Hepatic arterial collaterals after transcatheter oily chemoembolization of hepatocellular carcinoma.

From July 1989 to June 1999, 100 patients, 76 male and 24 female, were admitted for treatment of hepatocellular carcinoma (HCC) with transcatheter oily chemoembolization (TOCE) using lipiodol 10 ml mixed with an anticancer drug (mitomycin C 20 ml) and gelfoam particles, described by Nakamura H et al. The periodic follow-up angiogram showed hepatic collaterals which developed according to the mode of embolization. For peripheral hepatic arterial embolization such as segmental or lobar arterial embolization, the intrahepatic collaterals were commonly demonstrated. However, for more proximal hepatic arterial embolization of the tumor feeder arteries such as the proper hepatic artery and the common hepatic artery, the extrahepatic collaterals were commonly demonstrated with fine, small tortuous vasculatures, rendering a repeat TOCE more difficult. The hepatic collaterals are presented.

Transcatheter oily chemoembolization of the extrahepatic collaterals in hepatocellular carcinoma.

Twenty patients with hepatocellular carcinoma who had hepatic artery occlusion from repeated transcatheter oily chemoembolization (TOCE), were treated with additional TOCE through extrahepatic collaterals. Repeated TOCE were performed through the inferior phrenic artery (10 patients), branches of the gastroduodenal artery (6 patients), the internal mammary artery (2 patients), the pancreatico-duodenal arcade (1 patient), the accessory hepatic artery (1 patient), the capsular branch of the right renal artery (1 patient) and the 12th intercostal artery (1 patient). The TOCE was unsuccessful in 4 patients with accessory hepatic artery, one patient with cystic artery arising from superior mesenteric artery, one patient with omentoepiploic artery and one patient with left gastric anastomose with right gastric artery. The success rate of TOCE in the extrahepatic arteries was 76.67 per cent while there was a 23.33 per cent failure rate. The overall cumulative survival rates were 80 per cent (6 months), 50 per cent (12 months) and 18.8 per cent (18 months). One patient developed skin necrosis at the right chest wall following TOCE of the right internal mammary artery for HCC. One patient developed hemiplegia following TOCE of the right 12th intercostal artery. The extrahepatic collaterals are important alternative routes for continuous transcatheter management of hepatocellular carcinoma following hepatic artery occlusion.

Hepatocellular carcinoma : treated with hepatic arterial embolization, an analysis of prognostic features in 150 cases.

From July 1989 to July 1999, 120 male and 30 female patients with hepatocellular carcinoma (HCC), whose ages ranged from 18 to 71 years, were treated by different modalities. The patients were divided into 3 groups according to treatment modalities: group 1 consisted of 35 cases treated by transarterial embolization (TAE) using gelatin sponge permeated with mitomycin-c 20 mg, group 2 - 100 cases treated by transcatheter oily chemoembolization (TOCE) using lipiodol 10 cc with mitomycin-c 20 mg together with gelatin sponge for hepatic embolization, and group 3 - 15 cases treated by TOCE followed by surgical wedge hepatic resection. The prognostic features following treatments were retrospectively analysed in relation to therapeutic modalities. The results revealed that TOCE was superior to TAE and that TOCE plus adjunct wedge hepatic resection was the best treatment modality with the best cumulative surgical rate (median survival 46.69 months). Analysis of the life-table methods of group 2 patients revealed that the stage of tumors and serum biochemistry on entry, both of which corresponded well with hepatic reserve function were statistically significant prognostic factors for treatment result and long-term outcomes. Further analysis of all the patients also revealed that tumor size and stage of tumors were significant prognostic factors for the treatment of hepatocellular carcinomas.

Bronchial artery embolization for hemoptysis.

BACKGROUND: Massive hemoptysis is a life-threatening condition. Since treatment from surgery has high mortality, bronchial artery embolization (BAE) is now safer and may be good for chronic hemoptysis as well. MATERIAL AND METHOD: Ten patients (6 male, 4 female) with hemoptysis underwent BAE. Five patients had massive life-threatening hemoptysis (4 tuberculosis and 1 bronchogenic carcinoma) and 5 had chronic hemoptysis (4 tuberculosis and 1 bronchogenic carcinoma). All patients received BAE by transfemoral arterial approach using gelfoam particles and Ivalon as the embolized materials. Bronchial arteries were abnormal in all cases except one patient who had bronchogenic carcinoma supplied by the acromiothoracic artery to the left upper lobe. RESULTS AND CONCLUSION: Chest radiograph may correlate well with angiographic findings if there is one lobar lesion, but multiple lobar lesions showed no correlation between the two modalities. Hypervascularity was a universal findings in all patients. Other angiographic findings were enlarged bronchial or nonbronchial arteries, systemic to pulmonary anastomosis, pseudoaneurysm, and extravasation of contrast media. The immediate result of BAE achieved 100 per cent but follow-up showed only a 70 per cent success rate with one mortality from recurrent massive hemoptysis and two recurrent cases due to complications. Ivalon which is a permanent embolized material may be useful for recurrent hemoptysis.

