Combined intraarterial 5-fluorouracil and intramuscular interferon-alpha therapy for advanced hepatocellular carcinoma

We report the case of a 66-year-old man with hepatic cirrhosis and multiple hypervascular tumors in both lobes of the liver as well as tumor thrombi in the portal vein. After unresectable hepatocellular carcinoma was diagnosed, transcatheter arterial embolization was considered to be difficult, because he had major portal vein thrombosis. Conventional ultrasonically-guided local treatments, such as percutaneous ethanol injection therapy and radiofrequency ablation, were also of no value because the tumors were huge and multiple. Ultimately, he was treated with a combination of intraarterial 5-fluorouracil and intramuscular interferon-alpha. After treatment, the multiple tumors became non-enhancing on contrast computed tomography scans and showed a marked decrease in size. There were no serious adverse effects (such as myelosuppression or hepatotoxicity) during treatment or follow-up and the patient is doing well at present. In conclusion, a combination of intraarterial 5-fluorouracil with intramuscular interferon-alpha appears to be useful for the management of advanced hepatocellular carcinoma, especially in patients for whom more aggressive treatment is not acceptable.     

Comparison of hepatectomy and transcatheter arterial chemoembolization for the treatment of hepatocellular carcinoma: necessity for prospective randomized trial.

Transcatheter arterial chemoembolization is now widely used in cases of surgically unresectable hepatocellular carcinoma. However, it is unclear whether patients with surgically resectable hepatocellular carcinoma should always be treated with hepatectomy as opposed to transcatheter arterial chemoembolization. Sixty-six patients with hepatocellular carcinoma underwent hepatectomy, whereas 29 patients with more advanced hepatocellular carcinoma were treated with transcatheter arterial chemoembolization at our hospital from 1984 to 1990. All cases were associated with cirrhosis of Child class A or B. All of them underwent hepatectomy or transcatheter arterial chemoembolization for the first time. Their outcomes were determined on March 31, 1991. The backgrounds and survival curves for hepatectomy and transcatheter arterial chemoembolization were compared in both Child A and Child B patients. For both Child A and B patients, no significant difference was found between hepatectomy and transcatheter arterial chemoembolization with respect to age, sex, cause of underlying cirrhosis, liver function assessed by indocyanine green test and maximum diameter of the main tumor. The incidence of multiple hepatocellular carcinoma, more advanced hepatocellular carcinoma (TNM stage III or IV) or both was significantly higher in the transcatheter arterial chemoembolization group than in the hepatectomy group for both Child A and Child B patients. The survival curves of both the hepatectomy and the transcatheter arterial chemoembolization groups showed no significant difference for both Child A and Child B patients. A prospective study is therefore warranted to elucidate whether hepatectomy or transcatheter arterial chemoembolization is more effective for treating resectable hepatocellular carcinoma associated with cirrhosis.     

Transcatheter arterial embolization for bleeding from bile duct tumor thrombi of hepatocellular carcinoma

BACKGROUND/AIMS: Advanced hepatocellular carcinoma usually invades the portal vein, forming tumor thrombi. Invasion of the bile duct, i.e., intrabile tumor growth or bile duct tumor thrombi is rare. Patients with bile duct tumor thrombi present with obstructive jaundice, abdominal pain or hemobilia. Hemobilia due to bile duct tumor thrombi is sometimes massive and fatal. The purpose of our study was to evaluate the effectiveness of transcatheter arterial embolization for hemobilia caused by bile duct tumor thrombi of hepatocellular carcinoma. METHODOLOGY: Between 1993 January and 2000 December, transcatheter arterial embolization was performed in 4 patients with hemobilia and gastrointestinal bleeding from bile duct tumor thrombi of hepatocellular carcinoma. RESULTS: In all 4 patients, transcatheter arterial embolization was successfully performed and resulted in cessation of bleeding. One patient had recurrent hemobilia, which was controlled by another transcatheter arterial embolization. Three patients were discharged from hospital after transcatheter arterial embolization. Patients died of hepatic failure or multiple tumors 5 to 7 months after the onset of hemobilia, although hemobilia had been fully controlled. CONCLUSIONS: Transcatheter arterial embolization seemed to be effective for the control of massive hemobilia caused by bile duct tumor thrombi associated with hepatocellular carcinoma.     

