Acute Obstructive Cholangitis after Transarterial Chemoembolization: the Effect of Percutaneous Transhepatic Removal of Tumor Fragment

Acute obstructive cholangitis due to the migration of necrotized tumor fragment is a rare complication occurring after a transarterial chemoembolization. The percutaneous tumor removal procedure following percutaneous transhepatic biliary drainage is an appropriate treatment over endoscopic removal for the relief of acute cholangitis in this case. Following this serial management, no invasive hepatocellular carcinoma of the bile duct recurred after two years of follow-up.

Local Recurrence of Hepatocellular Carcinoma after Segmental Transarterial Chemoembolization: Risk Estimates Based on Multiple Prognostic Factors

OBJECTIVE: To determine the prognostic factors for local recurrence of nodular hepatocellular carcinoma after segmental transarterial chemoembolization. MATERIALS AND METHODS: Seventy-four nodular hepatocellular carcinoma tumors < or = 5 cm were retrospectively analyzed for local recurrence after segmental transarterial chemoembolization using follow-up CT images (median follow-up of 17 months, 4-77 months in range). The tumors were divided into four groups (IA, IB, IIA, and IIB) according to whether the one-month follow-up CT imaging, after segmental transarterial chemoembolization, showed homogeneous (Group I) or inhomogeneous (Group II) iodized oil accumulation, or whether the tumors were located within the liver segment (Group A) or in a segmental border zone (Group B). Comparison of tumor characteristics between Group IA and the other three groups was performed using the chi-square test. Local recurrence rates were compared among the groups using the Kaplan-Meier estimation and log rank test. RESULTS: Local tumor recurrence occurred in 19 hepatocellular carcinoma tumors (25.7%). There were: 28, 18, 17, and 11 tumors in Group IA, IB, IIA, and IIB, respectively. One of 28 (3.6%) tumors in Group IA, and 18 of 46 (39.1%) tumors in the other three groups showed local recurrence. Comparisons between Group IA and the other three groups showed that the tumor characteristics were similar. One-, two-, and three-year estimated local recurrence rates in Group IA were 0%, 11.1%, and 11.1%, respectively. The difference between Group IA and the other three groups was statistically significant (p = 0.000). CONCLUSION: An acceptably low rate of local recurrence was observed for small or intermediate nodular tumors located within the liver segment with homogeneous iodized oil accumulation.

Long-term Results of Percutaneous Ethanol Injection for the Treatment of Hepatocellular Carcinoma in Korea

OBJECTIVE: To evaluate the long-term follow-up results of percutaneous ethanol injection (PEI) for the treatment of hepatocellular carcinoma (HCC) in Korea. MATERIALS AND METHODS: Sixty-eight nodular HCCs initially detected in 64 patients, were subjected to US-guided PEI as a first-line treatment. Long-term survival rates, local tumor progression rates, and complications were evaluated, as were the influences of tumor size and Child-Pugh class on these variables. RESULTS: No major complications occurred. The overall survival rates of the 64 patients at three and five years were 71% and 39%, and their cancer-free survival rates were 22% and 15%, respectively. The overall survival rate of patients with a small HCC (< or = 2 cm) was significantly higher (p = 0.014) than that of patients with a medium-sized HCC (< or = 2 cm). The overall survival rate of patients with Child-Pugh class A was significantly higher (p = 0.049) than that of patients with Child-Pugh class B. Of 59 cases with no residual tumor, local tumor progression was observed in ablation zones in 18, and this was not found to be significantly influenced by tumor size or Child-Pugh class. CONCLUSION: The results of our investigation of the long-term survival rates of PEI in HCC patients in Korea (a hepatitis B virus-endemic area) were consistent with those reported previously in hepatitis C endemic areas. Patients with a smaller tumor or a better liver function exhibited superior survival rates.

