Solitary hepatocellular carcinoma fed by the cystic artery: Limitation of transcatheter arterial embolization

Purpose: To clarify the limitations of transcatheter treatment for hepatocellular carcinoma (HCC) with parasitic feeders from the cystic artery. Methods: Three male patients had a solitary HCC (average diameter 3 cm) fed by the cystic artery among 221 patients with HCC from 1994 to 1997. One tumor was nourished entirely from the cystic artery arising from the medial branch of the left hepatic artery, and two tumors were fed partially by the cystic arteries arising from the anterior inferior branch of the right hepatic artery. We analyzed the indications for transcatheter treatment for these three patients. Results: We chose not to embolize the cystic artery for fear of necrosis of the gallbladder. Although embolization of the anterior branch of the right hepatic artery was performed in one patient with a tumor fed partially by the cystic artery, only half the tumor was embolized. Two patients underwent hepatic resection, and one received percutaneous ethanol injection therapy. At follow-up of 28–40 months (average 33 months) all patients are alive. Conclusion: Feeding by the cystic artery represents a limitation of TAE for HCC.     

Arterial embolization of unresectable hepatocellular carcinoma with use of cyanoacrylate and lipiodol.

PURPOSE: To assess the potential of transarterial permanent embolization with use of a mixture of cyanoacrylate and lipiodol for treatment of unresectable primary hepatocellular carcinoma (HCC). MATERIALS AND METHODS: In a retrospective study, 36 patients with histologically proven HCC were treated with transarterial embolization (TAE) of the hepatic arteries. None of these patients were candidates for surgical resection and some had advanced disease with multinodular disease or bulky tumor, thrombosis of a segmental branch of the portal vein, and/or extrahepatic spread. To induce permanent and more peripheral embolization, cyanoacrylate, an adhesive polymerizing on contact with blood, was used in TAE. From 1990 to 1998, a total of 76 embolization procedures were performed. Cumulative survival rates were calculated. RESULTS: Most of the patients presented with a self-limited postembolization syndrome. Severe procedure-related complications were found after four treatment sessions (5.2%). The 30-day perioperative mortality rate was 2.7%. The mean follow-up period was 20.3 months (range, 1-68 mo), with a median survival of 26 months. The median survival was also estimated for different Okuda stages of disease: stage II (n = 26) versus stage III (n = 5) disease (32 vs 9 months; P <.05); patients with (n = 9) or without (n = 27) extrahepatic metastasis (10 vs 26 months; P <.05); and patients with (n = 10) or without (n = 26) thrombosis of a segmental branch of the portal vein (7 versus 34 months [P <.005]). CONCLUSION: TAE with use of cyanoacrylate and lipiodol for unresectable HCC is a feasible treatment modality. This retrospective report indicates beneficial effects on survival even in patients with advanced disease.     

肝癌介入化疗栓塞前后的彩色多普勒显像观察

目的探讨CDFI对肝癌介入化疗栓塞(TAE)前后肝血供及肿瘤血供的表现特点,评价其治疗效果。材料和方法CDFI观察1995～1998年48例肝癌(TAE)前后肿瘤的血供情况、肝动脉血流动力学改变。结果肝癌主要由肝动脉供血,少部分由门静脉供血;TAE后肝动脉收缩期最大流速(Vmax)明显下降,肿瘤内部及周边动脉血流明显减少;TAE后肿瘤也明显减小。结论TAE前后,应用CDFI对肿瘤血供、肝动脉血流动力学改变进行观察分析,可以给TAE的预后提供重要指标,为下一步重复治疗提供依据。CDFI是目前肝癌化疗栓塞术治疗前后最好的影像检查方法。     

肝癌经导管脉灌注栓塞中操作技术对疗效的影响

对50例肝细胞癌(HCC)作105疗次经导管动脉灌注栓塞术(TAI/TAE)。发现16例 TAI/TAE 操作技术不当,包括:肝动脉超选插管不成功6例;首次或第2疗次后之 TAI/TAE 术中经狭窄肝动脉再插管失败6例;其余4例为未发现肿瘤的寄生性膈下动脉供血,因而未对其行 TAI/TAE 治疗,是由于在 TAI/TAE 术中忽略了腹主动脉造影造成。此16例操作技术不当的分析显示:肿瘤缩小程度多小于50%,或无变化,少数病例肿瘤较前增大。16例之肿瘤缩小率与对照组比较有显著性差异(P<0.01)。笔者认为 TAI/TAE 操作技术不当可明显影响 HCC 之 TAI/TAE 疗效。     