Benefit of transcatheter arterial embolization for ruptured hepatocellular carcinoma complicating liver cirrhosis

In 6 patients with spontaneous rupture of hepatocellular carcinoma complicating liver cirrhosis, but with no occlusion of the main portal trunk, transcatheter arterial embolization was performed within 7 days of the rupture. All 6 patients were thought to be inoperable because of shock state or severe hepatic dysfunction. In all 6 patients, the progressive decrease in the hematocrit ceased soon after the embolization. Five patients survived for 31-168 days after the embolization; 1 patient who developed septicemia died 10 days later. We conclude that transcatheter arterial embolization is beneficial as a procedure of first choice for ruptured hepatocellular carcinoma when the portal blood flow is maintained.     

Treatment of unresectable hepatocellular carcinoma less than 2 centimeters by transcatheter arterial chemoembolization with autologous blood clot

GOALS: To assess the efficacy of transcatheter arterial chemoembolization using autologous blood clot as an embolizing agent (short-TAE [S-TAE]) for the treatment of unresectable hepatocellular carcinoma less than 2 cm. STUDY: Twenty-eight consecutive patients with unresectable hepatocellular carcinoma less than 2 cm in diameter were treated by S-TAE alone. All patients had documented cirrhosis (Child class B:C = 20:8). S-TAE was performed by injecting a mixture of iodized oil and anticancer drugs followed by embolization of hepatic arteries with autologous blood clot. RESULTS: A total of 147 sessions of embolization with clots were performed. S-TAE maintained patency of hepatic arteries. The overall survival rates at 1, 3, 5, and 8 years were estimated to be 89%, 52%, 34%, and 17%, respectively, which were better compared with prior records for the gelfoam method. The survival rates for Child class B patients were significantly better than that for Child class C patients (P < 0.05). The Cox proportional hazard model also demonstrated that Child staging of cirrhosis was the sole factor significantly predicting the survival (P < 0.05). CONCLUSIONS: The long-term outcomes of S-TAE for unresectable hepatocellular carcinoma less than 2 cm are satisfactory. Prognosis of these patients was significantly dependent on clinical stages of coexisting liver cirrhosis.     

Percutaneous ethanol injection for hepatocellular carcinoma originating in the caudate lobe

BACKGROUND/AIMS: Hepatocellular carcinoma originating in the caudate lobe is rare and the treatments for caudate hepatocellular carcinoma were thought difficult, because of its unique location at hepatic resection, or because of complex arterial supply at transcatheter arterial embolization. Percutaneous ethanol injection is an effective treatment for small hepatocellular carcinoma. The aim of this study was to assess the efficacy of percutaneous ethanol injection for hepatocellular carcinoma originating in the caudate lobe. METHODOLOGY: During the past 4 years, 7 patients with 7 hepatocellular carcinomas originating in the caudate lobe underwent percutaneous ethanol injection as a curative treatment. The outcomes of percutaneous ethanol injection and the survival of the 7 patients were evaluated. RESULTS: Percutaneous ethanol injection was successfully carried out with no severe complications in all patients. During follow-up periods local recurrence was noticed in a patient, that was treated with percutaneous ethanol injection again. Four patients had recurrence in other parts of the liver, who were treated with percutaneous ethanol injection alone or percutaneous ethanol injection and transcatheter arterial embolization. Six patients were alive for 12-55 months after percutaneous ethanol injection and 1 patient died of hepatic failure 15 months after the procedure. CONCLUSIONS: Percutaneous ethanol injection was a safe and effective treatment, and it would be an alternative therapy for hepatocellular carcinoma originating in the caudate lobe.     

