Hepatic Transcatheter Research Articles

Clinical application of gelatin sponge microparticles combined with pirarubicin for hepatic transcatheter arterial chemoembolization in breast cancer liver metastasis treatment: results of a single-center long-term study

ObjectiveTo retrospectively analyze the safety and long-term clinical efficacy of gelatin sponge microparticles combined with the chemotherapy drug pirarubicin for hepatic transcatheter arterial chemoembolization (GSMs-TACE) in order to treat breast cancer liver metastasis (BCLM).MethodsTwenty-seven BCLM patients who underwent GSMs-TACE from July 2010 to July 2016 were enrolled. Tumor target blood vessels were slowly and regionally embolized with absorbable gelatin sponge particles and pirarubicin injections. Plain computed tomography (CT) scans and biochemical indexes were re-examined at 4 days after treatment, and enhanced CT scans or magnetic resonance images and biochemical indexes, 1 month later. For patients with stable tumors, the follow-up period was 2 to 3 months, and the tumor response was evaluated using Modified Response Evaluation Criteria in Solid Tumors. Adverse reactions, survival time, and prognostic factors were assessed.ResultsBy October 2019, 27 patients with BCLM had undergone GSMs-TACE, with an average of 2.44 ± 1.58 treatments. The 1-, 3-, and 5-year survival rates were 62.96%, 22.22%, and 14.81%, respectively, and the mOS was 22.0 months. No serious complications, such as acute liver failure and liver abscess, had occurred. There were two cases of acute cholecystitis that recovered after symptomatic treatment. Multivariate analysis of the prognosis showed that the primary tumor size, number of metastatic lymph nodes, estrogen receptor/progesterone receptor (ER/PR) status, and time to postoperative liver metastasis and combination therapy were statistically significant.ConclusionsThe overall prognosis of BCLM was poor. GSMs-TACE was safe and effective for BCLM treatment and could prolong the median survival time of patients. Therefore, it is worthy of widespread clinical application.

Real-world efficacy and safety of axitinib in combination with anti-programmed cell death-1 antibody for advanced mucosal melanoma

PurposeThe combination of vascular endothelial growth factor receptor (VEGFR) inhibitor and programmed cell death-1 (PD-1) blockade provides promising therapeutic opportunities for advanced mucosal melanoma in early phase trials. The aim of this retrospective study was to evaluate the efficacy and safety of the combination regimen for advanced mucosal melanoma in the real world. MethodsPatients with advanced mucosal melanoma received an anti-PD-1 antibody plus the VEGFR inhibitor axitinib until confirmed disease progression or unacceptable toxicity. In addition, those with liver metastasis were allowed to take hepatic transcatheter arterial chemoembolisation (TACE). The primary endpoint was overall response rate (ORR). Secondary endpoints included disease control rate (DCR), time to treatment failure (TTF), duration of response (DOR), overall survival (OS) and treatment-related adverse events (TRAEs). ResultsEighty-one and sixty-six patients received axitinib plus immunotherapy as first-line and salvage therapy, respectively. Overall, ORR was 24.5% (95% CI, 17.3–31.6), DCR was 72.7% (95% CI, 65.3–80.1). Median TTF, DOR and OS were 5.2 months (95% CI, 3.7–6.6), 9.2 months (95% CI, 7.2–11.2) and 11.1 months (95% CI, 7.2–15.0). ORR was 30.0% (95% CI, 19.7–40.3) and 17.5% (95% CI, 7.8–27.1) as first-line and salvage therapy, respectively. No statistical difference among the primary sites was noted for ORR. The ORR of patients with liver metastasis with or without hepatic TACE was 26.1% (95% CI, 6.7–45.5) and 15.0% (95% CI, 2.1–32.1), respectively (P = 0.467). Elevated LDH and poor ECOG status are negative predictive factors. ConclusionThis is the largest analysis of anti-PD-1 plus VEGFR inhibitor therapy for mucosal melanoma to date. Immunotherapy plus anti-angiogenesis is applicable for advanced mucosal melanoma, especially as front-line. Hepatic TACE might act synergistically with systemic immunotherapy and anti-angiogenesis.