Accumulation of Iodized Oil Within the Non-Neoplastic Liver Adjacent to Hepatocellular Carcinoma via the Drainage Routes of the Tumor After Transcatheter Arterial Embolization

PURPOSE: After transcatheter arterial embolization (TAE) with iodized oil (Lipiodol), a relatively dense accumulation of Lipiodol is often seen in the nontumorous liver adjacent to a hypervascular hepatocellular carcinoma (HCC) nodule. We compared this phenomenon with the findings obtained with single-level dynamic CT during hepatic arteriography (SLDCTHA) and presumed its possible mechanism. METHODS: Fifty-six patients with HCC underwent hepatic angiography including SLDCTHA followed by segmental or subsegmental TAE with a mixture of an anticancer drug and Lipiodol. We compared the drainage area of the HCC depicted on SLDCTHA with the Lipiodol accumulation in the nontumorous liver adjacent to the HCC on CT after TAE (LpCT). RESULTS: In 26 of the 56 patients, a definite corona enhancement around the HCC, suggesting the drainage of blood from the tumor into the surrounding liver parenchyma, was seen on the late phase of SLDCTHA. In 17 of these 26 patients (65.4%), LpCT showed a more intense accumulation of Lipiodol in the nontumorous liver adjacent to the HCC that corresponded to the drainage area revealed on SLDCTHA. CONCLUSION: The drainage of blood from the HCC was considered to be a possible mechanism of the accumulation of Lipiodol in the nontumorous liver adjacent to the HCC.     

微导管在肝癌介入治疗上的应用

目的探讨微导管在肝癌化疗性栓塞中的作用。方法将4F～5FYashiro、Kouno亲水超滑导管、5F牧羊钩导管作为导引导管插入肝总或肝固有动脉及肠系膜上动脉,3F微导管经导引导管置入肝段或肿瘤滋养动脉施行肝癌化疗性栓塞术。结果本组35例共行化疗性栓塞50例次,其中16例小肝癌行肝段栓塞,19例非小肝癌但癌灶尚局限者行左/右叶或右叶前、后叶栓塞。随访1～2年生存期分别为100％、87.5％及52.6％、42.1％。术后肝功能损害轻微,无并发症。结论在小肝癌、非小肝癌但癌灶尚局限者或伴有肝动脉异常迂曲、损伤后狭窄、发育变异的情况下,使用微导管提高栓塞精度对改善疗效和避免并发症具有十分重要的临床应用价值。     

Hepatocellular carcinoma with blood supply from omental branches: treatment with transcatheter arterial embolization

PURPOSE: To evaluate the usefulness of transcatheter arterial embolization (TAE) through the omental branch in the treatment of hepatocellular carcinoma (HCC) with blood supply from the omental branch. MATERIALS AND METHODS: Fifteen patients with HCC fed by the omental branch underwent TAE. All but one had previously undergone several therapies for HCC, including TAE. Three patients had intraperitoneal hemorrhage caused by ruptured HCC fed by the omental branch, and two necessitated emergency TAE. The technical success rate, therapeutic effect, and safety of TAE via the omental branch were evaluated. RESULTS: Twenty-six omental branches that fed HCC were observed angiographically. Attenuation or occlusion of the hepatic artery was observed in 80%. Nineteen omental branches (73%) could be successfully embolized. Hepatic hemostasis was achieved in all patients with ruptured HCC. Tumor recurred in 80% of patients who underwent successful TAE of the omental branch, and additional therapy was performed in six patients. Ten patients died after 2-26 months (mean, 8 mo). Five patients were alive for 3-13 months (mean, 7 mo). Severe complications were not observed in any patient. CONCLUSION: TAE of the omental branch is safe and has become technically feasible in almost all patients, but tumors frequently recur.     

