Underwent Transcatheter Arterial Chemoembolization Research Articles

Transcatheter Arterial Chemoembolization in Patients with Hepatocellular Carcinoma on the Waiting List for Orthotopic Liver Transplantation

The objective of this study was to perform a retrospective analysis of patients with hepatocellular carcinoma (HCC) who underwent transcatheter arterial chemoembolization (TACE) before undergoing liver transplantation at our institution. From January 2000 to August 2005, 56 patients with HCC underwent TACE before orthotopic liver transplantation (OLT). Radiologic findings before and after TACE were assessed and correlated with histologic findings after OLT. The area of induced necrosis was pathologically evaluated in each HCC nodule. One hundred thirty-one HCC nodules were detected at histologic study. One hundred seventeen HCC nodules (91.4%) were hyperenhancing in the arterial phase on the preoperative imaging studies. The percentage of tumor necrosis was greater than 90% in 48 nodules (38%), between 50% and 90% in 19 nodules (15%), and less than 50% in 61 nodules (48%); tumor necrosis data were not recorded for the remaining three nodules. The size of the preoperatively detected lesions ranged from 0.2 to 9 cm (mean, 2.58 cm). The mean percentage of tumor necrosis was 67.8% in this group, but it rose to 79.2% in the hypervascular lesions. The size of the nodules that were not detected preoperatively ranged from 0.1 to 1.9 cm (mean, 0.68 cm), and the mean percentage of tumor necrosis was only 1.57%. TACE is a safe treatment in well-selected patients. Its antitumoral effect is high in hypervascular lesions (mean necrosis, 79.2%). It provides good local control in preoperatively diagnosed HCC (mean necrosis, 67.8%), but its impact is limited in lesions not detected preoperatively (mean necrosis, 1.57%).

Imaging findings and transcatheter arterial chemoembolization of hepatic malignancy with right atrial embolus in 46 patients

To analyze the imaging findings of hepatic malignancy with right atrial (RA) embolus. Forty-six patients with an embolus in the RA were diagnosed, including 44 patients with hepatocellular carcinoma (HCC), 1 patient with cholangiocellular carcinoma and 1 patient with hepatic carcinoma metastasis. The diagnosis was confirmed by clinical examination, serum alpha-fetoprotein and imaging. Seventeen patients underwent transcatheter arterial chemoembolization (TACE). On enhancement computer tomography (CT) or magnetic resonance (MR) imaging, a nodular filling defect in the RA could be easily found, with a slight enhancement in the arterial phase. The coronal images of CT or MR showed the extent of lesion. Lipiodol entered the embolus after TACE, hence reducing the speed of embolus growth. There was a survival benefit for patients receiving anticancer treatment. Patients with HCC, showing a filling defect of the inferior vena cava (IVC), hepatic vein (HV) and RA on images, can be diagnosed with RA embolus. Encroachment of the RA is very rare in patients with hepatic malignancies. Furthermore, a prolongation of survival time is found in those patients who underwent TACE.

Analysis of the origin of the right inferior phrenic artery in 178 patients with hepatocellular carcinoma treated by chemoembolization via the right inferior phrenic artery

No previous report has described the level of the origin of the right inferior phrenic artery (RIPA) based on an analysis of the relationships between the level of the RIPA, the celiac artery (CA), the superior mesenteric artery (SMA), and the right renal artery (RRA) in a series of cases. To evaluate the origin of the RIPA by retrospectively analyzing angiographic findings in 178 patients with hepatocellular carcinoma (HCC) who underwent transcatheter arterial chemoembolization (TACE) via the RIPA. In patients treated with intraarterial chemoembolization for HCC, additional superselective chemoembolization of the RIPA branches was necessary in 178 cases. We analyzed the level of the origin of the RIPA in these patients according to the relationships between the level of the origin of the RIPA, the CA, the SMA, and the RRA on angiography. Among the 178 cases, the RIPA arose from 1) the aorta directly in 102 cases (57%), 2) the CA in 53 (30%), 3) the left gastric artery (LGA) in three (2%), 4) the dorsal pancreatic artery (DPA) in one (1%), and 5) the RRA in 19 (11%). The level of the origin of the RIPA that originated directly from the aorta was supraceliac in 56 cases (32%), between the CA and the SMA in 31 (17%), and between the SMA and the RRA in 15 (8%). In our study, the RIPA originated from the aorta between the CA and the SMA directly in 17% of cases. When it is difficult to identify the origin of the RIPA, we must keep in mind that the RIPA may originate from the right part of the aorta within the small distance between the SMA and the CA.