Effects of psychological flexibility intervention on symptoms and self-management efficacy of patients after hepatic arterial infusion chemoembolization

Objective To explore the effects of psychological flexibility intervention on the symptoms and self-management efficacy of patients after hepatic arterial infusion chemoembolization. Methods By convenient sampling, a total of 90 patients with hepatocellular carcinoma who had undergone hepatic arterial transcatheter chemoembolization in the First Affiliated Hospital of Zhengzhou University from January to February 2018 were selected. By random number table method, they were divided into the observation group and the control group, with 45 participants in each group. The control group received routine nursing intervention, and the observation group received psychological flexibility intervention, both for 2 weeks. Before and after the intervention, the Memorial Symptom Assessment Scale (MSAS) and the Chinese version of the Strategies Used People to Promote Health (SUPPH) were used to assess the symptomatic distress and self-management efficacy of the two groups in order to evaluate the effects of the intervention. Results There were no significant statistical differences in the average scores of physical symptoms, psychological symptoms, distressed index, and main clauses of MSAS before intervention between the two groups (P>0.05) . After intervention, the physical symptoms of the patients in both groups had no statistical difference compared with those pre-intervention (P>0.05) , while the average scores of psychological symptoms, distress index, main clauses of MSAS were all lower than those pre-intervention with statistical significance (P 0.05) . After intervention, the total score of SUPPH and the scores from each dimension increased with statistical significance (P 0.05) . The total score of SUPPH and the scores from each dimension were all higher than the control group with statistical significance (P<0.01) . Conclusions The psychological flexibility intervention can effectively reduce the patients' psychological distress after chemoembolization, and promote their self-management efficiency, therefore is worth promoting in the clinical practice. Key words: Liver neoplasms; Psychological flexibility; Hepatic arterial infusion chemoembolization; Symptomatic distress; Self-management efficacy

Factors Influencing Cyst Infection in Autosomal Dominant Polycystic Kidney Disease

Background: Cyst infection is a frequent and serious complication of autosomal dominant polycystic kidney disease (ADPKD) that is often difficult to treat. However, the factors influencing cyst infection are still unknown. Therefore, we investigated clinical factors related to the duration of hospitalization and death due to cyst infection. Methods: All ADPKD patients undergoing cyst drainage or nephrectomy or partial hepatectomy at Toranomon Hospital from January 2004 to March 2016, in whom cyst fluid analysis showed bacteria or neutrophils indicating definite cyst infection, were reviewed retrospectively. Factors influencing the duration of hospitalization and death due to cyst infection were analyzed. Results: A total of 243 patients with cyst infection were enrolled, including 104 men and 139 women (mean age: 62.6 ± 10.0 years). Seventeen patients died of cyst infection. Multivariate logistic regression analysis revealed that hepatomegaly, positive cyst contents culture, and the maximum white blood cell (WBC) count were significantly associated with death from cyst infection. Death was significantly more likely if patients had massive hepatomegaly (≥5,113.2 mL) compared with mild hepatomegaly (< 1,898.7 mL; odds ratio 38.1; 95% CI 2.9–492.6, p = 0.0004). Multivariate Cox proportional hazards analysis revealed that older age, dialysis duration, hepatic transcatheter arterial embolization, maximum WBC count, and hepatomegaly were significantly associated with longer hospital stay for cyst infection, while female sex, nephrectomy, serum albumin, and serum cholinesterase were significantly associated with shorter hospital stay. Discharge alive from hospital was significantly associated with massive hepatomegaly versus mild hepatomegaly (hazard ratio 0.0072; 95% CI 0.0008–0.0659, p < 0.0001). Conclusions: Hepatomegaly was strongly associated with both death and longer hospital stay due to cyst infection.

Arterial Infusion of Rapamycin in the Treatment of Rabbit Hepatocellular Carcinoma to Improve the Effect of TACE.