Risk Factors for Local Tumor Recurrence after Segmental Transarterial Chemoembolization for Hepatocellular Carcinoma: the Importance of Tumor Located in the Segmental Border Zone

OBJECTIVE: We wanted to evaluate whether tumors located in a segmental border zone are predisposed to local recurrence after performing segmental transarterial chemoembolization for hepatocellular carcinoma. MATERIALS AND METHODS: Seventy-three hepatocellular carcinoma nodules were retrospectively analyzed for local tumor recurrence after performing segmental transarterial chemoembolization by using follow-up CT studies (median follow-up period: 20 months, range: 4-77 months). The tumors were divided into two groups according to whether the lesions were located at the segmental border zone (Group I) or not (Group II). Comparison of the tumor characteristics and chemoembolization methods between the two groups was performed using the chi-square test. The local recurrence rates were compared by Kaplan-Meyer method and analyzed with the log rank test. RESULTS: Local tumor recurrence occurred for 25 hepatocellular carcinoma nodules (42.9%). The follow-up periods, tumor characteristics and chemoembolization methods between Groups l and ll were comparable. The local recurrence rate was 64.0% (16/25) in Group I and 18.8% (9/48) in Group II. The difference was statistically significant on the univariate and multivariate analyses (p = 0.000 for both). CONCLUSION: Tumor location in a segmental border zone was a significant risk factor for local tumor recurrence after performing segmental transarterial chemoembolization for hepatocellular carcinoma.

Radio-frequency Ablation in Patients with Malignant Hepatic Tumor and Experimental Model: Comparison of Expandable Needle and Water-Cooled Needle

PURPOSE: The purpose of this study was to compare the shape and volume of the radio-frequency induced lesions produced by two commercially available radio-frequency ablation (RFA) systems, the expandable and cooled-tip needles, in clinical patients and an experimental model. MATERIALS AND METHODS: A twelve-array anchor expandable needle electrode and a single cooled-tip needle electrode were used to treat hepatic tumors with a single session in 23 patients (20 hepatocellular carcinomas and 3 hepatic metastases) and fourteen patients (10 hepatocellular carcinomas and 4 hepatic metastases), respectively. Twenty RFA induced lesions were created with each system in 10 explanted bovine livers. The shape of the RFA induced lesions were divided into oval lesions along or perpendicular to the axis of the electrode and spherical lesions, and we then calculated the volumes of the RFA induced lesions. RESULTS: Fourteen (61%) lesions of the 23 patients treated with the expandable system were oval perpendicular to the axis of the electrode and nine (39%) of the lesions were spherical. All the lesions (100%) of the 14 patients treated with the cooled-tip needle were oval along the axis of the electrode. In the ex vivo bovine livers, the shape of the all RFA induced lesions was oval perpendicular to the axis of the electrode for the expandable needle, and oval along the axis of the electrode for the cooled-tip needle. The mean diameter and volume of the RFA induced lesions in the patients were 3.35+/-0.56cm and 19.9+/-6.53 cm3, respectively, for the expandable needle and 3.58+/-0.78 cm and 23.19+/-5.27 cm3, respectively, for the cooled-tip needle. In the ex vivo model, the mean diameter and volume of RFA induced lesions were 3.41+/-0.59 cm and 26.59+/-8.02 cm3, respectively, for the expandable needle, and 4.04+/-0.65 cm and 33.82+/-6.16 cm3, respectively, for the cooled-tip needle (p<0.05). CONCLUSION:These results indicate that the shape of RFA induced lesions with the expandable needle were oval perpendicular to the axis of the electrode but those with the cooled-tip needle were oval along the axis of the electrode in both the clinical and experimental models. The cooled-tip needle induced significantly larger lesions than the expandable needle in the clinical patients and the experimental model. We need to consider these characteristic findings for RFA when we are performing such procedures.

Hepatocellular Carcinoma after Radiofrequency Ablation: Recurrent Pattern and Influenting Factor

PURPOSE: To evaluate patterns of recurrence and factors which influence them in radiofreqency (RF) ablation for the treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Between May 1999 and March 2000, 69 patients with 82 HCCs underwent RF ablation for complete necrosis. They were diagnosed by tissue biopsy or tumor marker, and the results of triphasic spiral CT. The indications were that nodular lesions were clearly visualized at sonography, less than 5 cm in size and less than four in number, and that patients had no history of previous treatment. Local therapeutic efficacy such as complete necrosis and marginal recurrence, and new lesions were evaluated by means of triphasic spiral CT performed at least six months after the completion of ablation. We then analyzed the correlation between local therapeutic efficacy and various influential factors such as tumor size, whether the tumor was attached to the portal vein, gross morphology, Child-Pugh classification, and alpha- fetoprotein level before the procedure, as well as the correlation between new lesions and influential factors which included the alpha-fetoprotein level before the procedure, Child-Pugh classification, and multiplicity per person. RESULTS: During a mean follow-up period of 8.95 (range, 6-14) months after RF ablation, the rate of complete necrosis and of marginal recurrence was 91% and 12%, respectively. When a tumor was larger and was attached to a large branch of the portal vien, the incidence of incomplete necrosis and marginal recurrence was greater. The occurrence rate of new lesion was 19.4%. When the alpha-fetoprotien level before the procedure was higher and a tumor was multiple in number, new lesions occurred more frequently. CONCLUSION: Sufficient knowledge of patterns of recurrence and the factors which influence them might improve the therapeutic effects of RF ablation in patients with HCC.

