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Beads – Julia Curtis Beadwork
Questions about this class? Course Details. Start Date:. Despite the overall 5-year survival being similar for both liver resection and transplantation in patients with early disease, recurrence has been observed to be greater in patients treated with liver resection than with liver transplantation Sapisochin et al. Chemoembolization combines an agent that occludes the hepatic artery feeding the tumor and local release of a chemotherapeutic agent.
An added benefit is that hypoxic damage to the tumor cells may facilitate the uptake of chemotherapy by those cells Lewandowski et al. Tumor necrosis also reduces the risk for tumor dissemination during transplant surgery. Although this article focuses on the treatment of HCC, other malignancies with metastatic disease isolated to the liver have also been treated with chemoembolization.
Multiple staging systems, based on various disease factors and liver function, are used to determine the course of therapy and prognosis in staging HCC. Following the initial diagnosis, the National Comprehensive Cancer Network NCCN categorizes patients into four categories based on the potential for success with various treatment strategies. This system uses Child-Pugh stage, tumor morphology, alpha-fetoprotein AFP , and portal vein thrombosis in scoring disease to aid in determining prognosis and planning treatment. When survival statistics for each stage of disease according to the various systems were compared, the CLIP system had distinct survival periods without overlap, as well as a statistical difference between adjacent prognostic scores.
These outcomes indicate the validity of this particular staging system. Chemoembolization is recommended for intermediate-stage HCC. Reproduced with permission from Forner et al. Because of the heterogeneity of patients considered BCLC stage B, researchers have worked to further subdivide the class, with the goal of selecting an appropriate population for treatment with TACE Bolondi et al.
These subclassifications are based on liver function, performance status, and tumor burden.
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Median survival time following the first treatment with TACE differed between these subgroups B1 subgroup [41 months] vs. B2 subgroup [ B3 subgroup [ TACE has also been shown to be effective in patients recommended for liver transplantation if the expected time to transplant is more than 6 months Cheng et al. Extensive extrahepatic disease is still considered a contraindication to treatment with TACE Cheng et al. The BCLC staging system see Figure 2 links this patient to resection or transplantation for curative therapy.
Our patient, THA, benefited from locoregional therapy, in that treatment with drug-eluting beads—TACE allowed for control of his disease while workup for liver transplant took place. Furthermore, with this sort of bridging therapy, the wait for transplantation did not negatively affect his overall prognosis. Conventional TACE is not a new technology.
Materials used as embolizing agents have included gelatin particles, polyvinyl alcohol PVA particles, and ethiodized oil Lipiodol. Limitations to the use of some of these agents include large particle size or irregular shape, making it more likely larger vessels will be occluded instead of the smaller targeted distal vasculature feeding the tumor. Embolizing agents with a spherical shape and calibrated sizes are now available and may overcome some of the issues associated with the use of gelatin sponge and PVA particles Osuga et al.
Ethiodized oil has also been used in combination with various chemotherapy agents, such as doxorubicin, epirubicin, mitoxantrone, fluorouracil 5-FU , mitomycin, and cisplatin, for the treatment of HCC. One issue with the use of ethiodized oil is incomplete arterial occlusion, making it necessary to add an embolizing agent e. Incompatibility with hydrophilic antineoplastic agents is another issue with the use of ethiodized oil. To overcome compatibility issues, the chemotherapy drug must first be dissolved in other substances, such as water-soluble x-ray contrast agents.
The mixture is then added to the ethiodized oil. This combination of chemotherapy, ethiodized oil and an embolizing agent, had been viewed as the standard of care for patients with intermediate-stage HCC until the introduction of drug-eluting beads DEBs. The LC Beads are made of polyvinyl alcohol modified by sulfonate sodium salt, and QuadraSphere is made of vinyl alcohol and a sodium acrylate co-polymer. Pharmacokinetic studies of both preparations have been done in animal models to evaluate doxorubicin plasma concentrations, release rate, and concentration at the tumor site.
The study that evaluated doxorubicin-loaded DEBs in a rabbit model of liver cancer demonstrated a significantly lower plasma concentration of doxorubicin compared with intra-arterial administration.
A peak intratumor doxorubicin concentration of Intratumor doxorubicin concentrations remained high through days 7 Plasma concentrations in the group treated with DEBs were minimal at all measured time points Hong et al. Similar results were reported with the QuadraSphere preparation loaded with doxorubicin, with peak tumor concentrations being observed at 3 days Pronounced tumor necrosis was observed at 3 days and continued through the 7-day study period Lee et al.
