Portal Hemodynamics in Fulminant Hepatic Failure as Assessed by Duplex Doppler Ultrasonography

Portal hypertension usually occurs in patients with fulminant hepatic failure (FHF). There is, however, no information on portal venous hemodynamics in patients with FHF. Therefore, we studied the portal venous hemodynamics in patients with FHF using duplex Doppler ultrasonography. We measured the portal vein diameter, flow velocity, and volume flow with duplex Doppler ultrasonography in 29 patients with FHF and 15 patients with uncomplicated acute viral hepatitis. No significant difference was observed in the portal vein parameters in the two groups. Nineteen patients with FHF survived. No difference in portal flow velocity and flow rate was observed between survivors and nonsurvivors. A significantly lower portal flow velocity was observed in nine patients of FHF with ascites compared with those without ascites (12.29 ± 2.81 vs 16.26 ± 4.87 cm/sec; P < 0.01). Portal hemodynamics do not significantly change in fulminant hepatic failure; therefore, it has no prognostic significance.     

Time-resolved 3D cine phase-contrast magnetic resonance imaging (4D-flow MRI) can quantitatively assess portosystemic shunt severity and confirm normalization of portal flow after embolization of large portosystemic shunts

Diagnosis and severity assessments of portosystemic shunts (PSSs) are important because the pathology sometimes results in severe hepatic encephalopathy, which can be treated almost completely by shunt embolization. At present, morphological assessment of PSS is performed mainly by computed tomography, and ultrasound is used for blood flow assessment. In two cases of PSS-related hepatic encephalopathy, we used time-resolved 3D cine phase-contrast (4D-flow) magnetic resonance imaging (MRI) to assess blood flow before and after shunt embolization. Before the intervention, blood flow in the main trunk of the superior mesenteric vein was mostly hepatofugal. However, post-interventional 4D-flow MRI revealed hepatopetal superior mesenteric vein flow with significantly increased portal vein blood flow. 4D-flow MRI is an ideal adjunct to Doppler ultrasonography, allowing for objective and visual assessment of morphology and blood flow of the portal venous system, including PSSs, and is useful in determining the indications for, and outcome of, PSS embolization.     

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.     

Hepatic arterial blood flow in large hepatocellular carcinoma with or without portal vein thrombosis: assessment by transcutaneous duplex Doppler sonography

BACKGROUND: As liver cirrhosis progresses, the portal venous blood (PVBF) flow decreases, accompanied by an increase in hepatic arterial blood flow. Large hepatocellular carcinoma is a hypervascular tumour with a rapid growth, which seems to require an increase of the tumoral arterial blood flow. Furthermore, hepatocellular carcinoma is frequently associated with portal vein thrombosis, which subsequently impedes portal blood supply. METHODS: The purpose of our study was to estimate alterations in the hepatic arterial blood flow in large hepatocellular carcinomas occurring in liver cirrhosis, in comparison with liver cirrhosis and controls. Liver blood flow measurements were determined by duplex Doppler sonography in 47 patients with large hepatocellular carcinomas (13 with portal vein thrombosis and 34 without this thrombosis), 42 liver cirrhosis patients and 30 controls. The Doppler perfusion index was calculated as the ratio of hepatic arterial blood flow to total hepatic blood flow. RESULTS: The patients with liver cirrhosis had a significant increase of hepatic arterial blood flow as compared to controls (P < 0.001), accompanied by a significant reduction in PVBF (P < 0.005). As a result, the Doppler perfusion index was increased in patients with liver cirrhosis as compared to controls (P < 0.001). The hepatic arterial blood flow was increased in patients with hepatocellular carcinoma but without portal vein thrombosis as compared to the cirrhotic patients (P < 0.001), with a significant reduction of PVBF (P < 0.001). Hepatic arterial blood flow was also increased in patients with both hepatocellular carcinoma and portal vein thrombosis as compared to the patients without this thrombosis (P < 0.001). CONCLUSION: These results suggest that in large hepatocellular carcinomas there is a decreased PVBF, accompanied by an increased hepatic arterial blood flow. The hepatic arterial buffer response seems to be active in hepatocellular carcinomas and maintains liver perfusion to adequate levels.     

