR-Spheres microspheres delivered?
During the procedure, the interventional radiologist threads a tiny catheter through the large artery in the leg. Then the catheter is advanced into the hepatic artery, which supplies the liver tumors with blood. Once the catheter is in position, millions of microspheres are delivered directly to the tumor site. The SIR-Spheres microspheres become lodged in the tumor bed and emit radiation to the tumors, while the surrounding healthy liver tissue remains unaffected.
How are SIR-Spheres microspheres different from other treatments?
Radiation is an effective therapy which is often used to treat cancer. However, normal liver cells are very sensitive to radiation. The targeted nature of SIR-Spheres microspheres therapy enables doctors to deliver up to 40 times more radiation to the liver tumors than would be possible using normal external beam radiotherapy, while sparing the surrounding healthy liver tissue from damage.
How common is this procedure?
SIR-Spheres microspheres are currently being offered at more than 800 sites around the world, including more than 300 centers in the U.S. Over 50,000 doses of SIR-Spheres microspheres have been supplied worldwide.
Other than treating the cancer, what are the benefits to the patients?
Besides offering patients an effective treatment option to control the spread of the cancer in their liver, therapy with SIR-Spheres microspheres also help patients maintain a good quality of life. The procedure is performed as an outpatient service which minimizes the time spent at the hospital and results in relatively minimal side effects.
What are the likely side effects?
Almost all treatments and drugs produce unwanted side effects. Most side effects following a SIRT procedure are minor, but a small number can be serious. Many patients experience abdominal pain or tightness in their abdomen, nausea and loss of appetite which normally subsides within a week. Patients may also develop a mild fever that may last for up to a week and fatigue which may last for several weeks.
What are the potential complications?
In rare instances, a small number of microspheres may inadvertently reach other organs in the body, such as the gallbladder, stomach, intestine, or pancreas. If microspheres reach these organs, they can cause inflammation or ulceration. These complications are rare, but if they do occur they will require additional medical treatment.
Do patients have to take special precautions?
There are some simple precautions that patients need to take during the first 24 hours following the SIRT procedure. These precautions include: thorough hand washing after using the toilet, and cleaning up any spills of body fluids such as blood, urine or stools and disposing of them in the toilet. Otherwise, patients can resume normal contact with family members.
Patients must not receive SIRT treatment if they are pregnant, and must not become pregnant within two months of receiving the treatment as this may cause harm to the unborn baby.
Does insurance cover the procedure?
Most insurance companies generally cover the cost of SIR-Spheres microspheres for the treatment of colorectal cancer which has spread to the liver. Under the terms of the Medicare Prescription Drug Improvement and Modernization Act (MMA) of 2003, Medicare, for the most part, reimburses hospitals for the cost of outpatient treatment with SIR-Spheres microspheres. Many private payers have recognized the safety and efficacy of the SIR-Spheres microspheres procedure and have issued positive coverage policies for treatment.
1. Hendlisz A et al. J Clin Oncol. 2010;28:3687-3694.
2. Gray B et al. Ann Oncol. 2001;12:1711-1720.
3. Seidensticker R et al, Cardiovascular Interventional Radiology, 2011 July 29; Epub.
4. SIR-Spheres microspheres are indicated for the treatment of unresectable metastatic liver tumors from primary colorectal cancer with adjuvant intra-hepatic artery chemotherapy (IHAC) of FUDR (Floxuridine).
YES! Beat Liver Tumors
American Liver Foundation
CanLiv: The Hepatobiliary Cancers Foundation
Chris 4 Life Colon Cancer Foundation
Cryoablation is a method of “freezing” a tumor. It is similar to RFA or microwave ablation in that the energy is delivered directly into the tumor by a probe that is inserted through the skin. But rather than killing the tumor with heat, cryoablation uses an extremely cold gas to freeze it. This technique has been used for many years by surgeons in the operating room, but in the last few years, the needles have become small enough to be used by interventional radiologists through a small nick in the skin, without the need for an operation. The "ice ball" that is created around the needle grows in size and destroys the frozen tumor cells. This technique is most often used to kill inoperable kidney or renal tumors.
Any patient with a renal tumor that may not be a candidate for surgery (nephrectomy or partial nephrectomy) may be considered for ablative therapy by either cryoablation or microwave ablation.
The medical information on this site is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. This information is not intended to be patient education, does not create any patient-physician relationship, and should not be used as a substitute for professional diagnosis and treatment.
Do not eat or drink anything after midnight the day prior to your procedure. This is so that we can give you sedation medicine as needed. You should take your regular medications and may take small sips of water to wash them down. This is very important and if not followed could result in re-scheduling or canceling your procedure.
Depending on your procedure, you may be contacted to undergo Pre-Anesthesia Testing. If so, please ensure you make the appointment in a timely fashion to avoid delays in your treatment.
Please make arrangements to have someone drive you home after your procedure. If you do not have a driver, your procedure may need to be cancelled or postponed.
If you have an allergy to x-ray iodinated contrast (“x-ray dye”) please call the Vascular Institute at (609) 652-6094 to receive a prescription for a medication “prep” prior to the procedure.
If you are taking blood thinners (Coumadin, Lovenox, Plavix, Xarelto, etc.) please call the Vascular Institute at (609) 652-6094 to discuss temporary discontinuation of these agents. Failure to do so will cause your procedure to be delayed or postponed.
If you have had any blood work done within one month of your planned procedure, please make arrangements to have the results forwarded tothe Vascular Institute at fax number (609) 625-1075.