A New Technique for Superselective Catheterization of Arteries: Preshaping of a Micro-Guide Wire into a Shepherd's Hook Form

OBJECTIVE: We wanted to introduce a new technique for superselective catheterization of arteries with preshaping of a micro-guide wire into a shepherd's hook form, and this is useful for superselection of small arteries branching at an acute angle from a large parent artery for the treatment of tumors and hemorrhages. MATERIALS AND METHODS: We developed a superselective catheterization technique by using preshaping of a micro-guide wire into a shepherd's hook form. We encountered six patients in our practice for whom we failed to catheterize the small tumor-feeding arteries that branched at an acute angle from wide parent arteries during chemoembolization of hepatocellular carcinoma; the parent arteries were the right inferior phrenic artery (n = 4) and the left gastric artery (n = 1) from the celiac axis with celiac stenosis due to compression by the median arcuate ligament and the proper hepatic artery from the gastroduodenal artery (n = 1) in a patient who had celiac axis occlusion with collateral circulation via the pancreaticoduodenal arcade from the superior mesenteric artery. In these consecutive six patients, we tested the usefulness of this new technique with employing preshaping of a micro-guide wire into a shepherd's hook form for superselective catheterization of targeted vessels. RESULTS: The target arteries were successfully catheterized and satisfactory transcatheter arterial chemoembolization was performed in all six patients. There were no significant complications such as arterial dissection. CONCLUSION: We developed a technique that is effective for superselection of vessels with preshaping of micro-guide wire into a shepherd's hook form, and we successfully applied it during chemoembolization of hepatocellular carcinoma. This technique can be useful for superselection of small arteries that branch from a large parent artery at acute angles for the treatment of tumors and hemorrhages.

Morphologic Characteristics of Hepatocellular Carcinoma in Patients with more than 5 Year-Survival

PURPOSE: To determine which morphologic and radiologic characteristics and common features of HCC in patients with a survival time of more than five years are useful for prognosis and appropriate therapeutic modality. MATERIALS AND METHODS: Among 178 patients in whom HCC was diagnosed at our hospital and who underwent dynamic CT and angiography, we retrospectively reviewed the cases of 12 who survived more than five years. Initially, the gross finding, size, number, vascularity of HCC, and extent of portal vein invasion were analyzed. The presence of lymph node enlargement was investigated during follow-up study and in cases confirmed surgically, the results were compared with the histopathologic findings. The therapeutic modalities of the 12 patients were as follows; only surgical resection, 3 cases(1 case: re-operation); surgical resection with transarterial chemoembolization(TAE), 5 cases(1 case: re-operation); only TAE, 4 cases (1 case: combined with hollium in-jection); and at present, expiry after survival for more than five years, 3 cases; survival with disease, 3 cases and survival without disease, 6 cases(2 cases: re-operation after recurrence). RESULTS: In 12 patients who survived more than five years, initial gross classification was single nodular type in 11 cases and massive type in one case; all showed typical ypervascularity on dynamic CT and hepatic angiography. With regard to extent of portal vein invasion, two cases showed involvement of the lobar branch and in one case invasion of the segmental branch was noted. In the other nine cases there was either invasion of the distal small branch or no definite portal vein invasion. HCC size ranged from 2 to 10 (mean, 5)cm. In eight cases involving surgical resection (reoperation : two cases), the histopathologic findings indicated, pre-dominantly, the trabecular type and Edmondson grade II -III. The exception was one case of grade III -IV. In eight cases of single HCC at the time of diagnosis, multiple recurrent HCCs were present. In four cases tumors did not recur, and follow-up study revealed no lymph node enlargement. CONCLUSION: Initial radiologic findings [number of tumors (one only), gross classification (nodular type), vascu-larity(hypervascularity), portal vein invasion(lesser extent), histopathologic findings(predominantly trabecular type)] and the absence of lymph node enlargement are thought to be more important factors than tumor size in the prognosis of HCC. If initial examination of HCC reveals the above mentioned radiologic features, a more aggressive and active therapeutic management approach should be carefully considered.

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.

Prognostic Factors in Transcatheter Arterial Chemoembolizationc of Hepatocellular Carcinoma: Analysis of Morethan 3 Year Survivors

PURPOSE: To determine which prognostic factors contribute to long-term survival after transcatheter arterialchemoembolization(TACE) of hepatocellular carcinoma. MATERIALS AND METHODS: In 100 patients who expired withinone year and 84 who survived or have survived for more than 3 years after TACE, prognostic factors wereretrospectively evaluated. TACE was accomplished by hepatic arterial infusion of a suspension of Lipiodol andanticancer drugs(Mitomycin-C and Adriamycin), either alone or followed by gelfoam embolization. Fisher 's exacttest of probability was used to determine which prognostic factors were statistically significant. RESULTS:Statistically significant prognostic factors were as follows: Child classification(p0.05). CONCLUSION: The prognosisof patients with hepatocellular carcinoma treated by TACE was affected favorably by good liver function(Childclassification A), low alphafetoprotein value, nodular or massive-type tumor, patent main and first-order portalvein, and hypervascular tumor.

