Efficacy and safety of preoperative lobar or segmental ablation via transarterial administration of ethiodol and ethanol mixture for treatment of hepatocellular carcinoma: clinical study

Identifying the Best Anticancer Agent Combination in TACE for HCC Patients: A Network Meta-analysis

Objective: We conducted a network meta-analysis to comprehensively compare various anticancer agents used in transarterial chemoembolization (TACE) based on the Bayesian theorem. Methods: Globally recognized electronic databases, including PubMed, EMBASE, and Cochrane Central, were searched to retrieve relevant randomized controlled trials (RCTs) comparing anticancer agents in TACE for hepatocellular carcinoma (HCC) patients. The therapeutic response, adverse events and overall survival rate were selected as parametric data to evaluate the clinical efficacy. Quantitative network meta-analysis and pair-wise analysis were conducted to compare the relative parameters. Results: Of the 4242 retrieved articles, 17 RCTs containing 2330 patients fulfilled the inclusion criteria. The network meta-analysis exhibited that the application of anthracycline and mitomycin plus pyrimidine presented the best clinical values regarding all parametric data (probability P=0.45, 0.32 and 0.35 regarding comparison of response rate, adverse event and overall survival, respectively). Accordingly, further investigation on specific anticancer agents indicated that the combination of doxorubicin and mitomycin plus gemcitabine was the best agent combination in TACE (probability P=0.49, 0.37 and 0.77 regarding comparison of response rate, adverse event and overall survival, respectively). Moreover, an additional study indicated that the single use of an anticancer agent prior to embolism brought no benefit compared with bland embolism without any agent (Test Z=0.15, 0.84, 1.22 and P=0.88, 0.40, 0.22 regarding comparison of response rate, adverse event and overall survival, respectively). However, the combined use of anticancer agents in TACE showed significantly better clinical efficacy than single use (Test Z=4.40, 3.94, 0.24 and P<0.001, <0.001, =0.81 regarding comparison of response rate, adverse event and overall survival, respectively); thus, combination utilization was recommended. Conclusions: The combined use of anticancer agents in TACE was recommended. Application of anthracycline and mitomycin plus pyrimidine seemed to be the best choice for clinical consideration. Additionally, the combination of doxorubicin and mitomycin plus gemcitabine may be the best specific anticancer agent combination in TACE currently, although additional RCTs are expected to support our conclusion.

Arterial injury during transcatheter arterial chemoembolization for hepatocellular carcinoma: predictors of risk and outcome

PURPOSE

To investigate clinical features and results of follow-up in patients with arterial injury during transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma.

METHODS

From 2005 to 2015, 2219 TACE procedures were performed in 906 patients in our hospital. Iatrogenic arterial injury occurred during 38 TACE procedures (sessions) in 35 patients (24 men, 11 women; mean age 71.8 years). The incidence of arterial injury was 1.7%. We evaluated the characteristics of arterial injury, and evaluated the risk factors for incomplete recanalization of the injured artery at follow-up angiography conducted after 1-11 months (mean 102.5 days).

RESULTS

Iatrogenic arterial injury was caused by the microcatheter in 34 of 38 cases (86.8%). There were 15 cases (39.5%) in which the replaced hepatic artery or the extrahepatic artery was the parasitic supply. Extravasation occurred in five cases. In 36 of 38 cases, follow-up angiography was performed. We divided 36 cases into two groups: complete reopening (n = 24) and non-complete reopening (n = 12). The two groups were compared regarding the factors associated with incomplete recanalization of the injured artery at follow-up. Injury length >3 cm (p = 0.0002) and proximal arterial injury (proximal to the segmental artery; p = 0.03) were significant risk factors for non-complete reopening of the injured artery.

CONCLUSION

Iatrogenic arterial injury frequently occurred in the extrahepatic artery or replaced hepatic artery. Recanalization rate of arterial injury was high; however, injury length >3 cm and proximal arterial injury were risk factors for non-complete reopening of the injured artery.

Combined resection and radiofrequency ablation versus transarterial embolization for intermediate-stage hepatocellular carcinoma: A propensity score matching study

BACKGROUND/PURPOSE

This study aimed to compare the outcomes of combined hepatic resection (HR) plus intraoperative radiofrequency ablation (RFA) and transarterial embolization (TAE) for Barcelona Clinic Liver Cancer (BCLC) stage B hepatocellular carcinoma (HCC) in case-controlled patient groups using the propensity score.

METHODS

A total of 179 patients with multifocal HCC treated with HR plus RFA (n = 26) or TAE (n = 153) were retrospectively studied. All patients were classified as BCLC stage B and Child-Pugh class A. Analyses were performed over all participants as well as for propensity score-matched (1:3) patients to adjust for baseline differences. Cumulative overall survival (OS) and time to progression (TTP) were compared between the two groups using the Kaplan-Meier method, and independent predictors were identified by multivariate Cox regression analysis.

RESULTS

Patients treated with HR plus RFA had better OS and longer TTP than those with TAE (p = 0.011 and p < 0.001, respectively). Multivariate Cox regression analysis showed that combined therapy (hazard ratio 0.31; 95% confidence interval (CI), 0.12-0.78; p = 0.013), BCLC substage B2 (hazard ratio 1.82; 95% CI, 1.13-2.92; p = 0.013) and alpha-fetoprotein ≥ 400 ng/ml (hazard ratio 1.85; 95% CI, 1.12-3.05; p = 0.016) were independent factors associated with OS. After propensity score matching, combined therapy was the significant factor associated with OS and TTP by univariate and multivariate analyses.

