2 The condition, current treatments and procedure
2.1 The most common types of primary liver cancer are hepatocellular carcinoma (also known as hepatoma) and cholangiocarcinoma. However, cancer in the liver has often metastasised from other sites such as the lung, colon, stomach and eye (particularly ocular melanoma, also known as uveal melanoma).
2.2 Treatment for primary or metastatic cancer in the liver depends on the location and stage of the cancer and how much liver function is preserved. Treatment options include surgical resection, thermal ablation, systemic chemotherapy, transarterial chemoembolisation, isolated hepatic perfusion and selective internal radiation therapy. In patients with primary liver cancer, surgical removal with curative intent and liver transplantation may be possible. For most patients with liver metastases, treatment with curative intent is not possible.
2.3 Melphalan chemosaturation with percutaneous hepatic artery perfusion and hepatic vein isolation is done under general anaesthesia. A high dose of melphalan chemotherapy is delivered directly into the hepatic artery. Blood leaving the liver is diverted out of the body and filtered to reduce the level of melphalan before being returned to the circulation. The aim is to allow high doses of melphalan chemotherapy to be used, which would otherwise not be tolerated because of severe systemic side effects.
2.4 An infusion catheter is inserted into the femoral artery and guided into the hepatic artery. The femoral vein is cannulated and a multi‑lumen, double-balloon catheter is inserted into the inferior vena cava and across the hepatic veins. The balloons are inflated so that all blood leaving the liver through the hepatic veins enters the catheter rather than the systemic circulation. High doses of melphalan are infused directly into the liver through the hepatic artery infusion catheter over about 30 minutes. Blood leaving the liver passes through an extracorporeal filtration system to remove most of the melphalan and is returned to the circulation through a catheter in the internal jugular vein. Full anticoagulation with heparin is needed throughout the procedure.
2.5 The procedure causes significant changes in the patient's haemodynamic status, which must be managed by the anaesthetic team with support from a clinical perfusion scientist.