Combined Therapy involving Hepatic Arterial Chemoinfusion through a Percutaneously Implanted Port, and External Irradiation for Advanced Hepatocellular Carcinoma

PURPOSE: To evaluate the efficacy of combined therapy involving intra-arterial hepatic chemoinfusion through a percutaneously implanted port and external irradiation for the treatment of advanced hepatocellular carcinoma. MATERIALS AND METHODS: Fifteen patients (12 males and 3 females; mean age=47.5 years) with advanced hepatocellular carcinoma localized in one lobe and with portal vein thrombosis (stage IVa) were included in this study. To permit chemoinfusion through the hepatic artery, a Chemoport(R); was implanted percutaneously in the right inguinal area via the femoral artery. Initial external radiation therapy lasted five weeks (44 Gy in a daily fraction of 1.8 Gy), with concurrent intra-arterial hepatic infusion of 5-fluorouracil. This initial treatment was followed by five cycles of intra-arterial hepatic infusion of cisplatin and 5-fluorouracil for three consecutive days every month. Two and six months after treatment was begun, the patients underwent CT scanning and angiography, and their response was assessed in terms of change in tumor size and vascularity, the degree of portal vein thrombosis and arterio-portal shunt, and alpha-fetoprotein levels. Any complications arising from this combined therapy and the clinical status of each patient were also followed up during the treatment period. RESULTS: The response rates at months 2 and 6 were 60% and 33.3%, respectively. One patient (6.7%) showed complete remission, and serum alpha-fetoprotein levels decreased significantly in all patients who responded. In five of the twelve patients, the thrombi in the main portal vein showed marked regression. The one-year survival rate was 30% and the median survival period was 10.6 (range, 3.7 to 28) months. The complications arising after treatment involved the catheter-port system (n=2) or were due to gastroduodenitis (n=9). CONCLUSION: In these patients with advanced hepatocellular carcinoma and portal vein thronbosis, combined therapy involving hepatic arterial chemoinfusion through a Chemoport(R) and external irradiation achieved favorable results. Further controlled studies aimed at evaluating the prognostic factors involved are, however, required.

CT Spectrum of Transient Peritumoral Hyperemia after Radiofrequency Thermal Ablation of Hepatic Tumors

PURPOSE: To determine the incidence and pattern of peritumoral hyperemia at CT after radiofrequency thermal ablation of hepatic tumors, as well as its correlation with local marginal recurrence. MATERIALS AND METHODS: Forty-five tumor nodules in 28 patients with hepatocellular carcinoma (n=34) or metastasis (n=11) were treated by RF thermal ablation. Serial follow-up contrast- enhanced CT scans were reviewed by three radiologists for 1) the presence, 2) the morphological characteristics [circumferential, THAD (transient hepatic attenuation difference), nodular form], and 3) the temporal course (acute, persistent, delayed onset pattern) of peritumoral hyperemia after RF thermal ablation. These findings were correlated with the frequency of recurrence at the margin of the treated tumors. RESULTS: The frequency of acute hyperemia observed on immediate follow-up CT scans after RF ablation was 71% (32/45). There was the local recurrence in nine of 32 tumors (28%) with hyperemia and in one of 13 (8%) without hyperemia (p>0.05). Among 32 tumors, the circumferential form was observed in 22 (69%); the THAD form in eight (25%); and the nodular form in two (6%). Marginal recurrence was noted in five of 22 tumors circumferential tumors (23%), in three of eight (38%) with the THAD form, and in one of two (50%) which were nodular. Among 32 nodules, an acute transient pattern was noted in 21 (66%), a persistent pattern in nine (28%), and a nodular pattern in two (6%). There was marginal recurrence in two (10%) of 21 tumors with acute transient hyperemia, in six (67%) of nine with persistent hyperemia, and in both tumors with delayed-onset hyperemia. There was significant correlation between the pattern of persistent/delayed-onset hyperemia and marginal tumor recurrence of (p=0.001). CONCLUSION: Although peritumoral hyperemia after RF thermal ablation therapy is a frequent transient finding at follow-up imaging studies, its temporal pattern may help detect early marginal tumor recurrence.

