Vascular supply with angio-CT for superselective intra-arterial chemotherapy in advanced maxillary sinus cancer

Recently popularised, the combined angiography and CT (angio-CT) system is useful for correctly identifying the feeding arteries and their perfusion in various organs. We applied this system for advanced maxillary cancer to expose its feeding arteries and their supplying territories. In addition to the maxillary artery, extramaxillary feeding arteries were usually observed, including the ophthalmic, accessory meningeal, facial, transverse facial and ascending palatine arteries. These extramaxillary feeding arteries exhibited uniform tendencies, depending on the site of extramaxillary tumour extension.Combined therapy with radiotherapy and superselective intra-arterial chemotherapy for advanced maxillary sinus carcinoma has recently been attempted at many institutions to preserve the organ and improve prognosis [1–3]. Although the maxillary artery is the usual main feeder, we frequently encounter extramaxillary supplying arteries when tumours grow exophytically or invade adjacent organs. Therefore, interventional radiologists should be familiar with the imaging findings of the supplying arteries associated with maxillary cancer. In this pictorial review, we illustrate the feeding arteries (and their supplying territories) of advanced maxillary cancer using a combined angiography and CT (angio-CT) system, which provides more accurate vascular anatomy than digital subtraction angiography (DSA).     

Feeding Artery of Laryngeal and Hypopharyngeal Cancers: Role of the Superior Thyroid Artery in Superselective Intraarterial Chemotherapy

The purpose of this study was to elucidate the role of the superior thyroid artery in intra-arterial infusion chemotherapy for laryngeal and hypopharyngeal cancers. Thirty-nine patients with laryngeal cancer and 29 patients with hypopharyngeal cancer underwent intra-arterial infusion chemotherapy. We performed a retrospective analysis of the feeding arteries confirmed by computed tomography during selective arteriography and compared the results with the extent of the tumors. In 14 of 39 laryngeal and 15 of 29 hypopharyngeal cancers, the tumor did not cross the midline (group 1). In the remaining 25 and 14 cancers, respectively, the tumor crossed the midline or located in the center (group 2). For 13 of 14 laryngeal and 7 of 15 hypopharyngeal cancers in group 1 and for 6 of 25 laryngeal cancers in group 2, the entire tumor was contrast enhanced by the ipsilateral superior thyroid and/or superior laryngeal artery. For 12 of 25 laryngeal and 1 of 14 hypopharyngeal cancers in group 2, the entire tumor was contrast enhanced by the bilateral superior thyroid artery. For the other patients, infusion via the other arterial branches such as the inferior thyroid and the lingual arteries were needed to achieve contrast enhancement of the entire tumor. Superselective intra-arterial chemotherapy for laryngeal cancer from the superior thyroid artery is appropriate, whereas that for hypopharyngeal cancer is less sufficient. To accomplish contrast enhancement of the entire tumor, additional intra-arterial infusion from other arteries such as the inferior thyroid artery is often necessary.     

A Novel External Carotid Arterial Sheath System for Intra-arterial Infusion Chemotherapy of Head and Neck Cancer

Purpose

The purpose of this study was to describe a novel system for treating advanced head and neck cancer consisting of an external carotid arterial sheath (ECAS) and a microcatheter to inject drugs retrogradely into multiple feeding arteries through the superficial temporal artery (STA).

Materials and Methods

Four consecutive patients with head and neck cancer that had more than one feeding artery were enrolled in this study. The ECAS was made of polyurethane and surface-coated with heparin resin to prevent thrombus formation, allowing it to remain in place for a prolonged period of time. The ECAS was inserted through the STA, and its tip was placed between the maxillary artery and facial artery. The tumor-feeding arteries were selected using a hooked-shaped microcatheter through the ECAS.

Results

A total of 13 target arteries were selected in the four patients. The microcatheter inserted via the ECAS was used to catheterize ten arteries (five lingual arteries and five facial arteries). The remaining three lingual arteries were directly selected by the catheter without ECAS. All of the target arteries were able to be catheterized superselectively. The technical success rate was 100%. Vascular occlusion, which might have been caused by the ECAS, was observed in one patient. No neurologic toxicities occurred.

