Endovascular Treatment of Massive Retroperitoneal Hemorrhage Due to Spontaneous Rupture of Right Adrenal Gland Metastasis that was Secondary to Invasive Hepatocellular Carcinoma: A Case Report

The reported incidence of spontaneous rupture of primary hepatocellular carcinoma (HCC) is up to 14.5%. However, rupture of the metastatic lesions of HCC is very rare. We describe here a case of massive retroperitoneal hemorrhage due to spontaneous rupture of right adrenal gland metastasis that was secondary to invasive HCC. This was successfully controlled by performing transcatheter arterial embolization (TAE).

The Safety and Efficacy of Hemostasis with Clo-Sur P.A.D. after Transcatheter Arterial Chemoembolization

PURPOSE: We wanted to evaluate the safety and efficacy of a new hemostatic device, Clo-Sur P.A.D., at an arterial access site after performing femoral arterial catheterization to achieve transcatheter arterial chemoembolization (TACE). MATERIALS AND METHODS: From August 2002 to March 2005, 113 patients who underwent TACE and agreed on using the Clo-Sur P.A.D. were enrolled in this study. We evaluated the mean time interval from compression to the first movement and also to the first walk. We also evaluated such complications as rebleeding, pseudoaneurysm, vascular occlusion, hematoma, infection and pain. For 92 patients who had previous experiences with manual compression, we evaluated their preference of hemostatic method by asking them. RESULTS: Successful hemostasis was achieved with the Clo-Sur P.A.D. in 105 subjects (92%). The mean time interval from compression to the first movement was 201 minutes, and that to the first walk was 267 minutes. There was no statistical difference between the complicated and the uncomplicated groups for the mean time, prothrombin time, Child-Pugh class and platelet count (p > 0.05). Rebleeding occurred in 3 patients (2.7%) and mild hematoma around puncture site was noted in 5 patients (5.4%). Eighty-seven patients (95%) preferred Clo-Sur P.A.D. to the manual compression method. CONCLUSION: The Clo-Sur P.A.D. is a safe and effective hemostatic device and it provides early ambulation after TACE.

A New and Simple Practical Plane Dividing Hepatic Segment 2 and 3 of the Liver: Evaluation of Its Validity

OBJECTIVE: The conventional method of dividing hepatic segment 2 (S2) and 3 (S3) is subjective and CT interpretation is unclear. The purpose of our study was to test the validity of our hypothesis that the actual plane dividing S2 and S3 is a vertical plane of equal distance from the S2 and S3 portal veins in clinical situations. MATERIALS AND METHODS: We prospectively performed thin-section iodized-oil CT immediately after segmental chemoembolization of S2 or S3 in 27 consecutive patients and measured the angle of intersegmental plane on sagittal multiplanar reformation (MPR) images to verify its vertical nature. Our hypothetical plane dividing S2 and S3 is vertical and equidistant from the S2 and S3 portal veins (vertical method). To clinically validate this, we retrospectively collected 102 patients with small solitary hepatocellular carcinomas (HCC) on S2 or S3 the segmental location of which was confirmed angiographically. Two reviewers predicted the segmental location of each tumor at CT using the vertical method independently in blind trials. The agreement between CT interpretation and angiographic results was analyzed with Kappa values. We also compared the vertical method with the horizontal one. RESULTS: In MPR images, the average angle of the intersegmental plane was slanted 15 degrees anteriorly from the vertical plane. In predicting the segmental location of small HCC with the vertical method, the Kappa value between CT interpretation and angiographic result was 0.838 for reviewer 1 and 0.756 for reviewer 2. Inter-observer agreement was 0.918. The vertical method was superior to the horizontal method for localization of HCC in the left lobe (p < 0.0001 for reviewers 1 and 2). CONCLUSION: The proposed vertical plane equidistant from S2 and S3 portal vein is simple to use and useful for dividing S2 and S3 of the liver.