Shrinkage Rate of Necrotic Lesion after Radiofrequency (RF) Ablation of Hepatocellular Carcinoma: Correlation with Marginal Recurrence and Influencing Factors

PURPOSE: To compare the CT findings of hepatocellular carcinomas (HCCs) immediately after radiofrequency (RF) ablation with those obtained at six months' follow-up, to analyse the relationship between degree of shrinkage of a necrotic lesion and marginal recurrence, and to evaluate the factors influencing shrinkage. MATERIALS AND METHODS: We retrospectively evaluated 54 patients with 62 HCCs who underwent only RF ablation between May 1999 and July 2000. For six months after ablation, all had been free from marginal recurrence ad new-growth tumors. The findings of six-month follow-up CT were compared with those obtained immediately after RF ablation, and the volume of each necrotic lesion was calculated and compared. In terms of degree of shrinkage, tumors were classified as belonging to either group I (below 50%), group II (50-80%) or group III (above 80%). Each tumor was analysed in terms of its Child-Pugh classification, vascularity at CT, size, treatment details, the post-ablation appearance of its margins, and the presence, during necrosis, of peritumoral vessles and air bubbles. For statistical evaluation, Fisher's exact test was used. Shrinkage after ablationwas correlated to marginal recurrence during a period of more than one year. RESULTS: The Follow-up CT at six months showed that since immediately after ablation, necrotic lesions had shrunk by an average of 72%. Peritumoral vessels were seen in 12 of 14 cases in group I (86%), three of 13 in cases of group II (23%), and 11 of 35 in group III (31%)(p=0.001). Immediate CT revealed the presence of air bubbles in two cases in group I (14%), five in group II (38%), and 24 in group III (69%)(p<0.05). At follow-up CT performed during a period of more than one year, marginal recurrence was noted in four cases in group I, two in group II and two in group III (p<0.05). CONCLUSION: When a necrotic lesion contains no peritumoral vessels but does contain air bubbles, the degree of post-RFablation shrinkage increases. The greater the shrinkage, the less the marginal recurrence rate.

The Feasibility of CT-Guided Percutaneous Ethanol Injection Therapy for Hepatic Tumors

PURPOSE: To describe the technical features of CT-guided percutaneous ethanol injection therapy (PEIT) for hepatic tumors that are undetectable or inaccessible under ultrasound guidance, to analyze its short-term therapeutic results, and to discuss its feasibility and limitations with a review of the related literature. MATERIALS AND METHODS: During a 22-month period, 17 patients with 28 hepatic tumors (27 hepatocellular carcinomas and one metastasis) underwent 38 sessions of CT-guided PEIT. Follow-up CT scanning was also performed. All tumors were undetectable or inaccessible under ultrasound guidance. The quantity of ethanol injected depended on their maximum diameter, which was 0.9 -5.1 (mean, 2.2) cm. To determine the puncture site and direction of the needle, the graduated grid system was used. A 21 or 22-G PEIT needle was introduced into the tumor stepwise, with intermittent CT monitoring, and if the CT images obtained immediately after initial injection demonstrated incomplete perfusion, an additional dose of ethanol was administered. During the follow-up period of 28 -619 (mean, 261) days, three-phase spiral CT scans were obtained. We focused on whether or not a viable portion of ablated tumor was present, and if so, the interval during which the extent of viable portion had changed, as well as the CT findings which suggested a predisposition to incomplete ablation. RESULTS: PEIT was successfully performed in all patients. During each session, 3 -30 (mean, 12.1) mL of ethanol was injected for 35 -115 (mean, 85) mins, with 1 -7 (mean, 3.7) trials to determine the puncture site and needle direction. The follow-up CT results showed that 20 tumors (71.4%) contained no viable portion, that this portion had decreased in four (14.3%), and was unchanged or had increased in four (14.3%). In the eight tumors for which multiple sessions were required, follow-up CT showed that the viable portion was absent or had decreased in size in all except one. In five of the patients with a tumor containing a viable portion at follow- up CT, the procedure was incomplete because of unendurable pain (n = 2) or noncooperation (n = 3). A CT finding which suggested a predisposition to incomplete ablation was a poor margin (n = 3). Complications included severe pain (n = 6) and scanty peritoneal hemorrhage (n = 1). CONCLUSION: Despite several limitations of our study, the therapeutic results of CT-guided PEIT appeared to be similar to or slightly worse than those of well-established ultrasound-guided PEIT with the former procedure, however, intermittent CT monitoring indicates whether perfusion is complete, and for this reason, CT-guided PEIT is believed to be an effective treatment modality when a hepatic tumor is undetectable or inaccessible under ultrasound guidance.