CONCLUSION

Combined HR plus RFA may provide survival advantage compared to TAE in patients with BCLC stage B HCC.

Limits of and Complications after Embolization of the Hepatic Artery and Portal Vein to Induce Segmental Hypertrophy of the Liver: A Large Mini-Pig Study

Background: The aim of this study was to compare arterial embolization (AE) with portal vein embolization (PVE) for the induction of segmental hypertrophy regarding procedural efficacy, safety and outcome. Methods: A total of 29 mini pigs were subjected to PVE, AE or assigned to the sham (SO) group. Correspondingly, 75% of the hepatic artery or portal vein branches were embolized. Growth and atrophy of the liver lobes, calculating the liver-to-body weight index (LBWI), laboratory data, arteriography, portography, Doppler ultrasound (US) and histopathology were analyzed. Results: After PVE, 2 animals had to be excluded due to technical problems. After AE, 4 animals had to be excluded because of technical problems and early sacrifice. Postprocedural US demonstrated effective AE and PVE of the respective lobes. Four weeks after PVE, portography showed a slow refilling of the embolized lobe by collateral portal venous vessels. Four weeks after AE, arteriography revealed a slight revascularization of the embolized lobes by arterial neovascularization. Segmental AE led to extensive necrotic and inflammatory alterations in the liver and bile duct parenchyma. Significant hypertrophy of the non-embolized lobe was only noted in the PVE group (LBWI: 0.91 ± 0.28%; p = 0.001). There was no increase in the non-embolized lobe in the AE (LBWI: 0.45 ± 0.087%) and SO group (LBWI: 0.45 ± 0.13%). Conclusion: PVE is safe and effective to induce segmental hypertrophy. Portal reperfusion by collateral vessels may limit hypertrophy. AE did not increase the segmental hepatic volume but carries the risk of extensive necrotic inflammatory damage.

Use of Ethanol in the Trans-Arterial Lipiodol Embolization (TAELE) of Intermediated-Stage HCC: Is This Safer than Conventional Trans-Arterial Chemo-Embolization (c-TACE)?

Purpose

To evaluate safety and efficacy of Trans-Arterial Ethanol-Lipiodol Embolization (TAELE) compared with conventional Trans-Arterial Chemo-Embolization (cTACE) in the treatment of small intermediate-HCC (BCLC-Stage B).

Materials and Methods

A random sample of 87 patients (37.93% male; 62.07% female; age range, 36–86 years) with documented small intermediate-HCC and treated with TAELE (mixture 1:1 of Ethanol and Lipiodol) or cTACE (mixture of 50mg-Epirubicin and 5cc-Lipiodol) were retrospectively studied in an institutional review board approved protocol. The two procedures were compared with χ²-test, χ²-test with Yates correction, McNemar’s exact test, ANOVA test and log-rank test.

Results

TAELE and cTACE therapies were performed in 45 and 42 patients, respectively. Thirty days after the procedure, a Multi-Detector Computed Tomography (MDCT) showed no significant difference in the number of patients with partial and complete response between the two groups (p-value = 0.958), according to mRECIST. Contrary, significant differences were found in tumor-devascularization, lesion-reduction and post-embolization syndrome occurrence (p-value = 0.0004, p-value = 0.0003 and p-value = 0.009, respectively). Similar survival was observed during 36-month follow-up (p-value = 0.884).

Conclusion

Compared to cTACE, TAELE showed a better toxicity profile with similar 36-month survival and similar one-month anti-tumor effects, which makes it better tolerated by patients, especially in case of more than one treatment.

Validation and modification of a proposed substaging system for patients with intermediate hepatocellular carcinoma

BACKGROUND AND AIM

Based on up-to-seven criteria and Child-Pugh score, four substages of Barcelona Clinic Liver Cancer (BCLC) intermediate hepatocellular carcinoma (HCC) were proposed. The purpose of this study was to validate and modify this proposal.

METHODS

Between January 2002 and February 2011, newly diagnosed intermediate HCC patients underwent transarterial embolization (TAE) were enrolled. Patients were stratified into four (B1-B4) substages and followed up until death or end of 2012. Patients' survivals and discriminatory ability of substaging systems were compared.

RESULTS

Five-hundred and eighty patients were enrolled. There were 56.6%, 33.8%, 7.4%, and 2.2% in substage B1, B2, B3, and B4. The 5-year survival rate was 21.4%, 13.9%, 7.4%, and 7.7% with median survival time of 2.4, 1.3, 0.5, and 0.8 years (P < 0.001). In addition to substage B1-B4, α-fetoprotein (AFP) level was an independent factor associated with survival in multivariate analysis. According to AFP < or > 200 ng/mL, B1 was classified into B1a and B1b, and B2 into B2a and B2b. There were no differences in survivals between B1b and B2a (P = 0.174), and B2b and B3 (P = 0.785). Patients were re-classified into modified (m)B1 (B1a), mB2 (B1b + B2a), mB3 (B2b + B3). The modified substages (mB1-mB3) showed a more desirable substaging system.