Polyvinyl Alcohol Embolization Adjuvant to Oily Chemoembolization in Advanced Hepatocellular Carcinoma with Arterioportal Shunts

OBJECTIVE: To assess the feasibility and safety of polyvinyl alcohol (PVA) embolization adjuvant to transarterial oily chemoembolization (P-TACE) in advanced hepatocellular carcinoma (HCC) with arterioportal shunts (APS). MATERIALS AND METHODS: Nineteen patients who underwent PVA embolization for APS before a routine chemoembolization (TACE) procedure were retrospectively reviewed. 10 of these 19 patients underwent follow-up TACE or P-TACE after P-TACE (Group A), but nine patients underwent only initial P-TACE because of progression of HCC and/or underlying liver cirrhosis (Group B). Hepatic function tests, APS grades, and portal flow directions were evaluated before and after P-TACE sessions. Complications after procedures and survival days were also evaluated. RESULTS: In group A, APS grade was improved in eight patients and five of six patients with hepatofugal flow showed restored hepatopetal flow postoperatively. No immediate complication was developed in either group. Transient hepatic insufficiency developed in eight (42.1%) of 19 patients after P-TACE, and seven (87.5%) of these eight recovered within two weeks under conservative care. The mean and median survival time all study subjects was 280 days and 162 days. CONCLUSION: P-TACE is feasible and safe in advanced HCC patients with APS.

Microvascular Injury of the Peribiliary Plexus Associated with Transarterial Chemoembolization: A Study of Surgical Specimens

PURPOSE: We attempted to evaluate the relationship between transarteiral chemoembolization (TACE) and injury to the peribiliary plexus by evaluating the number of microvessels in the peribiliary plexus of surgical specimen. MATERIALS AND METHODS: Surgical specimens were obtained from 78 hepatocellular carcinoma patients and 22 patients with liver metastases. They were divided into 4 groups (Group 1; hepatocellular carcinoma without TACE [n=30], Group 2; hepatocellular carcinoma receiving preoperative TACE once [n=37], Group 3; hepatocellular carcinoma receiving preoperative TACE more than two times [n=11] and Group 4; metastatic carcinoma of the liver patients without a history of liver disease [n=22]). Immunohistochemical staining for factor VIII-related antigen was performed in all the specimens and the number of microvessels in the inner capillary layer and the outer venous layer of the bile duct (> 200 micrometer in diameter) was counted. RESULTS: The mean numbers of microvessels in the inner capillary layer were 4.50, 4.08, 1.64 and 2.05, and those in the outer venous layer were 25.23, 20.00, 18.36 and 12.32 for the 4 groups, respectively. The number of microvessels in group 4 was statistically fewer than that of group 1 (p<0.01). In the hepatocellular carcinoma patients, the number of microvessels was decreased as the number of TACE sessions was increased. CONCLUSION: The number of microvessels in the peribiliary plexus is increased in chronic liver disease patients. It may be from the increased portal pressure and flow stagnation in the sinusoidal and portal venules. TACE can have an effect on microvascular injury of the peibiliary plexus, and this can be a cause of bile duct necrosis and biloma.

Transcatheter Arterial Chemoembolization of Hepatocellular Carcinoma: Prevalence and Causative Factors of Extrahepatic Collateral Arteries in 479 Patients

OBJECTIVE: We wanted to investigate the prevalence and causative factors of extrahepatic arterial blood supply to hepatocellular carcinoma (HCC) at its initial presentation and during chemoembolization. MATERIALS AND METHODS: Between February 1998 and April 2000, consecutive 479 patients with newly diagnosed HCC were prospectively enrolled into this study. A total of 1629 sessions of transcatheter arterial chemoembolization (TACE) were performed in these patients (range: 1-15 sessions; mean: 3.4 sessions) until April 2004. For each TACE procedure, we determined the potential extrahepatic collateral arteries (ExCAs) depending on the location of the tumor, and we performed selective angiography of all suspected collaterals that could supply the tumor. The prevalence of ExCAs and the causative factors were analyzed. RESULTS: At initial presentation, 82 (17%) of these 479 patients showed 108 ExCAs supplying tumors. Univariate analysis showed that tumor size (p or = 5 cm) was significantly higher than that for those patients with a small tumor (< 5 cm) (p < 0.01). CONCLUSION: The presence of ExCAs supplying HCC is rather common, and the tumor size is a significant causative factor for the development of these collateral arteries.