Radiofrequency Thermal Ablation of Malignant Hepatic Tumors: Post-Ablation Syndrome

PURPOSE: To evaluate post-ablation syndrome after radiofrequency thermal ablation of malignant hepatic tumors. MATERIALS AND METHODS: Forty-two patients with primary (n=29) or secondary (n=13) hepatic tumors under-went radiofrequency thermal ablation. A total of 65 nodules ranging in size from 1.1 to 5.0 (mean, 3.1) cm were treated percutaneously using a 50W RF generator with 15G expandable needle electrodes. We retrospec-tively evaluated the spectrum of post-ablation syndrome including pain, fever(> or =38 C degrees), nausea, vomiting, right shoulder pain, and chest discomfort according to frequency, intensity and duration, and the findings were cor-related with tumor location and number of ablations. We also evaluated changes in pre-/post-ablation serum aminotransferase(ALT/AST) and prothrombin time, and correlated these findings with the number of abla-tions. RESULTS: Post-ablation syndrome was noted in 29 of 42 patients (69.0%), and most symptoms improved with conservative treatment. The most important of these were abdominal pain (n=20, 47.6%), fever (n=8, 19.0%), and nausea (n=7, 16.7%), and four of 42 (9.5%) patients complained of severe pain. The abdominal pain lasted from 3 hours to 5.5 days (mean; 20.4 hours), the fever from 6 hours to 5 days (mean; 63.0 hours). and the nau-sea from 1 hour to 4 days (mean; 21.0 hours). Other symptoms were right shoulder pain (n=6, 14.3%), chest discomfort (n=3, 7.1%), and headache (n=3, 7.1%). Seventeen of 20 patients (85%) with abdominal pain had a subcapsular tumor of the liver. There was significant correlation between pain, location of the tumor, and number of ablations. After ablation, ALT/AST was elevated more than two-fold in 52.6%/73.7% of patients, respectively but there was no significant correlation with the number of ablation. CONCLUSION: Post-ablation syndrome is a frequent and tolerable post-procedural process after radiofrequency thermal ablation. The spectrum of this syndrome provides a useful guideline for the post-ablation management.

Radiofrequency Ablation of Small Hepatocellular Carcinoma: Early Experience of Efficacy and Safety

PURPOSE: To evaluate the efficacy and safety of radiofrequency (RF) ablation for the treatment of small hepato-cellular carcinoma (HCC). MATERIALS AND METHODS: Forty-four patients with 51 HCCs underwent ultrasound guided RF ablation using ex-pandable needle electrodes and a monopolar RF generator. The patients were not considered suitable candidates for surgery or declined this option, and had no history of previous treatment. Mean tumor diameter was 2.5 cm (range, 1.0 -4.0 cm). Therapeutic efficacy was evaluated by means of three-phase helical computed tomography (CT) performed at least one month after the completion of ablation. The recurrence rate was also evaluated by follow-up CT at least four months after treatment. RESULTS: Using RF ablation, complete necrosis was achieved in 48 of 51 tumors (94%). Among 20 patients in whom follow-up CT was performed at least four months after ablation, one (5%) showed marginal recurrence and in another (5%) there was recurrence in remote liver parenchyma. We experienced neither procedure-re-lated mortality nor major complications which required specific treatment. Three minor complications (one small pneumothorax and two cases of intraperitoneal bleeding) occurred, but these disappeared without specific treatment. CONCLUSION: RF ablation using an expandable needle electrode showed a high rate of complete necrosis and a low rate of complications. The technique is therefore considered effective and safe for the local control of small HCCs.

