Gelatin Sponge Particles Research Articles

Dose-Dependency of Hepatocellular Necrosis in a Canine Model of Chemoembolization

The degree of local tissue toxicity from hepatic arterial chemoembolization relative to the dose of anticancer drugs was evaluated in 13 dogs. Animals were divided into four groups. Group 1 was the control group in which embolization was performed with gelatin sponge particles only (n = 4); group 2 animals underwent embolization with 0.4 mg/kg of Adriamycin (ADR) and 0.2 mg/kg of mitomycin C (MMC) (n = 4); group 3, with 0.8 mg/kg of ADR and 0.4 mg/kg of MMC (n = 2); and group 4, with 1.6 mg/kg of ADR and 0.8 mg/kg of MMC (n = 3). Animals were killed 1 week after embolization, and histopathologic evaluation was performed. The average percentage liver necrosis in the embolized lobe was 0% in group 1, 1% in group 2, 85% in group 3, and 92% in group 4. Hepatic arterial chemoembolization with high doses of anticancer drugs causes severe liver damage, but 0.4 mg/kg of ADR and 0.2 mg/kg of MMC is relatively safe, causing only minimal changes in this canine model.

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

Effects of hepatic artery embolization with Lipiodol and gelatin sponge particles on normal swine liver.

In order to evaluate the effects of hepatic artery embolization (HAE) with Lipiodol (Lp) and gelatin sponge particles (GSP) on swine liver tissue, we embolized the hepatic arteries of 3 pigs with GSP, 9 with Lp, and 9 with Lp + GSP. None of the pigs embolized with GSP died spontaneously during the 4-week experimental period. One pig embolized with 1 ml/kg Lp and three pigs with 2 ml/kg Lp died within 2 h. Two pigs embolized with 0.5 ml/kg Lp + GSP died the following day. The portal vein pressure (PVP) and wedge hepatic vein pressure (WHVP) values before HAE, immediately after, 1 h after, and 4 weeks after HAE showed no remarkable change in the GSP group. Remarkable and temporary elevation was observed in the more than 0.2 ml/kg Lp group. Remarkable and continuous elevation was observed in the 0.2 ml/kg Lp + GSP and 0.5 ml/kg Lp + GSP groups. Gross and histological studies demonstrated no liver damage in the GSP and Lp group. Liver infarction, circular coagulation necrosis with pseudocapsule, and liver atrophy were found in the Lp + GSP group 4 weeks after HAE. The incidence of infarction, circular coagulation necrosis, and liver atrophy in the livers embolized with 0.2 ml/kg Lp + GSP and 0.5 ml/kg Lp + GSP were 67%, 100%, and 75%, respectively. In conclusion, when the hepatic artery is embolized with Lp + GSP, the volume of Lp should be limited to less than 0.1 ml/kg.

Small hepatocellular carcinoma: treatment with subsegmental transcatheter arterial embolization.

The effectiveness of subsegmental transcatheter arterial embolization (TAE) therapy for small hepatocellular carcinomas (HCCs) was retrospectively analyzed. TAE was performed in 100 patients with liver cirrhosis. There was a total of 124 nodular-type HCCs less than 4 cm in diameter. TAE was performed by injecting a mixture of iodized oil and anticancer drugs followed by gelatin sponge particles or a mixture of iodized oil and absolute ethanol into the more distal branches of the subsegmental artery. Complete necrosis was seen at histologic examination in seven of 11 resected lesions. Among the remaining 113 lesions in 90 patients followed up without surgery, the 1-and 4-year local recurrence rates after TAE were 18% and 33%, respectively. The 1- and 4-year survival rates for 82 patients with Child class A or B disease were 100% and 67%, respectively. No substantial deterioration of liver function was observed. Subsegmental TAE improved the prognosis of the patients with liver cirrhosis associated with small HCCs.

