Melphalan chemosaturation with percutaneous hepatic artery perfusion and hepatic vein isolation for primary or metastatic cancer in the liver

Evidence-based recommendations on melphalan chemosaturation with percutaneous hepatic artery perfusion and hepatic vein isolation for primary or metastatic cancer in the liver. This involves diverting the blood flow from the liver to the rest of the body (hepatic vein isolation) while the drug is delivered directly into the liver (percutaneous hepatic artery perfusion). Blood leaving the liver is taken out of the body and filtered to remove the drug, then returned. The aim is to destroy the cancer with a very high dose of the drug (chemosaturation) without causing side effects in the rest of the body.

# Recommendations
Evidence on the safety of melphalan chemosaturation with percutaneous hepatic artery perfusion and hepatic vein isolation for cancer or metastases in the liver shows there are serious, wellrecognised complications.
For patients with metastases in the liver from ocular melanoma, there is some evidence of shortterm tumour response. For these patients, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research. Find out what special arrangements mean on the NICE interventional procedures guidance page.
For patients with primary liver cancer or metastases in the liver that are not from ocular melanoma, evidence of efficacy is inadequate in quality and quantity. For these patients, this procedure should only be used in the context of research. Find out what only in research means on the NICE interventional procedures guidance page.
Clinicians wishing to do melphalan chemosaturation with percutaneous hepatic artery perfusion and hepatic vein isolation for patients with metastases in the liver from ocular melanoma should:
Inform the clinical governance leads in their healthcare organisation.
Give patients (and their families and carers as appropriate) clear written information to support shared decision making, including NICE's information for the public.
Ensure that patients (and their families and carers as appropriate) understand the procedure's safety and efficacy, and any uncertainties about these.
Audit and review clinical outcomes of all patients having the procedure. The main efficacy and safety outcomes identified in this guidance can be entered into NICE's interventional procedure outcomes audit tool (for use at local discretion).
Discuss the outcomes of the procedure during their annual appraisal to reflect, learn and improve.
Healthcare organisations should:
Ensure systems are in place that support clinicians to collect and report data on outcomes and safety for every patient having this procedure.
Regularly review data on outcomes and safety for this procedure.
The procedure should only be done in specialist centres by a melanoma multidisciplinary team that includes an interventional radiologist, an anaesthetist, an oncologist and a clinical perfusion scientist trained and experienced in the procedure.
Further research should be in the form of randomised controlled trials against current best practice, including other liverdirected and systemic therapies. It should report details of patient selection, concurrent therapies and techniques, and adverse events, including those related to chemotherapy.# The condition, current treatments and procedure

# The condition
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).

# Current treatments
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.

# The procedure
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.
An infusion catheter is inserted into the femoral artery and guided into the hepatic artery. The femoral vein is cannulated and a multilumen, 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.
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.