BackgroundHepatocellular carcinoma is one of the leading causes of cancer-related death. Hepatic transcatheter arterial chemo-embolization (TACE) is commonly used clinically for advanced hepatocellular carcinoma treatment.AIMThe aim of this study was to evaluate whether arterial infusion of rapamycin can improve the effect of TACE in treatment of rabbit hepatocellular carcinoma.Material and MethodsEighteen healthy New Zealand white rabbits weighing 2.6 ± 0.3 kg were used in a standardised hepatocellular carcinoma model and randomly divided into three groups of 6 rabbits. Group A: the rabbits were treated with rapamycin and TACE by administering arterial perfusion of 2 mg/kg rapamycin + 1 mg/kg epirubicin, 0.2 mg/kg mitomycin, and lipiodol emulsion embolization. Group B: rapamycin was reduced to 1 mg/kg. And for Group C, the rabbits received only TACE treatment. 14 days post operation, CT scan and digital subtraction angiography (DSA) was performed to examine TACE efficacy. The rabbits were killed by air embolism and the expression of HIF-1a, VEGF, iNOS, and CD34 were measured in an immunohistochemical assay of thetumor tissue.ResultsHIF-1a, VEGF and iNOS protein expression in Group A was significantly lower than that of Group B and Group C (P<0.05). The tumor MVD in group C was significantly higher than that of group A and group B (P<0.05); and the tumor MVD of group B was significantly higher than group A (P<0.05).ConclusionArterial infusion of rapamycin combined with TACE can improve treatment efficacy by decreasing HIF-1a, VEGF, iNOS and CD34 expression.

Zoledronic acid inhibits infiltration of tumor-associated macrophages and angiogenesis following transcatheter arterial chemoembolization in rat hepatocellular carcinoma models.

Hepatic transcatheter arterial chemoembolization (TACE), a minimally invasive procedure to block the blood supply of tumors and release of cytotoxic agents, is preferentially applied to patients with hepatocellular carcinoma (HCC) who are not able to receive radical treatments. However, the long-term effects of TACE are unsatisfactory, as the microenvironment following procedure stimulates tumor angiogenesis, which promotes recurrence and metastasis of residual tumors. Tumor associated macrophages (TAMs) have been revealed to stimulate tumor growth and angiogenesis associated with poor prognosis in HCC. The present study focused on the changes in TAMs following TACE, and explored the effects of TACE in combination with the TAM inhibitor zoledronic acid (ZA) in rat HCC models. Orthotropic HCC rats were divided into three groups: Sham TACE, TACE alone and TACE combined with ZA treatment. At 7 or 14 days following TACE, tumor growth was evaluated by magnetic resonance imaging (MRI). Infiltration of TAMs was assessed by histological analysis and flow cytometry. Tumor angiogenesis was measured as the mean vessel density, and initial slope was calculated from dynamic contrast enhancement MRI. Local and systemic levels of vascular endothelial growth factor (VEGF) were determined by western blotting or an ELISA, respectively. The results revealed that TACE inhibited tumor growth at 7 days following the procedure, but this inhibition was attenuated at 14 days following the procedure compared with the sham TACE control. If combined with ZA treatment, TACE exhibited a stable inhibition effect on tumor growth until the end of observation. Investigation of the underlying mechanisms demonstrated that TACE combined with ZA treatment inhibited infiltration of F4/80 positive TAMs and tumor angiogenesis compared with the TACE alone group at 14 days following the procedure. Additionally, the combination treatment significantly inhibited secretion of VEGF in the present models. In conclusion, ZA treatment enhanced the effects of TACE through inhibiting TAM infiltration and tumor angiogenesis in rat HCC models.

Evaluation of Antiemetic Therapy for Hepatic Transcatheter Arterial Infusion Chemotherapy with Cisplatin.