Segmental Transcatheter Hepatic Artery Chemoembolization with Iodized Oil for Hepatocellular Carcinoma: Antitumor Effect and Influence on Normal Tissue

Segmental transcatheter arterial embolization (TAE) with use of iodized oil mixed with an anticancer drug, followed by injection of gelatin sponge particles, was undertaken to evaluate its antitumor effect and its influence on normal tissue in patients with hepatocellular carcinoma (HCC). Histologic findings in 12 patients who underwent hepatectomy after segmental TAE were compared with findings on plain radiographs and computed tomographic (CT) scans. Visualization of the portal veins contiguous to the tumor on radiographs and the pattern of iodized oil accumulation in the tumor and vicinity on CT scans after TAE were assessed. Complete necrosis of the tumor was achieved in 10 cases (83%), while complete necrosis of daughter nodules and capsular invasion was observed histologically in eight of these 10 patients (80%). The degree of tumor necrosis correlated with the pattern of iodized oil accumulation in and near the tumor. Partial necrosis of normal tissue near the tumor correlated with accumulation of iodized oil. Segmental TAE may be an excellent therapeutic method for treatment of HCC that is localized in one or a few segmental or subsegmental regions.

Hepatic arterial chemoembolization in patients with liver metastases of endocrine tumors a prospective phase II study in 24 patients

Liver metastases of endocrine tumors are of major prognostic significance. The various therapeutic approaches have given disappointing results; however, locoregional treatment has allowed transient control of hepatic tumor growth. Twenty-four patients with liver metastases of endocrine tumors (mainly carcinoid tumors [n = 18] and gastrinomas [n = 5]) were included in a Phase II study of hepatic arterial chemoembolization (CE). Metastases were bilateral in all patients and invaded more than 50% of the liver in 12. They were synchronous of the primary tumor in 62.5% of the patients. Seventeen patients had not responded to previous intravenous chemotherapy. CE courses were performed every 3 months using an emulsion of 10 ml of iodized oil and doxorubicin 50 mg/m2 injected into tumor vessels, followed by CE arterial occlusion with gelatin sponge particles. Seventy-one CE courses were performed in 23 patients; there was one technical failure. Among patients with carcinoid tumors, disappearance of diarrhea and/or flushing was observed in 8 of 11. Serotonin and/or its metabolite 5-hydroxyindoleacetic acid levels decreased by more than 50% in 57% of the patients. The size of liver metastases decreased by at least 50% in 6 of 18 patients, i.e., in 33% (range, 12-54%). Two had complete responses. The median duration of the responses was 14 months (range, 6-40). Among patients with noncarcinoid tumors, minor response or stabilization occurred in three of five patients. Major side effects were bleeding peptic ulcer (one patient) and oligoanuric renal failure (one patient). Abdominal pain, fever, and increases in hepatic enzyme levels were common and transient. These results suggest that CE is effective in patients with liver metastases of endocrine tumors, mainly in carcinoids. In the latter, CE allows control of the carcinoid syndrome and regression or stabilization of the liver tumors in 80% of patients.

Distribution and effect of iodized poppyseed oil in the liver after hepatic artery embolization: experimental study in several animal species.

To define the intrahepatic distribution of iodized poppyseed oil and its effect on the liver, hepatic artery embolization (HAE) was performed in five mice, 12 rats, four rabbits, and 21 pigs with the iodized oil alone or in combination with gelatin sponge powder (GSPow) in three rats or gelatin sponge particles (GSPs) in nine pigs. All mice, rats, and rabbits underwent radiography of the upper abdomen and in vivo microscopy of the hepatic periphery during and immediately after injection and 1, 4, and 24 hours later. All pigs underwent angiography before and after HAE as well as measurement of portal venous pressure before HAE and 15, 30, 45, and 60 minutes and 4 weeks after HAE. Follow-up radiographs were obtained in 18 pigs. HAE performed with the iodized oil only was well tolerated by the liver, even when high doses were used, likely because of continuous flushing of the sinusoids by high blood flow from peripheral arterioles. When HAE was performed with the iodized oil and GSPow, this blood flow ceased and necrosis developed. The degree of necrosis after HAE with the iodized oil in combination with GSPs was directly associated with the dose of iodized oil. HAE performed with GSPs only did not cause damage.

Response of early-stage hepatocellular carcinoma and borderline lesions to therapeutic arterial embolization.

