mcwilliams sir 2012

Primary and metastatic liver cancer

Justin McWilliams, MD

UCLA Interventional Radiology

PATIENT CARE I: PRE- AND POST-PROCEDURE

EVALUATION

Initial office visit for liver cancer

Pre-procedure decision-making

Post-procedure follow-up

INTERVENTIONAL ONCOLOGY CLINICINITIAL OFFICE VISIT – GENERAL PRINCIPLES

• Have a dedicated clinic day if possible

• Set aside a full hour for new patients

• Assume they have been told nothing (usually true)

• Discuss all relevant treatment options, including non-IR treatments

• Discuss prognosis with and without treatment (no one else has)

• Explore patient’s goals and expectations

• Level V consultation

HEPATOCELLULARCARCINOMA

HEPATOCELLULAR CARCINOMA

• What would you like to know?

• Age

• Performance status

• Labs

• Child class

• Comorbidities

HEPATOCELLULAR CARCINOMA

• Age 63

• Performance status normal

• Normal labs except Plt 100

• Child A

• No major comorbidity

• Imaging:

• Cirrhosis, splenomegaly, no ascites

• 4.7 cm HCC in right lobe (segment 6)

• 1.5 cm HCC in left lobe (segment 3)

• No vascular invasion, no extrahepatic disease

• The patient is referred to IR for consideration of locoregional therapy.

or Y90

DOWNSTAGE OR C

OMBO THERAPY

DOW

NSTAG

EC

OM

BO

TH

ER

AP

Y

HEPATOCELLULAR CARCINOMAPRE-PROCEDURE DECISION-MAKING

• Age 63



• Child A


• Wants treatment

• 4.7 cm HCC in right lobe (seg 6)

• 1.5 cm HCC in left lobe (seg 3)

OLT DOWNSTAGE THEN OLT

PVE THEN RESECTION (+/- RFA)

TACE AND RFA

Y-90TACE +

NEXAVAR

What would you like to do?

TACE

RESECTION (+/- RFA)

NEXAVAR SBRT NOTHING

RFA


• You chose OLT.

• This is the preferred treatment for cirrhotic patients with low volume disease

• 75% 4-year survival if within Milan

• But, the patient is beyond Milan criteria!

• He has two HCCs and therefore both must be under 3 cm to qualify for exception points.

• Modest expansion of the Milan criteria (UCSF) may increase eligibility without worsening outcomes, but this is not yet widely accepted

• The patient has a MELD of 10 and dies on the list from tumor progression

• THE END

START OVER

Milan criteria:• One HCC up to 5 cm• 2 or 3 HCC, each up to 3 cm• No vascular invasion• No extrahepatic disease

LESSONS LEARNED

Mazzaferro V, Regalia E, Doci R, et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med 1996; 334: 693–99.Duffy JP, Vardanian A, Benjamin E, Watson M, Farmer DG, Ghobrial RM, Lipshutz G, Yersiz H, Lu DS, Lassman C, Tong MJ, Hiatt JR, Busuttil RW. Liver transplantation criteria for hepatocellular carcinoma should be expanded: a 22-year experience with 467 patients at UCLA. Ann Surg. 2007 Sep;246(3):502-9; discussion 509-11.


• You chose DOWNSTAGE THEN OLT.

• This is a reasonable option for patients initially beyond Milan criteria

• Rate of successful downstage = 24-69%

• 5-year survival if downstaged to OLT = 55-94%

• The patient undergoes TACE of the dominant lesion and 6 weeks later, RFA of the smaller lesion

• He is successfully downstaged, receives MELD exception points, and receives OLT 1 year later

• THE END

UCSF downstage criteria:• 1 lesion 5-8 cm• 2 or 3 lesions, at least 1 being >3

and <5 cm, total tumor diam <8 cm• 4 or 5 lesions, all <3 cm, total tumor

diam <8 cm• 3 month waiting period after

downstaging• No vascular invasion, no

extrahepatic disease

LESSONS LEARNED

Gordon-Weeks AN, Snaith A, Petrinic T, Friend PJ, Burls A, Silva MA. Systematic review of outcome of downstaging hepatocellular cancer before liver transplantation in patients outside the Milan criteria. Br J Surg. 2011 Sep;98(9):1201-8.

START OVER


• You chose RESECTION.

