Transcatheter arterial embolization followed by percutaneous ethanol injection in the treatment of hepatocellular carcinoma

Purpose The aim of this study was to evaluate the effectiveness of transcatheter arterial embolization (TAE) followed by percutaneous ethanol injection (PEI) in the treatment of large hepatocellular carcinoma (HCC) lesions.Methods Fifteen patients with HCC were treated by means of TAE followed by 6–16 ethanol injections. In 10 patients, the HCC was solitary (3–8 cm); 3 patients had 1, and 2 patients had 2 daughter nodules (3 cm or smaller) in addition. In 12 of 15 main tumors and in 4 of 7 daughter nodules, a tumor capsule was observed by computed tomography or magnetic resonance imaging.Results Combined treatment with TAE and PEI resulted in complete necrosis of 12 of 15 main tumors and 7 of 7 daughter nodules on biopsy. Treatment failure (incomplete necrosis) occurred in 3 unencapsulated main tumors. The 1-year survival rate in 10 patients was 100%.Conclusion The combination of TAE and PEI proved to be an effective treatment for large HCC, including those with 1–2 small daughter nodules. The presence of a tumor capsule significantly correlates (p < 0.05) with a favorable outcome of treatment.     

Evaluation of the vascular pattern of hepatocellular carcinoma with dynamic computed tomography and its use in identifying optimal temporal windows for helical computed tomography

The aim of this work was to study the vascularization of hepatocellular carcinoma (HCC) by means of dynamic CT and to demonstrate the existence of optimal temporal windows for visualization of HCC in order to develop new protocols for helical CT of the liver. We studied, by means of dynamic CT, 42 histologically proved HCCs in 30 patients after injecting contrast medium (100 ml, 3 ml/s). We performed a time–density analysis of the aorta, liver, portal vein, spleen and lesion. We identified three temporal curves of attenuation of the neoplastic tissue. Curve 1 was three-phasic: hyperattenuation, isoattenuation and hypoattenuation; curve 2 was two-phasic: hyperattenuation and isoattenuation; curve 3 was two-phasic: isoattenuation and hypoattenuation. Thirty-two lesions were homogeneous (curve 1 in 22 cases, 68.7 %; curve 2 in 7 cases, 21.8 %; curve 3 in 3 cases, 9.4 %), whereas 10 lesions were non-homogeneous. Two optimal temporal windows were identified: the first, with predominantly hyperattenuating lesions (range 29–65 s, 90.4 % sensitivity); the second, with predominantly hypoattenuating lesions (range 132.1–360 s, 76.1 %). There is an interposed time range of reduced visualization (range 62–127 s, 54.7 %) in which lesions are isoattenuating. Combined CT study during the first and second temporal windows improves the detection of HCCs especially for homogeneous and small lesions. The intermediate isoattenuation time range does not increase lesion detection rate. Received: 22 March 1996; Revision received 3 September 1996; Accepted 21 March 1997     

Combined transcatheter arterial chemoembolization and percutaneous ethanol injection for the treatment of large hepatocellular carcinoma: local therapeutic effect and long-term survival rate

The aim of our study was to investigate local therapeutic effects and long-term results of combined transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) in the treatment of large hepatocellular carcinoma (HCC). Eight-six patients (67 males and 19 females, age range 48–75 years, mean age 65.1 years) with Child-Pugh class A (n = 48) or B (n = 38) liver cirrhosis and a large HCC (main tumor 3.1–8 cm in diameter with no more than two daughter nodules) were enrolled in a prospective study. All patients underwent a single TACE session followed by PEI. Follow-up ranged from 4 to 65 months (mean 27.8 months, median 26 months). No major complication occurred. The local therapeutic effect, as assessed on the basis of findings at CT and MR imaging, was complete response in 71 of 86 patients (82 %) and partial response in 15 of 86. Overall survival rates by the Kaplan-Meier method were 92 % at 1 year, 83 % at 2 years, 69 % at 3 years, 58 % at 4 years, and 47 % at 5 years. Survival of Child-Pugh A patients (75 % at 3 years and 59 % at 5 years) was significantly longer (p < 0.01) than that of Child-Pugh B patients (61 % at 3 years and 35 % at 5 years). Combined TACE and PEI is an effective treatment for large HCC. Received 10 June 1997; Revision received 28 August 1997; Accepted 2 September 1997     