CONCLUSIONS

For BCLC intermediate HCC patients, substages B1-B4 were useful in predicting survival after TAE. However, modified substaging system provided better prognostic prediction.

Surgical resection improves the survival of selected hepatocellular carcinoma patients in Barcelona clinic liver cancer stage C

BACKGROUND

Sorafenib is the only approved agent recommended by the American Association Study of Liver Disease guidelines for hepatocellular carcinoma patients in Barcelona Clinic Liver Cancer stage C.

AIMS

To calculate and compare overall survival rates in hepatocellular carcinoma patients in Barcelona Clinic Liver Cancer stage C treated with various therapies or supportive care alone.

METHODS

This was a retrospective study, in which medical data from 411 newly diagnosed hepatocellular carcinoma patients in Barcelona Clinic Liver Cancer stage C and Child-Pugh class A were analyzed and compared.

RESULTS

Eighty-eight patients were treated with supportive care and 323 were treated with surgical resection (68/323, 21.1%), local ablation therapy (8/323, 2.5%), transarterial embolization (140/323, 43.3%), systemic chemotherapy or radiotherapy (96/323, 29.7%), and sorafenib (11/323, 3.4%). Median survival was 11 months (95% confidence interval, 9.0-13.1) in treated patients compared with 3.9 months in the supportive care group (hazard ratio, 0.45; 95% confidence interval, 0.35-0.59; p<0.001). Patients who underwent surgical resection had the longest survival compared to patients undergoing other treatments (33.4 months versus 8.1 months, p<0.001).

CONCLUSIONS

Surgical resection resulted in excellent outcomes. Although sorafenib is currently recommended, oncologists should endeavour to select optimal candidates for surgical resection to gain more survival benefit.

Usefulness of portography and contrast-enhanced computed tomography to predict the embolized area in percutaneous transhepatic portal vein embolization with absolute ethanol under temporary balloon occlusion

PURPOSE

To assess the usefulness of portography and contrast-enhanced computed tomography (CECT) for predicting the embolized area after the first injection of absolute ethanol (AE) in right portal vein embolization (RPVE).

MATERIALS AND METHODS

Portograms were retrospectively reviewed in 50 patients (30 men and 20 women, mean age 65 years) who had undergone percutaneous transhepatic RPVE with AE under temporary balloon occlusion (TBO) between February 2002 and October 2009. The enhancement pattern before embolization and the embolization pattern after the first AE injection were analyzed by portography. The angles of portal branches against the horizontal plane were measured in 48 patients using pre-treatment CECT.

RESULTS

The enhancement pattern was not consistent with the embolization pattern in 35 patients (p < 0.001). When the anterior branch angles were divided into two groups at -5°, 0°, 10°, and 15°, the frequency of the posterior-branch-dominant embolization pattern was higher in the more negatively angled group (p = 0.002-0.041).

CONCLUSION

The distribution of AE is different from that of contrast medium in percutaneous transhepatic RPVE under TBO. The pre-treatment measurement of the angles of portal branches against the horizontal plane on CECT is suggested to be useful for predicting the embolized area.

Liver anatomy: microcirculation of the liver

Comprehension of the structural and functional characteristics of the hepatic microcirculation can help improve the design, planning, and practice of imaging-guided treatment for hepatic tumors and for portal vein embolization (PVE). The hepatic microcirculation derives dual blood supply from the portal vein and the hepatic artery. The terminal portal venules directly connect to the hepatic sinusoids, but the terminal hepatic arterioles connect to arterioportal communications before entering the sinusoids: the peribiliary plexus, the terminal arteriosinus twigs, the vasa vasorum on the portal vein, and the direct arterioportal anastomosis. These communications play important roles in the balance of blood perfusion to the liver parenchyma and in controlling the blood supply to hepatic tumors and the anticipated remnant liver (in cases of PVE). At the microcirculatory level, various embolic agents present different distribution patterns. To further our understanding, iodized oil has been found to pass into the portal vein after hepatic arterial administration through the peribiliary plexus and subsequently traverses the sinusoids to enter the lungs and then the systemic circulation. Ultimately, a thorough knowledge of the host environment at the microcirculatory level is essential in developing strategies for both tumor treatment and for inducing liver regeneration.

Transarterial embolization ablation of hepatocellular carcinoma with a lipiodol-ethanol mixture

AIM: To determine the safety and effectiveness of transarterial embolization ablation (TEA) of hepatocellular carcinoma (HCC) with a lipiodol-ethanol mixture.

METHODS: Between January 1 and December 31, 2009, 15 patients with HCC (13 men/two women, aged 38-75 years) accepted TEA treatment and were enrolled in this study, including five newly diagnosed patients and 10 with refractory disease. Two months after TEA, angiography and contrast computed tomography (CT) were performed, and responses were assessed using a modified version of Response Evaluation Criteria in Solid Tumors (RECIST version 1.1). The follow-up period was to June 30, 2010.

