Prospective study of chemoembolization (CE) of liver metastases from endocrine tumors. A report of 15 cases

Fifteen patients with unresectable liver metastases of endocrine tumors (nine carcinoid tumors and six gastrinomas) were treated with an intraarterial emulsion of iodized oil and adriamycin followed by gelatin sponge particles. Therapeutic efficacy was evaluated in terms of hormone levels and tumor size as measured with computed tomography. Six patients showed a reduction in tumor size, and 4 a response in tumor marker levels. All these metastases were derived from primary carcinoid. All cancer-related syndromes disappeared. There were two major complications. The response in these 6 patients lasted from 2 to 39 months. Metastasis from primary gastrinomas did not respond to CE. These results indicate that chemoembolization is useful palliative therapy for patients with hormone-secreting tumors of the liver, particularly in carcinoids Correspondence to: P. Legmann     

Embolization of glomus tumors of the carotid: Temporary or definitive?

The authors describe the use of preoperative embolization of glomus tumors in 7 patients. In two cases a nonresorbable substance (IBCA) was used for the embolization, and no subsequent operation was needed. They therefore suggest that embolization could be a definitive treatment and an alternative to surgery.     

Analysis of Nontarget Embolization Mechanisms During Embolization and Chemoembolization Procedures

Complications of embolization and chemoembolization remain a problem even with the development of low-profile catheter material and the introduction of new embolization agents. In recent years many new embolization materials have become available for clinical use, so the possibilities and limitations of these new materials must be understood to allow safe and effective embolization. Although up to now some scientific work has been published reporting the basic risk of embolization procedures, the underlying pathomechanism remains the object of speculation. Besides complications like drug toxicity, allergic reactions, and bleeding of the puncture site, the characteristics of embolization materials must be known to understand the potential complications of nontarget embolization and reflux of embolization material. This article gives an overview of established and new embolization materials, their potential risks, and the underlying pathophysiology.     

Embolization of intradural vascular spinal cord tumors

Introduction Spinal cord tumors (SCT) are best treated by surgery. Vascular SCT (VSCT) represent a special challenge because of the bleeding that may occur during surgery and the subsequent difficulties in operating on these lesions. Embolization has been proposed as an approach that would facilitate VSCT resection. Methods The clinical and radiological charts of five patients, each with a large solid VSCT (four cervical hemangiobastomas, one filum terminale paraganglioma), were retrospectively reviewed. All of these hypervascular lesions were superselectively embolized prior to surgery (four with N-butyl cyanoacylate (glue), one with particles). Results Intranidal deposition of the glue was successful in all four patients, resulting in significant devascularization of the tumor. Because of arterial tortuosities, it was not possible to reach distally a cervical hemangioblastoma, and the latter was consequently embolized with particles. No permanent complications arose after embolization. Surgery became possible in each case under improved conditions with minimal blood loss, thereby allowing total (four cases of hemangioblastomas) or subtotal (one case of paraganglioma) removal of the tumor. Conclusion Embolization of intradural vascular tumors is a safe procedure if applied according to strict anatomical and technical guidelines. Whenever possible, glue can be considered as a first intention embolus, particles being reserved to cases where selectivity cannot be achieved. Despite its solid aspect after deposition, glue does not hinder surgery but facilitates the manipulation and eradication of the tumor. Due to its initial liquid aspect, glue penetrates deeply into the tumoral capillary bed, which favors satisfactory devascularization of the lesion.     

Trans-catheter arterial chemoembolization as first-line treatment for hepatic metastases from endocrine tumors