Antiemetic prophylaxis with aprepitant, a 5-hydroxytryptamine3 (5-HT3) receptor antagonist and dexamethasone is recommended for patients receiving intravenous cisplatin chemotherapy. Whether the same antiemetic regime is superior for hepatic transcatheter arterial infusion chemotherapy with cisplatin (CDDP-TAI) is unknown. We conducted a retrospective study of antiemetic prophylaxis protection against chemotherapy-induced nausea and vomiting (CINV) in CDDP-TAI at Nagasaki University Hospital. The rate of complete response (CR) to antiemetics in the acute (<24 h) and delayed phases (24-120 h) was measured. Twenty-four patients were treated with a 5-HT3 receptor antagonist (granisetron or azasetron) and dexamethasone on the day of chemotherapy (day 1 only). There was a significant difference between the CR rates in the acute and delayed phases, 91.6, and 69.7%, respectively. Combination of a 5-HT3 antagonist and dexamethasone on day 1 is effective against acute CINV, but not delayed CINV during CDDP-TAI. These results may help guide the management of nausea and vomiting during CDDP-TAI to achieve better tolerance and compliance for fewer interventions and increased favorable therapeutic outcomes.

MRI visible drug eluting magnetic microspheres for transcatheter intra-arterial delivery to liver tumors.

Magnetic resonance imaging (MRI)-visible amonafide-eluting alginate microspheres were developed for targeted arterial-infusion chemotherapy. These alginate microspheres were synthesized using a highly efficient microfluidic gelation process. The microspheres included magnetic clusters formed by USPIO nanoparticles to permit MRI and a sustained drug-release profile. The biocompatibility, MR imaging properties and amonafide release kinetics of these microspheres were investigated during in vitro studies. A xenograft rodent model was used to demonstrate the feasibility to deliver these microspheres to liver tumors using hepatic transcatheter intra-arterial infusions and potential to visualize the intra-hepatic delivery of these microspheres to both liver tumor and normal tissues with MRI immediately after infusion. This approach offer the potential for catheter-directed drug delivery to liver tumors for reduced systemic toxicity and superior therapeutic outcomes.

Intravascular Embolization Therapy in Patients With Enlarged Polycystic Liver

Hepatic transcatheter arterial embolization (TAE) has become an accepted treatment option for patients with symptomatic autosomal dominant polycystic kidney disease (ADPKD) who also have polycystic liver disease and who are not good candidates for surgery. However, indications for TAE and long-term outcome with it are still unclear. Retrospective cohort study. Symptomatic patients with ADPKD with polycystic liver disease who underwent hepatic TAE, June 2001 to December 2012, at Toranomon Hospital and whose liver volume data were available were studied (N=244; 56% on dialysis therapy, none with kidney transplants). Mean age was 55 ± 9 (SD) years, and mean liver volumes were 8,353 ± 2,807 and 6,626 ± 2,485 cm(3) in men and women, respectively. Target arteries were embolized from the periphery using platinum microcoils. Sex-specific quartiles (6,433, 8,142, and 9,574 cm(3) in men and 4,638, 6,078, and 8,181 cm(3) in women) of total liver volume pretreatment. All causes of mortality were obtained from medical records, followed up until July 31, 2013. Laboratory values were measured before TAE and 1, 3, 6, and 12 months after. Organ volumes were measured pretreatment, then 6 and 12 months after, by summing the products of the organ areas traced in each computed tomographic image. Liver/cyst volume decreased to 94.7% (95% CI, 93.5%-95.8%) at 6 months and 90.8% (95% CI, 88.7%-92.9%) at 12 months of pretreatment volumes. Serum protein and hematocrit values improved significantly without liver damage. Survival was significantly better for patients with liver volume ≤ 9,574 cm(3) (men) and ≤ 8,181 cm(3) (women) than for those with larger livers (5-year survival, 69% and 48%; P=0.02). Infection and liver failure caused most deaths, especially in patients with larger livers. Referral bias and lack of control group. Hepatic TAE appears to be a safe and less invasive option for patients with symptomatic polycystic liver, especially those contraindicated for surgical treatment (eg, with malnutrition or on dialysis therapy), improving both hepatic volume and nutrition.