Retransplantation for De Novo Hepatocellular Carcinoma in a Liver Allograft with Recurrent Hepatitis B Cirrhosis 14 Years After Primary Liver Transplantation

To the Editor: A 43-year-old Japanese man with end-stage hepatitis B-related cirrhosis had undergone orthotopic liver transplantation at Baylor University Medical Center, Dallas, Texas, in 1990. The patient was HBV-DNA seropositive before transplantation. No hepatocellular carcinoma (HCC) was found in the explanted liver. Since therapy to prevent reinfection of hepatitis B using hepatitis B immunoglobulin (HBIG) was not available at that time, the patient was reinfected and developed severe chronic hepatitis despite interferon therapy between the first and the second posttransplant year in Japan. The liver biopsy performed 8 years after transplantation demonstrated liver cirrhosis. Fourteen years after transplantation, a single nodule of HCC, 3 cm in diameter, was diagnosed by computed tomography at the Jikei University Hospital, for which the patient underwent transcatheter arterial chemoembolization (TACE) therapy (Fig. 1) and was subsequently retransplanted at the Baylor University Medical Center 4 months after TACE. Histological examination of the HCC in the explanted liver showed poorly differentiated HCC without portal vein invasion. After retransplantation, the patient was treated with the HBIG and lamivudine (100 mg daily) to prevent reinfection with hepatitis B. In addition, the Baylor protocol of posttransplant adjuvant chemotherapy using doxorubicin (10 mg/m2 × 20 times, weekly) was given for 5 months after

New Indication for Reduction Surgery in Patients with Advanced Hepatocellular Carcinoma with Major Vascular Involvement

The prognosis of advanced hepatocellular carcinoma (HCC) remains poor, particularly in patients with tumor thrombi (TT) in the major vessels. From July 1992 to October 2004, 161 patients diagnosed as having advanced HCC with major vascular involvement were seen consecutively at our hospital. Among these patients, 32 (20%) underwent surgical resection [16 complete resection (CR), 16 reductive resection (RR)]. Eighteen patients (11%) received radiotherapy (RT), 73 (45%) underwent transcatheter arterial chemoembolization (TACE) or transcatheter arterial infusion chemotherapy (TAI), 8 (5%) with distant metastases received systemic chemotherapy, and 30 (19%) received palliative therapy. Excluding the CR group, the patients in the RR group had a higher 1-year survival rate than the other treatment groups. However, there was no significant difference in the overall survival rates of the RR, RT, and TACE/TAI groups. When we evaluated prognostic factors to clarify the indications for RR in the multidisciplinary treatment of patients with advanced HCC with TT, prothrombin activity (PA) was identified as a significant independent preoperative factor for overall survival in the RR group. The survival rate in patients with PA of < or = 78% was significantly lower than that of patients with PA of > 78% (P = 0.0004). The median survival time of patients with serum PA of > 78% who underwent RR was 13.9 months and that of patients who underwent CR was 9.1 months, with no survival difference between the groups. In advanced HCC with major vascular involvement, patients who had RR with PA of greater 78% achieved a similar survival to those who had CR. The surgeon should still proceed with RR in those patients with serum PA of > 78% if CR does not seem feasible on preoperative evaluation.