In Japan, borderline lesions and early-stage hepatocellular carcinoma (HCC) are now histopathologically divided into two subgroups; one includes adenomatous hyperplasia and atypical adenomatous hyperplasia, and the other includes early HCC and early advanced HCC. In order to evaluate the efficacy of transcatheter arterial embolization for treating such lesions, histopathologic studies were done after embolization and resection in 27 patients. The lesions consisted of two adenomatous hyperplasias, one atypical adenomatous hyperplasia, 22 early HCCs, and 13 early advanced HCCs. All patients had chronic liver diseases in nontumorous parenchyma in addition to HCC. For transcatheter arterial embolization, one of the following embolizing materials was used: iodized oil (Lipiodol) alone (n = 4), an emulsion of doxorubicin in Lipiodol (n = 8), and the same emulsion followed by gelatin sponge particles (n = 15). The frequencies of tumor stain on the angiogram and retention of Lipiodol within the tumor were 84% and 94% in overt HCC, 23% and 69% in early advanced HCC, and 9% and 9% in early HCC, respectively. The average size of overt HCC was significantly (p < .01) larger than that of early advanced HCC and early HCC. The amount of necrosis induced by embolization relative to the size of the mass was 56% on average in overt HCCs, 14% in early advanced HCCs, and 0% in early HCCs, atypical adenomatous hyperplasias, and adenomatous hyperplasias. Significant differences (p < .01) in mean necrosis rate were seen between overt HCCs and early advanced HCCs, between early advanced HCCs and early HCCs, and between overt HCCs and early HCCs. The frequency of Lipiodol retention correlated with mean necrosis rate for tumor. With reference to therapeutic techniques, only for the overt HCCs was a significant difference (p < .01) in the mean necrosis rate found between the group that received the emulsion of doxorubicin in Lipiodol and the group that received the emulsion and then particles of gelatin. This study suggests that transcatheter arterial embolization has limited efficacy for treating early-stage HCC and borderline lesions compared with its efficacy for treating overt HCC.

Successful Arterial Embolisation of Giant Liver Haemangioma

A 28-year old man presented with a symptomatic giant haemangioma. On June 26, 1983, at laparotomy, no resection was attempted because the lesion involved the right lobe of the liver and a part of segments II and III. The patient underwent a right hepatic arterial embolisation with gelatine sponge particles. During follow-up, the patient remained asymptomatic. Five-year review by CT-scan showed a diminution of the size of the haemangioma and hypertrophy of the left lobe. On October 21, 1988, the patient was reoperated on for liver abscess and complete necrosis of the haemangioma. A right hepatectomy was performed. In conclusion, the long-term effect of hepatic arterial embolisation, as demonstrated in our case by regular CT-scans, is useful in cases of diffuse haemangioma as an alternative to hazardous major liver resection. To our knowledge, the long-term effect of hepatic arterial embolisation on symptoms and tumor size have never been reported for giant liver haemangioma.

Preoperative Embolization of the Spleen in Children with Hypersplenism

Splenomegaly associated with myelodysplastic disorders in children may be massive and can result in pancytopenia, abdominal discomfort, and respiratory distress. When these symptoms cannot be relieved by nonsurgical means, splenectomy may be indicated. Under such conditions, surgical splenectomy carries increased risks, as the thrombocytopenia is difficult to correct secondary to splenic sequestration. Additionally, the surgical anatomy is often distorted secondary to the massive spleen and dissection can be difficult. These factors can lead to uncontrollable hemorrhage. In an attempt to decrease intraoperative blood loss, the authors successfully performed preoperative splenic artery embolization in 11 of 12 children (age range, 1-11 years) with pancytopenia due to hypersplenism. Hypersplenism requiring surgical splenectomy was due to leukemia (n = 9), myelodysplastic syndrome (n = 1), immune thrombocytopenia (n = 1), and osteopetrosis (n = 1). Embolization was performed under general anesthesia, prior to surgery, with gelatin sponge particles alone, Gianturco coils alone, or a combination of polyvinyl alcohol sponge particles and Gianturco coils. Embolization allowed for safe surgical splenectomy.

Angiographic embolization for control of pelvic genital tract hemorrhage. Report of 14 cases.

Fourteen patients with intractable bleeding of obstetric or gynecological origin underwent transcatheter angiographic arterial embolization. Three patients had postpartum hemorrhage associated with dilutional coagulopathy, anticoagulant therapy and placental leukemic metastases, or placenta percreta. One patient had locally advanced gestational trophoblastic tumor, one had uterine sarcoma and 8 had advanced cervical malignancy. Bleeding was completely controlled in all patients regardless of the initiating event. The embolizing material was gelatin sponge particles in 12 patients, and spring coil in 2. In experienced hands, angiographic arterial embolization is a safe, effective and less invasive alternative to surgical ligation in some clinical states of pelvic female genital tract hemorrhage.