Analysis of hepatofugal flow in portal venous system using ultrasonic Doppler duplex system

Blood flow directions of the portal trunk, splenic vein, and superior mesenteric vein were studied using an ultrasonic Doppler duplex system in 146 healthy adults, 132 patients with liver cirrhosis, 76 with hepatocellular carcinoma, 32 with idiopathic portal hypertension, 134 with chronic hepatitis, 18 with acute hepatitis, and 142 with other diseases. Spontaneous hepatofugal flow in one or more of the three vessels examined was detected in 14 patients. Spontaneous hepatofugal flow in the portal trunk was detected in three patients with liver cirrhosis. In two of these three patients, the hepatofugal flow in the portal trunk disappeared after medication. This is interesting, since hepatofugal flow may, in fact, be more common than we suspected in patients who, because of the severity of their disease, are not able to undergo invasive examination. Postoperative hepatofugal flow in the portal system was detected in 20 of 71 cases: 15/17 patients after interposition mesocaval shunting, 2/17 after distal splenorenal shunting, 2/31 after splenectomy, and 1/6 after splenic artery occlusion with steel coils. In more than half the cases of interposition mesocaval shunting (9/17 patients), blood flow in the portal trunk was hepatofugal. However, hepatopetal blood flow in the portal trunk was maintained in most cases of distal splenorenal shunting (13/17), showing the merits of this technique as a selective portosystemic shunt operation.     

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.     

Preservation of segment 4 inferior by distal middle hepatic vein reconstruction combined with extended right hepatectomy after portal vein embolization in a patient with a huge initially unresectable HCC

An extended hepatectomy combined with preoperative portal venous embolization can offer curative resection in patients with initially unresectable hepatocellular carcinoma. However, hypertrophy of the future remnant liver is occasionally unsatisfactory after portal venous embolization in some patients to remove the initially unresectable tumor. In these patients, hepatic venous reconstruction to preserve hepatic parenchyma may contribute to the possibility of resection. The present case report shows a patient with an initially unresectable huge hepatocellular carcinoma in whom transarterial chemoembolization, portal vein embolization, and an extended right hepatectomy combined with distal middle hepatic venous reconstruction were performed to preserve Segment 4 inferior. The patient was a 66-year-old male. He presented with a huge hepatocellular carcinoma located at Segment 8, 7 and 4 superior, but the volume of the left lateral segment was only 267 mL. Transarterial chemoembolization was performed twice and right portal vein embolization was performed once, but the volume of the left lateral segment was only 318 mL compared to 487 mL which was a limit of future remnant liver volume. We therefore performed an extended right hepatectomy combined with distal middle hepatic venous reconstruction to preserve Segment 4 inferior. The left saphenous venous graft was used for this hepatic venous reconstruction. His postoperative course was almost uneventful. Postoperative abdominal computed tomography showed the satisfactorily preserved Segment 4 inferior. Distal hepatic venous reconstruction combined with an extended hepatectomy may further offer a chance of a curative resection for patients in whom enough hypertrophy of the future remnant liver is not obtained after portal venous embolization.     

Idiopathic intrahepatic arterioportal fistula treated by hepatectomy assisted by balloon-occluded retrograde transvenous obliteration: Report of an elderly case.

An 80-year-old woman with hepatic encephalopathy and esophagogastric varices was admitted. Doppler sonography and arteriography demonstrated an arterioportal fistula in the right anterior superior segment of the liver. Two attempts at transcatheter arterial embolization failed to manage the fistula and portacaval collaterals. We carried out hepatectomy and balloon-occluded retrograde transvenous obliteration, by which the portal flow changed from hepatofugal to hepatopetal. The resected specimen demonstrated multiple small holes in the right portal vein, which are arterioportal fistula. The underlying liver was normal. After treatment, esophagogastric varices and hepatic encephalopathy were markedly improved. Hepatectomy is useful as a reliable therapy for arterioportal fistula in case of failure of transarterial embolization.     