Local recurrence is an important prognostic factor of hepatocellular carcinoma

To clarify the importance of complete treatment by PEIT. A total of 140 previously untreated cases of HCC were enrolled in this study from 1988 to 2002. The inclusion criteria were: a solitary tumor less than 4 cm in diameter or multiple tumors, fewer than four in number and less than 3 cm in diameter, without extrahepatic metastasis or vessel invasion. As general principles for the treatment of HCC, the patients underwent transcatheter arterial chemoembolization (TACE) prior to PEIT. After the initial treatment of the patients, ultrasonography and computed tomography were performed, and measurement of serum levels of alpha-fetoprotein (AFP) was determined. When tumor recurrences were detected, PEIT and/or TACE were repeated whenever the hepatic functional reserve of the patient permitted. We then analyzed the variables that could influence prognosis, including tumor size and number, the serum levels of AFP, the parameters of hepatic function (albumin, bilirubin, ALT, hepaplastin test, platelet number, and indocyanine green retention at 15 min (ICG-R15)), combined therapy with TACE, distant recurrence, and local recurrence. Univariate analysis identified the ICG test, serum levels of AFP and albumin, tumor size and number, and local recurrence, but not distant recurrence, as significant prognostic variables. In multivariate analysis using those five parameters, the ICG test, tumor size, tumor number, and local recurrence were identified as significant prognostic factors. In both univariate and multivariate analyses, the relative risk for the ICG test was the highest, followed by local recurrence. We found that local recurrence is an independent prognostic factor of HCC, indicating that achieving complete treatment for HCC on first treatment is important for improving the prognosis of patients with HCC.

Liver metastasis 30 years after enucleation of the left eyeball for choroidal melanoma

Here, we report a case of 70-year-old female with metastatic choroidal melanoma in the liver, which was detected 30 years after enucleation of the left eyeball. At first, two hypovascular tumors (4cm and 1cm in diameter) were detected in the liver as high-density areas on plain computed tomography (CT). They were demonstrated as hyper- and hypo-intensity lesions on T1- and T2-weighted image of magnetic resonance imaging (MRI), respectively, with superparamagnetic iron oxide uptake. During about 2-years follow-up, the larger tumor did not change significantly in size and in the character. However, the smaller one grew up in size and changed its nature to hypervascular and hyper-intensity on T2-weighted image of MRI. These hypervascular tumors increased in number and in size rapidly. The specimens obtained with tumor biopsy revealed epithelioid tumor cells positive for HMB45 immunohistochemical stain with and without brown pigment, and the tumors were diagnosed as melanoma. The patient underwent transcatheter arterial chemoembolization with cisplatin and epirubicin hydrochloride, and subsequent transcatheter arterial infusion chemotherapy with cisplatin, nimustine and dacarbazine. Unfortunately, however, the tumor rapidly progressed and she died. We discuss the imaging of the melanoma metastasized to the liver with the estimation of doubling time (DT) of the tumors.

Quantitative perfusion map of malignant liver tumors, created from dynamic computed tomography data 1

Rationale and Objectives. To apply perfusion computed tomography (CT) technique to variable malignant liver tumors, and to define the usefulness of quantitative color mapping. Materials and Methods. Perfusion CT images were created for 36 malignant liver tumors in 28 patients (age, 66.4 ± 10.1 years; range, 48–85) with metastatic liver tumors (n = 17; nine colorectal carcinomas, eight other malignant tumors) and hepatocellular carcinomas (n = 11). A single-slice dynamic CT was performed after an intravenous bolus injection of 40 mL of contrast material (320 mgI/mL) with 8 mL/sec. The parameters were calculated pixel-by-pixel using maximum slope method, and quantitative maps of arterial and portal perfusion were created. In four patients who underwent transcatheter arterial chemoembolization, perfusion CT was performed before and after transcatheter arterial chemoembolization. Results. In all patients, liver tumors were shown as hypervascular lesions on arterial perfusion CT. The average arterial perfusion value of the metastatic tumors from the colorectal carcinomas was 0.67 ± 0.33 mL/min/mL, and that of hepatocellular carcinomas was 0.94 ± 0.26 mL/min/mL ( P = .03). The other metastatic tumors from various primary tumors showed a wide range (0.19–1.45 mL/min/mL) of arterial perfusion. Arterial perfusion of the liver tumors was obviously decreased after successful transcatheter arterial chemoembolization. In 12 of 15 tumors, in which portal perfusion CT images could be created, region-of-interest analysis showed no portal perfusion in the tumors. In two cases, decreased portal perfusion in the segments, which malignant tumors involved, was demonstrated. Conclusion. Perfusion CT can provide quantitative information about arterial and portal perfusion of liver tumors, combined with good anatomic detail in one image. This technique has a potential to evaluate the angiogenesis of liver tumors, to show secondary changes in perfusion, such as decreased portal perfusion in apparently normal liver adjacent to metastases, and to monitor the therapeutic response in vivo.