Embolization of Seve re Arterioportal Shunts in the Patients with Hepatocellular Carcinoma: Safety and Influence on Patient Survival

PURPOSE: To evaluate the safety and the influence of embolization of severe arterioportal shunts, and the effect of the procedure on the survival rate of patients with hepatocellular carcinoma combined with portal vein tumor thrombosis. MATERIALS AND METHODS: This study involved a total of 54 patients with hepatocellular carcinoma in whom hepatic arteriography revealed severe arterioportal shunt. From among this total, 34 patients (embolization group) underwent chemoinfusion after shunt embolization, while 19 (control group) underwent chemoinfusion only. The embolic materials included PVA particles and/or Gelfoam pieces. The frequency of postembolization symptoms (Chi-squared test) and changes in laboratory values (paired t-test) were compared between the two groups, and shunt improvement was also evaluated. Patient survival was tested using the Kaplan-Meier method. RESULTS: Fever and RUQ pain were more frequent in the embolization group (p<0.001). The complications of embolization included severe postembolization syndrome (n=1), acute hepatic failure (n=2), hepatic infarction (n=1), and sepsis (n=1). There were no significant changes in laboratory values. Among the 28 patients (24 of embolization group and four of control group) who underwent follow-up angiography, arterioportal shunt became less severe or disappeared in ten of the embolization group. For the embolization and control groups, the mean survival interval was 29.5 +/-5.4 weeks and 10.3 +/-3.1 weeks (p=0.0002), respectively. The best results were seen in the PVA particle group (p=0.01). CONCLUSION: The embolization of severe arterioportal shunts is relatively safe and increases patient survival rate.

The Effect of Subsegmental Transcatheter Arterial Chemoembolization in Hepatocellular Carcinoma: PathologicCorrelation

PURPOSE: To assess the effectiveness of subsegmental transcatheter arterial chemoembolization(TAE) forhepatocellular carcinomas(HCCs) on the basis of tumor necrosis rate. MATERIAL AND METHODS: Between May 1996 andMarch 1998, ten patients with single HCC after subsegmental TAE underwent surgical resection. Subsegmental TAE wasperformed by injecting a mixture of lipiodol and adriamycin followed by gelatin sponge particles into the distalbranches of the subsegmental arteries. Tumor size and the extent of necrosis were analyzed in ten resectedlesions, and in all patients, complications after subsegmental TAE were assessed. RESULTS: The size of resectedtumors ranged from 1 to 5,5cm. On histological examination, complete necrosis was seen in 6 to 10 resected lesionsand 95% necrosis in three. In the remaining lesion, 85% necrosis had occured. Complete necrosis was noted in 4 of6 small HCCs(less than 3cm in diameter), while in the remaining two the extent of necrosis was 95%. Nocomplications were observed. CONCLUSION: For the treatment of HCC, subsegmental TAE is safe and effective.Curative therapy must, however, involve follow-up and repeated TAE.

Combined Therapy of Transjugular Intrahepatic Portosystemic Shunt(TIPS) and Transcatheter Hepatic ArteryChemoembolization (TACE) in Patients with Hepatocellular Carcinoma and Gastroesophageal Variceal Bleeding

PURPOSE: To evaluate the efficacy of combined TIPS and superselective TACE therapy in patients withhepatocellular carcinoma and variceal bleeding. MATERIALS AND METHODS: Of a total of 132 patients who underwentTIPS, 14 had hepatocellular carcinoma ; of these six with a patent main portal vein who had undergone TACE wereincluded this study. One underwent TIPS 13 months after TACE, and five underwent TACE at various points during theTIPS follow-up period. TIPS followed the standard procedure, while TACE involved superselective segmental orsubsegmental embolization in four patients, lobar artery embolization in one, and non-selective chemoembolizationin one with on advanced tumor. RESULTS: Except for mild hepatic encephalopathy in two patients, no clinicallysignificant immediate complication was seen after TIPS or TACE. Three patients died due to hepatic failure ; theysurvived for one to three months after combined therapy, a mean of 2.3 months. After combined therapy, otherpatients survived for between five and 49 (mean, 22) months. CONCLUSION: Combined TIPS and TACE therapy iseffective for the threatment of patients with hepatocellular carcinoma and esophagogastric variceal bleeding.