Clinical significance of removal of tumor thrombi in the main portal vein in patients with hepatocellular carcinoma

Twenty-two patients with portal vein tumor thrombi secondary to hepatocellular carcinoma were studied to evaluate the effectiveness of diagnostic and treatment procedures. B-mode ultrasonography is a simple and accurate means for the detection of tumor thrombus in the portal vein. All of the 22 patients were correctly diagnosed by this method, which should be used as the initial screening procedure in such patients. Fourteen of the 22 patients underwent surgical procedures, including embolectomy from the portal trunk; removal of the tumor thrombi combined with hepatectomy or through the rechanneled umbilical vein; and operative transcatheter arterial chemotherapy. The other 8 patients were treated by transcatheter arterial embolization or were not treated. The surgical treatment effectively prevented acute variceal bleeding in the patients who underwent the procedures successfully. The mean value of the portal venous pressure was reduced from 46 cmH₂O to 32 cmH₂O after the surgery. As a result of the effective portal decompression, the patients in the surgical group had a better prognosis and longer mean survival than the others. Our study suggests that portal vein tumor thrombus is not an absolute contraindication for surgery, and that accurate detection and prompt treatment are the keys to the achievement of better clinical results.     

Significance of portal hemodynamic investigation in prediction of hepatic functional reserve in patients with hepatocellular carcinoma undergoing operative treatment

BACKGROUND/AIMS: To evaluate clinical significance of portal hemodynamic investigation in prediction of hepatic functional reserve in patients with hepatocellular carcinoma undergoing operative treatment. METHODOLOGY: By using the color Doppler velocity profile technique, preoperative portal hemodynamic status was assessed in 29 patients with hepatocellular carcinoma treated surgically, including 15 segmentectomies, 6 hemihepatectomies and 8 transarterial chemoembolizations. Forty-six normal volunteers were taken as control. Comparison of preoperative portal hemodynamics between patients recovering from operation smoothly (tolerant subgroup) and those with major complications or death (intolerant subgroup) was done, and discriminant analysis was employed to identify the cut-off value for significant parameters that maximally separate the tolerant subgroup from the intolerant subgroup. RESULTS: In the portal trunk, CSVmax (maximum cross-sectional mean velocity) was significantly lower in the hepatocellular carcinoma group compared with the normal group (P < 0.01); flow volume was not obviously different between the two groups; congestion index was markedly higher in the hepatocellular carcinoma group than that of the normal group (P < 0.05). In the splenic vein, CSVmax and congestion index was not obviously different between the hepatocellular carcinoma and the normal groups; flow volume was significantly higher in the hepatocellular carcinoma group than that of the normal group (P < 0.05). In the hepatocellular carcinomas, twenty-three patients recovered smoothly from the operation and the remaining 6 had severe complications or death. Tolerant subgroup had a significantly higher preoperative CSVmax and flow volume and lower congestion index of the portal trunk compared with the intolerant subgroup (all P < 0.01). Discriminant analysis revealed that portal trunk CSVmax > 13.50 cm/s and flow volume > 12.13 mL/min/kg could predict tolerance for surgery, with an accuracy of 82.7% and 89.7%, respectively. CONCLUSIONS: The results suggest that preoperative portal hemodynamic status in hepatocellular carcinomas had a close correlation with hepatic functional reserve, and CSVmax and flow volume of portal trunk might become valuable predictive parameters.     