Study Of Local Three-Dimensional Conformal Radiotherapy Combined With Transcatheter Arterial Chemoembolization for Patients With Stage III Hepatocellular Carcinoma

The purpose of this study was to evaluate treatment-related toxicity, outcome, patterns of failure, and prognostic factors for patients with stage III unresectable hepatocellular carcinoma (HCC) treated with a combination of local 3-dimensional conformal radiotherapy (3D-CRT) and transcatheter arterial chemoembolization (TACE) under the support of G-CSF. From October 1997 to August 2001, 45 patients with stage III unresectable hepatocellular carcinoma underwent transcatheter arterial chemoembolization with local 3D-CRT. Twenty-seven patients were classified as having stage IIIA disease according to the American Joint Committee on Cancer (AJCC) staging system and 18 were classified as stage IIIB. The mean diameter of the treated hepatic tumor was 8.5 cm. Before 3D-CRT, 2 cycles of transcatheter arterial chemoembolization were prescribed. Forty-eight hours later, the G-CSF was prescribed for 5 days after the completion of every TACE. With the interval of 10 to 14 days after the second cycle of TACE, 3D-CRT was prescribed to all patients with a total dose of 50.4 Gy at 1.8 Gy per fraction 5 days per week. After the completion of 3D-CRT, the additional 2 cycles of TACE were given. All patients were monitored for treatment-related toxicity, outcome, patterns of failure, causes of death, and prognostic factors. Forty-two of 45 patients were treated smoothly with the primary schedule. In a median follow-up period of 27 months, 22 patients were alive and 23 were dead. Progressive disease occurred in 28 patients, including local recurrence alone (4 patients), distant metastases with local recurrence (8 patients), and distant metastases alone (16 patients). Nine patients developed radiation-induced liver disease (RILD). Three patients had treatment-related gastrointestinal bleeding. There were 2 treatment-related deaths, including 1 from RILD and 1 from gastrointestinal bleeding. Complete regression (CR) was observed in 6 patients, partial regression (PR) in 35 patients, and stable disease (SD) in 4 patients. The median overall survival duration from treatment was 23.5 months with a 1-year overall survival rate of 68.5%, a 2-year survival rate of 48.3%, and a 3-year survival rate of 22.6%. The median freedom from progressive disease survival duration from treatment was 25 months with 1-year, 2-year, and 3-year progression-free survival rates of 76.2%, 56.8%, and 42.4%, respectively. The stage of HCC, regional lymph node status, portal vein thrombosis, pretreatment alpha-fetoprotein level (AFP), and tumor size affected the treatment outcomes significantly. Therefore, for patients with stage III unresectable hepatocellular carcinoma, combined local 3D conformal radiotherapy with transcatheter arterial chemoembolization under the support of G-CSF is an effective treatment protocol. Further research is required to decrease distant metastases and to determine the safe irradiation dose-volume.