RESULTS: Every new case was treated once. Angiography was performed immediately after TEA, and showed that the tumor-feeding vessels were completely embolized and that lipiodol was densely deposited inside tumors. Two months after treatment, contrast CT showed no enhanced lesions. Alpha fetoprotein levels returned to normal in four patients and markedly decreased in another. mean ± SD survival after treatment was 10.8 ± 4.5 mo. All five patients survived during the follow-up period. Ten patients with refractory disease were treated a total of 14 times. Angiography immediately after TEA showed that blood flow to the tumors was obviously decreased in all cases, and contrast CT showed obvious depositions of lipiodol. Two months after treatment, the tumors had shrunk (6/10) or were stable (3/10). One had progressed after 2 mo and died of tumor rupture 3 mo after TEA. mean ± SD survival after treatment was 8.6 ± 4.3 mo; two patients survived during the follow-up period. Adverse effects included reversible hepatic decompensation, upper abdominal pain, and fever.

CONCLUSION: TEA is an effective therapy for patients with HCC and might be more effective than transcather arterial chemoembolization for treating refractory disease.

Hepatocellular carcinoma surveillance and appropriate treatment options improve survival for patients with liver cirrhosis

OBJECTIVE/AIM

Hepatocellular carcinoma (HCC) surveillance is a common practice for patients with liver cirrhosis. The aims of the study were to assess impacts of surveillance and therapeutic options on survival of patients with HCC.

METHODS

A total of 1436 cirrhotic patients with newly diagnosed HCC were enrolled between January 2002 and December 2004. Patients with HCC detected within periodic surveillance were the surveillance group (n=318, 22.1%). The other patients with HCC incidentally detected were the non-surveillance group (n=1118, 77.95%). Initial treatment options were recorded and overall survival was analysed.

RESULTS

Compared with patients in the non-surveillance group, larger proportions of patients in the surveillance group possessed small tumours, at an early stage without vascular invasion or metastases, and afforded more curative treatment options including surgical resection, radiofrequency ablation and percutaneous ethanol injection. The overall survival was better for patients in surveillance (3-year survival rate: 59.1% versus 29.3%, p<0.001), early stages by Barcelona Clinic Liver Cancer (BCLC) staging or curative treatment options. Multivariate analysis demonstrated surveillance, hepatitis aetiology, alpha-fetoprotein, tumour gross type, tumour stage and treatment options were associated factors for patients' survival. Moreover, surveillance patients in curative BCLC stage following the treatment guideline for HCC proposed by the American association for the study of liver disease (AASLD) had a significantly better 3-year survival rate (77.1% versus 55.2%, p<0.001).

CONCLUSIONS

HCC surveillance for cirrhotic patients could detect HCC at early and curative stages. However, appropriate treatment options following AASLD guideline further improve the survival for patients in early stage.

Intimal dissection of the hepatic artery following transarterial embolization for hepatocellular carcinoma: an intraoperative problem in adult living donor liver transplantation

The objective of this study was to describe the relationship between intimal dissection (ID) in the recipient hepatic artery (HA) and transarterial embolization (TAE) and highlight the reconstructive methods for the different types of ID encountered in living donor liver transplantation (LDLT). Fifty-four patients with hepatocellular carcinoma underwent LDLT. ID was classified as mild, moderate, or severe, and this classification was based on the extent of intimal injury. Mild, moderate, or severe ID were defined as ID that was less than one-quarter of the circumference of the HA, had reached one-half of the circumference of the HA, or was more than one-half of the circumference of the HA or involved the entire vessel wall, respectively. The reconstructive methods were based on the severity of ID encountered. Forty patients underwent TAE before LDLT, and 23 of these patients (57.5%) had ID. Nine patients had mild ID, 6 had moderate ID, and 8 had severe ID. In the 14 patients who did not undergo TAE, 4 had ID (28.6%; 3 mild and 1 severe). The other 10 patients (71.4%) had normal HA. In mild and moderate ID, the native HA was used after trimming of the HA until a healthy segment was encountered. In severe ID, the HA was reconstructed with alternative vessels. Two HA thromboses occurred postoperatively. TAE increased the risk of developing ID 2-fold. There was no graft loss or mortality in this series due to HA complications. In conclusion, ID of the HA is associated with pretransplant TAE among hepatocellular carcinoma patients undergoing LDLT. Intraoperative recognition of this complication and trimming until good vessel quality is encountered or using alternative vessels are important.

Embolization efficacy and treatment effectiveness of transarterial therapy for unresectable hepatocellular carcinoma: a case-controlled comparison of transarterial ethanol ablation with lipiodol-ethanol mixture versus transcatheter arterial chemoembolization

PURPOSE

To compare the embolization efficacy and treatment effectiveness of transarterial ethanol ablation (TEA) versus those of chemoembolization and evaluate the correlation between embolization efficacy and treatment effectiveness of these treatments for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

A case-controlled study was undertaken with 30 patients in each group matched based on Child-Pugh grade, tumor characteristics, and performance status. Primary endpoints were embolization efficacy (ie, Lipiodol retention within tumor at 2 months) and treatment effectiveness as evaluated by tumor response, disease progression, progression-free survival, and overall survival. The secondary endpoint was correlation between embolization efficacy and treatment effectiveness.

RESULTS

Lipiodol retention was greater in the TEA group (89.5% +/- 10.7% vs 47.5% +/- 21.2%; P < .0001). The tumor progression rate at 1 year was higher in the chemoembolization group (five of 30 vs zero of 30; P = .0261). One- and 2-year overall survival rates were higher in the TEA group (93.3% and 80.0%, respectively, vs 73.3% and 43.3%, respectively; P = .0053). One- and 2-year extrahepatic disease progression rates were lower in the TEA group (P = .0002). There were no differences in progression-free survival and intrahepatic disease progression rates at 1 and 2 years. Patients with greater Lipiodol retention (ie, >60%) had better treatment outcomes at 1 year than those with lesser retention, with higher overall survival rates (88.9% vs 66.7%; P = .0192), lower intrahepatic disease progression rates (25.6% vs 59.4%; P = .0169), lower extrahepatic disease progression rates (0.31% vs 35.5%; P = .0047), and higher progression-free survival rates (72.1% vs 36.3%; P = .005).