Percutaneous ethanol injection therapy of hepatoma

Percutaneous ethanol injection (PEI) under ultrasound guidance is a new therapeutic possibility for patients with small hepatocellular carcinoma (HCC). In our series, 35 patients with a total of 50 tumors were treated (tumor size 0.8–5.0 cm). No significant complications occurred after 502 sessions of ethanol injection. Thirty patients presented complete remission, as no evidence of residual HCC was revealed during the follow-up (mean 16 months). Five patients with lesions larger than 3.5 cm presented only partial remission. The survival curves at 1, 2, and 3 years (Kaplan Meier method) were 100%, 100%, and 80%, respectively. In comparison with the survival curves of untreated and surgically treated patients. PEI seems to be the better treatment for operable HCC smaller than 3 cm, and for lesions smaller than 5 cm in patients with high surgical risk.     

Spontaneous rupture of a necrotic hepatic angiosarcoma: findings on dual-phase computed tomography and angiography

We present dual-phase computed tomographic (CT) and angiographic findings of a ruptured hepatic angiosarcoma. These tumors can be divided into two types: those with and those without gross central necrosis with hemorrhage. In our case, the tumor had gross central necrosis, and CT and angiographic findings showed a small number of areas with a centripetal enhancement pattern and the rest of the tumor with avascular areas. We found that dual-phase CT and angiographic findings are able to distinguish angiosarcoma, which mimics a hemangioma, as these lesions show avascular areas that reflect a mass with gross central necrosis.     

FDG-PET for Evaluating the Antitumor Effect of Intraarterial 3-Bromopyruvate Administration in a Rabbit VX2 Liver Tumor Model

Objective

We wanted to investigate the feasibility of using FDG-PET for evaluating the antitumor effect of intraarterial administration of a hexokinase II inhibitor, 3-bromopyruvate (3-BrPA), in a rabbit VX2 liver tumor model.

Materials and Methods

VX2 carcinoma was grown in the livers of ten rabbits. Two weeks later, liver CT was performed to confirm appropriate tumor growth for the experiment. After tumor volume-matched grouping of the rabbits, transcatheter intraarterial administration of 3-BrPA was performed (1 mM and 5 mM in five animals each, respectively). FDG-PET scan was performed the day before, immediately after and a week after 3-BrPA administration. FDG uptake was semiquantified by measuring the standardized uptake value (SUV). A week after treatment, the experimental animals were sacrificed and the necrosis rates of the tumors were calculated based on the histopathology.

Results

The SUV of the VX2 tumors before treatment (3.87 ±1.51 [mean ±SD]) was significantly higher than that of nontumorous liver parenchyma (1.72 ±0.34) (p < 0.0001, Mann-Whitney U test). The SUV was significantly decreased immediately after 3-BrPA administration (2.05 ±1.21) (p = 0.002, Wilcoxon signed rank test). On the one-week follow up PET scan, the FDG uptake remained significantly lower (SUV 1.41 ±0.73) than that before treatment (p = 0.002), although three out of ten animals showed a slightly increasing tendency for the FDG uptake. The tumor necrosis rate ranged from 50.00% to 99.90% (85.48% ±15.87). There was no significant correlation between the SUV or the SUV decrease rate and the tumor necrosis rate in that range.

Conclusion

Even though FDG-PET cannot exactly reflect the tumor necrosis rate, FDG-PET is a useful modality for the early assessment of the antitumor effect of intraarterial administration of 3-BrPA in VX2 liver tumor.     