• This is the preferred treatment in non-cirrhotics and carefully selected Child A cirrhotics

• Normal bilirubin

• No portal HTN (no splenomegaly, platelets >100)

• 5-year survival up to 70% can be achieved in early, solitary HCC

• Improved surgical techniques have reduced mortality for major liver resection to <5%

• The patient undergoes R lobectomy and intra-op RFA of the L lobe lesion. His liver remnant is 30% of liver volume. He goes into post-operative fulminant liver failure and dies.

• THE END

Llovet JM, Fuster J, Bruix J. Intention-to-treat analysis of surgical treatment for early hepatocellular carcinoma: resection versus transplantation. Hepatology 1999; 30: 1434–40.Kishi Y, Hasegawa K, Sugawara Y, Kokudo N. Hepatocellular carcinoma: current management and future development – improved outcomes with surgical resection. Int J Hepatology 2011; Epub 2011 Jun 23.

LESSONS LEARNED

START OVER

Consider resection for selected Child A cirrhotics with:• Solitary HCC (5-year OS 50-70%)• Large HCC (5-year OS ~30%)• 2 or 3 HCC in same lobe (5-year

OS 30-40%)• HCC with PV/HV invasion (5-year

OS 20-40%)


• You chose PVE THEN RESECTION.

• Pre-operative PVE improves perioperative outcome for major hepatic resection

• PVE can achieve about 50% hypertrophy of the future liver remnant (i.e. from 500 cc to 750 cc)

• The patient undergoes right PVE with increase in FLR from 30% of liver volume to 45% of liver volume. He undergoes successful R lobectomy with intra-op RFA of the left lobe lesion, and is tumor-free 3 years later.

• THE END

Consider PVE if FLR is:• <40% in cirrhotic patients• <30% in post-chemo patients• <20% in non-cirrhotics

LESSONS LEARNED

Palavecino M, Chun YS, Madoff DC, Zorzi D, Kishi Y, Kaseb AO, Curley SA, Abdalla EK, Vauthey JN. Major hepatic resection for hepatocellular carcinoma with or without portal vein embolization: Perioperative outcome and survival. Surgery. 2009 Apr;145(4):399-405.

START OVER


• You chose RFA.

• RFA is a potentially curative modality with excellent tumor control rates in small tumors

• For tumors >3 cm, complete ablation rate with single treatment decreases

• Tumor <3 cm = 91%

• Tumor 3-5 cm = 74%

• Tumor >5 cm = 36%

• The patient undergoes RFA of both lesions. The left lobe lesion is completely ablated, but the right lobe lesion recurs, and the patient dies 3 years later of tumor progression.

• THE END

• RFA is treatment of choice in non-operative candidates with very early or early HCC

• Tumor size up to 3 cm• No vascular invasion• No extrahepatic spread• Child class A or B

LESSONS LEARNED

Peng ZW, Zhang YJ, Chen MS, et al. Risk factors of survival after percutaneous radiofrequency ablation of hepatocellular carcinoma. Surg Oncol. 2008 Jul;17(1):23-31.Crocetti L, de Baere T, Lencioni R. Quality improvement guidelines for radiofrequency ablation of liver tumours. Cardiovasc Intervent Radiol (2010) 33:11-17.Guglielmi A, Ruzzenente A, Battocchia A, Tonon A, Fracastoro G, Cordiano C. Radiofrequency ablation of hepatocellular carcinoma in cirrhotic patients. Hepatogastroenterology. 2003 Mar-Apr;50(50):480-4.

START OVER


• You chose TACE.

• TACE reduces mortality in HCC compared to symptomatic treatment (OR 0.54)

• But, it is non-curative

• 3-year survival ~25-30%

• DEB-TACE reduces liver toxicity and side effects compared to cTACE

• The patient undergoes repeated TACE procedures with initial response but eventual tumor progression. He dies 2 years later.

• THE END

• TACE is first-line non-curative therapy for non-surgical patients with large or multifocal HCC who do not have vascular invasion or extrahepatic spread

LESSONS LEARNED

Camma C, et al. Transarterial chemoembolization for unresectable hepatocellular carcinoma: meta-analysis of randomized controlled trials. Radiology 2002.Lammer J, et al. Prospective randomized study of doxorubicin-eluting-bead embolization in the treatment of hepatocellular carcinoma: results of the PRECISION V study. Cardiovasc Intervent Radiol (2010) 33:41-52.

START OVER


• You chose TACE AND RFA.