Combination therapy of percutaneous mitoxantrone injection, percutaneous ethanol injection, and transcatheter arterial embolization for intrahepatic hepatocellular carcinoma and adrenal metastasis

We treated a 63-year-old man who had recurrent large hepatocellular carcinomas (> 5 cm in diameter) and left adrenal metastasis with the combination approach of percutaneous intratumoral chemotherapy with mitoxantrone, percutaneous ethanol injection, and transcatheter arterial embolization. He received repeated transcatheter arterial embolization and percutaneous ethanol injection combination therapy for intrahepatic hepatocellular carcinomas, which controlled his disease for 6 months from the first treatment. After that, left adrenal metastasis was detected by biopsy specimen. Therefore, we repeated more transcatheter arterial embolization and percutaneous ethanol injection to the liver and left adrenal gland, but this combination therapy could not control the hepatocellular carcinomas in these organs. With the patient's consent, he was treated with the combination approach of percutaneous intratumoral chemotherapy with mitoxantrone, percutaneous ethanol injection, and transcatheter arterial embolization for hepatocellular carcinomas of the liver and left adrenal gland. After this combination therapy, we followed-up the viable lesions by color Doppler ultrasonography and computed tomography examination. However, we could not detect these viable lesions of hepatocellular carcinomas in his body until one month before he died. When the degree of hepatic failure worsened due to the natural course of cirrhosis, this combination therapy was stopped 7 months before he died. He died of pulmonary tumor emboli from metastasis of inferior vena cava 24 months after the combination therapy started. However, on autopsy there was almost no remaining hepatocellular carcinoma found in the main lesions of liver and left adrenal gland. We suggest that a combination approach of percutaneous intratumoral chemotherapy with mitoxantrone, percutaneous ethanol injection, and transcatheter arterial embolization may be indicated in elderly cases of intrahepatic large hepatocellular carcinoma and adrenal metastasis, which are not under control only by transcatheter arterial embolization and percutaneous ethanol injection.     

Subsegmental transcatheter arterial embolization for small hepatocellular carcinoma

BACKGROUND/AIMS: The evaluation of long-term outcome of subsegmental transcatheter arterial embolization, which was designed to bring about sufficient anti-tumor effect, in the primary cases of small hepatocellular carcinoma. METHODOLOGY: We analyzed and compared the anti-tumor effect and the survival rate in the primary cases of solitary small hepatocellular carcinoma (< or = 3 cm) with cirrhosis treated by subsegmental transcatheter arterial embolization, chemolipiodolization or percutaneous ethanol injection therapy during the last eight years, retrospectively. RESULTS: The complete tumor necrosis by one session of subsegmental transcatheter arterial embolization, which means that treated tumor showed complete response and did not show local recurrence thereafter, was seen in approximately 50% of the cases. The rate of complete tumor necrosis was superior to that in the patients treated by chemolipiodolization although it was lower than that in the patients treated by percutaneous ethanol injection therapy. Both of the 5- and 7-year survival rates in the patients treated by subsegmental transcatheter arterial embolization were 41.2%. It was slightly higher than those in the other treatment groups without significant difference. CONCLUSIONS: Subsegmental transcatheter arterial embolization might be effectively performed as an initial treatment for the primary cases of the solitary small hepatocellular carcinoma when tumor was fully supplied by hepatic arterial blood regardless of small size.     

CASE REPORT: Steatonecrosis in the upper abdomen following transcatheter arterial embolization for hepatocellular carcinoma

A 66-year-old female with liver cirrhosis was treated by transcatheter arterial embolization (TAE) for a small hepatocellular carcinoma. She developed steatonecrosis with tenderness which occurred in the upper abdomen after TAE. The hepatic falciform artery from the middle hepatic artery was detected by arteriography. Necrosis in the upper abdomen was considered to be due to ischaemic changes caused by micromaterials for embolization of this artery, injuries of hepatic arterial endothelia slowly caused by carcinostatics, and chemotoxicity. It was considered that such complication as observed in this patient should be taken into consideration when performing TAE.     