胆管腫瘍栓を伴う再発を繰り返す胆管内発育型肝細胞癌に対して3回の肝切除とTACEにより長期生存中の超高齢者の1例―自験36例の臨床的検討―

症例は92歳，男性．2005年1月，C型慢性肝炎を背景とする径3.8 cmの胆管内発育型肝細胞癌に対してTACE後に肝後区域切除が施行された．中分化型肝癌で胆管腫瘍栓もほぼ壊死に陥っていた．2006年8月，胆管前枝から肝門部におよぶ腫瘍栓に対して肝前区域切除を施行した．切除標本内に径1.5 cmの結節型を呈する中分化型癌と連続する胆管腫瘍栓を認めた．2008年7月，肝S4の径1.5 cmの再発結節に対してRFAを施行した．2010年3月，肝門部胆管閉塞を発症しまずPTCSにより腫瘍栓を確認した．TACEを施行し2週間後に再度観察したところ腫瘍栓は完全に壊死に陥りその後脱落した．2012年9月，肝門部胆管腫瘍栓の再発を認め，2012年10月，2013年4月と8月にTACEを施行した．しかし腫瘍栓の増大とPTCD後も尾状葉胆管枝の拡張を認めた．2013年9月，尾状葉切除と胆管腫瘍栓摘出術を施行したが孤立性の胆管腫瘍栓であり肝内腫瘍はなかった．これまでに経験した胆管内発育型肝癌は非切除29例と肝切除7例でMSTはそれぞれ4.5カ月と22.9カ月であり予後不良であった．自験例は超高齢者であるが3回の肝切除を軸とする集学的治療により長期生存がえられたと考えられる．

Solitary mediastinal metastasis of hepatocellular carcinoma treated by video-assisted thoracic surgery: report of a case

Solitary mediastinal metastasis of hepatocellular carcinoma (HCC) is extremely rare. We report a case of solitary mediastinal metastasis arising from HCC treated by video-assisted thoracic surgery (VATS). A 75-year-old man underwent hepatic resection and transcatheter arterial embolization for HCC. The level of protein induced by vitamin K antagonist was subsequently found to be elevated. Computed tomography showed a 2-cm mediastinal tumor. (18)F-fluorodeoxy-glucose positron emission tomography revealed slight uptake by the tumor. VATS was performed. The histopathological diagnosis was metastatic HCC of the lymph nodes. The postoperative course was uneventful, with a postoperative hospital stay of 6days. There has been no recurrence at 4months after surgery. VATS is a minimally invasive and useful treatment for solitary mediastinal metastasis of HCC.

Hepatic Transcatheter Arterial Chemoembolization Complicated by Postembolization Syndrome

Postembolization syndrome (PES) is a common complication after embolic procedures, and it is a frequent cause of extended inpatient hospital admissions. PES is a self-limited constellation of symptoms consisting of fevers, unremitting nausea, general malaise, loss of appetite, and variable abdominal pain following the procedure. Although a definite cause is unknown, this syndrome is thought to be a result of therapeutic cytotoxicity, tumor ischemia, and resulting intrahepatic and extrahepatic inflammation. The authors report a case of PES precipitated by transcatheter intrarterial chemoembolization of hepatic metastases.

A Case of Painful Erythema on Upper Abdominal Wall after Hepatic Transcatheter Arterial Embolization

A Case of Painful Erythema on Upper Abdominal Wall after Hepatic Transcatheter Arterial Embolization

High incidence of low O6-methylguanine DNA methyltransferase expression in invasive macroadenomas of Cushing's disease