Radiation-induced liver disease after three-dimensional conformal radiotherapy for patients with hepatocellular carcinoma: dosimetric analysis and implication

Purpose: To analyze the correlation of radiation-induced liver disease (RILD) with patient-related and treatment-related dose-volume factors and to describe the probability of RILD by a normal tissue complication probability (NTCP) model for patients with hepatocellular carcinoma (HCC) treated with three-dimensional conformal radiotherapy (3D-CRT). Methods and Materials: Between November 1993 and December 1999, 93 patients with intrahepatic malignancies were treated with 3D-CRT at our institution. Sixty-eight patients who were diagnosed with HCC and had complete 3D dose-volume data were included in this study. Of the 68 patients, 50 had chronic viral hepatitis before treatment, either type B or type C. According to the Child-Pugh classification for liver cirrhosis, 53 patients were in class A and 15 in class B. Fifty-two patients underwent transcatheter arterial chemoembolization with an interval of at least 1 month between transcatheter arterial chemoembolization and 3D-CRT to allow adequate recovery of hepatic function. The mean dose of radiation to the isocenter was 50.2 ± 5.9 Gy, in daily fractions of 1.8–2Gy. No patient received whole liver irradiation. RILD was defined as Grade 3 or 4 hepatic toxicity according to the Common Toxicity Criteria of the National Cancer Institute. All patients were evaluated for RILD within 4 months of RT completion. Three-dimensional treatment planning with dose-volume histogram analysis of the normal liver was used to compare the dosimetric difference between patients with and without RILD. Maximal likelihood analysis was conducted to obtain the best estimates of parameters of the Lyman NTCP model. Confidence intervals of the fitted parameters were estimated by the profile likelihood method. Results: Twelve of the 68 patients developed RILD after 3D-CRT. None of the patient-related variables were significantly associated with RILD. No difference was found in tumor volume (780 cm 3 vs. 737 cm 3, p = 0.86), normal liver volume (1210 cm 3 vs. 1153 cm 3, p = 0.64), percentage of normal liver volume with radiation dose >30 Gy (V 30 Gy; 42% vs. 33%, p = 0.05), and percentage of normal liver volume with >50% of the isocenter dose (V 50%; 45% vs. 36%, p = 0.06) between patients with and without RILD. The mean hepatic dose was significantly higher in patients with RILD (2504 cGy vs. 1965 cGy, p = 0.02). The probability of RILD in patients could be expressed as follows: probability = 1/[1 + exp −(0.12 × mean dose − 4.29)], with coefficients significantly different from 0. The best estimates of the parameters in the Lyman NTCP model were the volume effect parameter of 0.40, curve steepness parameter of 0.26, and 50% tolerance dose for uniform irradiation of whole liver [TD 50(1)] of 43 Gy. Patients with RILD had a significantly higher NTCP than did those with no RILD (26.2% vs. 15.8%; p = 0.006), using the best-estimated parameters. Conclusion: Dose-volume histogram analysis can be effectively used to quantify the tolerance of the liver to RT. Patients with RILD had received a significantly higher mean dose to the liver and a significantly higher NTCP. The fitted volume effect parameter of the Lyman NTCP model was close to that from the literature, but much lower in our patients with HCC and prevalent chronic viral hepatitis than that reported in other series with patients with normal liver function. Additional efforts should be made to test other models to describe the radiation tolerance of the liver for Asian patients with HCC and preexisting compromised hepatic reserve.

External beam radiation therapy for inoperable hepatocellular carcinoma with portal vein thrombosis.

Portal vein thrombosis (PVT) in patients with hepatocellular carcinoma (HCC) has a poor impact on prognosis. Many of these tumors may cause intrahepatic and extrahepatic metastases. From January 1991 to December 1996, 41 unresectable HCC patients with PVT underwent transcatheter arterial chemoembolization (TACE) and external beam radiation therapy (EBRT) to the portion of PVT. The irradiated field, with a mean equivalent field size of 6.6 x 7.1 cm2, was localized and simulated by abdominal sonography, angiography and computed tomography. Radiation dose ranged from 36 to 66 Gy (mean dose: 51.4 Gy), in a daily fraction of 1.8 to 2 Gy. The response of EBRT was evaluated by abdominal sonography within 3 months of completion of EBRT. The response rates of the PVT after treatment were 39% for complete response (CR), 41% for partial response (PR), and 19% for no response (NR), respectively. The median overall survival time from start of radiotherapy was 10 months for all patients, 17 months for CR patients, 8 months for PR patients and 4 months for NR patients. By multivariate analysis, response of PVT resulted in a significant improvement in survival. (P = 0.001) There was no occurrence of severe complication of radiation-induced liver disease. The results obtained with combined treatment modality of EBRT and TACE in the treatment of HCC patients with PVT are encouraging.