Transcatheter arterial embolization of ruptured hepatocellular carcinoma associated with liver cirrhosis

Four cases of hepatocellular carcinoma treated by transcatheter arterial embolization have been reported. In three patients, the bleeding stopped completely after the procedure. Embolized tumor appeared to be necrotized in two cases. Transcatheter arterial embolization should be considered the treatment of choice for the emergency therapy of ruptured hepatocellular carcinoma.     

Postresection recurrence of hepatocellular carcinoma treated by arterial embolization: analysis of prognostic factors.

Of 270 consecutive patients with hepatocellular carcinoma who underwent surgery, 50 who had recurrence and were subsequently treated with transcatheter arterial embolization were analyzed. The longest interval between surgery and recurrence in the 50 patients who underwent transcatheter arterial embolization was 7 yr. Recurrence was initially found in the remnant liver in all patients but one; extrahepatic metastases were detected in 13 patients (26%) during follow-up. A "multiple" type was the most common (64%) hepatic recurrence pattern on angiography, followed by the "solitary" (16%) and "tumor thrombus" (12%) patterns. Hepatic recurrence was most frequently found in the ipsilateral lobe (48%) relative to the site of the primary hepatocellular carcinoma. Multivariate analysis of the factors affecting survival after transcatheter arterial embolization indicated that recurrence pattern (p = 0.025) and distant metastases (p = 0.011) were significant. Of 13 patients with distant metastases, 11 had the "multiple" pattern of hepatic recurrence. Survival rates for all 50 patients after initial surgery and after transcatheter arterial embolization were 90% and 64%, respectively, at 1 yr; 52% and 24%, respectively, at 3 yr; and 27% and 5%, respectively, at 5 yr. On analysis of survival rates after transcatheter arterial embolization in 37 patients with recurrence only in the liver and of the response of recurrent hepatocellular carcinoma to transcatheter arterial embolization, a significant difference was noted between those with "partial response" and "progressive disease" (p less than 0.05) and between those with "no change" and "progressive disease" (p less than 0.05).     

The separate-lesion type combined hepatocellular carcinoma and cholangiocarcinoma

The separate-lesion type of combined hepatocellular carcinoma and cholangiocarcinoma is particularly rare. We treated two such patients with hepatic resection after performing dynamic computed tomography. In case 1, a 64-year-old Japanese man with chronic hepatitis C underwent right hepatic lobectomy for two hepatic tumors; both tumors originally were thought to be hepatocellular carcinomas because both were hypervascular. However, histologic examination revealed that one tumor was hepatocellular carcinoma and another tumor was tubular adenocarcinoma. In case 2, a 73-year-old man, a second lesion was detected 8 months after transcatheter arterial embolization for hepatocellular carcinoma associated with chronic hepatitis C. The newer lesion in case 2 showed delayed enhancement by dynamic computed tomography. We diagnosed the lesion as cholangiocarcinoma and performed right hepatic lobectomy and dissection of lymph nodes in the hepatoduodenal ligament. Histologic examination confirmed that the new lesion was tubular adenocarcinoma. Case 1 and 2 respectively represent synchronous and metachronous occurrence of the separate-lesion variety of combined hepatic cancer.     

Transcatheter arterial chemoembolization therapy combined with percutaneous ethanol injection for unresectable large hepatocellular carcinoma: an evaluation of the local therapeutic effect and survival rate.