Evaluation of Newly Developed Small (< or = 20 mm) Enhancing Nodules on the Arterial Phase CT after Transcatheter Arterial Cheomoembolization in Patients with Hepatocellular Carcinoma

PURPOSE: We assessed the clinical significance of newly developed small (< or = 20 mm) early-enhancing hepatic nodules on arterial phase CT after performing transcatheter arterial cheomoembolization (TACE) in patients suffering with hepatocellular carcinoma (HCC). MATERIALS AND METHODS: We searched for the radiologic reports that showed small early enhancing nodule (< or = 20 mm) on the arterial phase imaging of follow-up CT after performing TACE. Thirty-seven lesions in 30 patients had round or oval shaped nodules and the numbers of nodule for one patient was less than five. We classified the nodules by size, location and the decreased attenuation seen on the portal venous phase. The latest follow-up CTs were reviewed to assess the nodules for the final diagnosis. All the follow-up CTs were two-phase spiral CT scans. RESULTS: Twenty-five (67%) of the 37 nodules were recurred HCC, as was determined on the basis of their interval growth and lipiodol uptake after TACE. Among the 37 nodules, seven (18%) disappeared on the latest follow-up CT and they were considered as definite pseudolesions. The remaining five (15%) were stable in size or they decreased in size, and they were considered as probable pseudolesions. The mean size of the nodules on initial CT was 11 mm. The mean size of the malignant nodules was 11+/-4.2 mm and that of the benign pseudolesions was 9+/-4.9 mm. The nodules located on the hepatic surface were possible to definite benign pseudolesions (p<0.05). All ten low attenuated nodules seen on the portal phase were HCCs. CONCLUSION: When seen on the follow-up CT scans of HCC patients after performing TACE, the newly developed small early-enhancing nodules were considered to have high potential of being HCC by their locations and enhancing patterns.

Treating hepatic carcinoma with internal mammary artery blood supply through transcatheter arterial chemoembolization / 介入放射学杂志

Objective To study blood supply by the internal mammary artery(IMA)for hepatic carcinoma and evaluate the efficacy and safety of transcatheter arterial chemoembolization(TACE)via IMA. Methods 86 cases of hepatic cancer(HCC)fed by the IMA underwent TACE of the IMA.All of the patients had previously undergone several TACE for HCC.16 patients had undertaken percutaneous microwave coagulation therapy in addition to TAE.4 patients had a history of surgery for upper abdomen.Plain and enhanced CT and MRI scannings were performed before operation.Internal mammary arteriography was carried out during the interventional procedure to clarify the feeding range and then the superselected catheterization of the feeding branch was done with TACE.The IMA angiographic features,tumor location,clinical observation, laboratory tests,imageology were evaluated,and finally were correlated with the angiographic findings of the IMA.Results All lesions were massive type and located at the ventral aspect and subcapsular region of the liver:57 cases in segment 4,5,8,and 29 cases in segment 5,7,8.Recurrent HCCs were supplied by the right IMA in 80 cases,from the left IMA in 5 cases and with the bilateral IMA in 1 case.Lipiodol-TACE of the IMA for HCC can be performed without skin complications in cases of subselective catheterization.Conclusion Tumors located ventrally and superficially in the liver may recruit blood supply through IMA collaterals,often occurring in massive type of HCC after several times of TACE.TACE of IMA is safe and has become technically feasible in almost all patients,although cutaneous damage should be cautious during the interventional procedure.(J Intervent Radiol,2007,16:816-819)