• Combination TACE/RFA has been shown to reduce local recurrence compared to RFA alone

• 6% vs. 39% local progression rate for tumors 3.1-5.0 cm

• The patient undergoes TACE of the dominant lesion, followed by RFA of both lesions, with complete response. He remains tumor-free at follow-up.

• THE END

Morimoto M, Numata K, Knodou M, Nozaki A, Morita S, Tanak K. Midterm outcomes in patients with intermediate sized hepatocellular carcinoma: a randomized controlled trial for determining the efficacy of radiofrequency ablation combined with transcatheter arterial chemoembolization. Cancer 2010;116(23):5452-5460.

START OVER


• You chose YTTRIUM-90 EMBOLIZATION.

• No RCTs

• Response rate and survival appear similar to TACE in cohort studies

• Less side effects and hepatic toxicity

• The patient undergoes mesenteric mapping followed by sequential lobar Y-90 treatment. He has initial tumor response but dies 2 years later of tumor progression.

• THE END

• Low embolic effect and mild side effects may make Y-90 a good option for elderly patients, patients with reduced performance status, and patients with portal vein invasion

LESSONS LEARNED

Sangro B, Carpanese L, Cianni R, et al; European Network on Radioembolization with Yttrium-90 Resin Microspheres (ENRY). Survival after yttrium-90 resin microsphere radioembolization of hepatocellular carcinoma across Barcelona clinic liver cancer stages: a European evaluation. Hepatology. 2011 Sep 2;54(3):868-78.

START OVER


• You chose TACE + NEXAVAR.

• These treatments have each shown survival improvement for patients with intermediate or advanced HCC.

• The combination remains unproven

• One RCT showed longer time to progression with addition of Nexavar to TACE; another RCT showed no benefit

• The patient undergoes TACE followed by Nexavar. He tolerates the treatment but eventually recurs, and dies 3 years later.

• THE END

• TACE + Nexavar is promising but unproven for intermediate and advanced HCC

• Results of several RCTs are expected in next 2 years

LESSONS LEARNED

Sansonno D, Lauletta G, Russi S, Conteduca V, Sansonno L, Dammacco F. Transarterial chemoembolization plus sorafenib: a sequential therapeutic scheme for HCV-related intermediate-stage hepatocellular carcinoma: a randomized clinical trial. Oncologist. 2012 Feb 14.Kudo M, Imanaka K, Chida N, et al. Phase III study of sorafenib after transarterial chemoembolisation in Japanese and Korean patients with unresectable hepatocellular carcinoma. Eur J Cancer. 2011 Sep;47(14):2117-27.

START OVER


• You chose NEXAVAR.

• Oral multikinase inhibitor

• Extends survival from 7.9 to 10.7 months in advanced HCC

• Diarrhea, weight loss, hand-foot syndrome are common side effects

• The patient does not have advanced HCC. He progresses on Nexavar and dies 18 months later.

• THE END

SHARP inclusion criteria:• Not candidate for

locoregional therapy• ECOG 0-2• Child A• Vascular invasion and

extrahepatic spread OK

LESSONS LEARNED

Llovet JM, Ricci S, Mazzaferro V, et al. SHARP Investigators Study Group. Sorafenib in advanced hepatocellular carcinoma. N Engl J Med. 2008 Jul 24;359(4):378-90.

START OVER


• You chose SBRT.

• Stereotactic body radiotherapy is noninvasive and shows efficacy against small-medium HCC

• 73% response rate (usually partial)

• 60% 2-year survival

• Not yet enough data to recommend as part of the HCC treatment paradigm

• The patient undergoes SBRT with partial response of the tumors. They eventually recur and he dies 3 years later.

• THE END

• SBRT is a promising noninvasive treatment for small HCC that is ineligible for locoregional treatment

LESSONS LEARNED

Price TR, Perkins SM, Sandrasegaran K, Henderson MA, Maluccio MA, Zook JE, Tector AJ, Vianna RM, Johnstone PA, Cardenes HR. Evaluation of response after stereotactic body radiotherapy for hepatocellular carcinoma. Cancer. 2011 Oct 24.

START OVER


• You chose NOTHING.

• Patients always have the right to refuse treatment

• Survival is dismal (3-17% at 3 years)

• The patient receives only supportive care, and dies 1 year later.

• THE END

Camma C, et al. Transarterial chemoembolization for unresectable hepatocellular carcinoma: meta-analysis of randomized controlled trials. Radiology 2002.