BACKGROUND/AIMS: This study was undertaken to evaluate the effectiveness of combination therapy with transcatheter arterial chemoembolization followed by percutaneous ethanol injection in patients with unresectable large hepatocellular carcinoma by comparing the use of this combined regimen with transcatheter arterial chemoembolization alone. METHODOLOGY: Six hundred and thirty-one consecutive patients with hepatocellular carcinoma lesions observed from Jan 1989 to Dec 1999 (11 years) at the Internal Medicine Department, Saga Prefectural Hospital Koseikan were retrospectively enrolled in the study. The series included 120 patients with large unresectable hepatocellular carcinoma lesions, the largest of which were greater than 3 cm in largest dimension. Fifty-two patients underwent a single transcatheter arterial chemoembolization followed by percutaneous ethanol injection, which were compared with 68 patients treated by transcatheter arterial chemoembolization alone. Both groups of patients with hepatocellular carcinoma did not differ regarding the base-line characteristics. The overall survival rates and recurrence ratio of initially treated lesions were compared in both groups. RESULTS: On overall survival rates by the Kaplan-Meier method, three- and five-year survival in the transcatheter arterial chemoembolization and percutaneous ethanol injection group (59.0%, 32.1%) proved to be significantly longer than those in the transcatheter arterial chemoembolization group (27.1%, 17.0%). In addition, during the follow-up local recurrence in the combination group (23.1%) was significantly lower than that in the transcatheter arterial chemoembolization group (50.0%). CONCLUSIONS: The combined treatment with transcatheter arterial chemoembolization and percutaneous ethanol injection proved to be more effective and safer. Furthermore, a lower incidence of local recurrence was observed than transcatheter arterial chemoembolization alone which resulted in an increased survival of the patients associated with unresectable large hepatocellular carcinoma lesions.     

The acquired vitamin K-dependent gamma-carboxylation deficiency in hepatocellular carcinoma involves not only prothrombin, but also protein C

Protein C, one of the vitamin K-dependent plasma proteins synthesized in the liver, was measured immunologically in normal subjects (n = 20), patients with hepatocellular carcinoma (n = 60), liver cirrhosis (n = 60), acute hepatitis (n = 16), chronic hepatitis (n = 19), malignant neoplasms other than hepatocellular carcinoma (n = 35) and patients on warfarin treatment (n = 20). We also assayed gamma-carboxyglutamic acid-complete (carboxylated) protein C in these population by using a monoclonal antibody directed against human protein C, JTC-1, which recognizes the gamma-carboxyglutamic acid domain-related conformational change induced by metal ions. We demonstrated that the plasma of patients with hepatocellular carcinoma contains considerable amounts of gamma-carboxyglutamic acid-incomplete protein C, evidenced by the significantly reduced protein C:gamma-carboxyglutamic acid/protein C:antigen ratios in hepatocellular carcinoma as compared to those seen in normal controls, other liver diseases and other malignant neoplasms (p less than 0.01). In two patients with hepatocellular carcinoma with the reduced protein C:gamma-carboxyglutamic acid/protein C:antigen ratios, successful treatment (transcatheter hepatic arterial embolization or lipiodolization of antitumor agent) led to the very rapid normalization of the ratios. Intravenous administration of vitamin K, however, induced no such effects in three other patients with hepatocellular carcinoma with the abnormality. We conclude that the impaired vitamin K-dependent gamma-carboxylation observed in patients with hepatocellular carcinoma involves not only prothrombin, but also protein C, and that the impairment is not due to vitamin K deficiency.     

Transcatheter arterial embolization-induced bilious pleuritis in a patient with hepatocellular carcinoma

A 52-year-old man with hepatocellular carcinoma (HCC) was admitted with cough and fever. He had undergone four series of treatments, including transcatheter embolization and chemoembolization with lipiodol and anticancer drugs, over the previous 2 years. Computed tomography demonstrated dilated hepatic ducts, localized necrosis in the right hepatic lobe, and subphrenic abscess. He died of respiratory failure, because of increased effusion of the right pleura, about 3 weeks after admission. Autopsy revealed adhesions in the lower lobes of the right lung, diaphragm, and liver, with granulomas with bile pigment. A fistula was observed from the necrotic regions of the right hepatic lobe to the pleura through the diaphragm. A tumor thrombus in the portal trunk was histologically confirmed as well and moderately differentiated HCC with trabecular arrangement. Direct invasion of HCC with necrotic tissue to the pleura through the diaphragm appeared to have caused the respiratory failure. Although bilious pleuritis is a rare complication of transcatheter arterial embolization (TAE), it should be considered as an adverse effect of TAE in patients with a dilated hepatic duct.     