Clinical Study on the treatment of colorectal liver metastasis using PRFA in combination with PEI / 中国医师杂志

Objective To assess the local treatment efficacy of percutaneous radiofrequency ablation(PRFA) in combination with percutaneous ethanol injection(PEI) therapy protocol for liver metastases in patients with colorectal cancer.Methods From February 2000 to February 2004, total of 61 liver metastatic lesions(1.5～7.8 cm) from 37 colorectal cancer patients were ablated by using RF-2000 generator and 10-needle LeVeen electrode percutaneously guided by B-ultrasound.Tumors larger than 2.5 cm in diameter were treated by multiple overlapping radiofrequency ablations encompassing the entire lesion as well as a rim of normal liver tissue(approximately 1.0 cm).PEI was performed additionally.The Chiba needle and Quadra-Fuse multi-pronged injection needle were used for tumors ranged 1～2 cm and for those larger than 3 cm respectively.Results The procedures were performed successfully in all patients.The post-PRFA/PEI complication rate was 5.4%.The follow-up rate was 97.3%(36/37).Thirteen patients achieved a complete response(CR),and 21 achieved a partial response(PR).The effective rate(CR+PR) was 94.4%.The patients' survival rates were 97.2% at 1 year,75.0% at 2 years,and 52.8% at 3 years respectively.Conclusion The results of this study suggest that the treatment protocol of PRFA in combination with PEI was an effective mini-invasive local ablation therapy,which was part of the comprehensive management of the colorectal liver metastases.

Microwave Tissue Coagulation: Effects of Power and Treatment Time on Coagulation size

PURPOSE: To determine the effects of power and coagulation time on lesion size of ex-vivo bovine liver using microwaves. MATERIALS AND METHODS: Six bovine livers were divided into two groups(first group: 30W output, secondgroup: 60W output) and microwave coagulation was performed for 30, 60, and 120 sec. thermal injury site was thenobserved by means of sonography, and the maximal transverse diameter of the echo-change portion after microwave coagulation was measured. On the section of specimen, maximal transverse diameters of the thermal injury site weremeasured by gross inspection and compared with the result of sonographic measurement. RESULTS: Maximal transversediameters of hyperechoic lesions of the first group, as seen on sonography were 8.3 mm, 12.2mm, and 15.6mm, andthe maximal transverse diameters of thermal injury sites on gross specimens were 9.1mm, 12.0mm, and 15.1mm,respectively. Maximal transverse diameters of hyperechoic lesions of the second group, as seen on sonography, were12.1 mm, 17.4 mm, and 21.2 mm and maximal transverse diameters of thermal injury sites on gross specimens were13.2 mm, 16.0 mm, and 20.0 mm, respectively. Statistically maximal transverse diameters of hyperechoic lesions, asseen on sonography, correlated closely with the gross findings of maximal transverse diameters of thermal injurysites(p<0.05). CONCLUSION: Maximal transverse diameters of thermal injury sites were significantly increased asthe output of the microwave coagulator and the duration of coagulation time increased(p<0.05).

Color Doppler Ultrasound of Hepatocellular Carcinoma: Evaluation of Recurrence after Transcatheter Arterial Chemoembolization

PURPOSE: To evaluate the efficacy of color and pulsed Doppler ultrasound (US) for the detection of arterial revascularization of hepatocellular carcinoma (HCC) after transcatheter arterial chemoembolization (TACE). MATERIALS AND METHODS: One hundred and four histologically proven HCCs (0.7-12.5 cm, mean 4.14 cm) of 87 consecutive patients who had undergone TACE using a Lipiodol-chemoagent suspension were examined using color Doppler equipment. The criteria for diagnosing arterial revascularization of HCC were detection of inward blood vessels within HCC and demonstration by spectral Doppler US of pulsatile arterial flow within the vessel. Color Doppler US was prospectively performed using a multi-Hertz probe (2.5-5 Hz), and was followed by digital subtraction angiography (DSA). RESULTS: In 37 of 104 HCCs in 87 patients treated with TACE, color and spectral Doppler US demonstrated intratumoral arterial flows, with peak systolic velocity of 4.2-220 (mean, 59) cm/sec. DSA revealed neovascularity or tumor stains in 38 HCCs (3.4-12.5 cm, mean 5.9 cm in size) including 37 which on Doppler US showed arterial flow. The remaining 66 of 104 HCCs (0.7-6.3 cm, mean 3.2 cm) did not stain during DSA. Doppler US showed a false negative result in only one HCC (4.6 cm, located at segment VII of the Couinaud classification), which stained faintly during DSA. The sensitivity, specificity, and accuracy of color and spectral Doppler US used for the detection of recurrent HCC were 97.4%, 100%, and 99%, respectively. CONCLUSIONS: Color and spectral Doppler US is an effective method for the evaluation of arterial revascularization of HCC after TACE.