Survival Rates in Hepatocellular Carcinoma Patient Treated by Transarterial Chemoembolization: Comparison withOperable and Inoperable Cases

PURPOSE: To pr6edict the prognosis of hepatocellular carcinoma (HCC) patients who underwent transarte6rialchemoembolization(TACE). MATERIALS AND METHODS: The study unvestigated the one- and two-year survival rates of 211patients who were divided into two groups : 74 operable Child's grade A or B cases, and 137 inoperable casesinvolving Child's grade C or poor prognostic factors such as metastasis, main portal thrombus, and total bilirubinabove 2.0mg/dl. Cumulative survival curves were obtained by the Kaplan-Meier method, beginning with the day of thefirst TACE. RESULTS: The one- and two-year cummulative survival rates were 80.8% and 47.9% for the 74 operablecases and 37.6% and 14.0% for the 137 inoperable cases, respectively(P<0.01). CONCLUSION: The prognosis of HCCpatients who underwent TACE can be predicted by classifying then into two groups, operable or inoperable cases.

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.

Effectiveness of Transarterial Chemoembolization in Hepatoblastoma: A Preliminary Study

PURPOSE: To evaluate the therapeutic effectiveness and useful as well as the ness, systemic effect andeffectiveness, of preoperative TACE when used in patients with unresectable or high risk hepatoblastoma. MATERIALS AND METHODS: We retrospectively evaluated four patients with pathologically proven hepatoblastoma. One was maleand three were female, and they were aged between 8 and 27 (mean, 15) months. All underwent selective hepaticangiography and chemoembolization after superselection of tumor feeding vessels. Cisplatin 90mg/m2 (50-80mg),adriamycine 40mg/m2 (20mg) and lipiodol suspension 4cc ere used and chemotherapeutic angents. Embolization wasthen performed, gelfoam particles. TACE was repeated at intervals of 3 weeks, and after the second episode, allpatients underwent hepatic resection. To evaluate changes in the size, volume, internal texture and margin of themass, as well as the systemic toxicity of chemotherapeutic drugs, we performed contrast-enhanced CT and checkedAFP, CBC and GOT/GPT before and after TACE. RESULTS: In all patients, TACE was successfully performed and majorproblems related to the procedure and toxicity of chemotherapeutic agents used were not noted. The largestdiameter and volume of tumors were reduced by 33% (from 8.3 to 5.6cm) and 69% respectively. Tumor necrosis wasevident in all patients. Lipiodol uptake by tumors was homogenous and tumors were well distinguished from normalparenchyma. Compared to pre-TACE, serum alpha-feto-protein was reduced from 994(range:615-1690ng/ml) to 46ng/ml(42-47ng/ml)after the second TACE, and six months after surgery was in the normal range(13ng/ml;3-23ng/ml).SGOT/SGPT levels were temporally elevated after TACE but normalized within a few weeks. CONCLUSION: TACE can be auseful technique for preoperative treatment of hepatoblestomas. In tomors which are high-risk or inoperable, thetherapeutio agents involved were not shown to be toxic.

CT Findings of Hepatoblastoma Before and After Chemotherapy: Correlation with Pathologic Features

PURPOSE: The purpose of this study was to analyze the CT findings of hepatoblastoma before and afterchemotherapy, and to compare them with surgical and pathologic features. MATERIALS AND METHODS: Twelvehepatoblastoma patients underwent chemotherapy prior to surgery; in all cases, CT scanning was performed beforeand after chemotherapy. We reviewed the findings with special attention to changes in tumor volume, the extent andpattern of contrast enhancement, the extent of low-attenuation area in the tumor, the presence of a septum, andcalcification or ossification within the mass before and after chemotherapy. Post-chemotherapy CT findings werecompared with operative and pathologic findings. RESULTS: After chemotherapy, the volume of the tumor massdecreased in all patients, and the extent of involved segments decreased in nine(75%), the non-enhancing areawithin the mass, on the other hand, increased in nine (75%). On pre-chemotherapy CT, calcifications were detectedin seven patients(58%), and on post-chemotherapy CT, in nine (75%); the extent of calcification increased in sevenpatients. On the basis of CT findings, viable tumor and necrosis areas could not be distinguished. Massivecalcification or an osteoid mixed with loose connective tissue was noted in the mesenchymal component of thetumor; the whirling pattern of enhancement within the area of low density asen on CT scanning corresponded toosteoid mixed with loose connective tissue, which contained rich blood vessels. CONCLUSION: We describe the CTfindings of hepatoblastoma both before and after chemotherapy, highlighting the changes which occurred. Anunderstanding of these changes is helpful for the proper management of this condition.