Transcatheter Arterial Chemoembolization for Hepatic Carcinoma with Blood Supply from the Intercostal Arteries / 中国微创外科杂志

Objective To study the safety of transcatheter arterial chemoembolization(TACE)via the intercostal artery(ICA)for hepatic carcinoma.Methods A total of 24 patients with hepatic carcinoma(HCC)fed by the ICA underwent TACE via the artery in our hospital.Among the cases,15 were mass type and 9 were nodular type.Plain and enhanced CT or MRI scan were performed before the operation.During the procedure,we carried out intercostal arteriography.Selected catheterization of the feeding branch and then TACE were done.The ICA angiographic features,tumor location,clinical observation,laboratory tests,and imageology were evaluated after the surgery.Results In our cases,the HCCs supplied by the ICA collaterals were located at segments six and/or seven.Angiography showed that all the ICA collaterals originated from the right side at the levels of T8(7.5%,3/40),T9(15.0%,6/40),T10(47.5%,19/40),or T11(30.0%,12/40).The procedure was completed in 22 of the patients.CT scan performed after the procedure showed that the tumor was completely filled with lipiodol in 87.5%(21/24)of the cases.The serum level of AFP decreased significantly in 82.6%(19/23)of the patients.Three patients complained of severe pain at the shoulder after the operation,1 patient had skin itching during TACE,and 5 developed skin erythema after the procedure.Conclusions HCC supplied with ICA collaterals are often detected in the patients who have the tumor at the right posterior segment(S6 and S7)and had received TACE for several times.TACE via the ICA is safe but may leads to skin injuries.

Massive Tumor Pulmonary Embolism Following Transcatheter Arterial Chemoembolization of Hepatocellular Carcinoma

Pulmonary embolism complicated by transcatheter arterial chemoembolization (TACE) is known to be due to the use of large amount of lipiodol as an embolic agent. To our knowledge, massive tumoral pulmonary embolism following TACE and confirmed by surgery has not been described in the literature. In this report, we detail the case of a 49-year-old man in whom cyanosis and hypotension developed abruptly on the day of TACE. Chest CT revealed diffuse low-attenuated lesions in both pulmonary arteries. Histopathological specimens after emergent pulmonary arterial embolectomy confirmed the presence of massive tumor emboli of hepatocellular carcinoma.

In vivo Pharmacokinetics of Adriamycin after Hepatic Arterial Chemo-Embolization with Adriamycin-Lipiodol Emulsion

PURPOSE: To analyse the parameters of in vivo pharmacokinetics such as absorption, distributionin , and excretion of adriamycin patients with hepatocellular carcinoma, and investigate the stagnation of adriamycin, in the liver. MATERIALS AND METHODS: Five patients in whom hepatocellular carcinoma was diagnosed and who were admitted for transhepatic chemoembolization were involved in this study. Fifty mg of adriamycin was mixed with 2.5 mL of water-soluble contrast material and 12 -15 mL of lipiodol, and the emulsion was injected into a selected tumor-supplying artery using a 3-F catheter. Between 1 minute and 72 hours after chemoembolization, peripheral blood samples were then obtained, and from these the blood concentration curve of adriamycin was calculated and applied to a two-compartment model. Using the model, several pharmacokinetic parameters were estimated. RESULTS: The volume of the central and the peripheral compartment was 45 L and 4090.6 L, respectively. 75.14% of adriamycin was delivered to the liver directly, and the absorption rate constant was 2.448/hr. Distribution clearance was 969.3 L/hr, and excretion and metabolic clearance was 136.4 L/hr. CONCLUSION: Using a two-compartment model, the in vivo pharmacokinetics of adriamycin after hepatic arterial chemoembolization were successfully analyzed. On the basis of the parameters determined, it may be concluded that in these five patients, adriamycin remained in the liver in much greater quantities and for longer. Index words : Liver neoplasms Liver neoplasms, chemotherapeutic embolization Chemotherapy, regional