Radiation-induced liver disease after three-dimensional conformal radiotherapy in patients with hepatocellular carcinoma: dosimetric analysis and implication

Purpose: This study is to use the dose-volume analysis to predict radiation-induced liver disease (RILD) for patients with hepatocellular carcinoma (HCC) and a large proportion of chronic hepatitis treated with three-dimensional conformal radiotherapy (3DCRT). Materials and Methods: From November 1993 through December 1999, 93 patients with intra-hepatic malignancies were treated with 3DCRT at our institution. Sixty-eight patients who were diagnosed with HCC and had complete three-dimensional dose-volume data were included in this study. The reasons for patient exclusion were follow-up interval less than 3 months after radiotherapy, incomplete dose-volume data in the palliative treatment, or the diagnosis other than HCC. Fifty of the 68 patients had chronic hepatitis before treatment, either type B or type C. According to Child-Pugh classification for cirrhosis of liver, 53 patients were in class A and 15 in class B. Forty-six patients underwent transcatheter arterial chemoembolization at least a month before 3DCRT to allow adequate recovery of hepatic function. RILD was defined as either anicteric elevation of alkaline phosphatase level of at least twofold and non-malignant ascites (classic RILD), or elevated transaminases of at lease fivefold the upper limit of normal or of pre-treatment level (Grade 3 or 4 hepatic toxicity of Common Toxicity Criteria Version 2.0 by National Cancer Institute)(non-classic RILD). No patient had whole liver irradiation. All patients were evaluated for RILD by physical examination, blood chemistries, and computed tomography of the abdomen, within 4 months from completion of radiotherapy. Three-dimensional treatment planning using dose-volume histogram analysis of the normal liver was used to compare the dosimetric difference between patients with and without RILD. Results: Twelve of the 68 patients developed RILD after 3DCRT, including 2 with classic type and 10 with non-classic type. Mean prescribed dose was 50.2 ± 5.9Gy, in a daily fraction of 1.8-2Gy. None of the patient-related variables were associated with RILD. There was no difference in tumor volume (780ml vs. 737ml, p=0.86), normal liver volume (1210ml vs. 1153ml, p=0.64), V30Gy (percent volume of normal liver with radiation dose >30Gy)(42% vs. 33%, p=0.05), and V50% (percent volume of normal liver with >50% of the isocenter dose)(45% vs. 36%, p=0.06), between patients with and without RILD. Mean hepatic dose was significantly higher in patients with RILD (2504cGy vs. 1965cGy, p=0.02). Patients receiving radiation dose more than 28Gy had a significantly higher rate of RILD (4/5 vs. 8/51, p=0.02). The probability of produced RILD in patients could be expressed as: probability=1/[1+exp-(0.12∗mean dose-4.29)], with coefficients differed from 0 at the level of p= 0.0018 and 0.027, respectively. With the normal tissue complication probability (NTCP) model using volume effect parameter (n) of 0.32, curve steepness parameter (m) of 0.15, and TD50(1) of 40Gy, patients with RILD had significantly higher NTCP than those with no RILD (36.6% vs. 19.1%, p=0.005). With an attempt to estimate a new “n” by grouping patients and using a quartile plot, the best agreement between the calculated and observed complication probability was obtained with the value of 0.28. Conclusion:1 Dose volume histogram analysis can be effectively used to quantify the tolerance of liver to radiation. Patients with RILD had significantly higher mean hepatic dose and NTCP. The hepatic tolerance, expressed as either mean hepatic dose or the parameterization of NTCP model, was much lower in our patients with HCC and a high prevalence of chronic hepatitis, as compared to the other series. Further efforts should be made to test the modified model in an independent clinical trial.