Hepatic arterial embolization in patients with unresectable hepatocellular carcinoma--a randomized controlled trial

A randomized controlled trial of hepatic arterial embolization was conducted in 63 consecutive patients who had unresectable but still embolizable hepatocellular carcinoma. Patients were randomized into three groups. Patients in group 1 received multiple hepatic arterial embolizations; patients in group 2 were given hepatic arterial embolization once, followed by monthly chemotherapy with high doses of 5-fluorouracil; and patients in group 3 received only monthly chemotherapy with high doses of 5-fluorouracil. Complete response was achieved in only 1 patient who received multiple hepatic arterial embolizations. Partial responses were observed in 13 patients (61.9%) in group 1, 10 patients (47.6%) in group 2, and 2 patients (9.5%) in group 3. The survival rates of patients in group 1 at the end of the ninth, 12th, 15th, 18th, and 21st months were 53.2%, 42.2%, 42.2%, 42.2%, and 42.2%, respectively, which were not significantly different from those of patients in group 2 but were better than the survival rates of patients in group 3. The results suggest that hepatic arterial embolization is an effective palliative treatment that prolongs survival of patients with unresectable hepatocellular carcinoma.     

Staged hepatectomy following arterial embolization for ruptured hepatocellular carcinoma

BACKGROUND/AIMS: While hemostasis by transcatheter arterial embolization is often the first choice in the initial treatment of ruptured hepatocellular carcinoma, post-transcatheter arterial embolization treatment has not fully been established. We studied the prognoses of ruptured hepatocellular carcinoma cases where hepatectomy was possible after transcatheter arterial embolization. METHODOLOGY: We retrospectively reviewed 10 cases of ruptured hepatocellular carcinoma which had been treated in our institution between 1989 and 1998. In all the 10 cases, emergency transcatheter arterial embolization was performed, which successfully achieved hemostasis. RESULTS: Following the achievement of hemostasis by transcatheter arterial embolization, hepatectomy was carried out in 5 cases after evaluation of general condition, functional liver reserve and extent of tumor spread. There was neither operative nor hospital death. One-year and 3-year survival rates were 100% and 40%, respectively, and 50% survival time was 36 months. In the other 5 patients, hepatectomy was decided to be impossible after evaluation of general condition, functional liver reserve and extent of tumor spread; all of them died within 0.5-10 months after transcatheter arterial embolization. CONCLUSIONS: Among the patients with ruptured hepatocellular carcinoma, those in which hepatectomy was decided to be possible after evaluation of general condition, functional liver reserve and extent of tumor spread, following successful hemostasis by transcatheter arterial embolization, had fairly good prognoses.     

Prognosis of unresectable hepatocellular carcinoma: an evaluation based on multivariate analysis of 90 cases.

A multivariate analysis of data from 90 patients with unresectable hepatocellular carcinoma was performed using Cox's regression model to identify factors possibly affecting their prognoses. Thirty-one patients underwent arterial anticancer chemotherapy, and the remaining 59 patients received transcatheter arterial embolization with anticancer agents. Four of 27 variables tested for all the patients (i.e., encapsulation [p less than 0.05], gross appearance of hepatocellular carcinoma [p less than 0.01], clinical stage [p less than 0.01] and therapy [p less than 0.01]) were found to be prognostically significant. Five of 27 variables tested were prognostically significant for the transcatheter arterial embolization group; they were an extension rate of hepatocellular carcinoma (p less than 0.01), encapsulation (p less than 0.01), alpha-fetoprotein (p less than 0.01), prothrombin time (p less than 0.01) and serum sodium (p less than 0.01). Regression equations were used to describe a prognostic index. A prognostic index was defined as the regression equation derived from the results of a total of 90 patients; PI-1 = eY, where PI-1 = prognostic index 1 Y = 1.549 (gross appearance of hepatocellular carcinoma - 1.344) + 0.778 (encapsulation - 1.622) + 0.818 (clinical stage - 1.800) + 1.760 (therapy - 1.344) and prognostic index 2, the regression equation derived from the results of the transcatheter arterial embolization group of patients; PI-2 = eY, where PI-2 = prognostic index 2 Y = 1.210 (extension rate of hepatocellular carcinoma - 1.576) + 1.179 (encapsulation - 1.475) + 0.0001277 (alpha-fetoprotein - 1420.792) -0.039 (prothrombin time - 72.237) - 0.214 (serum sodium - 138.427).(ABSTRACT TRUNCATED AT 250 WORDS)     