Safety of Superselective Transcatheter Arterial Chemoembolization through Cystic Artery for Treatment of Hepatocellular Carcinoma

PURPOSE: To report on the safety and efficacy of superselective transcatheter arterial chemoembolization( TACE) of tumor feeding branches originating from the cystic artery for the treatment of hepatocellular. MATERIALS AND METHODS: From, May 1995 to, September 1999, eleven HCC patients aged between 38 and 82 (mean, 57.4) years with tumor-feeding branches originating from the cystic artery underwent TACE. In eight, for whom superselection of these branches was possible, TACE was done with the use of Gelfoam and a mixture of Lipiodol and cisplatin, while for three, for whom superselection was impossible, a mixture of Lipiodol and cisplatin only was used. Immediately after TACE, remnant tumor staining was angiographically evaluated,and tumor response was determined by follow-up CT at one month. After procedure, the development of cholecystitis was assessed clinically. RESULTS: Post-TACE angiography showed remnant tumor staining in one patient who underwent embolization with Gelfoam and the mixture of Lipiodol and cisplatin, and in one for whom the mixture of Lipiodol & cisplatin only was used. Among the eight for whom Gelfoam and the mixture of Lipiodol and cisplatin was used,one-month follow-up CT showed compact Lipiodol uptake in five, partial Lipiodol uptake in three, no change in tumor size in six, increased tumor size in one, and decreased tumor size in one. Among the three for whom the mixture of Lipiodol and cisplatin only was used, one-month follow-up CT showed neither Lipiodol uptake nor change in tumor size in one patient, partial Lipiodol uptake and increased tumor size in one, and compact Lipiodol uptake and decreased tumor size in one. Cholecystitis developed in only one patient who underwent embolization with Gelfoam and the mixture of Lipiodol and cisplatin, but was cured by conservative treatment. CONCLUSION: Superselective TACE of tumor feeding branches originating from the cystic artery seems to be a safe and effective method for the treatment of hepatocellular carcinoma.

Percutaneous Microwave Coagulation Therapy combined with Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma: Preliminary Results

PURPOSE: To evaluate the efficacy of percutaneous microwave coagulation therapy (PMCT) combined with transcatheter arterial chemoembolization (TACE) for the treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Twenty-five nodular HCCs [long diameter of 1.2 -10 (mean, 3.4) cm] in 19 patients (15males and 4 females) were treated by PMCT 4-138 days after TACE. Under ultrasound guidance, the carcinomas were punctured with a 14-G guideneedle through which a microwave electrode(25.0 cm in length, 1.6mm in diameter) was inserted. To coagulate the HCCs and surrounding hepatic parenchyma, microwave irradiation at 60W for 45 -60 seconds was then applied. One to three sessions of PMCT were performed at intervals of 2-6 days, and one week to 29 months later, the therapeutic effect was evaluated by spiral CT, angiography, and serum alpha-fetoprotein. RESULTS: Eighteen of 25 HCCs (72.0%) were necrotized completely, but seven (28.0%) recurred. Ninety percent of HCCs smaller than 4 cm in long diameter showed complete remission, but all those larger than 4 cm recurred. Alpha-fetoprotein levels decreased markedly in five patients (26.3%), while in 12 (63.2%), asparate aminotransferase (AST)/alanine aminotransferase (ALT) showed transient elevation. Minor complications occurred after PMCT (mild abdominal pain in 8 patients, fever in 7, pleural effusion in 3, portal vein thrombosis in 1, and hepatic abscess in 1), but in no case was this serious. CONCLUSION: PMCT combined with TACE provides effective and safe treatement for nodular HCCs with a long diameter of less than 4 cm.