CONCLUSIONS

The embolization efficacy and treatment effectiveness of TEA are probably superior to those of chemoembolization for HCC.

A comparison of three transarterial lipiodol-based formulations for hepatocellular carcinoma: in vivo biodistribution study in humans

This study aimed to evaluate and compare the biodistribution properties of three transarterial Lipiodol-based therapeutic regimens in human hepatocellular carcinoma (HCC). In this prospective study with 13 patients randomly allocated to one of three study groups, each of the patients received transcatheter intra-arterial administration into a solitary HCC with one of three different Lipiodol-based formulations: Lipiodol-ethanol mixture (LEM; Group A), Lipiodol alone (Group B), and Lipiodol and gelatin pledgets (Group C). With the use of radioactive iodine-131-labeled Lipiodol, each group was assessed for (1) pattern of Lipiodol accumulation in the lungs within the first 2 weeks as evaluated by single-photon emission computed tomography and (2) decomposition of Lipiodol formulation within the first 2 weeks as evaluated by radioactivity detected in peripheral blood and urine. The degree of Lipiodol retention in the tumor within the first 4 weeks was evaluated with CT. No statistically significant difference in Lipiodol accumulation in the lungs was detected among the three groups. However, the peak accumulation in the lungs was delayed 3 days for Group A compared to Groups B and C. The degree of Lipiodol retention within the tumor in Group A was significantly greater than that in Groups B and C on day 14 (p = 0.014) and day 28 (p = 0.013). This study showed that LEM is associated with a greater embolic effect in intrahepatic HCC at 4 weeks, and a comparable degree of lung shunting and decomposition rates, compared with ethanol-free Lipiodol formulations.

Transarterial ethanol ablation of hepatocellular carcinoma with lipiodol ethanol mixture: phase II study

PURPOSE

This prospective trial aimed to evaluate the safety and effectiveness of transarterial ethanol ablation (TEA) of intrahepatic lesions of hepatocellular carcinoma (HCC) with a Lipiodol-ethanol mixture.

MATERIALS AND METHODS

Seventy-seven patients were recruited and 164 lesions (mean size, 5.2 cm +/- 3.0) were treated. Inclusion criteria included histologic proof of HCC, refusal of (n = 9) or contraindication to (n = 68) surgical resection, Eastern Cooperative Oncology Group performance status no greater than 2, and intrahepatic disease without vascular invasion. The mixture consisted of 33% ethanol by volume, with the total dose of Lipiodol-ethanol mixture limited to 60 mL for each treatment session. The primary endpoint was patient survival. Secondary endpoints were tumor response, adverse effects of treatment, and progression-free survival. Median follow-up time for the whole cohort was 2.3 years.

RESULTS

Median overall survival was 2.2 years. Overall survival and progression-free survival rates at 1 year and 2 years were 77.9% and 50.1% and 63.6% and 46.3%, respectively. Complete ablation according to radiologic criteria was achieved in 61 patients (79.2%) and 86% of the 164 treated lesions. Mean tumor volume reduction was 65.22%. Patient survival was significantly better in patients with tumors no larger than 5 cm (Cox proportional-hazards regression, P = .0074). Treatment response was significantly better for patients with tumors no greater than 7 cm (chi2 test, P = .0462; Fisher exact test, P = .0326). Adverse effects included irreversible hepatic decompensation (0.6% of procedures), pain (4.8%), and fever (13.8%).

CONCLUSIONS

TEA is a safe and effective means to establish local control of unresectable and resectable intrahepatic lesions of HCC.

Liver Embolizations in Oncology. A Review. Part II. Arterial Radioembolizations, Portal Venous Embolizations, Experimental Arterial Embolization Procedures

Arterial embolization of the liver may temporarily retard the growth of its primary and secondary tumors which are both mainly nourished arterially. Addition of radioisotopes, mostly (131)I or (90)Y, results in radioembolizations which predominantly act by radiation and less by ischemia. They may therefore be utilized in the absence of portal venous flow when conventional embolization is hazardous. (131)I-oily radioembolization seems to prolong short-term survival in such patients with unresectable hepatocellular cancers, and to improve the prognosis after resection of hepatocellular cancer. The procedure does however not palliate better than "cold" chemoembolization in patients with preserved portal flow, except for having milder side effects. Embolization with (90)Y-coupled microspheres may shrink primary and secondary liver tumors but has so far unproven effects on survival. Embolization of portal venous branches gives compensatory hypertrophy of the non-embolized liver and can increase the volume of the future remnant liver before resection. This diminishes the risk for postoperative liver failure after extensive resection and/or in the presence of chronic liver disease, and permits wider surgical indications. Tumor growth may however be accelerated, and the hypertrophy is inhibited by severe liver parenchymal disease in which situation the method would be most needed. Experimental use of liver arterial embolizations includes combined arterial and portal embolizations, i.e. "chemical hepatectomy," arterial embolizations before external radiotherapy, administration of boron for neutron capture therapy, immunoembolizations, and future gene therapy.

