Clinical Evaluation of the Cancer Patient
Karen Marshall
Robert J. Lewandowski
The evaluation and management of cancer patients is complex, requiring a comprehensive approach. Ideally, a patient is presented at a dedicated tumor board and a multidisciplinary team determines the best treatment plan. The interventional radiologist (IR) has the expertise to assess pre- or posttreatment imaging and should take an active role in these conferences. Furthermore, the IR must gain and utilize knowledge regarding the outcomes of all cancer therapies as well as the clinical management of these patients.
Patient Assessment
Candidates for interventional oncology (IO) therapies should be seen in consultation. At minimum, the following information is required:
1. Method of diagnosis
a. Primary liver cancer (e.g., hepatocellular carcinoma [HCC])
(1) Diagnosis made by imaging or biopsy (1)
(a) In setting of cirrhosis, tumors >1 cm that demonstrate arterial enhancement and venous washout are HCC (either CT or MRI).
(b) Tumors not meeting these criteria require biopsy.
b. Secondary liver cancer (e.g., metastatic colon cancer [mCRC])
(1) Diagnosis made by biopsy +/− positron emission tomography (PET)
2. Tumor burden/extent of disease (multiphasic, contrast-enhanced imaging optimal)
a. Primary liver cancer
(2) Patients most often have liver-only disease.
Table e-74.1 Child-Pugh Score | ||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
(3) Patients present with varying tumor morphologies:
(a) Solitary nodule versus multifocal disease
(b) Unilobar versus bilobar disease
(c) Mass-forming tumors versus infiltrative disease
(4) Vascular invasion not infrequent (about one-third have portal vein thrombosis [PVT])
b. Secondary liver cancer
(1) CT (triphasic) preferable for metastatic disease
(2) Candidates for IO therapies have liver-only or liver-dominant disease.
(a) Presence of liver metastases negatively impacts survival outcome.
(3) Patients most often have multifocal, bilobar disease at presentation.
3. Liver function (for those patients being considered for liver-directed therapy)
a. Primary liver cancer
(1) Liver function affected by underlying cirrhosis and tumor burden.
(a) Patients with more advanced liver dysfunction might be candidates for IO therapy if selective treatments are being considered or if patient is a transplant candidate.
b. Secondary liver cancer
(1) Liver function affected by prior systemic therapy and tumor burden
(a) Systemic therapies have negative impact on liver function.
(2) Typically evaluated by reviewing serum total bilirubin
(a) Serum albumin, platelets, and international normalized ratio (INR) are also important.
(3) Best candidates for IO therapies have normal liver functions.
4. Patient performance status