Spontaneous closure of cerebral arteriovenous malformation demonstrated by angiography and computed tomography

Summary Spontaneous disappearance of a cerebral arteriovenous malformation, presumably secondary to thrombosis, was demonstrated in a young female patient by angiography and computed tomography 11 and 13 years respectively after the initial radiographic demonstration of the lesion.     

16层螺旋CT头颈部血管减影成像技术初探

目的：探讨16层螺旋CT血管减影成像技术显示头颈部血管的能力及优势。方法：对20例行头颈部CT灌注的脑梗塞或（和）短暂性脑缺血发作（transient ischemicattack,TIA）患者进行CT血管减影成像检查。常规平扫后,选取基底节区进行静脉团注对比剂CT灌注（CTPeffusionimaging,CTP）扫描;然后根据CT灌注扫描获得动脉内对比剂峰值时间,用以设定平扫后动脉期的延迟时间,进而进行增强前后的同步薄层扫描,将增强前后（动脉期）的图像相减,即可获得动脉血管的原始图像,进行三维重建后显示动脉。结果：20例减影图像均能清晰显示颈内动脉颅内段、海绵窦段及颅内大动脉及其主要分支,其中15例无颅底骨质干扰,动脉显示良好,余5例因患者头部轻微运动,颅底骨质未能完全减去,但动脉尚能显示完整,不影响诊断。结论：16层螺旋CT血管减影成像,图像后处理简易省时,能提供类似MRA和DSA的血管图像,可广泛应用于临床,结合CTP资料,可有效预测颅内缺血性病变的发生。     

Ectasia of the intracranial arteries diagnosed by computed tomography

Summary The megadolichobasilar anomaly may be diagnosed by CT as an extra-axial lesion in the cerebellopontine angle. It enhances in a tubular fashion after intravenous injection of contrast. Hydrocephalus resulting from obstruction of CSF circulation may be demonstrated.     

Scrotal cystocele diagnosed by computed tomography

Computed tomographic scans of the pelvis that demonstrate anterolateral “pointing” of the urinary bladder suggest the possibility of inguinoscrotal herniation (scrotal “cystocele”), a rare but clinically relevant condition if it is not recognized preoperatively.     

Left portal vein pseudothrombus: A pitfall on contrast medium-enhanced computed tomography

Portal vein (PV) thrombosis may be detected on contrast medium-enhanced computed tomographic (CECT) scans of patients with acute abdominal pathology. We describe a pitfall of dynamic CECT related to the normal arched configuration of the left PV umbilical segment. On axial images, just caudal to the left PV arch, there is an apparent discontinuity in the left PV lumen filled with low-attenuation fat in the intersegmental fisure. If opacified hepatic artery branches traverse the fissure at this level, an appearance mimicking segmental PV thrombosis with mural enhancement can result. A retrospective review of 180 CECT scans in patients without PV thrombosis revealed this phenomenon in seven cases (4%). Awareness of this pitfall obviates the need for superfluous investigations that might otherwise be necessary to confirm PV patency.     

Radiation exposure to operating staff during rotational flat-panel angiography and C-arm cone beam computed tomography (CT) applications

Purpose

To evaluate the radiation exposure for operating personel associated with rotational flat-panel angiography and C-arm cone beam CT.

Materials and methods

Using a dedicated angiography-suite, 2D and 3D examinations of the liver were performed on a phantom to generate scattered radiation. Exposure was measured with a dosimeter at predefined heights (eye, thyroid, breast, gonads and knee) at the physician's location. Analysis included 3D procedures with a field of view (FOV) of 24 cm × 18 cm (8 s/rotation, 20 s/rotation and 5 s/2 rotations), and 47 cm × 18 cm (16 s/2 rotations) and standard 2D angiography (10 s, FOV 24 cm × 18 cm).