Our objective was to report the outcome in patients with liver metastasis from endocrine tumors who underwent transarterial chemoembolization (TACE) as first-line non-surgical treatment. From January 1990 to December 2000, 14 patients with progressive unresectable liver metastases from digestive neuroendocrine tumor were treated with TACE (mean of 3.6 sessions) before any non-surgical treatment (somatostatin analogue, chemotherapy or interferon). Liver involvement was less than 50% in 11 patients. Size of the largest lesion ranged from 1.5 to 10 cm. Ten patients presented with carcinoid symptoms. The TACE was performed with Doxorubicin emulsified in Lipiodol and gelatin sponge particles. Symptomatic response upon flushes and/or diarrhea was complete in 7 of 10 cases and partial in 2 of 10 cases. An objective morphologic response was noted in 12 of 14 cases. The 5- and 10-year survival rate from diagnosis was 83 and 56%, respectively. Six patients were alive at the end of the study after 27–100 months from first TACE and 38–142 months from diagnosis. Three of them were successfully palliated for 55, 69, and 100 months with only TACE as treatment. Long-term palliation is possible in unresectable liver metastases from digestive neuroendocrine tumors with a few sessions of TACE as first-line and eventually exclusive treatment. Electronic Publication     

骨肿瘤的术前动脉栓塞治疗

研究和评估骨肿瘤手术前选择性动脉栓塞治疗的价值，作用，探讨影响骨肿瘤术前动脉栓塞疗效的因素。材料与方法：对２４例骨肿瘤进行选择性动脉栓塞，先用明胶海绵颗粒栓塞肿瘤区小血地以明胶海绵细条栓塞供血动脉主士，于栓塞后１－５天进行手术。结果：共栓塞肿瘤供血动脉４７支，２３例手术成功，手术过程顺利，其中２０例肿瘤被完全切除，３例被大部切除，术中平均失血为９６０ｍｌ，无１例发生术中死亡或术后严重并发症；１例在     

X-chromosomal markers: Past,present and future

Experience gained in clinical genetics led to the fundamental idea of using X-chromosomal markers in a wide range of forensic applications. To date more than 30 STRs have been established as forensic markers. Joint typing of very tightly linked STRs yields stable haplotypes, and can be used for establishing the relationship between distant relatives, such as aunt–niece pairs and cousins. For such applications the new ChrX typing kit Argus X-8^® which is commercially available now is a powerful tool. This paper is aimed at presenting a brief survey of historical developments and discussing present and future aspects of forensic X-chomosomal testing.     

Radiofrequency thermal ablation of liver tumors

Radiofrequency ablation (RFA) of liver tumors was first proposed in 1990. New technologies enable us to produce liver thermal lesions of approximately 3–3.5 cm in diameter; RFA has consequently become an emerging percutaneous therapeutic option both for small hepatocellular carcinoma (HCC) and for non-resectable liver metastases, mainly from colorectal cancer. New devices (for example, triplet of cooled needles, wet needles) and combined therapies (tumor ischemia and RFA) have made it possible to treat large tumors. RFA can be carried out by a percutaneous, laparoscopic or laparotomic approach. Percutaneous RFA can be performed with local anaesthesia and mild sedation; deep sedation or general anaesthesia are also used. The guidance system is generally represented by ultrasound. CT or MR examinations are the more sensitive tests for assessing therapeutic results. The series of patients treated with RFA allow the technique to be considered as effective and safe, achieving a relatively high rate of cure in properly selected cases; it should be classified as curative/effective treatment for HCC, replacing percutaneous ethanol injection. The complication rate of RFA is low but not negligible; key elements in a strategy to minimize them are identified.     

Lipiodol retention within hepatic cavernous hemangioma

Intraarterial injection of Lipiodol has been recommended to differentiate hepatocellular carcinoma from benign lesions such as cavernous hemangioma, because uptake and prolonged retention of the contrast medium is a characteristic of the malignant tumors. In two cases of cavernous hemangioma of the liver in which we injected Lipiodol, uptake and retention up to 3 months was demonstrated. We conclude that the intraarterial injection of Lipiodol may not be reliable in differentiating hepatocellular carcinoma from cavernous hemangioma of the liver.     