Transarterial versus Transhepatic Portal Vein Embolization to Induce Selective Hepatic Hypertrophy: A Comparative Study in Swine

PURPOSE

Portal vein embolization (PVE) is used to induce liver hypertrophy for surgical candidates with marginal future liver remnant (FLR) volumes. We compared the feasibility, safety, and effectiveness of a transarterial approach for PVE (TA-PVE) with those of a transhepatic approach for PVE (TH-PVE) in a swine model.

MATERIALS AND METHODS

Ten experimental pigs (TA-PVE, n = 5; TH-PVE, n = 5) and six controls (TA, n = 3; TH, n = 3) were studied. For TA-PVE, a microcatheter was advanced into arteries supplying the left and left middle hepatic lobes. A 3 to 1 Ethiodol-ethanol mixture was infused into selected arteries to cross the arterioportal peribiliary plexus and remain within the portal veins (PVs). For TH-PVE, PVs in the same lobar distribution were embolized with 355- to 500-micro m polyvinyl alcohol particles and coils. Controls were similarly catheterized for saline infusion. Computed tomography with volumetry was performed before and 7, 14, 21, and 28 days after PVE to assess FLR hypertrophy (absolute FLR volume change and FLR/total liver volume [TLV]). Computed tomographic volumetry, laboratory data, and histopathology were compared between groups.

RESULTS

All procedures were technically successful. The increases in mean absolute FLR volume (TA-PVE, 148 +/- 84 cm(3); TH-PVE, 62 +/- 19 cm(3); P = .082), mean FLR hypertrophy (TA-PVE, 93.2%; TH-PVE, 48.4%; P = .178), and mean FLR/TLV (TA-PVE, 31.0%; TH-PVE, 16.2%; P = .130) from day 0 to day 28 between experimental groups were better for TA-PVE. Changes in laboratory data among all groups were minimal. Two complications occurred from TA-PVE (right gastric artery embolization [n = 2] without sequela) and two from TH-PVE (acute segmental right PV thrombosis [n = 1]; death 3 weeks after PVE of unknown cause [n = 1]).

CONCLUSIONS

Transarterial portal vein embolization is feasible, safe, and effective for inducing future liver remnant hypertrophy in swine and may represent an improvement over previously reported transhepatic portal vein embolization methods.

Transarterial Ethanol Ablation of Cirrhotic Liver With Lipiodol-Ethanol Mixture

PURPOSE

The intra-arterial administration of lipiodol-ethanol mixture (LEM, mixed in 4:1 by volume) through the hepatic artery is known to produce dual hepatic-arterial and portal-venous embolization that could be a potent treatment of hepatocellular carcinoma. The aim of this animal experiment was to study the effectiveness and safety of such transarterial ethanol ablation in cirrhotic livers.

METHODS

The study model consisted of a control group of 6 normal rats and a study group of 6 cirrhotic rats. LEM was infused intra-arterially into the right lobe of all 12 rats after selective catheterization under microscopic observation. LEM distribution within the hepatic vasculature, liver function tests, change in liver volume, and histology of the embolized lobe were studied.

RESULTS

The radiographs showed peripheral distribution of LEM within the portal venule in the right lobe of all rats. There was a marked reduction in the volume of right lobe 14 days after LEM, with an average reduction of 63.4 +/- 16.9% and 59.4 +/- 20.6% observed in the control group and study group, respectively. The difference between the 2 groups was not statistically significant. Before LEM treatment, there was a difference between the 2 groups (P = 0.002) regarding the plasma level of albumin and bilirubin, indicating that the blood test was sensitive enough to differentiate the liver function status between the normal rats and cirrhotic rats. On day 14, there was no difference between the 2 groups in plasma albumin, bilirubin, and ALT levels (P = 0.065, 0.818, 0.589), indicating almost equal extent of hepatic reaction towards LEM administration in normal and cirrhotic rats. On day 14, histologic study showed complete vascular infarction in 90% to 100% of the right lobe in both groups.

CONCLUSION

Intraarterial ethanol ablation with LEM is equally effective in causing infarction of hepatic tissue in both normal and cirrhotic liver; it can be tolerated with equal safety by both normal and cirrhotic rats in this animal experiment.

Functional CT quantification of tumor perfusion after transhepatic arterial embolization in a rat model

PURPOSE

To quantify tumor perfusion after transcatheter arterial embolization (TAE) with functional computed tomography (CT) and to validate the reproducibility of quantification measurements.

MATERIALS AND METHODS

This study was conducted in accordance with an institutional animal care and use committee-approved protocol. Sixteen rats with liver tumors underwent TAE with 1 mg (group 1) or 3 mg (group 2) of polyvinyl alcohol particles. In each group, four rats underwent functional CT immediately after TAE (day 0) and four others underwent functional CT 2 days after TAE (day 2). Another four rats served as control rats. Blood flow (BF), blood volume (BV), mean transit time (MTT), and permeability-surface area product were measured by using a functional CT software program. For evaluation of reproducibility, six additional rats with mammary tumors underwent functional CT twice, with examinations 2 hours apart. The mixed-effect model was used to assess the TAE treatment effect, and the Pearson correlation test was used to determine measurement reproducibility.