Results

Measurements showed the highest radiation dose at the eye and thyroid level. In comparison to 2D-DSA (3.9 μSv eye-exposure), the 3D procedures caused an increased radiation exposure both in standard FOV (8 s/rotation: 28.0 μSv, 20 s/rotation: 79.3 μSv, 5 s/2 rotations: 32.5 μSv) and large FOV (37.6 μSv). Proportional distributions were measured for the residual heights. With the use of lead glass, irradiation of the eye lens was reduced to 0.2 μSv (2D DSA) and 10.6 μSv (3D technique with 20 s/rotation).

Conclusion

Rotational flat-panel angiography and C-arm cone beam applications significantly increase radiation exposure to the attending operator in comparison to 2D angiography. Our study indicates that the physician should wear protective devices and leave the examination room when performing 3D examinations.     

Value of computed tomography in the diagnosis of intrapulmonary arteriovenous shunts

A case of intrapulmonary arteriovenous malformations (AVMs), its diagnosis, and a literature review is presented. We consider the diagnosis of intrapulmonary AVMs by noninvasive methods, such as plain chest radiography, fluoroscopy, computed tomography (CT), and particularly dynamic CT imaging of the thorax. To determine hemodynamic factors, oxygen consumption, oxygen saturation and blood gas analyses of the central pulmonary circulation digital subtraction angiography as well as invasive pulmonary angiography are needed. This work is dedicated to Prof. Dr. J. Vollmar to mark his 60th birthday     

急性主动脉壁间血肿的多层螺旋CT血管造影影像学表现和诊断价值

目的探讨急性主动脉壁间血肿（AAIH）的多层螺旋CT血管造影（MSCTA）影像学特征和临床应用价值。方法回顾性分析临床确诊76例AAIH患者的主动脉MSCTA检查资料,依据Stanford分型分为A型和B型,比较不同Stanford分型AAIH的影像学表现有无差异。根据患者随访期间的不同变化分为进展组与稳定和缓解组,分析进展的相关因素。所有结果均行统计学分析,符合正态分布的定量资料采用两独立样本t检验;不符合正态分布的定量资料采用Mann-Whitney U检验。定性资料采用χ2检验。结果Stanford A型27例（35.5%）、B型49例（64.5%）。A型、B型壁间血肿最大厚度、溃疡类病变、局灶性强化、胸腔积液上的差异均无统计学意义（Z=-0.788、χ2=0.441、χ2=0.383、χ2=0.338,均P > 0.05）。A型、B型溃疡类病变的深度分别为（2.8±2.9）mm、（2.5±3.3）mm,差异有统计学意义（Z=-2.345,P=0.019）。心包积液15例（19.7%）,A型12例多于B型3例,差异有统计学意义（χ2=16.138,P < 0.001）。41例AAIH患者短期随访,进展组20例,稳定和缓解组21例。单因素分析显示,进展组与稳定和缓解组在溃疡类病变、溃疡深度、胸腔积液间的差异均具有统计学意义（χ2=9.227、Z=-2.689、χ2=4.111,均P < 0.05）;在Stanford分型、壁间血肿厚度、局灶性强化、心包积液上的差异均无统计学意义（χ2=1.453、Z=-0.874、χ2=0.006、χ2=1.733,均P > 0.05）。将单因素分析中有统计学意义的指标纳入多因素Logistic回归分析,显示溃疡类病变是影响AAIH的独立危险预测因子。结论AAIH在MSCTA上表现为平扫密度较高、增强无强化的环形或新月形增厚主动脉管壁。MSCTA检查可以对AAIH做出快速、准确诊断。溃疡性病变是影响AAIH进展的独立危险因素。AAIH早期需要密切随访,监测有无进展。     

上肢无脉症的MSCTA诊断（附44例分析）

目的：探讨多层螺旋CT血管成像（MSCTA）在上肢无脉症的应用价值。方法：对44例临床疑患无脉症的患者行MSCTA检查,所获数据传输至AW4.2工作站,进行最大强度投影（MIP）、曲面重建（CPR）、容积显示（VR）及高级血管分析（AVA）等多种后处理并结合原始图像进行分析。结果：44例的血管重建图像对无脉症均有特征显示,动脉硬化闭塞症34例,多发性大动脉炎5例,外伤后动脉栓塞2例,动脉内癌栓2例,锁骨下动脉瘤人工血管置换术后1例。结论：MSCTA可以清楚而准确的显示上肢无脉症的病变情况,是上肢无脉症理想的影像学检查方法。     