Conclusion

This ECAS system is a new approach for retrograde superselective intra-arterial chemotherapy that covers the entire tumor with anticancer drugs. It has the potential to increase the effectiveness of therapy for advanced head and neck cancer.

Level of Evidence

Level 4, Case Series.

     

A cone-beam volume CT using a 3D angiography system with a flat panel detector of direct conversion type: usefulness for superselective intra-arterial chemotherapy for head and neck tumors

BACKGROUND AND PURPOSE: The development of flat panel detectors (FPDs) has made cone-beam CT feasible for practical use in a clinical setting. Our purpose was to assess the usefulness of cone-beam CT using the FPD in conjunction with conventional digital subtraction angiography (DSA) for performing superselective intra-arterial chemotherapy for head and neck tumors. MATERIALS AND METHODS: Twenty-three consecutive patients (43 feeding arteries) were prospectively examined. All of the patients underwent intra-arterial rotational angiography using an FPD system, and the cone-beam CT was reconstructed from the volume dataset. Two radiologists evaluated the quality of the cone-beam CT and then evaluated whether the additional information provided by the cone-beam CT was useful for the interventional procedures. RESULTS: In 41 (95%) of 43 arteries, the extent of contrast material perfusion was sufficiently visualized on cone-beam CT. In 20 (47%) of 43 arteries, the DSA plus cone-beam CT was superior to the DSA alone regarding the precise understanding of vascular territory of each artery. This information was helpful for predicting the drug delivery for superselective intra-arterial chemotherapy, especially in deeply invasive tumors with multiple feeding arteries. CONCLUSION: In superselective intra-arterial chemotherapy for head and neck tumors, cone-beam CT with FPD provides useful additional information, which allows interventional radiologists to determine the feeders, as well as the dose of antitumor agent for each feeder.     

Superselective continuous arterial infusion chemotherapy through the superficial temporal artery for oral cavity tumors

BACKGROUND AND PURPOSE: High-dose intraarterial chemotherapy with repeated one-shot infusion may be useful for treating head and neck tumors. We evaluated the efficacy of superselective continuous arterial infusion chemotherapy administered via a coaxial catheter system and compared the results with those of subselective catheterization for treatment of oral cavity tumors. METHODS: Forty-nine consecutive patients with tumors of the oral cavity (clinical stage I, 12 cases; stage II, 19 cases; stage III, six cases; stage IV, 12 cases) were treated by arterial infusion chemotherapy. After a guiding catheter was advanced into the superficial temporal artery, superselective catheterization was performed using a coaxial system microcatheter. Superselective catheterization was accomplished in 34 cases, and was unsuccessful in 15, owing to difficulties in performing catheterization or to multiple feeding arteries. In the latter cases, the tip of the catheter was placed near the origin of the feeding arteries (subselective catheterization). RESULTS: Thirty (88%) of 34 patients had a complete response to superselective arterial infusion chemotherapy and two (6%) had a partial response. Twelve (80%) of 15 patients had a complete response to subselective arterial infusion chemotherapy and three (20%) had a partial response. Local recurrence was more frequent after subselective treatment (13%) than after superselective (6%) treatment. CONCLUSION: Superselective continuous arterial infusion chemotherapy may be suitable for local control of oral cavity tumors, with a low rate of recurrence.     

乳腺癌术前经动脉新辅助化学治疗及栓塞的疗效分析

目的探讨乳腺癌患者外科术前经动脉化学治疗药物灌注并栓塞供养血管后,对外科手术方式以及疗效的影响。方法23例女性单侧乳腺癌确诊患者,在外科手术前6～17 d,行锁骨下动脉局部化学治疗药物灌注和栓塞,化学治疗药物采用FAC/FEC方案,栓塞剂为碘化油和明胶海绵。外科手术前1～3 d行钼靶摄片,测量肿块变化,记录手术出血量和手术方式。结果经动脉化疗灌注栓塞无严重并发症;化学治疗灌注栓塞后5～15 d,部分缓解61%(14/23),病变稳定39%(9/23);20例患者行乳腺癌改良根治术,3例患者行保乳手术。手术出血量45～400 mL,平均出血量(141±96)mL,并与同时期同科室52例乳腺癌改良根治手术(术前未化学治疗栓塞)的出血量90～450 mL,平均(209±83)mL进行对比,差异有统计学意义(P<0.05)。结论乳腺癌术前经动脉新辅助化学治疗及栓塞供养动脉,可使肿块缩小,减少术中出血量,利于手术切除,并增加保乳手术的机会。     