Crooke's cell adenoma (CCA), characterized by massive Crooke's hyaline change in corticotroph adenoma, causes a rare subtype of Cushing's disease. In contrast to ordinary corticotroph adenomas, CCAs are generally aggressive and present as invasive macroadenomas, which are refractory to both surgery and radiotherapy and have a high-recurrence rate. Moreover, some patients with CCA present with distant or craniospinal metastases. Currently, there are no effective standard therapies for CCA. We report a patient with Crooke's cell carcinoma who presented with local invasion and liver metastases, which was refractory to conventional therapeutic modalities including transsphenoidal surgery, radiosurgery, medications, and hepatic transcatheter arterial embolization. After all these treatments failed, the patient had monthly temozolomide administrations, resulting in gradual clinical improvement and biochemical data that were consistent with tumor shrinkage. In glioblastoma, low O(6)-methylguanine DNA methyltransferase (MGMT) expression is associated with epigenetic gene silencing and predicts a better response to temozolomide. We thus investigated MGMT expression, immunohistochemically, in seven CCAs (five invasive macroadenomas and two invasive microadenomas) and 17 ordinary-type adenomas (OTAs; three noninvasive macroadenomas, 12 noninvasive microadenomas, and two invasive microadenomas) from patients with Cushing's disease. In seven CCAs, all five invasive macroadenomas exhibited low MGMT expression, defined as <5% nuclear MGMT staining. In 17 OTAs, only one adenoma showed low MGMT expression. In Cushing's disease, invasive macroadenomas including CCA usually have low-MGMT expression. Temozolomide thus may be a new therapeutic option for invasive macroadenomas such as CCA particularly when conventional treatments are ineffective.

Lipiodol brain embolism during hepatic transcatheter arterial chemoembolization

Sir, Transcatheter arterial chemoembolization (TACE) for advanced hepatocellular carcinoma, i.e., the injection of a mixture of iodized oil (lipiodol) and a chemotherapeutic via the tumor feeding artery, hitherto has been complicated by lipiodol brain embolism (LBE) in a few cases [1–5]. Only two of these patients had repeat MRI that documented extensive reversion of the initial DWI abnormalities [5]. We present a case of TACE-associated LBE that demonstrated near-complete resolution of DWI lesions suggesting cytotoxic edema. During his fourth course of TACE, a 71-year-old man with advanced hepatocellular carcinoma presented a modest monoparesis of the right arm along with transient dysarthria and dizziness. CT scan immediately after the procedure showed multiple infraand supratentorial brain lesions consistent with the deposition of iodized oil. Three hours later, MRI disclosed multiple nonenhancing cortical and subcortical hyperintense lesions, which represented areas of decreased diffusion on DWI. In particular, the magnitude of ADC decrease in the lesioned areas ranged roughly between 15 and 25% compared to contralateral normal-appearing brain tissue. The patient recovered completely over the following 48 h. A repeat MRI after 1 month documented near-complete resolution of the lesions (Fig. 1). Hyperintense DWI lesions that exhibit low ADC values are typically suggestive of cytotoxic edema in a setting of acute brain ischemia. Although ischemia-associated DWI hyperintensities can be reversible to a certain extent, it is remarkable that in a setting of both cerebral fat [6, 7] and LBE post-TACE [5], widespread areas of presumed cytotoxic edema have been reported not to evolve to complete infarction (established T2 or FLAIR lesions). To the best of our knowledge, such an extensive reversal of DWI abnormalities has not been reported in acute ischemic stroke. A possible explanation would be that what looks like cytotoxic edema in DWI is actually an overestimation of the true extent of the lesion or a cytotoxic edema ‘‘mimic.’’ A MRI spectroscopy study [6] has suggested that soon after fat embolism, areas of restricted diffusion may simply reflect the presence of large quantities of ‘‘sluggish’’ lipids compared to water. However, secondary ischemia [6] or a neurotoxic effect of free fatty acids [7] may occur later if the embolic material is not rapidly cleared from the brain circulation. This would also explain the ‘‘preference’’ of the lipid emboli and of the associated permanent lesions for the watershed areas of the brain where a slow blood flow cannot be compensated quickly and adequately by collaterals. In our patient, fast clearance of the lipid burden may account for the rapid clinical recovery and the reversion of DWI abnormalities. Concerning the etiology of brain embolism in patients undergoing TACE, right-to-left shunt (either via a patent foramen ovale or intrapulmonary arteriovenous shunts), shunt from the inferior phrenic artery to the pulmonary vasculature, and an increased dose of infused lipiodol are commonly advocated [1–4]. However, the passage of oil T. Karapanayiotides (&) G. Georgiadis Department of Neurology, Hippokrateion Hospital, 50, Aigaiou Str., 551 33 Thessaloniki, Greece e-mail: theonen@ath.forthnet.gr; tkarapanayiotides@yahoo.gr