Rapid progression of hepatocellular carcinoma after transcatheter arterial chemoembolization and percutaneous radiofrequency ablation in the primary tumour region

We report one patient who showed rapid progression of hepatocellular carcinoma (HCC) after undergoing transcatheter arterial chemoembolization (TACE) and percutaneous radiofrequency ablation (PRFA) for a small HCC measuring 2.5 cm in diameter. Enhanced magnetic resonance imaging (MRI) following treatment showed complete tumour necrosis and did not reveal the presence of a tumour around the treated area. Furthermore, the serum alpha-fetoprotein (AFP) level decreased at the completion of therapy. However, the HCC advanced in a very short time. Numerous tumours around the treated area were observed on enhanced computed tomography (CT) 50 days after PRFA. It is strongly suspected that the tumour was disseminated through the portal system because of the presence pattern of tumours. We believe this to be the first case illustrating a hepatic cancer that progressed rapidly following TACE and PRFA.

Transcatheter arterial chemoembolization as primary treatment for hepatocellular carcinoma

Background: Hepatocellular carcinoma (HCC) in Western populations has historically been associated with poor survival. Methods: In this study, we conducted a 7-year retrospective analysis of patients with HCC undergoing transcatheter arterial chemoembolization (TACE) at our institution and examined demographics, outcomes, and complications. Results: During the period of study, 39 patients (25 male [64%], mean age 58 [range 17 to 86]) underwent a total of 78 chemoembolization treatments. During the same time period, an additional 31 patients received supportive care only. The majority of patients had late stage disease (American Joint Committee on Cancer stage III, IVa, or IVb) with no statistical difference noted between the two groups ( P = 0.2). However, patients receiving supportive care only had significantly worse hepatic dysfunction by Child’s classification ( P = 0.005). Twenty-nine patients (74%) had documented cirrhosis, with hepatitis C being the most common cause in 11 of 29 (38%). In patients undergoing TACE, overall actuarial survival was 35%, 20%, and 11% at 1, 2, and 3 years with a median survival of 9.2 months, significantly improved over the group receiving supportive care only ( P < 0.0001). Median survival for the group receiving supportive care was less than 3 months. Neither age nor stage had a significant impact on survival. The most common complications of TACE included transient nausea, abdominal pain, vomiting, and fever. Conclusions: TACE is a safe and effective therapeutic option for selected patients with HCC not amenable to surgical intervention.

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

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

Use of carbon dioxide microbubble-enhanced sonographic angiography for transcatheter arterial chemoembolization of hepatocellular carcinoma.

Our objective was to determine the usefulness of sonographic angiography with carbon dioxide microbubbles during transcatheter arterial chemoembolization for hepatocellular carcinoma. Thirty-four patients with hepatocellular carcinoma underwent sonographic angiography during transcatheter arterial chemoembolization. Digital subtraction angiography failed to reveal tumors in 27 patients. Tumor stain became obscure on digital subtraction angiography after the catheter was inserted into distal branches in seven patients. Sonographic angiography was performed after injection of carbon dioxide microbubbles into the hepatic artery selected for transcatheter arterial chemoembolization. In angiographically undetectable hepatocellular carcinomas, sonographic angiography revealed tumor vascularity in 17 patients in whom transcatheter arterial chemoembolization was then performed. For the two patients who underwent a second transcatheter arterial chemoembolization, the existence of alternative feeding vessels was confirmed by sonographic angiography. In the remaining 10 patients, tumor vascularity was not seen on sonographic angiography; percutaneous ethanol injection therapy was then performed. Sonographic angiography clearly revealed tumor vascularity in patients in whom staining became obscure on digital subtraction angiography after the catheter was inserted into a peripheral branch of the hepatic artery. In all 24 patients who underwent transcatheter arterial chemoembolization, sonographic angiography was useful for determining the artery suitable for transcatheter arterial chemoembolization and for monitoring tumor perfusion in the selected artery. Sonographic angiography can be used to determine not only the therapeutic strategy for treatment of hepatocellular carcinoma but also whether the tumor is supplied by the artery selected for transcatheter arterial chemoembolization, especially when the tumor is not revealed by digital subtraction angiography.