Hepatocellular Carcinoma with Extensive Hepatic Artery Injury: Transcatheter Arterial Chemoembolization through Collaterals after Coil Embolization of Gastric Arteries

PURPOSE: To evaluate the efficacy and safety of transcatheter arterial chemoembolization(TACE) after coil embolization of the gastroduodenal artery in hepatocellular carcinoma cases with multiple collateral arteries caused by proper hepatic artery injury. MATERIALS AND METHODS: Between March 1997 and November 1998, a prospective trial of transcatheter arterial chemoembolization (TACE) was performed through collaterals from the gastroduodenal artery of 31 hepato-cellular carcinoma patients with extensive proper hepatic artery injury due to repeated TACE. Among this number, 16 (group A) underwent TACE after coil embolization of the right gastric and gastroduodenal artery. The other 15 patients (group B) underwent TACE without coil embolization. The two groups had the same T-NM stage and Child-Pugh status. During the follow-up period, group A underwent additional TACE 3.3 times, and group B 2.8 times. The therapeutic effect of TACE was evaluated with computed tomography and by measuring alpha-fetoprotein levels. Complications were evaluated by means of gastrofibroscopy, laboratory data, and evalvation of the patients clinical symptoms. The results obtained after six months and one year were compared within and between each group. RESULTS: At six months follow-up, CT findings had improved or were unchanged in 11 patients(69 %) in group A, and four patients(27 %) in group B(p=0.032). In ten patients in each group, the level of alpha-fetoprotein was above 200 ng/ml. Its level was decreased in five patients(50%) and three patients(30%), respectively. The six-month survival rate was 81 %(13/16) in group A and 67 %(10/15) in group B (p=0.43), while the one-year survival figures for these two groups were 50 %(8/16) and 20%(3/15), respectively(p=0.135). In group A, the CT findings were steady in five out of eight patients(63%), while in group B, CT findings showed that tumors with increased alpha-fetoprotein levels had increased in size and/or number. In group A, it was found that in two (33 %) of six patients whose initial alpha-fetoprotein level was over 200ng/nl, this level had decreased. Acute gastric ulcer was found in two patients in group A, and mild acute pancreatitis in one. One patient in group B was also found to have an acute gastric ulcer. CONCLUSION: In view of the advanced disease stage of patients for whom a long period has elapsed since initial diagnosis, TACE after coil embolization of gastric arteries may be a safe and acceptable method for use in the treatment of hepatocellular carcinoma with extensive hepatic artery injury.

Effect of Holmium-166 Injection into Hepatocellular Carcinomas (SK-HEP1) Heterotransplanted in Mice

PURPOSE: Holmium-166(H0-166) is a potent beta-emitter with a short half-life(26.83 hours) and high betaenergy(1.85MeV), and its necrotic effect on breast carcinoma has been proved. In cases of hepatocellularcarcinoma, Ho-166 can therefore be used for internal radiation therapy. The purpose of this study is to evaluatethe therapeutic effect of Ho-166 on hepatocellular carcinomas and to estimate the required dosage, according totheir size. MATERIALS AND METHODS: Tumor cells of hepatocellular carcinomas(SK-HEP1) were subcutaneouslyheterotransplanted into 71 nude mice and 71 hepatocellular carcinomas less than 2cm in diameter were grown. Ho-166was directly injected into a tumor at a dosage of between 0.5mCi(18.5MBq) and 3.0mCi(11MBq). After initialinjection of Ho-166, tumor uptake and radioactivity were indicated by gamma camera scanning. Hepatocellularcarcinomas in a control group of 20 mice were injected with 0.025ml of normal saline(n=10) and chitosansolution(n=10). Pathologic examination was performed and the necrotic tumor area was measured with an imageanalyzer. RESULTS: All specimens of Ho-166-injected hepatocellular carcinomas showed coagulation necrosisconsistent with radiation effect, while the control group did not show necrosis. As the injected dosage of Ho-166was increased, the necrotic area extended proportionally and the dosage required for total necrosis was calculatedaccording to tumor size. Gamma scintigraphy showed that injected Ho-166 had accumulated within the tumor, withoutthe accumulation of radioactivity in other organs ; the required dosage could be predicted on the basis ofradioactivity count indicated by a gamma camera. CONCLUSION: High-energy beta radiation emitted by Ho-166 can besufficient to kill tumor tissue without associated radiation damage to neighboring organs; intratumoral injectionis thought to be a promising therapeutic approach and a new method for the treatment of hepatocellular carcinoma.