Arterio-portal shunt in liver rescued by hepatectomy after arterial embolization

Arterio-portal shunts are generally treated with transcatheter arterial embolization, as a therapeutic measure for bleeding of esophageal varices. However, transcatheter arterial embolization is frequently associated with reestablishment of arterio-portal shunts. We now report our experience with partial hepatectomy to remove the arterio-portal shunt associated with esophageal varices, which recurred after transcatheter arterial embolization. The patient was a 60-year-old female, who had massive hematemesis caused by rupture of esophageal varices. Doppler sonography and arteriography demonstrated an arterio-portal shunt in the right anterior superior segment of the liver. Temporary hemostasis was achieved with transcatheter arterial embolization, however, hemorrhage recurred one month later. The second transcatheter arterial embolization failed to manage the shunt and varices. The patient developed hepatic coma. After recovery from coma, she was referred to our hospital. We carried out partial hepatectomy, which provided remarkable hemodynamic improvement; the portal vein flow changed from hepatofugal to hepatopetal. Esophageal varices and hepatic coma have totally disappeared. This patient has had no complaint and has remained free of esophageal varices, for 3 years postoperatively. She is having a normal life. The partial hepatectomy to remove the arterio-portal shunt induced complete resolution of the arterio-portal shunt, as well as dramatic improvement in portal flow and hepatic coma. Our experience in the present case suggests that partial hepatectomy should be considered as a radical therapy for arterio-portal shunt, without insistence on transcatheter arterial embolization.     

Hepatic arterial buffer response in patients with advanced cirrhosis

Hepatic arterial buffer response (HABR) is considered an important compensatory mechanism to maintain perfusion of the liver by hepatic arterial vasodilation on reduction of portal venous perfusion. HABR has been suggested to be impaired in patients with advanced cirrhosis. In patients with hepatopetal portal flow, placement of a transjugular intrahepatic portosystemic shunt (TIPS) reduces portal venous liver perfusion. Accordingly, patients with severe cirrhosis should have impaired HABR after TIPS implantation. Therefore, the aim of this study was to investigate the effect of TIPS on HABR as reflected by changes in resistance index (RI) of the hepatic artery. A total of 366 patients with cirrhosis (Child-Pugh class A, 106; class B, 168; class C, 92) underwent duplex Doppler ultrasonographic examination with determination of RI and maximal flow velocity in the portal vein before and 1 month after TIPS placement. Portosystemic pressure gradient was determined before and after TIPS placement. In 29 patients with hepatofugal portal blood flow, RI was significantly lower than in 337 patients with hepatopetal flow (0.63 plus minus 0.02 vs. 0.69 plus minus 0.01; P <.001). TIPS induced a significant decrease of the RI in patients with hepatopetal flow (RI, 0.69 plus minus 0.01 before vs. 0.64 plus minus 0.01 after TIPS; P =.001) but not in patients with hepatofugal flow (RI, 0.63 plus minus 0.02 before vs. 0.63 plus minus 0.02 after TIPS; NS). This response was not dependent on the Child-Pugh class. In conclusion, our results suggest that some degree of HABR is preserved even in patients with advanced cirrhosis with significant portal hypertension.     

Measurement of portal blood flow by an ultrasonic "duplex" system composed of a pulsed Doppler flowmeter and a linear-type real time B mode electroscanner

The portal vein hemodynamics of patients with various liver diseases were investigated by means of a duplex system consisting of a linear electroscanner and a pulsed Doppler flowmeter. In cases of chronic liver disease, the cross-sectional area of the portal vein trunk became greater as the liver injury proceeded, while the maximum velocity tended to decrease. However, blood flow volume was no different between the controls and the chronic liver disease group. On the other hand, the splenic venous flow volume tended to increase as the liver injury advanced, suggesting that the increase in splenic venous flow volume is closely related to the formation of esophageal varices. This method permits non-invasive observation of changes during the course of various types of liver disease.     

Combination of preoperative embolization of the right portal vein and hepatic artery prior to major hepatectomy in high-risk patients: a preliminary report