Treatment of hepatocellular carcinoma by transcatheter arterial embolization combined with intraarterial infusion of a mixture of cisplatin and ethiodized oil

The therapeutic effectiveness of transcatheter arterial embolization (TAE) with intraarterial infusion of cisplatin/ethiodized oil mixture in treatment of resectable and unresectable hepatocellular carcinoma was compared with TAE with intraarterial infusion of doxorubicin mixed with and without ethiodized oil. The series included 97 patients with unresectable hepatocellular carcinoma and 40 patients with resectable hepatocellular carcinoma. With TAE using doxorubicin infusion, a partial response of the tumor was seen in only 11%, and the 2-yr survival was calculated to be only 5%. Histologic examination of the specimens obtained by hepatectomy also showed that this treatment was relatively ineffective in daughter tumor and portal tumor thrombi. In contrast, TAE with infusion of cisplatin/ethiodized oil mixture significantly increased the rate of partial response (38%), and significantly prolonged the 2-yr survival (45%). Histologically this treatment gave severe necrosis in daughter tumors (69%) and tumor thrombi (78%) as well as main tumor (75%). This treatment was significantly better than TAE with doxorubicin and ethiodized oil infusion in terms of the tumor regression and histologic responses of main tumor and portal vein tumor thrombi, but not in terms of the 2-yr survival. However, 2 patients (8%) died within 4 wk of the latter treatment, whereas no deaths were reported after the former treatment. Therefore, TAE combined with intraarterial infusion of cisplatin/ethiodized oil mixture may be a safe and useful treatment modality for hepatocellular carcinoma.     

Portal venous hemodynamics in hepatocellular carcinoma. Effects of hepatic artery embolization

Portal hemodynamics were studied in 55 patients with hepatocellular carcinoma in comparison with 41 normal subjects, using the duplex system that consists of an electronic sector scanner and a pulsed Doppler velocitometer. Changes of portal hemodynamics after transcatheter hepatic artery embolization were also investigated in 15 of the patients with hepatocellular carcinoma. The duplex system showed that 9 of the 55 had no Doppler signal in the portal trunk, suggesting portal vein thrombosis, 2 had hepatofugal flow in the portal trunk indicative of arterioportal shunts, and 44 had hepatopetal flow in the portal trunk. One of the 9 patients with no significant portal venous flow showed hepatopetal flow in collateral veins at the porta hepatis, suggesting cavernous transformation of the portal vein. All of these ultrasound findings were confirmed by subsequent celiac-mesenteric angiography. In 44 of the 55 patients there was no tumor invasion in the portal trunk, and portal venous flow was found to be close to that of normal subjects regardless of the stage or size of tumor, and tumor invasion into relatively large portal branches. After transcatheter hepatic artery embolization, portal venous flow was increased, even on the next day, and it remained increased for at least 2 wk. Thus, the duplex system is useful to study qualitative and quantitative changes of portal hemodynamics in hepatocellular carcinoma. Our observations suggest that the portal venous flow is kept relatively constant by some homeostatic mechanism even in advanced hepatocellular carcinoma until the tumor invades into the portal trunk, and that it increases when hepatic arterial flow is occluded.