Intra-Arterial Cis-Diamminedichloroplatinum Infusion Treatment for Widespread Hepatocellular Carcinoma

PURPOSE: To evaluate the therapeutic efficacy of intra-arterial infusion of Cis-Diamminedichloroplatinum (C-DDP) for the treatment of hepatocellular carcinomas with widespread involvement. MATERIALS AND METHODS: We retrospectively analyzed 22 patients who between July 1994 and June 1996 had undergone intra-arterial c-DDP infusion therapy for the treatment of hepatocellular carcinomas with widespread involvement. The hepatomas involved both lobes in ten, portal venous obstructions in fourteen, arterio-portal shunts in nine, and arterio-venous shunts in two. Proper hepatic artery was selected for infusion of 100mg/BSA of C-DDP. The same procedure was repeated every 3 to 4 weeks, and the total number of infusions was 65. On the basis of WHO criteria, response was classified as complete remission, partial remission, stable, or progression of the disease. Six-month and one-year survival rates were estimated, and adverse reactions were evaluated. RESULTS: Complete remission was noted in one patient (4.5%) and partial remission in three (13.6%), while 18 showed no response or progression after treatment. The six month survival rate was 59.1%, and the one-year survival rate was 32.1%. Adverse reactions included nausea/vomiting (59.8%), abdominal pain (9.2%), fever (8.0%), acute renal failure (2.3%) and hepatic encephalopathy (1.1%). These adverse reactions were, however, transient and reversible. CONCLUSION: Although the response rate is not high, intra-arterial C-DDP infusion therapy can be used as an alternative treatment for hepatocellular carcinomas with widespread involvement; adverse reactions are tolerable.

Treatment of Single Nodular Hepatocellular Carcinoma Using Combination Methods of Percutaneous Ethanol Injection Therapy and Subsequent Transcatheter Arterial Chemoembolization

PURPOSE: To evaluate the usefulness of combination therapy composed of percutaneous ethanol injection treatment and subsequent transarterial chemoembolization in the treatment of single nodular hepatocellular carcinoma(HCC). MATERIALS AND METHODS: A total of eight patients with single nodule hepatocellur carcinoma (+/-5cm)were treated with a combination of initial percutaneous ethonol injection therapy(PEIT) and, a week later, transcatether arterial embolization(TAE). CT was performed 3 weeks after TAE to assess whether or not lipidol uptake had occurred. If lipiodol was accumulated in the nodule, the necrotic rate of the tumor was calculated by the following equation: (initially observed tumor volume - volume of nodule in which lipidol uptake occurred)x100/Initially observed tumor volume. Follow-up CT scan was performed every third or fourth month to evaluate tumor growth or recurrence. RESULTS: A nodule in which lipidol uptake occurred was seen in four of the eight patients; in one of these, a tumor-confirmed by angiogaphic examination and laboratory data-recurred twelve months later. The mean necrotic rate of a tumor treated PEIT alone was 83%(range, 37%-100%). CONCLUSION: Although limited in numbers of cases we studied, use of combination therapy composed of PEIT and subsequent TAE, appears to be effective in achieving the high rate of tumor necrosis as well as in the evaluation of the tumor during follow-up.

Nodular hepatocellular carcinoma: treatment with intraarterial injection of I-131 Lipiodol

Twenty four patients with hepatocellular carcinoma who refused surgery or had unresectable tumor ranging 2.5 to 8.0 cm in size were treated with intrahepatic arterial injection of iodine-131-labeled iodized oil (I-131 Lipodol) in an attempt to achieve internal radiation of tumor. 555-2,220 MBq in 3-8 ml of I-131 Lipiodol was injected into the hepatic artery or proximal to the tumor feeding vessel depending on the tumor size. Tumor size reduction was observed in 88.9% of tumor smaller than 4.0 cm in diameter, 65.5% between 4.1 to 6.0 cm, and 25.0% of larger than 6.1cm, respectively. The tumor size reduction was corresponded to the gradual drop of serum AFP levels, decreased uptake on gallium-67 scintigraphy, and devascularization on follow-up angiography. Tumors having significant A-V shunts revealed further tumor growth. Adverse reactions from the treatment include fever, mild abdominal pain, nausea and elevation of transaminases. These have been mild and well-tolerated by the patients. This method was able to provide long term local control without complications related to thyroid, lung, GI tract and bone marrow.