Pharmacokinetic studies in patients were consistent with animal studies. Both bead preparations are available in various sizes to accommodate vessels of various sizes. QuadraSphere microspheres are supplied as dry particles, which swell when hydrated. Studies have been conducted comparing various bead sizes to see whether there are differences in outcome depending on the bead size used. Choice of bead size was based on individual radiologist preference. Smaller-sized DEBs and the delivery of these beads closer to the tumor target may provide benefit due to smaller areas of ischemia induction and reduced ischemia in nontarget, normal liver tissue.
A second retrospective study showed similar results Prajapati et al. Common terminology criteria for adverse events CTCAE , grade III adverse events, and day mortality were significantly lower in patients who were treated with the smaller beads 6. He suffered minimal adverse events, primarily several days of mild fatigue and some mild nausea. When the QuadraSphere microsphere preparation was first marketed, our institution considered adding the product to our formulary.
Because of the absence of studies directly comparing the two bead preparations and existence at that time of extended stability data only for the doxorubicin-loaded LC Bead preparation Hecq et al. Risk for use of the wrong bead preparation was also considered in the decision to carry only a single bead product.
Since that time, the manufacturer of QuadraSphere has included extended stability information in its product information Merit Medical Systems, Supplementary analyses demonstrated differences in OR and DCR among patients with advanced disease One such study treated 10 consecutive patients with 10 tumors deemed refractory to conventional TACE of a total of patients who had undergone TACE at a single institution.
Refractory was defined as tumors that demonstrated more than two consecutive incomplete necroses on computed tomography CT.
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The authors hypothesized that not all tumors retain ethiodized oil—doxorubicin, likely making conventional TACE less effective than the prolonged release of doxorubicin when given as DEB Song et al. Median overall survival was days. Both authors noted that treating these patients with advanced disease with a combination of TACE and an antiangiogenic agent, such as sorafenib, would likely be beneficial.
The rationale for the use of the combination centers on the hypoxic damage caused by TACE, which increases various angiogenic growth factors, such as vascular endothelial growth factor NCCN, ; Sacco et al. Sorafenib could be added to TACE to block the effect of these growth factors on tumor growth. Studies evaluating this combination are ongoing.
Differences in the rates of doxorubicin-related adverse events, changes in liver enzymes, and postprocedural pain have been observed Lammer et al. These symptoms are self-limiting and rarely a cause for patient or practitioner concern. Some of these adverse events can be minimized or prevented with appropriate premedication.
Our institution routinely administers ondansetron, ceftriaxone, diphenhydramine, and dexamethasone prior to the TACE procedure. Patient-controlled analgesia PCA is used after the procedure for pain control, with the goal of switching the patient to oral medications prior to discharge. She then developed her own style of relief work on top of her highly detailed bead embroidery.
Rebecca's active involvement in the art world includes teaching and mentoring interested students. She has won awards for her beadwork. She exhibits her artwork and beadwork in the United States as well as New Zealand. Rebecca lives and works in Christchurch, New Zealand.
Advanced Bead Weaving Series: Seed Bead Embroidery with Unusually Shaped Focals by Kinga Nichols
She invented and manufactures the Sharondipity Tube Looms; Plexiglas looms designed for specific projects. She is available for questions or comments though her web site www. Would you like to tell us about a lower price? If you are a seller for this product, would you like to suggest updates through seller support? A long long time ago in a glass factory far far awayFor over a thousand generations the Bead-I knights were the guardians of peaceBefore the dark times of cheap mass production Oh, all right! It is, however, an innovative and inspiring adventure in stitch manipulation using five basic bead stitches: bead embroidery, brick, square, peyote, and right angle weave.
From flat to three-dimensional beadwork, this book covers a range of shapes and forms with seven projects designed for the intermediate to advanced beading enthusiasts who are looking for ways to expand their skill to a level above the norm. It is a book for those who are ready to unleash their passion for this under appreciated art medium and learn simple and exciting ways to give dimension to beadwork.
Read more Read less. The Best History Books of See his picks. About the Author Rebecca began her art training as a scientific illustrator with an emphasis on botanical Illustration. Read more. Tell the Publisher! I'd like to read this book on Kindle Don't have a Kindle? Chance to win daily prizes. Get ready for Prime Day with the Amazon App. No purchase necessary. Get started. Share your thoughts with other customers. Write a customer review.
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