Intraarterial chemotherapy of head and neck tumors

Forty-one patients with advanced recurrent or untreated and neck tumors were treated with intraarterial short-term (1-1 1/2 hr) infusion of cisplatin into the external carotid artery, achieving an immediate tumor response rate of 29.3%. Tumor extent within or beyond the territory of a single external carotid artery was the only significant factor identified affecting the tumor response rate (57.1% vs. 14.8%). Treatment with intraarterial chemotherapy using superselective catheterization before irradiation or surgery is beneficial in some patients.     

Pre-operative embolization of juvenile nasopharyngeal angiofibromas

Pre-operative embolization of juvenile nasopharyngeal angiofibroma was performed in 15 patients. The lesion was supplied by the internal carotid arteries (8 cases), by the internal maxillary artery (15 cases), the accessory meningeal artery (10 cases) and the ascending pharyngeal artery (10 cases). Superselective embolization of the external carotid artery feeders was performed with Ivalon particles, without neurological complications. Good control of per-operative blood loss was noted in 13 out of 15 cases, 2 patients presenting severe per-operative venous bleeding. Recurrence was noted in only one patient, which could be controlled by reembolization.     

脂肪乳作为溶剂行胰腺区域性动脉灌注化疗的临床应用

目的 探讨以脂防乳作为溶剂,行胰腺癌区域性动脉灌注化疗治疗中晚期胰腺癌的疗效.方法 6例中晚期胰腺癌选择性动脉插管于胰腺癌的供血动脉,灌注吉西他滨、20%脂肪乳混合液.观察疗效、临床受益反应、患者的生存期及不良反应等.结果 6例均获临床受益,2例均获临床缓解,Kaplan-Meier法计算6、9和12个月的分别生存6例、5例和4例.结论 以脂肪乳作为溶剂.行胰腺癌区域性动脉灌注化疗治疗中晚期胰腺癌.可获得较好的临床疗效,患者耐受良好,值得进一步研究.     

Superselective intracerebral chemotherapy of malignant tumours with BCNU

Summary Early experience shows that: 1. Superselective intra-arterial catheterization above the ophthalmic artery minimizes the orbital complications. 2. Catheterization in a distal branch may lead to the non-infusion of a part of the tumor territory. 3. A much higher concentration of the drug is achieved by superselective intra-arterial infusion than by intravenous injection. 4. Longer infusions seem more efficacious than bolus injection. 5. Early trapping of the drug appears to be essential for therapeutic efficacy.     

选择性鼻咽纤维血管瘤供血动脉术前栓塞的应用

目的 探讨选择性鼻咽纤维血管瘤供血动脉术前栓塞的应用价值。方法 对15例鼻咽纤维血管瘤行数字减影血管造影(DsA)检查和栓塞治疗。供血动脉主要为颈外动脉的颌内动脉和(或)咽升动脉，栓塞材料用明胶海绵。结果15例在选择性颈外动脉栓塞后行手术治疗，13例术中出血量明显减少，2例由颈外动脉，颈内动脉系统同时供血，仅选择性颈外动脉栓塞，术中出血量较多。栓塞后2～5d手术最为理想。结论鼻咽纤维血管瘤供血动脉术前栓塞是临床有效的治疗方法之一。     

鼻咽血管纤维瘤术前双重介入栓塞的临床价值

目的探讨双重介入栓塞对治疗鼻咽血管纤维瘤的临床价值。方法7例鼻咽血管纤维瘤患者,术前均行DSA造影检查,其中6例病灶主要由上颌动脉及颈内动脉分支供血,均行双重介入栓塞治疗即局部穿刺瘤体内直接栓塞 供瘤动脉栓塞;另1例仅上颌动脉供血,故仅行供瘤动脉栓塞。结果所有病灶在栓塞后造影检查中均明显缩小。结论双重介入栓塞治疗可作为鼻咽血管纤维瘤术前必备的辅助治疗措施。     