评价迭代重建法与滤过反投影法在冠状动脉CTA检查中的价值

目的：对行冠状动脉CTA检查的患者原始数据应用低剂量自适应迭代重建技术（AIDR ）与滤过反投影法（FBP ）两种方法的图像进行比较,旨在了解迭代重建算法的图像质量及其临床应用价值。方法：26例临床疑似稳定性心绞痛患者采用320排CT行冠状动脉CTA检查。利用AIDR 重建的常规X线剂量方案扫描,对采集得到的原始数据分别用AIDR和FBP两种方法进行图像重建。测量升主动脉开口、右冠状动脉近段、左冠状动脉主干、右冠状动脉中段、左前降支近段及左回旋支近段的CT值、背景SD并计算分析SNR、CNR值。比较两者的图像质量。结果：26例患者都在一次心动周期完成冠状动脉检查。在血管各节段测得的平均CT值差异无统计学意义（P＞0．05）,背景SD值的差异有统计学意义（P＜0．001）,计算得到的SNR、CNR差异有统计学意义（P＜0．001）。两组图像质量的主观评分差异有统计学意义,AIDR （3．73±0．49）、FBP（3．59±0．61）（P＜0．01）。结论：应用AIDR重建法的图像质量优于FBP 重建法,迭代重建技术可明显降低图像噪声,改善影像质量并具有降低辐射剂量的作用。     

膈下动脉碘油化疗药物栓塞治疗肝癌

目的　评价膈下动脉碘油化疗药物栓塞对肝癌治疗的疗效及膈下动脉供血的肿瘤的部位。方法　 2 5例肝癌 ,巨块型 12例、结节型 8例、多发结节型 5例。均采用Seldingers法行肝动脉和膈下动脉碘油化疗药物及明胶海绵颗粒栓塞。结果　膈下动脉发自于腹腔干起始处者 16例 ,占 6 4 % ,直接发自主动脉腹腔干周围者 8例 ,占 32 %。其中供应右叶 (Ⅶ ,Ⅷ段 ) 2 3例 ;肿瘤位于左叶 (Ⅳ段 )膈下者2例。膈下动脉碘油化疗药物栓塞后累积 1、2年生存率分别是 84 %和 6 8%。未出现严重并发症。结论　经膈下动脉碘油化疗药物栓塞治疗肝癌是一种安全有效的方法。当肿瘤位于膈下 ,邻近膈肌 ,肝韧带或肝裸区 ,特别是肝动脉造影时肿瘤染色有缺损或无肿瘤染色 ,但肿瘤在CT上有增强或血AFP升高时 ,应考虑到肿瘤由膈下动脉供血。     

64层螺旋CT血管成像在脊髓血管介入术前评估中的价值

目的 探讨64层螺旋CT在脊髓血管介入术前评估中的价值.方法 选择17例胸腰段脊髓损伤患者行脊柱64层螺旋CT增强扫描,重建薄层图像,层厚0.625 mm,间隔0.625 mm,以DICOM格式传输到ADW4.2工作站,采用容积显示(volume rendering,VR)、最大密度投影(maximum intensity projection,MIP)及多平面重建(multi-planar reformat,MPR)等后处理技术进行三维重建,分析脊髓供血动脉的走行特征.结果 17例患者中有16例患者(94%)胸腰段均可见根髓动脉供血脊髓,其中1支(6%)自T4/5左侧椎间孔进入椎管,2支(12%)自T10/11左侧椎间孔进入椎管,1支(6%)自T11/12左侧椎间孔进入椎管,4支(24%)根髓动脉自L1/2左侧椎间孔进入椎管,2支(12%)自L2/3左侧椎间孔进入椎管,2支(12%)自T11/12右侧椎间孔进入椎管,2支(12%)自T12/L1右侧椎间孔进入椎管,2支(12%)自L2/3右侧椎间孔进入椎管,10例(59%)患者根髓动脉自左侧椎间孔进入椎管.另有1例(6%)患者行CT和DSA检查均未发现根髓动脉.结论 64层螺旋CT能准确直观反映脊髓供血动脉的开口位置、走行方向、管径大小及其与周围血管的空间关系,为脊髓血管介入术前提供丰富的评估信息.