TAE治疗原发肝细胞癌(对不同组织细胞学类型疗效的初步研究)

目的：通过对一组１５７例经组织细胞学检查证实的原发性肝细胞癌患者生存资料及影像学资料的分析，初步研究经导管动脉栓塞（ＴＡＥ）对不同组织细胞学类型肝细胞癌的治疗效果。材料与方法：８种不同组织细胞学类型的资料较完整的原发性肝细胞癌患者，共计１５７例，分别接受单纯ＴＡＥ、单纯手术或ＴＡＥ＋手术切除治疗。对上述病例分别按照不同组织细胞学类型及不同治疗方法进行生存资料和影像学资料分析。结果：本组原发性肝细胞癌的１年、２年、３年和５年的累计生存率分别为７４．５２％、４８．４０％、３２．４８％和１１．４６％。各组织细胞学类型中，纤维板层型与透明细胞型肝细胞癌的５年生存率分别为２５％和２９％，。三种治疗方法中，单纯ＴＡＥ组、单纯手术组与ＴＡＥ＋手术组的平均生存时间分别为２５．０６（标准误＝１．８７）、３０．３８（标准误＝２．０５）和７２．７２（标准误＝６．９０）个月。结论：ＴＡＥ对不同组织细胞学类型的原发性肝细胞癌在治疗效果上存在差异；本组中，以透明细胞型肝细胞癌对ＴＡＥ较为敏感，而以小细胞型和低（未）分化型肝细胞癌较不敏感。     

Transcatheter arterial embolization of internal mammary artery in a hepatocellular carcinoma with abdominal wall invasion

Transcatheter arterial embolization (TAE) is alternatively employed to surgical resection in the management of hepatocellular carcinoma (HCC). TAE through the hepatic artery is sometimes insufficient since the blood supply to HCC may be from the collateral vessels as well. We report a case of HCC with abdominal wall invasion who underwent TAE through the right internal mammary artery after insufficient embolization of the tumor through the hepatic artery.     

Arterial hepatic embolization of unresectable hepatocellular carcinoma using a cyanoacrylate/lipiodol mixture

Purpose: A survival analysis in 16 patients with unresectable hepatocellular carcinoma (HCC) undergoing transcatheter arterial embolization (TAE) using a combination of lipiodol and N-butyl-2-cyanoacrylate (5 : 1) was performed in a retrospective study. Methods: A combination of lipiodol and N-butyl-2-cyanoacrylate (5 : 1) was used for TAE. All patients had disease compatible with Okuda stages I and II. Results: Twenty-four embolizations were done; five patients had more than one embolization. Median alpha-fetoprotein levels declined from 116 to 48.6 ng/ml. A median of 0.3 ml cyanoacrylate was administered per patient. Median survival was 8.5 months (range 2–49 months). After a median follow-up of 4 years, 12 patients have died (75%). Okuda stage I and II patients had a median survival time of 34.4 and 5.5 months respectively. Few side effects (19%) were seen. Conclusion: We conclude that the TAE procedure used [lipiodol and N-butyl-2-cyanoacrylate (5 : 1)] is safe and produced only few side effects, thus constituting a valuable therapeutic option for patients with Okuda stage I andII HCC.     

Comparison of intra-arterial digital subtraction angiography with conventional angiography after transcatheter arterial embolization for hepatic malignancy

Twenty patients with hepatic malignancy were treated with transcatheter arterial embolization (TAE) under examination by intra-arterial digital subtraction angiography (IA-DSA) and conventional angiography (CA). Comparison of these two angiographies revealed that the time required for confirmation of the embolized portion of the artery was about four-and-a-half times shorter with IA-DSA than CA. Moreover, IA-DSA revealed the obstructed portion more readily and accurately than CA. In particular, confirmation could not be made by CA in 35% of cases because of residual Gelform sponge containing contrast medium in the artery. The visualization of residual tumor stain after TAE was 40% better on IA-DSA than CA, because of residual Gelform sponge containing contrast medium and overlapping shadow with calcified costal cartilage, excretory pyelography, and original tumor stain. However, CA was better than IA-DSA in visualizing accidental obstruction of nonobjective arteries such as the cystic artery because of the poor spatial resolution and misregistration artifacts of IA-DSA. CA was better than IA-DSA in visualizing surrounding nonembolized hepatic parenchyma because of the misregistration artifacts of IA-DSA. For effective TAE without severe complication, we concluded that TAE for HCC should be performed under a combination of IA-DSA and CA.     