START OVER


• Age 63



• Child A


• Wants treatment





TACE AND RFA

Y-90TACE +

NEXAVAR


TACE

RESECTION (+/- RFA)


RFA




TACE AND RFA

Y-90TACE +

NEXAVAR


TACE

RESECTION (+/- RFA)


RFA

• Age 83

• Not able to work, but up and about >50% of waking hours (ECOG 2)


• Child A


• Wants treatment




• Age 83

• Not able to work, but up and about >50% of waking hours (ECOG 2)


• Child A


• Wants treatment





TACE AND RFA

Y-90TACE +

NEXAVAR


TACE

RESECTION (+/- RFA)


RFA


• Age 63

• ECOG 0

• Plt 50, T bili 2.5

• Child B


• Wants treatment





TACE AND RFA

Y-90TACE +

NEXAVAR


TACE

RESECTION (+/- RFA)


RFA

COLON CANCERMETASTATIC

METASTATIC COLON CANCER

• What would you like to know?

• Age

• Performance status

• Labs

• Comorbidities

• Chemo regimens

METASTATIC COLON CANCER

• Age 55


• Normal labs except CEA 200


• Status post L colectomy and FOLFOX + Avastin, then 2nd line Irinotecan with partial response

• 3 tumors now growing 6 months after last chemo

• Imaging:

• Three lesions in the right lobe (2 cm, 2 cm, 1 cm); PET positive

• No extrahepatic disease

• The patient is referred to IR for consideration of locoregional therapy.

METASTATIC COLON CANCERPRE-PROCEDURE DECISION-MAKING

• Age 55




• Status post L colectomy, FOLFOX + Avastin, Irinotecan

• 1 cm lesion segment 5

• 2 x 2 cm lesions segment 8

RESECTION

HAI


DEB-TACE

Y-90

SBRT NOTHING

RFA

SYSTEMIC CHEMO


• You chose RESECTION.

• Surgery is the standard treatment approach for resectable mCRC

• 5-year survival 30-50% following hepatic resection with curative intent

• Wedge vs anatomic resection is equivalent as long as tumor-free margin achieved

• Need 30% residual liver post-chemo

• The patient undergoes curative R lobectomy with 30% FLR, and slowly recovers. He remains disease-free for 4 years.

• THE END

START OVER

Risk factors for poor outcome with resection of mCRC:• >3 tumors• Tumor size >5 cm• CEA > 200 ng/mL

LESSONS LEARNED

Alberts S. Update on the optimal management of patients with colorectal liver metastases. Crit Rev Oncol/Hematol (2012), doi:10.1016/j.critrevonc.2012.02.007.


• You chose SYSTEMIC CHEMOTHERAPY.

• Chemotherapy prolongs survival for patients with mCRC

• Median survival 18-21 months

• Once 1st and 2nd line chemo has failed, 3rd line chemo yields response rates <20% and survival ~9 months

• The patient is placed on cetuximab and irinotecan. He progresses after 6 months and dies several months later.

• THE END

Once first and second line chemotherapy has failed, third line chemotherapy rarely yields objective response.

LESSONS LEARNED

Chong G, Dickson JL, Cunningham D, et al. Capecitabine and mitomycin C as third-line therapy for patients with metastatic colorectal cancer resistant to fluorouracil and irinotecan. Br J Cancer. 2005 Sep 5;93(5):510-4.Vincenzi B, Santini D, Rabitti C, et al. Cetuximab and irinotecan as third-line therapy in advanced colorectal cancer patients: a single centre phase II trial. Br J Cancer. 2006 Mar 27;94(6):792-7.

0

5

10

15

20

25

Med

ian

OS

(m

onth

s)

START OVER


• You chose RFA.

• This is a safe, well tolerated procedure with survival benefit in nonresectable mCRC

• 5-year survival 25-40%

• Meta-analysis shows that RFA is inferior to resection for resectable mCRC, mostly due to higher local recurrence rate

• The patient undergoes RFA of all 3 lesions. He is disease free for 3 years but then develops recurrence and dies 1 year later.

• THE END

Size is most important predictor of survival for RFA of mCRC• Median survival 41 months

if largest met < 3 cm• Median survival 22 months

if largest met > 3 cm

LESSONS LEARNED

Van Tilborg AA, Meijerink MR, Sietses C, et al. Long-term results of radiofrequency ablation for unresectable colorectal liver metastases: a potentially curative intervention. Br J Radiol. 2011 Jun;84(1002):556-65.Veltri A, Guarnieri T, Gazzera C, et al. Long-term outcome of radiofrequency thermal ablation (RFA) of liver metastases from colorectal cancer (CRC): size as the leading prognostic factor for survival. Radiol Med. 2012 Mar 19.