肝癌药物碘油栓塞术常见并发症

本文报道44例肝癌行82次药物碘油栓塞术所见的并发症及处理。一般反应有术中迷走神经反射,术后栓塞综合征。严重的并发症主要有术后消化道大出血3例:肝癌破裂引起腹腔内及消化道大出血1例;严重感染3例。对消化道及肝癌破裂出血者,作者采用导管动脉灌注血管收缩剂或动脉栓塞止血获得良好效果。     

Diagnosis of portal vein thrombosis discontinued with liver tumors in patients with liver cirrhosis and tumors by contrast-enhanced US: A pilot study

Aims

We assessed the role of contrast-enhanced ultrasound (CEUS) in the differential diagnosis between benign and malignant portal vein thrombosis (PVT) in patients who had liver tumors.

Methods

Seventeen consecutive patients who had cirrhosis, liver tumors, and PVT were prospectively studied with CEUS. CEUS was performed at low mechanical index after intravenous administration of a second-generation contrast agent (SonoVue, Bracco, Milan, Italy). Presence or absence of thrombus enhancement on CEUS were considered diagnostic for malignant or benign PVT. Five patients also underwent percutaneous portal vein fine-needle biopsy under US guidance. All patients were followed-up. Shrinkage of the thrombus and/or recanalization of the vessels on CDUS during follow-up were considered definitive evidence of the benign nature of the thrombosis, whereas the enlargement of the thrombus, disruption of the vessel wall, and parenchymal infiltration over follow-up were considered consistent with malignancy.

Results

Follow-up showed signs of malignant thrombosis in 14 of 17 patients. CEUS showed early arterial enhancement of the PVT in 14 patients of 14 malignant PVT, 1 patient of 3 benign PVT and the absence of thrombus enhancement in 2 patients of 3 benign PVT. FNB confirmed the results for malignant PVT in four of five patients, for benign granulomatous inflammation PVT in one of five patients in which CEUS showed early arterial enhancement of the PVT. The sensitivity, specificity and accuracy is 100%, 66.7% and 93.3% at diagnosis of malignant PVT using CEUS. In one patient with intrahepatic bile duct stone, CEUS were positive for malignant PVT, whereas FNB was negative (benign granulomatous inflammation PVT); follow-up examination confirmed benign PVT.

Conclusion

CEUS seems to be the pretty sensitive and specific test for diagnosing malignant portal vein thrombosis in patients with cirrhosis and tumors.     

A new liquid embolic material for liver tumors

Purpose: To evaluate the feasibility of a new liquid embolic material, Onyx, for treating liver tumors.Material and Methods: Onyx is a mixture of 6% (w/v) ethylene-vinyl-alcohol copolymer dissolved in anhydrous dimethyl sulfoxide (DMSO) with 28% (w/v) tantalum powder. In addition to 6% Onyx, we also tried 4%, 2% and 1% solutions, prepared by adjusting the amount of DMSO. We used 15 white rabbits with liver tumors created by percutaneous injection of VX2 tumor cells. In 4 groups with 3 rabbits in each, the liver arteries were embolized with 6%, 4%, 2% and 1% Onyx, respectively, and in 3 rabbits DMSO alone was injected. The injections were performed just proximal to the bifurcation of the proper hepatic artery, followed by celiac arteriography. Post mortem, the livers were examined by soft-tissue radiography, and liver-tissue section microscopy.Results: The maximum number of arterial branching points passed by embolic material in either the right or left hepatic arteries was 11, 15 and 16, for 6%, 4% and 2% Onyx, respectively, but was non-measurable for 1% Onyx. Minimum diameters of arteries reached by 6%, 4%, 2% and 1% Onyx in tumorous areas were 40 μm, 35 μm, 20 μm and 10 μm, respectively, and in non-tumorous areas 35 μm, 5 μm, 5 μm and 5 μm, respectively.Conclusion: This study suggests that Onyx may be feasible for treatment of hepatic tumors.     