Intra-arterial Infusion Chemotherapy for Advanced Non–Small-Cell Lung Cancer: Preliminary Experience on the Safety,Efficacy, and Clinical Outcomes

PurposeTo investigate the effectiveness and toxicity of intra-arterial infusion chemotherapy as a therapeutic modality for advanced non–small-cell lung cancer (NSCLC).Materials and MethodsIn a retrospective study, 40 patients with stage III NSCLC received intra-arterial infusion chemotherapy with gemcitabine and cisplatin. Tumor staining was graded based on angiography, and the number of NSCLC feeding arteries detected was recorded. Toxicity was assessed according to National Cancer Institute Common Toxicity Criteria for Adverse Events. The response to treatment was evaluated per Response Evaluation Criteria In Solid Tumors (RECIST). Efficacy was assessed based on time to tumor progression (TTP), and survival was estimated by Kaplan–Meier analysis. Prognostic factors influencing TTP and overall survival rate were evaluated by Cox regression analysis.ResultsThe most frequent drug-related adverse events were cough (n = 17; 42.5%), anorexia (n = 14; 35%), and pain (n = 9; 22.5%). Evaluated per RECIST, a total of 47.5% of patients (n = 19) exhibited response to therapy after completion of the first three cycles of intra-arterial infusion chemotherapy. The median TTP was 5 months. Patients had a median life expectancy of 9 months. By Cox regression analysis, tumor staining was shown to be an independent prognostic factor for TTP (relative risk, 0.405; 95% confidence interval, 0.216–0.760) and overall survival (relative risk, 0.348; 95% confidence interval, 0.185–0.656).ConclusionsIntra-arterial infusion chemotherapy for advanced lung cancer has the potential to reduce the size of tumors and has no severe adverse effects.     

Evaluation of Intrahepatic Perfusion on Fusion Imaging Using a Combined CT/SPECT System: Influence of Anatomic Variations on Hemodynamic Modification Before Installation of Implantable Port Systems for Hepatic Arterial Infusion Chemotherapy

BACKGROUND: In some patients with hepatic tumors, anatomic variations in the hepatic arteries may require hemodynamic modification to render effective hepatic arterial infusion chemotherapy delivered via implantable port systems. We used a combined CT/SPECT system to obtain fused images of the intrahepatic perfusion patterns in patients with such anatomic variations and assessed their effects on the treatment response of hepatic tumors. METHODS: Using a combined SPECT/CT system, we obtained fused images in 110 patients with malignant liver tumors (n = 75) or liver metastasis from unresectable pancreatic cancer (n = 35). Patients with anatomic hepatic arteries variations underwent hemodynamic modification before the placement of implantable port systems for hepatic arterial infusion chemotherapy. We evaluated their intrahepatic perfusion patterns and the initial treatment response of their liver tumors. The perfusion patterns on the fused images were classified as homogeneous, local hypoperfusion, and/or perfusion defect. Using the WHO criteria of complete response (CR), partial response (PR), no change (NC), and progressive disease (PD), we evaluated the patients' tumor responses after 3 months on multislice helical CT scans. The treatment was regarded as effective in patients who achieved a complete response or partial response. RESULTS: Anatomic hepatic artery variations were present in 15 of the 110 patients (13.6%); 5 manifested replacement of the left hepatic artery (LHA), 8 of the right hepatic artery (RHA), and 1 each had replacement of the RHA and LHA, and replacement of the LHA plus an accessory RHA. In 13 of these 15 patients (87%), occlusion with metallic coils was successful. On fusion imaging, the perfusion patterns were recorded as homogeneous in 6 patients (43%), as hypoperfusion in 7 (50%), and 1 patient had a perfusion defect (7.1%) in the embolized arterial region. Of the 8 patients with RHA replacement, 4 manifested a homogeneous distribution and 3 hypoperfusion. In 2 of 5 patients with LHA replacement, the distribution was homogeneous. In 1 patient with RHA and LHA replacement, and in 1 patient with LHA replacement and an accessory RHA, we noted hypoperfusion in the RHA territory. All 6 patients with homogeneous distribution were classified as PR or NC on follow-up multidetector CT. Of the 7 patients manifesting hypoperfusion, 3 were classified as PD (43%), 3 as NC (43%), and 1 as PR (14%) on follow-up CT. CONCLUSION: Hemodynamic modification of anatomic hepatic artery variations resulted in hypoperfusion on fusion images. Differences in the intrahepatic perfusion patterns may affect the response to hepatic arterial infusion chemotherapy.     