Massive Gastric Necrosis Following Chemoembolization for Hepatocellular Carcinoma

Purpose: Severe gastric necrosis due to trans arterial chemoembolization (TACE) for HCC has not been previously described to our knowledge. Methods: Presentation: A 72 yr old man with HCC presented with chest and abdominal discomfort and melena 4 days after undergoing TACE for hepatocellular carcinoma. He was pale but not febrile or orthostatic. Cardiac and abdominal exam was non focal. Rectal exam revealed melenic stool. The hemoglobin had decreased from 13 to 10gm/dL. Results: Diagnosis: Urgent EGD revealed giant, non bleeding, cratered gastric ulcers, with pigmented material, on the lesser curvature, incisura and posterior wall of the stomach. Biopsies showed extensive necrotic tissue with no malignancy. Abdominal MRI revealed a 5.2 cm mass in the left hepatic lobe similar to pre-chemoembolization images. No free air was seen. Review of the angiography at TACE revealed an aberrant take-off of the left gastric artery from the common hepatic artery, not the celiac artery. This resulted in inadvertent delivery of the chemotherapeutic agent via the left gastric artery to the lesser curvature of the stomach. Management: The patient was made NPO, treated with high dose PPIs, IV antibiotics, and monitored closely for gastric perforation. He did well on conservative therapy and was discharged on PPIs. Serial endoscopy 1 month and 4 months later documented progressive healing of the necrotic area. Conclusions: TACE is an increasingly used therapy for patients with HCC. Common side effects are fever, pain, increased serum amylase and transaminase levels. A 5% incidence of non-variceal bleeding after TACE has been reported (1). Gastric necrosis is a previously unreported complication of TACE with potentially significant clinical impact. Aberrant take-offs are a common occurrence (10–40%) in the mesenteric arterial system and physicians should be aware of potential vascular anomalies and use selective cannulization during chemoembolization to prevent gastrointestinal necrosis. Gastrointestinal bleeding after hepatic transcatheter arterial embolization in patients with hepatocellular carcinoma. GIE 1996; 43 (2)132–137

Feasibility of Blood Oxygenation Level–dependent MR Imaging to Monitor Hepatic Transcatheter Arterial Embolization in Rabbits

Blood oxygenation level-dependent (BOLD) magnetic resonance (MR) imaging is a noninvasive method to assess changes in oxygen delivery to tissues. It was hypothesized that BOLD MR imaging can detect changes in rabbit VX2 liver tumor oxygenation after hepatic artery embolization with polyvinyl alcohol particles. In four discrete VX2 liver tumors, a statistically significant mean reduction in apparent transverse relaxation time was shown, from 55 milliseconds before embolization to 41 milliseconds after embolization (P < .01). This reduction corresponded to a decrease in hepatic tumor oxygenation. The use of BOLD MR imaging to monitor changes in hepatic tumor oxygenation after embolization is feasible. These functional MR imaging measurements of hypoxia may be targeted as an endpoint for therapy in future studies.

Pulmonary embolism after transcatheter arterial chemoembolization

Metastatic hepatic tumours can be treated with hepatic transcatheter arterial chemoembolization (TACE). Common complications associated with TACE include hepatic insufficiency, fever, and pain. However, pulmonary embolism is rarely documented as a fatal adverse effect. We report a case of pulmonary embolism following TACE in a renal cell carcinoma patient with liver metastases. Total recovery is noted after the effective treatment.