Gigantic hepatocellular carcinoma, treated by transcatheter oily chemoembolization (TOCE) and wedge hepatic resection.

Four cases of gigantic hepatocellular carcinoma, considered by surgeons to be inoperable, were treated with repeated transcatheter chemoembolization (TOCE) until the serum alfafetoprotein reduced to normal or less than half of the original level or until the tumor reduced to less than half of the original size documented by CT scan and angiogram. Wedge hepatic resection was performed using ultrasonic dissector. Histologic section of the resected tumor mass revealed tumor necrosis. The extent of tumor necrosis was related to tumor size and corresponded inversely to the thickness of the tumor capsule. The survival periods were 48 to 108 months with only one to two episodes of recurrence during follow-up. Repeated wedge hepatic resection was performed successfully for recurrent cases. Serum alfafetoprotein (AFP) is a very sensitive and reliable tumor marker for follow-up results and appears to be a sensitive indicator for tumor recurrence.

Lipiodol enhanced CT scanning of malignant hepatic tumors.

From August 1984 to March 1991, 41 patients with malignant liver tumors, 30 males and 11 females, aged 30-75 years were treated at Ramathibodi Hospital with injection of mitomycin-C lipiodol emulsion into the tumor via the feeding artery followed by embolization of the feeding artery with gelfoam particles. The patients comprised 30 cases of hepatocellular carcinoma, 4 cases of cholangiocarcinoma and 7 cases of metastatic tumors of which one was from CA stomach, three were from CA breast, and three from CA colon. The vascularity of the tumor was assessed in angiogram obtained prior to treatment and retention pattern of lipiodol in the tumor was evaluated in lipiodol-enhanced CT scan images taken 2-4 weeks following therapy. The results showed that lipiodol CT scan images exhibited four patterns of lipiodol retention in the tumor appearing as opacity as follows (1) homogenous (2) heterogeneous (3) ring-like and (4) none. Lipiodol retention pattern appeared to be somewhat related to vascularity of the tumor. Most of the hypervascular tumors such as hepatocellular carcinoma had homogeneous lipiodol accumulation pattern if the tumor size was less than 5 cm. Metastatic tumors and cholangiocarcinoma showed heterogeneous or ring-like pattern of lipiodol accumulation because they were relatively hypovascular. Hypervascular hepatocellular carcinoma may exhibit heterogeneous or ring-like pattern if they are larger than 5 cms, and have multiple feeding arteries, necrosis or AV shunting. Hepatocellular carcinoma with AV shunting may not show any lipiodol accumulation at all.

Renal artery embolism: therapy with intra-arterial streptokinase infusion.

Two patients with acute renal artery embolism were reported. One patient had a history of rheumatic valvular heart disease and the other patient had hereditary cardiomyopathy. Both patients had atrial fibrillation on physical examination. Both patients presented with acute back pain and one patient had hematuria. The final diagnosis of acute renal artery embolism was made after one to three days of hospitalization and renal angiography was finally done documenting complete occlusion of the main branch of the renal artery on one side. Intra-arterial streptokinase infusion 5,000 unit per hour was given to both patients using an arterial pump for 17 hours to 30 hours with complete recanalization of the intrarenal branches and complete recovery of signs and symptoms of renal artery embolism although the renal scan still showed diminished renal function.

Iatrogenic hemobilia: management with transarterial embolization using gelfoam particles.

Four patients with life threatening bleeding hemobilia from the hepatic artery were successfully treated with transarterial embolization with small gelfoam particles with no recurrence of bleeding on follow-up study. The iatragenic hemobilia occurred inadvertently during surgery in two patients, with liver biopsy in one patient and percutaneous transhepatic biliary drainage procedure in another patient. Transarterial embolization appears safe and may be regarded as a life-saving treatment for bleeding hemobilia.