Selective intra-arterial cytostatic injections in malignant head and neck tumors

Summary Regional intra-arterial drug administration has been advocated in order to reduce the risks of systemic complications in conjunction with systemic tumor chemotherapy. We have been using superselective angiographic techniques to administer the antitumor drug mitomycin C directly into the feeding arteries of the tumor in 15 patients with advanced malignant head and neck tumors. No complications were observed. In five patients the tumor decreased significantly in size, in four patients, tumor cell necrosis was found. A marked decrease in pain was reported by nine of the 15 patients.     

Superselective internal carotid arteriography and embolization

Superselective arteriography and superselective embolisation is the future of a part of neuroradiology. After the first realisation in the territory of the external carotid artery, it was logical to extend it to the territory of the internal carotid artery. The technic of the balloon-catheter of Serbinenko is described and problems of embolisation in the internal carotid artery are discussed.     

Local intra-arterial fibrinolysis without arterial occlusion?

Local intra-arterial fibrinolysis (LIF) is the best choice at present for treatment of acute vessel occlusion in the vertebrobasilar territory and also, in selected cases, in the carotid territory. In almost all cases angiography demonstrates the site of occlusion exactly and gives information about collateral circulation. Contrary to this common approach, we report five patients with severe acute thromboembolic stroke in whom angiography revealed no occlusion of relevant arteries or their main branches. Under the hypothesis of persisting occlusion of perforating arteries to the brain stem we performed LIF in patients with a clinical basilar artery syndrome. Outcome in all but one of them was good following LIF. The clinical details are described and possible reasons discussed. Received: 30 September 1998 Accepted: 18 December 1998     

Collateral circulation imaging: MR perfusion territory arterial spin-labeling at 3T

BACKGROUND AND PURPOSE: Current knowledge of the collateral circulation remains sparse, and a noninvasive method to better characterize the role of collaterals is desirable. The aim of our study was to investigate the presence and distal flow of collaterals by using a new MR perfusion territory imaging, vessel-encoded arterial spin-labeling (VE-ASL).MATERIALS AND METHODS: Fifty-six patients with internal carotid artery (ICA) or middle cerebral artery (MCA) stenosis were identified by sonography. VE-ASL was performed to assess the presence and function of collateral flow. The perfusion information was combined with VE maps into high signal-intensity-to-noise-ratio 3-colored maps of the left carotid, right carotid, and posterior circulation territories. The presence of the anterior and posterior collateral flow was demonstrated by the color of the standard anterior cerebral artery/MCA flow territory. The distal function of collateral flow was categorized as adequate (cerebral blood flow [CBF] ≥10 mL/min/100 g) or deficient (CBF <10 mL/min/100 g). The results were compared with those of MR angiography (MRA) and intra-arterial digital subtraction angiography (DSA) in cross table, and κ coefficients were calculated to determine the agreement among different methods.RESULTS: The κ coefficients of the presence of anterior and posterior collaterals by using VE-ASL and MRA were 0.785 and 0.700, respectively. The κ coefficient of the function of collaterals by using VE-ASL and DSA was 0.726. Apart from collaterals through the circle of Willis, VE-ASL showed collateral flow via leptomeningeal anastomoses.CONCLUSIONS: In patients with ICA or MCA stenosis, VE-ASL could show the presence, the origin, and distal function of collateral flow noninvasively.