Transcatheter Arterial Chemoembolization of Liver Metastasis of Gastrointestinal Leiomyosarcoma

PURPOSE: To evaluate the usefulness of transcatheter arterial chemoembolization (TACE) in the management of gastrointestinal leiomyosarcoma metastatic to the liver. MATERIALS AND METHODS: Ten patients with gastrointestinal leiomyosarcoma and hepatic metastasis underwent TACE after surgical resection of the primary tumor. All of the leiomyosarcomas originated from the stomach (n=5), duodenum (n=1) or jejunum(n=4), and the interval between primary tumor resection and hepatic metastasis was 1-120 (mean 26) months. Using an emulsion of 3-20 mL of Lipiodol and 15-60 mg of doxorubicin. TACE was performed, and in five patients, gelfoam embolization was added. Therapeutic response was evaluated by follow-up CT, and nine patients underwent repeated TACE (range :2-9 times ; interval : 1-9 months). RESULTS: On celiac arteriography, all cases showed hypervascular tumor staining. As an initial therapeutic response based on CT assessment, more than 50% regression of the tumor (partial remission) was achieved in seven patients, and in the remaining three, regression was 20-30% (stable disease) ; neither complete remission nor progression was seen. With regard to long-term survival, five patients died at 5, 8, 14, 20 and 49 (median, 19) months after initial TACE. The remaining five, in whom follow-up has extended for 13-54 months, are still alive. Overall, survival time ranged from 5-54 (median, 19) months, and except for postembolization syndrome, there was no specific complication. The period of durable tumor regression before progression ranged from 6 to 54 (median, 17) months. CONCLUSION: TACE can be a safe and effective method for the palliation of gastrointestinal leiomyosarcoma metastatic to the liver.

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.

The Suppression Effect of the Intrahepatic Recurrence of Transcatheter Arterial Chemoembolization with Cisplatin in the Hepatocellular Carcinoma Patients: The Comparison of Adriamycin-Lipiodol Emulsion Infusions with Adriamycin-Lipiodol Emulsion Infusions

PURPOSE: To compare the suppressive effects in hepatocellular carcinoma patients of transhepatic arterial chemoembolization by the infusion of adriamycin-lipiodol emulsion and of this plus 10ml of cisplatin solution. MATERIALS AND METHODS: In a total of 151 cases, the frequency of intrahepatic recurrence was compared with follow-up angiographic findings after the first and second transhepatic arterial chemoembolization with adriamycin-lipiodol emulsion and adriamycin-lipiodol emulsion plus 10ml of cisplatin solution, respectively. RESULTS: Among 46 patients whose first single infusion was after mean 119 days, the recurrence rate was 22% ; for 42 who were given their first multiple infusion after mean 76 days this rate was 5% ; for 35 whose second single infusion was administered after mean 147 days, the rate was 34%, and among 28 whose second multiple infusion was after mean 110 days, the rate was 43%. CONCLUSION: During the first trial of transcatheter arterial chemoembolization with adriamycin-lipiodol plus cisplatin solution, hepatocellular carcinoma recurred much less frequently, but during the second trial with cisplatin, recurrence was not suppresed.

Analysis of Prognostic Factors in Patients with Hepatocellular Carcinoma after Transcatheter Hepatic Arterial Chemoembolization(TAE)

PURPOSE: To evaluate long-term survival rates and prognostic factors of patients with hepatocellularcarcinoma after TAE. MATERIALS AND METHODS: 225 patients with hepatocellular carcinoma treated with TAE between January 1988 and December 1994 were studied. Hepatocellular carcinoma was diagnosed either histologically(n=13) orclinically on the basis of findings characteristic for hepatocellular carcinoma obtained using such as diagnostic imaging methods such as ultrasonography, CT, MRI, and angiography as well as on the basis of high serumalpha-fetoprotein level(n=212). TAE was carried out between one and six times(mean, 1.4 time) using a mixture of lipiodol and Adriamycin, together with Gelfoam. Cumulative survival rates from the day of the first TAE were obtained by the Kaplan-Meier method. Parameters likely to influence the prognosis were subjected to univariate analysis using the log-rank test RESULTS: Cumulative survival rates at the end of the first, second, third, fourth, and fifth year were 55.9%, 32.6%, 21.9%, 17.9%, and 15.0%, respectively. The mean survival time was 727+/-76 days. Several factors, including Child-Pugh classification, Okuda's stage, tumor size, presence of portalvein invasion by tumor, of arterio-portal shunt, and of extra hepatic metastases, catheter selection level, and number of TAE showed significant correlation with the outcome. Degrees of Lipiodol accumulation in a tumor onfollow up CT were also correlated with survival rates. CONCLUSION: TAE is an effective measure for prolonging the patient's life expectancy and evaluation of prognostic factor is helpful for prognosis and in deciding on the optimal therapeutic modality.