START OVER


• You chose DEB-TACE.

• Irinotecan mounted on drug-eluting beads

• Only retrospective data available

• After failure of systemic chemo

• Response rate 75% at 12 months (including 15% complete response)

• Overall median survival 19 months

• The patient undergoes 2 sessions of irinotecan DEB-TACE with partial response; he dies 18 months later

• THE END

DEB-TACE is a promising therapy for chemoresistant patients who are not surgical or ablation candidates, but no RCT are yet available.

LESSONS LEARNED

Martin RC, Joshi J, Robbins K, et al. Hepatic intra-arterial injection of drug-eluting bead, irinotecan (DEBIRI) in unresectable colorectal liver metastases refractory to systemic chemotherapy: results of multi-institutional study. Ann Surg Oncol. 2011 Jan;18(1):192-8.

START OVER


• You chose Y-90.

• No RCT

• Retrospective data shows favorable response in chemo-refractory patients

• Overall survival 12-17 months

• Low toxicity

• Prospective data supporting Y-90 use in 1st or 2nd line setting is accumulating

• The patient has mesenteric mapping followed by right lobe infusion of resin microspheres. He has a partial response and dies 18 months later.

• THE END

Selection criteria for Y-90 in mCRC• Unresectable• ECOG 0-2• Life expectancy >12 weeks• Albumin >3, bili <2, no ascites• No GI shunt, <30 Gy lung

exposure

LESSONS LEARNED

Coldwell D, Sangro B, Wasan H, Salem R, Kennedy A. General selection criteria of patients for radioembolization of liver tumors: an international working group report. Am J Clin Oncol. 2011 Jun;34(3):337-41. Cosimelli M, Golfieri R, Cagol PP, et al; Italian Society of Locoregional Therapies in Oncology (SITILO). Multi-centre phase II clinical trial of yttrium-90 resin microspheres alone in unresectable, chemotherapy refractory colorectal liver metastases. Br J Cancer. 2010 Jul 27;103(3):324-31.

START OVER


• You chose HEPATIC ARTERY INFUSION.

• Direct infusion of FUDR (similar to 5-FU)

• Meta-analysis showed better response rate but no survival benefit compared to systemic chemo

• Problems: hepatic toxicity (biliary sclerosis), catheter displacement, catheter occlusion

• The patient undergoes pump insertion and HAI therapy with FUDR; he dies 1 year later.

• THE END

The role of HAI, if any, is unclear. Existing data used outdated chemotherapeutics and had high incidence of toxicity and catheter problems. Further study is needed.

LESSONS LEARNED

Bouchahda M, Lévi F, Adam R, Rougier P. Modern insights into hepatic arterial infusion for liver metastases from colorectal cancer. Eur J Cancer. 2011 Dec;47(18):2681-90.

START OVER


• You chose SBRT.

• Limited data suggest efficacy against oligometastatic disease

• 2-year local control 74%

• 2-year overall survival 83%

• Noninvasive

• The patient undergoes SBRT of all 3 lesions without event. He dies of tumor progression 3 years later.

• THE END

The role of SBRT in mCRC is unclear. It may have a role for patients with oligometastatic disease who are not surgical or RFA candidates.

LESSONS LEARNED

van der Pool AE, Méndez Romero A, Wunderink W, Heijmen BJ, Levendag PC, Verhoef C, Ijzermans JN. Stereotactic body radiation therapy for colorectal liver metastases. Br J Surg. 2010 Mar;97(3):377-82.

START OVER


• You chose NOTHING.

• Survival with supportive care alone after failure of first and second-line chemotherapy is dismal (3-4 months)

• The patient receives supportive care, and dies 4 months later of progressive disease.

• THE END

Seidensticker R, Denecke T, Kraus P, et al. Matched-Pair Comparison of Radioembolization Plus Best Supportive Care Versus Best Supportive Care Alone for Chemotherapy Refractory Liver-Dominant Colorectal Metastases. Cardiovasc Intervent Radiol. 2011 Jul 29.