Hepatocellular carcinoma: combined hepatic, arterial, and portal venous embolization

Transcatheter arterial embolization (TAE) is an effective means of treating primary hepatocellular carcinoma (HCC). However, in many cases of HCC the tumor recurs after treatment. In an attempt to obtain complete tumor necrosis, the authors studied the clinical and histologic effect of simultaneous embolization of both the hepatic artery and portal vein in ten patients with HCC. In those cases in which combined embolization caused infarction, tumor cells in the main tumor, tumor cells that had invaded the tumor capsule, and small intrahepatic metastases had become totally necrotic following treatment. No viable tumor cells were detected in four patients who subsequently underwent operations; nor were viable tumor cells present in one other patient who later died as a result of a perforated duodenal ulcer. Five patients who did not subsequently undergo operations were still free of the disease 2-17 months after combined arterial and portal embolization. The impact of combined embolization on liver function was nearly the same as that produced when TAE was performed alone. Combined embolization may be a viable alternative to hepatectomy for the treatment of HCC.     

无水乙醇-碘化油乳剂栓塞治疗肝脏血管瘤(附八例报告)

目的　探讨无水乙醇碘化油乳剂经导管血管内栓塞（ＴＡＥ） 治疗肝脏血管瘤的方法和效果。方法　回顾性分析８ 例肝脏血管瘤病例,以１∶１ 无水乙醇与碘化油乳剂５ ～２０ ｍｌ 行肝动脉栓塞。结果　所有病例均成功实施了栓塞治疗,其中,５ 例行肝右动脉分支栓塞,１ 例行肝左动脉栓塞,２ 例行肝固有动脉栓塞。栓塞后临床症状减轻、肿瘤血供中断、瘤体缩小及肿瘤内碘化油均匀聚集。结论无水乙醇碘化油乳剂治疗肝脏血管瘤可导致肿瘤完全坏死,疗效肯定,可达到外科手术切除的效果。     

Spontaneous Rupture of Hepatocellular Carcinoma Supplied by the Right Renal Capsular Artery Treated by Transcatheter Arterial Embolization

We present a case of spontaneous rupture of hepatocellular carcinoma (HCC) with poor liver function which was treated by transcatheter arterial embolization (TAE). The patient’s bilirubin value was 3.8 mg/dL. The tumor was fed by the right renal capsular artery according to selective arteriography. It was subsequently treated by TAE. With successful TAE, no hepatic failure was related to the treatment. We believe that if tumors are fed only by extrahepatic collateral vessels, TAE may be an effective treatment even in patients with poor liver function.     

Transcatheter Arterial Embolization for Hepatic Arterial Injury Related to Percutaneous Transhepatic Portal Intervention

Purpose

To assess the usefulness of transcatheter arterial embolization (TAE) for the hepatic arterial injury related to percutaneous transhepatic portal intervention (PTPI).

Materials and Methods

Fifty-four patients, 32 males and 22 females with a median age of 68 years (range 43–82 years), underwent PTPI. The procedures consisted of 33 percutaneous transhepatic portal vein embolizations, 19 percutaneous transhepatic variceal embolizations, and 2 percutaneous transhepatic portal venous stent placements. Two patients with gastric varices underwent percutaneous transhepatic variceal embolization twice because of recurrence. Therefore, the total number of procedures was 56. Among them, hepatic arterial injury occurred in 6 PTPIs in 5 patients, and TAE was performed. We assessed technical success, complications related to TAE, and clinical outcome. Technical success was defined as the disappearance of findings due to hepatic arterial injury on digital subtraction angiography.

Results

As hepatic arterial injuries, 4 extravasations and 2 arterioportal shunts developed. All TAEs were performed successfully. The technical success rate was 100 %. Complication of TAE occurred in 5 of 6 TAEs; 3 were focal liver infarction, not requiring further treatment, and 2 were biloma that required percutaneous drainage. Five TAEs in 4 patients were performed immediately after the PTPI, and these 4 patients were alive. However, one TAE was performed 10 h later, and the patient died due to multiple organ failure 2 months later although TAE was successful.

Conclusion

TAE is a useful treatment for hepatic arterial injury related to PTPI. However, it should be performed at an early stage.

     

Three-Dimensional Quantitative Color-Coding Analysis of Hepatic Arterial Flow Change during Chemoembolization of Hepatocellular Carcinoma

Purpose

To evaluate feasibility of using three-dimensional (3D) quantitative color-coding analysis (QCA) to quantify substasis endpoints after transcatheter arterial chemoembolization of hepatocellular carcinoma (HCC).