RESULTS

With the exception of BF in group 1 on day 2 (P = .41), BF and BV values in both groups on both days were significantly lower than BF and BV values in the control rats (with P values ranging from .018 to <.001). BF was significantly lower in group 2 than in group 1 on days 0 and 2 (P = .043 and P = .02, respectively). BV was significantly lower on day 2 than on day 0 in group 2 (P = .016). MTT was generally inversely related to BF. MTTs in group 2 on days 0 and 2 were significantly longer than those in the control rats (P < .001 and P = .03, respectively), and MTT was shorter on day 2 than on day 0 in group 2 (P = .02). Permeability-surface area product changes were similar to BF changes. There were no significant differences (P values ranged from .2 to .5) between perfusion parameters in the reproducibility study.

CONCLUSION

The results of this study validate the use of functional CT in the quantification of tumor perfusion after TAE and the reproducibility of such quantification measurements.

Percutaneous transhepatic portal vein embolization: effectiveness of absolute ethanol infusion with balloon catheter in a pig model

PURPOSE

To evaluate the effectiveness of portal vein embolization (PVE) with absolute ethanol using multidetector-row computed tomography (CT) angiography in a pig model.

MATERIAL AND METHODS

Percutaneous transhepatic PVE with 10 ml absolute ethanol was performed in liver segments (n = 5) or subsegments (n = 5) in 10 pigs. CT images and volumetric data were qualitatively and quantitatively assessed to determine future liver remnant (FLR) hypertrophy and to correlate with histopathologic changes 2-6 weeks after PVE. Effectiveness evaluation was based on changes in absolute FLR size and ratio of FLR to total estimated liver volume (TELV).

RESULTS

Occlusion of the embolized vessel was achieved immediately after injecting absolute ethanol within a range of 0.25-0.33 ml/kg. The TELV prior to PVE was 660.49 +/- 103.66 cm3 (range 527.22 to 833.70 cm3) and after PVE 769.51 +/- 29.36 cm3 (range 685.95 to 887.34 cm3). The mean FLR/TELV ratio increase after PVE was 14.2%. No statistically significant difference was found in the increase of TELV between segmental or subsegmental PVE. On microscopic observation, atrophy of the embolized liver was noted in all animals and was seen distinctly at 3 weeks after PVE in 2 animals.

CONCLUSION

Both regenerative response and histopathologic changes of the liver were seen after PVE with absolute ethanol with a mean FLR/TELV ratio of 14.2%.

Survival outcome of lobar or segmental transcatheter arterial embolization with ethanol-lipiodol mixture in treating hepatocellular carcinoma

AIM: To evaluate the clinical outcome and cost-effectiveness of transcatheter arterial ethanol-lipiodol embolotherapy on hepatocellular carcinoma (HCC).

METHODS: One hundred patients with HCC who were treated only by lobar or segmental transarterial embolization (TAE) with ethanol-lipiodol mixture were enrolled in this study. The 1st- and 2nd-year survival rates were analyzed to evaluate the feasibility of its method. These outcomes of our patients were individually correlated to the Child-Pugh classification and the computed tomographic features of HCC.

RESULTS: The overall 1st- and 2nd-year survival rates were 72% and 46%, respectively. The patients were classified into three groups according to their liver function status: 68 patients as Child-Pugh class A, 26 as Child B, and 6 as Child C. Child A had better survival rate than the Child B and/or C. The 1st-year survival rates of patients with Child A-C were 84%, 50%, and 33.3% respectively and the 2nd-year survival rates were 55.5%, 28.5%, and 33.3%, respectively. According to the computed tomographic features, solitary HCC with maximum diameter less than 5 cm had the best outcome with the 1st-year survival rate of 100% and the 2nd-year survival rate of 71.4%, while solitary HCC with maximum diameter over 5 cm and multiple HCC had the 1st-year survival rates of 75% and 63.7%, respectively, and the 2nd-year survival rates of 33.3% and 44.4%, respectively. Only one patient was complicated with abscess formation and was cured with antibiotic therapy. No mortality resulted from the procedures performed.

CONCLUSION: TAE with ethanol-lipiodol mixture is an economic, safe and feasible method for treating HCC, especially for the patients with smaller solitary HCC or with liver function status of Child-Pugh class A.

Impact of pre-operative transarterial embolization on the treatment of hepatocellular carcinoma with liver transplantation

AIM

To determine the effectiveness of pre-liver transplant (LT) transarterial embolization (TAE) in treating hepatocellular carcinoma (HCC) and the patient categories, which are likely to have a good outcome after LT.

METHODS

Twenty-nine patients with hepatitis-related cirrhosis and unresectable HCC after LT were studied over a 7-year period. The patients were divided into two groups: group A patients (19/29) received pre-LT TAE, whereas group B (10/29) underwent LT without prior TAE. According to Milan criteria, group A patients were further subdivided into: group A1 (12/19) who met the criteria, and group A2 (7/19) who did not. Patient survivals were compared.