Transcatheter oily chemoembolization in the management of advanced hepatocellular carcinoma in cirrhosis: Results of a Western comparative study in 60 patients

Transcatheter oily chemoembolization is widely used as palliative therapy for inoperable hepatocellalar carcinoma in high-incidence Asiatic areas. To assess its usefulness in the Western form of this cancer, 20 French patients were treated between 1987 and 1990 by intraarterial hepatic injection of a Lipiodoldoxorubicin emulsion followed by embolization with 0.5 to 1 mm gelatin sponge particles. The number of procedures ranged from one to five. All patients had advanced, symptomatic and inoperable hepatocellular carcinoma (Okuda's staging: I, n = 8; II, n = 14; III, n = 8); none was found under systematic screening. All had underlying cirrhosis (Child-Pugh's class: A, n = 15; B, n = 12; C, n = 3) that was alcoholic in origin in 27 case and posthepatitic B in origin in 3 cases. The results of the treatment were assessed by comparison with a group of 30 untreated patients admitted to the same unit between 1984 and 1987. Patients of both groups were closely matched for clinical presentation, global disease staging and precise anatomical extension. The overall 1- and 2-yr survival rate was 59% and 30%, respectively, for the treated patients vs. 0% at 1 yr for the untreated patients. The latter all died from local disease with end-stage liver failure and/or uncontrollable variceal bleeding. In the former, the three vatients with Child's class C cirrhosis died after the first procedure. During the follow-up (range = 3 to 26 mo), 11 additional patients died, 8 from metastatic generalization. In four of these cases, an adjuvant systemic chemotherapy with epirubicin was given and provided an effective response to functional symptoms in two cases (loss of pain caused by bone metastases). Fifteen autopsies were performed in the untreated group and all showed a cancerous thrombus of the main portal trunk, whereas this was found in only 1 of 10 autopsies in the treated group. We conclude that transcatheter oily chemoembolization is an efficient palliative treatment in the Western form of hepatocellular carcinoma complieating cirrhosis; it acts as a locoregional therapy that prevents the cancerous invasion of the portal system. Further trials are needed to define the best therapy to prevent or to treat extrahepatic dissemination. (HEPATOLOGY 1991;13:427–433.)

Transcatheter oily chemoembolization in the management of advanced hepatocellular carcinoma in cirrhosis: Results of a western comparative study in 60 patients

Transcatheter oily chemoembolization is widely used as palliative therapy for inoperable hepatocellular carcinoma in high-incidence Asiatic areas. To assess its usefulness in the Western form of this cancer, 30 French patients were treated between 1987 and 1990 by intraarterial hepatic injection of a Lipiodol-doxorubicin emulsion followed by embolization with 0.5 to 1 mm gelatin sponge particles. The number of procedures ranged from one to five. All patients had advanced, symptomatic and inoperable hepatocellular carcinoma (Okuda's staging: I, n = 8; II, n = 14; III, n = 8); none was found under systematic screening. All had underlying cirrhosis (Child-Pugh's class: A, n = 15; B, n = 12; C, n = 3) that was alcoholic in origin in 27 cases and posthepatitic B in origin in 3 cases. The results of the treatment were assessed by comparison with a group of 30 untreated patients admitted to the same unit between 1984 and 1987. Patients of both groups were closely matched for clinical presentation, global disease staging and precise anatomical extension. The overall 1- and 2-yr survival rate was 59% and 30%, respectively, for the treated patients vs. 0% at 1 yr for the untreated patients. The latter all died from local disease with end-stage liver failure and/or uncontrollable variceal bleeding. In the former, the three patients with Child's class C cirrhosis died after the first procedure. During the follow-up (range = 3 to 26 mo), 11 additional patients died, 8 from metastatic generalization.(ABSTRACT TRUNCATED AT 250 WORDS)

New plastic-coated coaxial catheter system for superselective hepatic catheterization: Technical note

With the use of a new improved coaxial catheter system, superselective hepatic catheterization has become easier. The improvements consist of a decrease in the outer and an increase in the inner diameters of the coaxial catheters from 0.98 to 0.96 mm and from 0.55 to 0.65 mm, respectively, and thickening of core guidewire material from 0.014 inch (0.35 mm) to 0.018 inch (0.40 mm). With this new catheter system, it is possible to inject contrast medium (iopamidol 300) at a higher rate (3 ml/sec) and gelatin sponge particles instead of gelatin powder for arterial embolization. The success rates for superselective catheterization using conventional (n = 10 procedures) and the improved coaxial catheter systems (n = 7) were 30% and 86%, respectively.