BACKGROUND/AIMS: Preoperative transhepatic portal vein embolization may not always be sufficient to achieve the desired changes in contralateral hepatic volume and function. The beneficial role of additional transcatheter arterial embolization performed after inadequate response to preoperative transhepatic portal vein embolization is described. METHODOLOGY: Four patients underwent both preoperative transhepatic portal vein embolization and transcatheter arterial embolization, and 6 control patients underwent preoperative transhepatic portal vein embolization only. Changes in right liver lobe volume fraction, residual left lobe volume fraction, and prediction score (low-risk, < 45; borderline, 45-55; high-risk > 55); were evaluated. RESULTS: 1) The change in right liver lobe volume after both preoperative transhepatic portal vein embolization and transcatheter arterial embolization (volume after/before) was 0.75 times that of the original level whereas after preoperative transhepatic portal vein embolization, they were only 0.81 times that of the original level. 2) The change in residual left liver volume after both preoperative transhepatic portal vein embolization and transcatheter arterial embolization (volume after/before) was 1.40 times that of the original level whereas after preoperative transhepatic portal vein embolization they were only 1.30 times than the original level. The changes in left liver volume after preoperative transhepatic portal vein embolization/transcatheter arterial embolization was more favorable than those after preoperative transhepatic portal vein embolization only. 3) The change in prediction score after both preoperative transhepatic portal vein embolization and transcatheter arterial embolization (after/before) was 0.81 times that of the original level. All prediction score in high-risk patients recovered to the borderline or safety zone. Change after preoperative transhepatic portal vein embolization only (before/after) was 0.87 times that of the original level. 4) All 4 patients who underwent both preoperative transhepatic portal vein embolization and transcatheter arterial embolization received right hepatic lobectomy successfully and returned to their normal life style. CONCLUSIONS: Preoperative occlusion of right hepatic inflow vessels increased the volume and function of the contralateral lobe where high-risk patients recovered to the borderline zone for major hepatic resection.     

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.     

Factors affecting the prognosis of patients with hepatocellular carcinoma invading the portal vein--a retrospective analysis using 952 consecutive HCC patients

BACKGROUND/AIMS: Hepatocellular carcinoma with portal venous invasion has a very poor prognosis. The aim of this study is to clarify the factors contributing to the survival of hepatocellular carcinoma patients with portal venous invasion. METHODOLOGY: Out of 952 patients with hepatocellular carcinoma admitted to Tokyo University hospital and its affiliated hospitals from 1987 to 1999, 53 patients developed portal venous invasion until December 2000. The main portal vein was invaded in 33 patients, and the first branch was invaded in the 20 patients. The factors contributing to the prognosis of hepatocellular carcinoma patients with portal venous invasion were determined by univariate and multivariate analyses using 19 clinicopathological parameters. RESULTS: Overall survival rates of the 53 patients at 6 months, and 1 and 2 years were 40%, 18%, and 12%, respectively. Univariate analysis indicated that the serum albumin level, Child classification, number of tumor foci, portal venous invasion-targeted irradiation, and percutaneous tumor ablation of the parenchymal main tumor were significant. Multivariate analysis showed that percutaneous tumor ablation (P = 0.033; risk ratio = 0.28) was the most important factor contributing to a favorable prognosis followed by number of tumor foci (P = 0.048; risk ratio = 0.41). CONCLUSIONS: This study showed the significance of treatment for the parenchymal main tumor in addition to portal venous invasion in patients with hepatocellular carcinoma involving portal venous invasion. Therefore, the efficacy of combined therapy using portal venous invasion-targeted irradiation and percutaneous tumor ablation for the parenchymal main tumor on survival of hepatocellular carcinoma patients with portal venous invasion is suggested.     

A prospective study of upper gastrointestinal hemorrhage in patients with hepatocellular carcinoma

Our purpose was to determine, in a prospective study, the causes of gastrointestinal hemorrhage in patients with hepatocellular carcinoma, and the relationship of portal vein invasion with variceal hemorrhage in these patients. During an 11-month period, 55 patients presented with hepatocellular carcinoma presented with signs and/or symptoms of upper gastrointestinal hemorrhage. Forty-seven percent had bleeding from varices, whereas the majority, 53%, had a nonvariceal bleeding source. Among those with nonvariceal bleeding, duodenal ulceration was the commonest cause. Direct tumor invasion into the gastrointestinal tract was found in three patients. Tumor invasion of the portal venous system was detected by ultrasound examination in 76% of the variceal bleeders, compared to only 45% of the nonvariceal bleeders. Despite the very high frequency of cirrhosis among patients with hepatocellular carcinoma, the source of bleeding was variceal in less than half of the patients. Portal vein invasion is a risk factor for subsequent variceal bleed.     