Dynamic Images for Prediction of Therapeutic Efficacy of Hepatocellular Carcinoma Treated with Transcatheter Oily Chemoembolization

PURPOSE: To predict the therapeutic efficacy of transcatheter oily chemoembolization(TOCE) in the treatment. MATERIALS AND METHODS: We reviewed the findings of 24 dynamic CT or MR scans examined for the purpose of diagnosis before TOCE, and follow-up CT scans obtained after this procedure. In 24 patients (M:F=20:4) with a mean age of 52.2 years, 43 nodular HCCs with a diameter of 5 cm or less were present. The patients underwent double dynamic CT or MR imaging as one arterial phase 30 seconds after the intravenous injection of contrast media, and this was followed by a delayed phase 5 minutes fter injection. HCCs were then classified as one of four types: Type I, high and low attenuation or intensity during the arterial and delayed phase, respectively; Type II, iso- and low; Type III, iso- and high; and Type IV, high and iso-. In addition, we classified the degree of lipiodol accumulation by HCC nodules as either Grade 5 (fullmoon-like lipiodolization), Grade 2 (about 40%), or Grade 1 (about 20%), as seen on follow-up CT scans after TOCE. RESULTS: Type I provided an accuracy of 72.1% considering to more than 50% lipiodol accumulation. However, a single finding demonstrating high atenuation or intensity during the arterial phase gave an accuracy of 79.1% better than that of Type I. CONCLUSION: A finding of high attenuation or intensity during the arterial phase, as seen on dynamic CT or MR images, provides the best information about the therapeutic efficacy of HCCs treated by means of with TOCE.

Complications after transcatheter arterial chemoembolization via the inferior phrenic arteries: incidence, risk factors, and prophylaxis / 介入放射学杂志

Objective To investigate the frequency, patterns of the angiographic findings and risk factors for development of complications after transcatheter arterial chemoembolization (TACE) via the inferior phrenic artery (IPA).Methods One hundred and sixty eight patients with hepatic tumor fed by the IPA underwent a total of 226 procedures of TACE of the IPA, with combined routine TACEO(88.7%) or without (11.3%) the combination of routine TACE of the hepatic artery. TACE of the malignancy was performed with an emulsion of iodized oil and anti-cancer agents and then followed by gelatin sponge particle injection. The complications were assessed on clinical observation, laboratory tests, and computed tomographic (CT) images after TACE of the IPA; and finally were correlated with the angiographic findings of the IPA. Results The tumor supplied by IPA was noted at initial TACE in 25 (14.9%), at successive TACE in 97 (57.8%), after percutaneous tumor ablation guided by ultrasound in 28 (16.7%), and after hepatic surgery in 18 (10.7%) cases. The abnormal findings on arteriography showed enlargement of the IPA with tumor staining in all cases, dense non-tumor staining in 61(36.3%), artery-to-artery anastomosis in 62(36.9%),arteriovenous shunts in 12(7.1%) cases. 96.4% of these patients complained of shoulder pain during TACE of the IPA. The cumulative complication rate after the procedure was 8.9%,including hiccup in 13 cases (5.8%), chest pain with cough and mild hemoptysis in 9 (4.0%), phrenoparalysis in 8 (3.5%), angina with abnormal ECG in 4 (1.8%), increasing of CPK, AST, and ALT significantly in 6 (2.7%), transient myeloparalysis in 2 (0.9%), and subphrenic abscess in 2 cases (0.9%). Two patients with the subphrenic abscess were successfully treated with percutaneous catheter drainage and antibiotics. The symptoms of these mild complications subsided with symptomatic treatment.Conclusions Complications of TACE via the IPA occur in about 9% of the patients and these complications do not worsen the patients survival. IAP angiographic abnormalities such as arteriovenous shunts, artery-to-artery anastomoses, dense non-tumor contrast staining,are important risk factors for complications of TACE of the IPA.