Positron emission tomography with F-18-fluorodeoxyglucose to evaluate the results of hepatic chemoembolization.

Positron emission tomography (PET) using F-18-flurodeoxyglucose (18FDG) is an imaging modality allowing direct evaluation of cellular glucose metabolism. The purpose of this study was to examine the role of 18FDG-PET in monitoring chemoembolization therapy of patients with liver metastases from adenocarcinoma. Thirty-four hepatic lesions in 4 patients were evaluated with 18FDG-PET before and 2-3 months after interventional therapy. All patients underwent transcatheter arterial chemoembolization. A total of nine PET studies were performed. Semiquantitative measurement of the metabolic activity of the lesions was performed using the standard uptake value (SUV) of 18FDG. Comparison was performed between sequential PET scans using Student's t test for paired data analysis. The PET findings were also compared with tumor marker levels measured at the time of the PET scans. Twenty-five of 34 lesions had decreased 18FDG uptake (SUV = 8 +/- 2 vs. 3 +/- 1; P < 0.00001), as expected in successful tumor chemoembolization. These findings were associated with a significant decrease in serum tumor marker levels (86 +/- 4%; P < 0.05) after treatment. However, there were 3 new lesions, and 6 of the 34 lesions demonstrated persistent or increased 18FDG uptake after treatment (SUV = 8 +/- 2 vs. 13 +/- 3; P < 0.05), consistent with the presence of residual viable tumor. These findings led to further interventional therapy in all patients. 18FDG-PET allows monitoring of response to treatment with hepatic chemoembolization in patients with liver metastases from adenocarcinoma. PET is a useful diagnostic tool and has the potential to be used to guide further interventional therapy.

Transcatheter Arterial Chemoembolization in Inoperable Hepatocellular Carcinoma: Four-year Follow-up

To evaluate the efficacy of repeated chemoembolization in patients with inoperable hepatocellular carcinoma (HCC). One hundred thirty-two patients with HCC underwent transcatheter arterial chemoembolization with an emulsion of iodized oil and cisplatin. In 104 patients, "light" gelatin sponge embolization was also used. Chemoembolization was repeated every 1.5-3.0 months in most patients (range, one to 18 chemoembolization sessions). In 74 patients, the HCCs became smaller or disappeared after chemoembolization. Decreases in size were seen in 55 of 76 HCCs 9 cm or smaller, 17 of 42 HCCs between 9 and 18 cm, and two of 14 HCCs larger than 18 cm. Use of gelatin sponge pledgets enhanced the response in tumors larger than 9 cm. Seven of 74 HCCs that responded to chemoembolization increased in size later. New daughter nodules that appeared at other sites responded to chemoembolization in 24 of 40 patients. Further new nodules appeared in 14 of 24 patients, and in six patients they responded to therapy. Median survival was 26 months for patients with responsive HCCs and 5 months for those with unresponsive lesions. Tumor size at the start of chemoembolization influenced the response to treatment and survival. The addition of gelatin sponge improved results only in tumors larger than 9 cm. Recurrence after an initial response was due more to the appearance of new daughter nodules in new locations rather than recrudescence of the presenting tumor.

Transcatheter arterial chemoembolization (TACE) in the treatment of unresectable liver cancer.

Basis, techniques, and recent strategies and results of interventional treatments for hepatoma were reviewed. The basic experimental researches indispensable to justify clinical technique and dosage have been accomplished. A total of 1310 unresectable cases underwent transcatheter arterial chemoembolization (TACE) and/or related therapies. The related therapies are several modified or strengthened TACE such as Lipiodol-TACE and subsegmental TACE. The therapies for unembolizable cases are balloon occluded arterial infusion, Lipiodol-SMANCS infusion and percutaneous direct injection chemotherapy, that reinforces the effect of TACE. As for the resectable cases, postoperative TACE was proved to be beneficial because it increased survival rates; however, preoperative TACE was not beneficial. The TACE and related interventional radiologic therapies for the hepatoma can be an equal or superior therapy by virtue of targeting chemotherapy.