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.

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).

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.

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.

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.

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

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.