Analysis of hepatocellular carcinoma fed by internal thoracic artery

Purpose: The purpose of this study was to elucidate the clinical features of hepatocellular carcinoma (HCC) fed by the internal thoracic artery (ITA). Methods: In seven patients HCC fed by the ITA was confirmed by digital subtraction angiography. The number of previous transcatheter arterial embolization (TAE), the period from the first TAE to TAE of the ITA, tumor location, tumor size, and occlusion of the hepatic artery (HA) and other collateral vessels were explored in each case. Results: The HCCs were located in S4 of the liver (n = 5) and in S8 (n = 1) and were fed by the right ITA and one nodule in S2-3 was fed by the left ITA. Tumor size was 3-10 cm. The number of previous TAE of the HA ranged from 2 to 12. The period from the first TAE to TAE of the ITA was 3-53 months. Angiography of these patients showed occlusion of the HA in six cases, and of the extrahepatic collaterals including the inferior phrenic artery (IPA) in five cases, intercostal artery (ICA) in one case, and epicholedocal artery (EPA) in one case. Conclusion: The ITA often supplies HCC located in the anterior superior region of the liver under the diaphragm; there can be long-term survival with repeated TAE and occlusion of HA.     

Clinical outcomes of symptomatic arterioportal fistulas after transcatheter arterial embolization

AIM: To evaluate the complications and clinical outcomes of transcatheter arterial embolization (TAE) for symptoms related to severe arterioportal fistulas (APFs). METHODS: Six patients (3 males, 3 females; mean age, 63.8 years; age range, 60-71 years) with chronic liver disease and severe APFs due to percutaneous intrahepatic treatment (n=5) and portal vein (PV) tumor thrombosis of hepatocellular carcinoma (n=1) underwent TAE for symptoms related to severe APFs [refractory ascites (n=4), hemorrhoidal hemorrhage (n=1), and hepatic encephalopathy (n=1)]. Control of symptoms related to APFs and complications were evaluated during the follow-up period (range, 4-57 mo). RESULTS: In all patients, celiac angiography revealed immediate retrograde visualization of the main PV before TAE, indicating severe APF. Selective TAE for the hepatic arteries was performed using metallic coils (MC, n=4) and both MCs and n-butyl cyanoacrylate (n=2). Three patients underwent repeated TAEs for residual APFs and ascites. Four patients developed PV thrombosis after TAE. During the follow-up period after TAE, APF obliteration and symptomatic improvement were obtained in all patients. CONCLUSION: Although TAE for severe APFs may sometimes be complicated by PV thrombosis, TAE can be an effective treatment to improve clinical symptoms related to severe APFs.     

Computed tomography of residual hepatomas following transcatheter arterial embolization

Computed tomography and angiography following transcatheter arterial embolization (TAE) was performed for 29 patients with hepatomas. In three cases crescent-shaped isodense regions were observed posterior to the necrotic tumor after TAE. They were located in the superior posterior segments of the right hepatic lobes and were consistent with residual tumor supplied by the right inferior phrenic artery. Recognition of this CT finding after TAE is important for evaluating the extent of embolization of the tumor.     

Clinical significance of the measurement of hepatic blood flow using xenon 133 and balloon catheter in patients undergoing treatment for hepatocellular carcinoma

Total hepatic blood flow and portal blood flow were measured separately using a modified xenon 133 clearance method during angiography in 71 patients with chronic liver diseases, including 40 with proven hepatocellular carcinoma, and in 12 patients without detectable chronic liver injury who served as controls. Total hepatic and portal blood flow rates in controls were 805 ±149 ml/min and 667 ± 206 ml/min, respectively. Total hepatic blood flow was significantly decreased in patients with compensated and decompensated liver cirrhosis (519 ± 156 ml/min and 317 ± 153 ml/min, respectively; P < 0.01), as was portal blood flow (399 ± 134 ml/min and 271 ± 134 ml/min, respectively; P < 0.01). Following transcatheter arterial embolization or hepatic resection (in 35 and 13 patients, respectively), hepatic failure occurred in 3 cases each. Embolization appeared contraindicated when hepatic portal blood flow was under 125 ml/min, and safe hepatic resection required an anticipated residual hepatic portal blood flow of at least 250 ml/min. Offprint requests to: S. Miyauchi