Abstract：

Objective To investigate the value of 64-slice spiral computed tomography(CT)angiography in preoperative evaluation of spinal vascular intervention.Methods Seventeen patients with segmental injury of the spinal cord underwent the enhanced 64-slice CT scan of the spine.Thin-slice reconstruction was done,with the slice thickness of 0.625 mm and interval of 0.625 mm.The data were transferred to the work station ADW4.2 in DICM format.Image postprocessing technologies such as volume rendering(VR),maximum intensity projection(MIP)and multi-planar reformat(MPR)were used to conduct three-dimensional reconstruction and analyze the anatomical characteristics of radiculomedullary artery.Results Radiculomedullary artery could be found in the thoracolumbar segment of 16 patients(16/17,94%).Among them,one artery(1/17,6%)went into the vertebral canal through the left intervertebral foramen of T4/5,two(2/17,12%)through the left intervertebral foramen of T10/11,one (1/17,6%)through the left intervertebral foramen of T11/12,four(4/17,24%)through the left intervertebral foramen of L1/2,two(2/17,12%)through the left intervertebral foramen of L2/3,two (2/17,12%)through the right intervertebral foramen of T11/12,two(2/17,12%)through the right intervertebral foramen of T12/L1,two(2/17,12%)through the right foramen of L2/3 andl0(10/17,59%)through the left intervertebral foramen.Either CT scan or DSA examination found no radiculomedullary artery in one patient.All the above findings were in accordance with the results of DSA examination.Conclusions Spiral 64-slice CT scan can provide significant preoperative evaluation information for spinal vascular intervention,for it can accurately and visually show the anatomical features of the radiculomedullary artery such as open position,flow tendency,caliber size and spatial relationship with the surrounding vessels.     

Long-term results of percutaneous ethanol injection therapy for hepatocellular carcinoma in cirrhosis: a European experience

The objective of our work was to evaluate the long-term results of percutaneous ethanol injection (PEI) for the treatment of hepatocellular carcinoma (HCC) in patients with liver cirrhosis. A total of 184 cirrhotic patients with HCC underwent PEI as the only anticancer treatment over an 8-year period. Patients were followed after therapy by means of clinical examinations, laboratory tests, and US and CT studies performed at regular time intervals. Survival rates were determined according to the Kaplan-Meier method. The overall survival was 67 % at 3 years, 41 % at 5 years, and 19 % at 7 years. The 3-, 5-, and 7-year survival rates of patients with single HCC ≤ 3 cm (78, 54, and 28 %, respectively) were significantly higher (p < 0.01) than those of patients with single HCC of 3.1–5 cm (61, 32, and 16, respectively) or multiple HCCs (51, 21, and 0 %, respectively). Survival of Child-Pugh A patients (79 % at 3 years, 53 % at 5 years, and 32 % at 7 years) was significantly longer (p < 0.01) than that of Child-Pugh B patients (50 % at 3 years, 28 % at 5 years, and 8 % at 7 years). A selected group of 70 patients with Child-Pugh A cirrhosis and single HCC ≤ 3 cm had a 7-year survival of 42 %. Long-term survival of cirrhotic patients with HCC treated with PEI is comparable to that reported in published series of matched patients submitted to surgical resection. Received 12 March 1996; Revision received 24 June 1996; Accepted 23 August 1996