Transcatheter arterial embolization in unresectable hepatocellular carcinoma

Seven hundred thirty-nine patients with unresectable hepatocellular carcinoma have been treated by transcatheter arterial chemoembolization using gelatin sponge particles soaked in a solution of Mitomycin C and Adriamycin. This therapy can be equal or superior to surgical resection and serves both as embolic therapy and targeted chemotherapy.

A technique for embolization of biopsy tracts.

Percutaneous needle biopsy under fluoroscopic, sonographic, or CT control is a widely applied diagnostic test. Generally, needles 18-gauge or smaller produce satisfactory samples for cytologic or histologic analysis. In some instances (e.g., classification of a lymphoma), it may be desirable to obtain a larger specimen, thus necessitating the use of a larger needle. For some liver and retroperitoneal biopsies for which an access route free of bowel or known vascular structures is available, a 1 4-gauge Tru-Cut needle (Travenol Laboratories, Deerfield, IL) is often used. In these circumstances, the major complication is bleeding. Two recent reports [1 , 2] describe embolization of such biopsy tracts to control bleeding. Chuang and Alspaugh [1] used a vascular sheath in combination with the Tru-Cut needle. After the needle was removed from the sheath, the tract was occluded with absorbable gelatin sponge particles (Gelfoam, Upjohn, Kalamazoo, Ml) as the sheath was withdrawn under fluoroscopic control. Allison and Adam [2] used a needle with a Tru-Cut “action,” which came equipped with an 8-French sleeve. They occluded the tract by using a specially designed needle to deliver a hemostasis coil. We have devised a simpler and more cost-effective technique for tract embolization. This method eliminates the need to anticipate bleeding and to use special equipment routinely, thereby needlessly incurring additional expense.

Iodized oil in the portal vein after arterial embolization.

Transcatheter embolization with a relatively large amount (average, 17 mL) of iodized oil and doxorubicin hydrochloride with or without gelatin sponge particles was performed in 50 patients with hepatocellular carcinoma and in eight patients with liver metastases. After an intraarterial hepatic injection of an emulsion of iodized oil and doxorubicin hydrochloride, iodized oil was seen in the portal vein; the amount correlated with the amount that was injected, despite the lack of arterioportal shunting. Prominent portal vein appearances were seen in six of 21 cases (29%) given 10 mL or less of iodized oil, in 14 of 21 cases (67%) with 10-20 mL, and in 18 of 21 cases (86%) with more than 20 mL. Iodized oil may enter the portal vein through an arterioportal communication after pooling in the sinusoids.

Selective Arterial Embolization-Reply

In response to the points raised by Drs Clare and Ghidoni, we agree that selective arterial embolization carries the risk of occlusion of arteries other than those intended. The angiographic techniques employed require precision and judgment, and even in extreme situations they cannot be regarded casually. The use of balloon-tipped catheters to prevent the reflux of emboli may be helpful in safeguarding critical areas such as the cerebral circulation. We have used embolization with absorbable gelatin sponge in more than 100 cases, and, although we have occasionally seen absorbable gelatin sponge particles dislodge from their intended position, we fortunately have not seen a case where aberrant emboli resulted in death or serious complication. Some causes of upper gastrointestinal hemorrhage are more effectively treated with vasopressin infusion than with embolization, and we rely heavily on endoscopy prior to the angiogram to formulate the right approach. Unless endoscopy is unsuccessful

Embolisation techniques for renal tumors (author's transl)

We have performed ten embolisations in nine patients with vascular renal tumours, eight of these pre-operatively. One patient had an inoperable hypernephroma which was embolised twice. We have used gelatine sponge particles (Gelaspon). In every patient it was possible to occlude the arterial supply. There were no complications.