START OVER


• Age 55







RESECTION

HAI


DEB-TACE

Y-90

SBRT NOTHING

RFA

SYSTEMIC CHEMO


• Age 55


• Normal labs except T Bili 2.1





RESECTION

HAI


DEB-TACE

Y-90

SBRT NOTHING

RFA

SYSTEMIC CHEMO

• Post-RFA

• Contrast CT on the table

• Recovery area for 2-3 hours

• MRI liver once awake enough

• Discharge home with Vicodin and Cipro

• Post-Y90

• Recovery area for 2-6 hours

• PPI + carafate

• [Medrol Dose-Pak]

• Post-TACE (overnight admission)

• PCA

• Zofran prn

• IVF

• Dexamethasone (if non-diabetic)

• [Cipro]

• AM labs: CBC, BMP, LFTs

• D/c Foley in AM

• Switch to PO Vicodin, ambulate and d/c home

LIVER CANCERPOST-PROCEDURE FOLLOW-UP – IN-HOSPITAL

• Pain

• Just keep on PCA until controlled

• For chest pain after anesthesia have high index of suspicion for MI

• Hypotension

• Evaluate groin (if arterial access)

• IVF

• Orthostatic? Oversedated?

• Consider stat CT

• Consider H&H, type and cross

• Transaminitis

• No action if not too high, and patient doing well

• If AST/ALT > 300 or TB increases by >1 point, consider keeping until LFTs begin to recover

LIVER CANCERIN-HOSPITAL PROBLEMS

• Pain

• Occasionally lasts weeks after RFA or TACE

• Motrin (anti-inflammatory), Vicodin

• Dual-phase CT if severe

• Endoscopy for pain >1 week after Y90

• Fever

• Usually just PES

• Tylenol for fever <101.5

• High fevers, especially >1 week after intervention, may require CT to evaluate for biloma or abscess (requires percutaneous drainage)

LIVER CANCERPOST-DISCHARGE PROBLEMS

• Post-RFA, TACE or Y90

• 1 month follow-up with Eovist MRI

• Clinic visit on same day as MRI

• CBC, BMP, LFTs, INR, AFP/CEA

• Discuss results, treatment plan

• If no residual disease, MRI and clinic visit q3 months

LIVER CANCERPOST-PROCEDURE FOLLOW-UP – CLINIC

THE END

[email protected]

INTERVENTIONAL ONCOLOGY CLINICINITIAL OFFICE VISIT – HISTORY

1. HPI:

• Liver disease

• Severity of cirrhosis (Child class)

• Ascites, encephalopathy, varices

• Liver tumor

• Tumor symptoms

• Prior treatments

• Activity level


1. HPI:

2. PMH:

• Diabetes?

• CAD/CHF?

• Renal disease?

• Other malignancy?


1. HPI:

2. PMH:

3. PSH:

• Prior liver surgery?

• Hepatoenteric anastomosis?

• Orthopedic hardware?


1. HPI:

2. PMH:

3. PSH:

4. Meds:

• Nexavar?

• Diuretics?

• Lactulose?


1. HPI:

2. PMH:

3. PSH:

4. Meds:

5. Allergies:

• Iodinated contrast?

• Gadolinium?

• Antibiotics?


1. HPI:

2. PMH:

3. PSH:

4. Meds:

5. Allergies:

6. FH:

• Usually noncontributory

• Vertical transmission of Hep B?

• Hemochromatosis?

• Autoimmune disease?


1. HPI:

2. PMH:

3. PSH:

4. Meds:

5. Allergies:

6. FH:

7. SH:

• Alcohol/drug use?

• Quantity and duration

• Support system?

INTERVENTIONAL ONCOLOGY CLINICINITIAL OFFICE VISIT – REVIEW OF SYSTEMS

• How have you been feeling, in general?

• Fatigue or weight loss

• Chest pain

• Dyspnea

• Hematemesis, hematochezia

• Diarrhea or constipation

• Nausea or vomiting

• Urinary retention

• Anxiety or depression

• Rash/pruritis

INTERVENTIONAL ONCOLOGY CLINICINITIAL OFFICE VISIT – PHYSICAL EXAM

1. Vitals

2. General appearance – well or sick?

3. Icterus, fetor hepaticus

4. Heart rate/rhythm

5. Breath sounds

6. Abdominal exam for tenderness, palpable mass, ascites, caput medusa

7. Peripheral pulses, edema, clubbing

8. Clarity of thought, asterixis

9. Spider angiomas, palmar erythema

mcwilliams sir 2012

Documents

procedure evaluationprimary

prior liver surgery

rfa normal labs

rfa nexavar

hepatocellular carcinoma

milan criteria ucsfmay

residual disease

renal disease