A New Chemoembolization Protocol in Refractory Liver Metastasis of Colorectal Cancer – a Feasibility Study

Introduction: In patients with advanced colorectal cancer (CRC) refractory to systemic chemotherapy including 5-fluorouracil (5-FU) / folinic acid (FA), oxaliplatin and irinotecan we assessed the feasibility, toxicity and response to hepatic transcatheter arterial chemoembolization (TACE). At the time of treatment, patients had exclusively or dominantly liver metastasis of CRC. Patients and Methods: The following protocol was applied via a selective transfemoral hepatic arterial approach: mitomycin C 5 mg/m², interferon-α2b 4.5 Mio IU, dexamethasone 20 mg mixed with Amilomer DSM 45/25 (Spherex^®) days 1 and 2 i.a. (bolus), oxaliplatin 50 mg/m² (2 h) day 1 i.a., FA 500 mg/m² (2 h) day 1 i.v., and 5-FU 1.500 mg/m² (24 h) day 1 i.a. Cycles have been repeated at days 15–22. The dose was adjusted according to the pretreatment performance status and elevation of alkaline phosphatase, bilirubin and serum albumin. Treatment was continued until progression or emergence of intolerable toxicity. Results: 11 patients received a total number of 43 TACE, with a range of 2–6 per patient. There was no TACE-related mortality. 4 patients died 5, 8, 10 and 11 months after initiation of treatment due to progression of disease. 7 patients are alive at 4+ (n = 2), 5+ (n = 1), 6+ (n = 1), 7+ (n = 1) and 11+ (n = 2) months after start of treatment. Toxicity (CTC) was mild with grade I–II asthenia (n = 10), grade I–II neurotoxicity (n = 5), grade II nausea and/or vomiting (n = 2) and grade II diarrhea (n = 1). Treatment had to be postponed due to grade I thrombocytopenia in 2 patients. No bleeding episodes or obvious infectious complications occurred during treatment intervals. 1 patient experienced an allergic reaction to oxaliplatin which led to exclusion from further therapy. Arterial catheter dislocation occurred in 3 patients. In 10 patients evaluable for response we observed 3 partial responses, 2 minor responses, and 4 times stable disease. Only 1 patient had further progression of disease under treatment. Conclusion: TACE, using a combination of mitomycin C, dexamethasone and interferon-α2b mixed with Spherex^®, followed by oxaliplatin, FA and 5-FU, appears to be an effective and feasible treatment option in the case of liver metastasis of CRC refractory to standard systemic chemotherapy. This treatment is associated with tolerable toxicity, which becomes apparent mainly as asthenia, neurotoxicity or thrombocytopenia. These preliminary data warrant further evaluation for patients with refractory disease and would probably also be of interest for first-line treatment in this patient population.

Gastrointestinal bleeding after hepatic transcatheter arterial embolization in patients with hepatocellular carcinoma

Background: Transcatheter arterial embolization is a popular palliative treatment for patients with hepatocellular carcinoma, but the incidence of post-treatment gastrointestinal bleeding is not well-defined.Methods: We retrospectively analyzed 206 patients with hepatocellular carcinoma who received transcatheter arterial embolization and compared them with 193 patients with hepatocellular carcinoma who underwent angiography alone.Results: Twenty-three episodes (8.5%) of gastrointestinal bleeding occurred within 3 months of hepatic transcatheter arterial embolization following 269 procedures involving 206 patients with hepatocellular carcinoma. Eight episodes (3.0%) of esophageal variceal bleeding and 15 episodes (5.5%) of nonvariceal bleeding were found. The sites of the nonvariceal bleeding episodes were the stomach (n = 7), duodenum (n = 5), and colon (n = 3). When compared with other sources, bleeding from esophageal varices took place earlier, required intensive treatment, and led to a higher mortality. Among another 193 patients with hepatocellular carcinoma who received angiography only, 6 patients developed gastrointestinal bleeding within 3 months (3.1%), and all bled from esophageal varices.Conclusions: This study suggests that esophageal variceal bleeding may occur after both angiography and transcatheter arterial embolization. Nonvariceal bleeding episodes, which were usually milder than episodes of variceal bleeding, may be related to the embolization procedure itself. (Gastrointest Endosc 1996;43:132-7.)