The protective effect of collateral circulation influences final clinical outcomes for patients with hemodynamically significant arterial stenosis. The principal source of collateral flow of cerebral arteries is through the arteries of the circle of Willis. Secondary collateral pathways include the external carotid artery via the ophthalmic artery and leptomeningeal anastomoses at the brain surface. However, the size and patency of these arteries are quite variable.Doppler sonography is the most common tool used to investigate the presence of collateral flows. MR angiography (MRA) can be used for determining the collaterals through the circle of Willis. However, both sonography and MRA do not show leptomeningeal collateral pathways, distal collateral flows, or the actual contribution of collateral flow to brain perfusion. Intra-arterial digital subtraction angiography (DSA) shows the presence and distal arteries of the collateral pathways.¹ However, to visualize all the collateral pathways, this technique requires an invasive and selective 3-vessel approach and is typically not performed in patients with acute stroke or cerebral arterial stenosis. Therefore, a noninvasive method that demonstrates selectively angiographic information may be desired to investigate collateral blood flow.²In MR perfusion territory arterial spin-labeling (ASL),^3–7 blood in individual or groups of feeding arteries is tagged by using ASL methodology, and images are acquired that map the vascular distribution of those feeding arteries. Recently, vessel-encoded ASL (VE-ASL) MR imaging⁸ was introduced as a more time-efficient method for mapping multiple vascular territories. The aim of our study was to investigate the presence and distal flow of collateral blood supply by using the VE-ASL technique at 3T on patients with carotid stenotic disease.     

Efficacy of Intra-Arterial Infusion Chemotherapy for Head and Neck Cancers Using Coaxial Catheter Technique: Initial Experience

The aim of this study was to evaluate the efficacy of intra-arterial infusion chemotherapy for head and neck cancers using a coaxial catheter technique: the superficial temporal artery (STA)–coaxial catheter method. Thirty-one patients (21 males and 10 females; 37–83 years of age) with squamous cell carcinoma of the head and neck (maxilla, 2; epipharynx, 4; mesopharynx, 8; oral floor, 4; tongue, 10; lower gingiva, 1; buccal mucosa, 2) were treated by intra-arterial infusion chemotherapy. Four patients were excluded from the tumor-response evaluation because of a previous operation or impossibility of treatment due to catheter trouble. Forty-eight sessions of catheterization were performed. A guiding catheter was inserted into the STA and a microcatheter was advanced into the tumor-feeding artery via the guiding catheter under angiographic guidance. When the location of the tumor or its feeding artery was uncertain on angiography, computed tomographic angiography was performed. The anticancer agent carboplatin (CBDCA) was continuously injected for 24 h through the microcatheter from a portable infusion pump attached to the patient’s waist. The total administration dose was 300–1300 mg per body. External radiotherapy was administered during intra-arterial chemotherapy at a total dose of 21–70.5 Gy. The initial response was complete response in 15 patients, partial response in 7 patients, and no change in 5 patients; the overall response rate was 81.5% (22/27). Complication-related catheter maintenance was observed in 15 of 48 sessions of catheterization. Injury and dislocation of the microcatheter occurred 10 times in 7 patients. Catheter infection was observed three times in each of two patients, and catheter occlusion and vasculitis occurred in two patients. Intra-arterial infusion chemotherapy via the STA–coaxial catheter method could have potential as a favorable treatment for head and neck tumors.     

中晚期肺癌动脉聚乙烯醇栓塞的疗效分析

目的探讨聚乙烯醇(PVA)颗粒动脉灌注栓塞治疗晚期支气管肺癌的近期疗效。方法对31例中晚期肺癌患者进行选择性支气管或肋间动脉造影,造影确定有富肿瘤血供动脉后行灌注栓塞术,先行将5-FU、阿霉素(THP)、顺铂灌注再用PVA颗粒经导管栓塞患侧供血动脉。结果31例患者中供血动脉以支气管动脉为主者21例,以肋间动脉为主者10例。治疗后临床症状改善率100%,且无严重并发症,有效率为80.6%(25/31)。结论PVA颗粒选择性栓塞治疗中晚期支气管肺癌具有较好的临床疗效,安全性高且并发症较少。