Place of Arterial Embolization in Severe Blunt Hepatic Trauma: A Multidisciplinary Approach

This study evaluates the efficacy of arterial embolization (AE) for blunt hepatic traumas (BHT) as part of a combined management strategy based on the hemodynamic status of patients and CT findings. From 2000 to 2005, 84 patients were admitted to our hospital for BHT. Of these, 14 patients who had high-grade injuries (grade III [n = 2], grade IV [n = 9], grade V [n = 3]) underwent AE because of arterial bleeding and were included in the study. They were classified into three groups according to their hemodynamic status: (1) unresponsive shock, (2) shock improved with resuscitation, and (3) hemodynamic stability. Four patients (group 1) underwent, first, laparotomy with packing and, then, AE for persistent bleeding. Ten patients who were hemodynamically stable (group 1) or even unstable (group 2) underwent AE first, based on CT findings. AE was successful in all cases. The mortality rate was 7% (1/14). Only two angiography-related complications (gallbladder infarction) were reported. Liver-related complications (abdominal compartment syndrome and biliary complications) were frequent and often required secondary interventions. Our multidisciplinary approach for the management of BHT gives a main role to embolization, even for hemodynamically unstable patients. In this strategy AE is very efficient and has a low complication rate.     

Arteritis following intra-arterial chemotherapy for liver tumors

Primary and metastatic tumors of the liver can be treated successfully with transcatheter chemoembolization (TACE) during selective arterial catheterism. Arteritis is a possible referred side effect which can lead to tortuosity of the arteries, stenosis and occlusion of vessels. In our hospitals 117 consecutive patients were treated with TACE from January 1990 to December 1992; 61 patients were affected by hepatocellular carcinoma (HCC) and 56 were affected by metastases from colorectal carcinoma. Each patient received from 1 to 4 treatments at monthly intervals using epirubicin/Lipiodol ultrafluid (E/LUF) or a mixture of epirubicin and mitomicin C (MC)/LUF and followed by gelatine sponge injection in the hepatic artery. Selective angiography performed 30–62 days after the first chemoembolization showed artery stenosis in 7 patients and thrombosis in 2 cases related to toxic arteritis due to chemoembolization. Reports about arteritis during TACE treatments are discussed. Received 6 April 1995; Revision received 4 August 1995; Accepted 9 July 1996     

Embolization of musculoskeletal tumors

Transarterial embolization should be considered in the treatment algorithm of primary or secondary bone tumors. Specific benefit is present where there is a high risk of bleeding at surgery, where there is spinal involvement and neural encroachment, where active bleeding is present, or in awkward surgical locations where prolonged surgery is anticipated.     

Multimodality diagnosis of liver tumors: feature analysis with CT, liver-specific and contrast-enhanced MR, and a computer model

RATIONALE AND OBJECTIVES: The purpose of this study was to measure and to clarify the diagnostic contributions of image-based features in differentiating benign from malignant and hepatocyte-containing from non-hepatocyte-containing liver lesions. MATERIALS AND METHODS: Six experienced abdominal radiologists each read images from 146 cases (including a contrast material-enhanced computed tomographic [CT] scan and contrast-enhanced and unenhanced magnetic resonance [MR] images) following a checklist-questionnaire requiring them to rate quantitatively each of as many as 131 image features and then reported on each of the two differentiations. The diagnostic value of each feature was assessed, and linear discriminant analysis was used to develop statistical prediction rules (SPRs) for merging feature data into computerized "second opinions." For the two differentiations, accuracy (area under the receiver operating characteristic curve [Az]) was then determined for the radiologists' readings by themselves and for each of three SPRs. RESULTS: Thirty-seven candidate features had diagnostic value for each of the two differentiations (a slightly different feature set for each). Radiologists' performance at both differentiations was excellent (Az = 0.929 [benign vs malignant] and 0.926 [hepatocyte-containing vs non-hepatocyte-containing]). Performance of the SPR that operated on the features from all modalities together was better than that of radiologists (Az = 0.936 [benign vs malignant] and 0.951 [hepatocyte-containing vs non-hepatocyte-containing]), but this difference was of marginal statistical significance (P = .11). Contrast-enhanced MR imaging and contrast-enhanced CT each made significant adjunctive contributions to accuracy compared with unenhanced MR imaging alone. CONCLUSION: Many CT- and MR imaging-based features have diagnostic value in differentiating benign from malignant and hepatocyte-containing from non-hepatocyte-containing liver lesions. Radiologists could also benefit from the fully informed SPR's "second opinions."