Clinical efficacy of portal vein stent placement in patients with hepatocellular carcinoma invading the main portal vein

BACKGROUND/AIMS: Hepatocellular carcinoma frequently invades the portal veins, and when it invades the main portal vein, the patient's prognosis is extremely poor. This study was undertaken to evaluate the clinical efficacy of stent placement into the portal vein in these patients. METHODS: Twenty-one patients with hepatocellular carcinoma invading the main portal vein were studied. Stents were placed in the portal veins to compress tumor thrombi after percutaneous transhepatic portography. RESULTS: Stents were successfully placed in the portal veins in all patients. Portal venous pressure significantly decreased from 25.3 +/- 7.4 mmHg to 22.4 +/- 6.6 mmHg (p < 0.0001) immediately after stent placement, leading to improvement in gastroesophageal varices, melena and ascites. Although a pseudoaneurysm of the hepatic artery related to portal vein puncture developed in one patient, there were no major complications in the other 20 patients. Blood flow through the stent was maintained during the survival period in 15 patients. The mean stent patency period was 12.4 months. Fifteen patients underwent transcatheter arterial chemoembolization without major complications after stent placement. The survival rate was 64.2% at 6 months and 29.2% at 1 and 2 years, respectively. The mean survival period was 13.7 months. CONCLUSION: Stent placement into the portal vein is a relatively safe and feasible procedure. It improves portal hypertension, expands treatment options, and helps to prolong the survival period in patients with hepatocellular carcinoma invading the main portal vein.     

A study of portal vein embolization with absolute ethanol injection in cirrhotic rats

AIM To investigate the effects of portal vein embolization (PVE) with absolute ethanol injection on the cirrhotic livers.METHODS Absolute ethanol was injected intraportally into normal and cirrhotic SD rats and the changes of the animals in anatomy, pathology, liver function as well as portal hemodynamics were observed.RESULTS At a dose of 0.05mL/100g of ethanol, the survival rate was 100% in normal rats compared with 40.9% in cirrhotic rats. PVE in the cirrhotic rats with 0.03mL/100g of ethanol, caused significant hypertrophy in non-embolized lobes, mild or moderate damage to the hepatic parenchyma, slight and transient alterations in liver function, portal pressure and portal flow.CONCLUSION PVE with absolute ethanol injection in the setting of liver cirrhosis could be safe at an appropriate dose, and precautions aimed at preserving liver function were preferable.INTRODUCTIONPortal vein embolization (PVE) plays an important role in the management of hepatocellular carcinoma (HCC). We modified the conventional method of transcatheter embolization and developed a new PVE technique with ethanol injection via a fine needle in experimental study[1] and subsequent clinical application under guidance of portoechography[2]. To further elucidate the therapeutic basis of this technique, particularly its effects on the cirrhotic liver, we observed the alterations in liver anatomy, pathology, biochemistry and portal hemodynamics in cirrhotic rats undergoing PVE with ethanol injection.     

Complete response by a combination of 5-fluorouracil and interferon-alpha chemotherapy for lung metastasis of hepatocellular carcinoma after hepatic resection with portal and hepatic vein tumor thrombectomy.

A 75-year-old female was admitted to our hospital and diagnosed with hepatocellular carcinoma (HCC). Computed tomography (CT) revealed a liver tumor with tumor thrombi in the portal trunk and main hepatic vein, as well as small lung metastases. The patient had good liver function with no sign of hepatitis B or C infection. She underwent right trisectionectomy of the liver with tumor thrombectomy. Intrahepatic recurrence and progression of lung metastases were observed 4 months later. Intrahepatic recurrent tumors were treated with transcatheter arterial chemoembolization (TACE), and lung metastases were treated with systemic combination chemotherapy of 5-fluorouracil (5FU) and interferon-alpha (IFN-alpha). Computed tomography showed no viable lesions in the liver and lung 6 months after these treatments. The patient has been disease free for 18 months. Prognosis is poor for patients with hepatocellular carcinoma with portal vein tumor thrombus (PVVT) or extrahepatic metastasis. This systemic combination chemotherapy with 5-fluorouracil and interferon-alpha might be effective for patients with good liver function when intrahepatic lesions are well controlled by multidisciplinary treatments, including hepatic resection with tumor thrombectomy.