RESULTS

In the explanted liver, CT images correlated well with pathological specimens showing that TAE induced massive tumor necrosis (>85%) in 63.1% of patients in group A and all 7 patients in group A2 exhibited tumor downgrading that met Milan criteria. The overall 5-year actuarial survival rate was 80.6%. The TAE group had a better survival (84% at 5 years) than the non-TAE (75% at 4 years). The 3-year survival of group A2 (83%) was also higher than that of group A1 (79%). Tumor necrosis >85% was associated with excellent survival of 100% at 3 years, which was significantly better than the others who showed <85% tumor necrosis (57.1% at 3 years) or who did not have TAE (75% at 3 years).

CONCLUSION

TAE is an effective treatment for HCC before LT. Excellent long-term survival was achieved in patients that did not fit Milan criteria. Our results broadened and redefined the selection policy for LT among patients with HCC. Meticulous pre-LT TAE helps in further reducing the rate of dropout from waiting lists and should be considered for patients with advanced HCC.

Preoperative embolization of thyroid arteries in a patient with large multinodular goiter and papillary carcinoma

We herein report the case of a 51-year-old woman, who presented with a large goiter (250-300 g on palpation) with extension to the mediastinum and compression of the trachea causing dyspnea and with associated lumbar pain. Although two fine-needle aspiration biopsies of the gland were negative, a biopsy of a lesion in the spine shown on computed tomography (CT) scan was positive for metastatic papillary thyroid carcinoma. Because of the extent of the goiter and the potential of significant blood loss, total thyroidectomy was considered to be high risk. In an attempt to reduce the goiter size and try to minimize surgical risks, preoperative embolization with polyvinyl alcohol in an emulsion with histoacryl particles was performed 7 days before surgery under conventional angiography. This procedure allowed a significant reduction in blood perfusion to the gland, which resulted in a decrease on the size of the goiter facilitating surgical removal of the gland.

Liver abscess complicating transcatheter arterial embolization: a rare but serious complication. A retrospective study after 3878 procedures

OBJECTIVES

Liver abscess is one of the complications of transcatheter arterial embolization (TAE) for hepatocellular carcinoma. We studied the clinical features and analysed the incidence, risk factors, helpful clinical clues, culture profiles and predictive factors of post-TAE liver abscess. The influence of abscess development on the evolution of the tumour process was also studied.

METHODS

We retrospectively reviewed records of 3878 TAE procedures performed over a 6 year period.

RESULTS

Ten cases of liver abscess developed in nine patients (eight males and one female). The incidence was 0.26% (10 episodes/3878 procedures). The main clinical presentations included fever (91.7%), chills (50%) and abdominal pain (33.3%). All but one febrile patient presented fever in a recurrent form. The positive culture rates were 41.7% for blood and 83.3% for pus. Gram negative bacteria were found in 80% of blood cultures and 68% of pus cultures. Polymicrobial infections were encountered in 60% of the blood cultures and 70% of pus cultures. Management included antibiotics, drainage and operation. Four patients died due to the direct complications of liver abscess. One patient experienced total tumour resolution after successful treatment for liver abscess. Patients with larger liver abscesses and patients with greater age carried higher mortality rates.

CONCLUSIONS

Liver abscess is a rare complication after TAE for hepatocellular carcinoma. Recurrent fevers after an initial symptom free interval should arouse suspicion of an abscess. The mortality is high and a large abscess and higher age predict an unfavourable outcome. Abscess formation can lead to complete tumour resolution.

Tissue Chemoablation

PURPOSE

To provide an overview of the state of the art of tissue chemoablation in animal and human organs and cancers. We also describe our experience with the feasibility, predictability, and reproducibility of necrosis produced by needle chemoablative therapies including ethanol, hypertonic saline, and acetic acid solutions as well as gels in a porcine renal model.

MATERIALS AND METHODS

A MEDLINE search was performed for articles on animal and human tissue chemoablation published since 1965. In addition, at Washington University, experimental chemoablation was performed in pigs with 95% ethanol (4 mL), 24% hypertonic saline (4 mL), or 50% acetic acid (4 mL) solutions as well as in gel form.

RESULTS

There is extensive literature on the use of chemoablation for liver metastases; recently, chemoablation of the prostate has become an area of research. Human studies have been limited to patients who are not surgical candidates or to investigational procedures performed prior to definitive prostatic surgery. Animal studies of renal chemoablation as a sole therapy have produced mixed results. In our studies, only acetic acid provided complete necrosis.

CONCLUSIONS

To date, ethanol chemoablation has been shown to be feasible and reproducible only for metastatic hepatic carcinoma. In urology, chemoablation is still very much in the investigational stage for both the prostate and the kidney. A significant drawback is that even in the gel form, the spread of the chemoablative substance through the tissue is irregular and unpredictable. In the future, chemoablation may become a more effective modality by combining it with radiofrequency or other energy sources.

Interventional radiology in the treatment of hepatic metastases

Recent technical developments have enabled the development of a range of non-surgical interventions for liver metastases. These include cryotherapy, chemoembolisation, and radiofrequency, laser or microwave ablation. These techniques are reviewed and their role in the management of liver metastases discussed. Chemoembolization does not reliably achieve destruction of hepatic metastases. Cryotherapy and radiofrequency treatment can ablate metastases in 50-90% of cases and are relatively safe compared to hepatic resection. There has been no randomised comparison to show that either cryotherapy or radiofrequency treatment alter long-term survival compared with chemotherapy alone. However, this may be related to the fact that most patients being referred for ablative treatment are considered unsuitable for hepatic resection. Randomised trials to accurately define the place of these innovative techniques are needed.