Angiographic demonstration of intrahepatic arterio-portal anastomoses in hepatocellular carcinoma

Portal vein embolization for closure of marked arterioportal shunt of hepatocellular carcinoma to enable radioembolization: A case report

BACKGROUND

Marked arterioportal shunt (APS) can be a contraindication for transarterial radioembolization (TARE) because of the risk of radiation-induced liver toxicity or pneumonitis. To date, the best method to close marked APS to reduce intrahepatic shunt (IHS) and hepatopulmonary shunt (HPS) before TARE has not been elucidated.

CASE SUMMARY

This case report describes a novel strategy of embolization of the portal venous outlet to reduce IHS and HPS caused by marked APS before TARE in a patient with advanced hepatocellular carcinoma (HCC). The patient had a significant intratumoral shunt from the tumor artery to the portal vein and had already been suspected based on pre-interventional magnetic resonance angiography, and digital subtraction angiography (DSA) confirmed the shunt. Selective right portal vein embolization (PVE) was performed to close the APS outlet and DSA confirmed complete closure. Technetium-99m macroaggregated albumin was administered and single photon emission computed tomography revealed a low HPS with 8.4%. Successful TARE was subsequently performed. No major procedure-related complication occurred.

CONCLUSION

Closure of APS with PVE during mapping angiography of advanced-stage HCC to enable reduction of HPS and subsequent TARE is feasible.

Combination therapy of sorafenib and drug-eluting bead transarterial chemoembolization for advanced hepatocellular carcinoma with and without hepatic arteriovenous shunt

BACKGROUND

To compare the efficacy and safety of combination therapy with sorafenib and drug-eluting bead transarterial chemoembolization (DEB-TACE) in advanced hepatocellular carcinoma (HCC) with or without hepatic arteriovenous shunt (HAVS).

METHODS

This retrospective, single-center study enrolled 59 advanced HCC patients treated with combination therapy, of whom 33 (55.9%) patients had HAVS. Tumor response according to the mRECIST criteria was evaluated based on the CT images 1 month after TACE, and changes in the arterial enhancement ratio (AER) of tumors and portal vein tumor thrombosis were also documented. Time-to-progression (TTP), overall survival (OS), and prognostic factors were analyzed. Safety was evaluated with the incidence of TACE-related complications within 6 weeks after TACE.

RESULTS

The tumor response between the two groups showed no significant difference in the objective response rate (69.2% in the group without HAVS vs 60.6% in the group with HAVS, p = 0.492) or disease control rate (92.3% vs 87.9%, p = 0.685). The two groups showed comparable TTP (4.23 vs 2.33 months, p = 0.235) and OS (12.77 vs 12.97 months, p = 0.910). A drop in the AER of tumors of more than 20% on post-TACE CT independently predicted better OS. With regard to safety, there was no significant difference between the two groups.

CONCLUSION

For advanced HCC, combination therapy had equal efficacy and safety in patients with HAVS compared to those without HAVS, indicating that DEB-TACE is an optional and effective treatment in these patients.

Hepatic Arterioportal Fistula Is Associated with Decreased Future Liver Remnant Regeneration after Stage-I ALPPS for Hepatocellular Carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) patients often developed hepatic arterioportal fistula (APF). The aim of this study is to evaluate the impact of APF on future liver remnant (FLR) regeneration and surgical outcomes after the first stage of associating liver partition and portal vein ligation for staged hepatectomy (stage-I ALPPS).

METHODS

Consecutive HCC patients who underwent ALPPS at our center between March 2017 and May 2019 were retrospectively studied. Data for the association between APF and clinicopathological details, liver volume, and surgical outcomes were analyzed.

RESULTS

The enrolled 35 HCC patients were divided into three groups: 15 patients with preoperative APF were classified as the APF I group, 10 patients developed APF after stage-I ALPPS as the APF II group, whereas the other 10 patients without APF before and after stage-I ALPPS as the control group. After stage-I ALPPS, patients in the APF I and APF II groups had lower kinetic growth rate (KGR) of FLR volume (6.1±3.2%, 11.4±8.4%, 25.0±8.8% per week, respectively, P<0.001) and took longer median time to reach the sufficient FLR volume for stage-II ALPPS (17.5 days, 12 days, 6 days, respectively, P<0.001) than those in the control group. Meanwhile, the incidence of posthepatectomy liver failure (PHLF) in the APF I and APF II groups was significantly higher than that of the control group (P=0.007). There are 27 (77.1%) patients who completed stage-II ALPPS. The overall survival (OS) rates at 1 and 3 years were 59.3% and 35.1%, whereas the disease-free survival (DFS) rates at 1 and 3 years were 44.4% and 22.9%, respectively.

CONCLUSIONS

Hepatic APF is significantly associated with decreased FLR regeneration and a higher risk of PHLF after stage-I ALPPS. HCC patients who are to undergo ALPPS may benefit from the timely perioperative intervention of APF.

Advanced Hepatocellular Carcinoma With Hepatic Arterioportal Shunts: Combination Treatment of Transarterial Chemoembolization With Apatinib

Object: This study aimed to compare the efficacy and safety of transarterial chemoembolization (TACE) combining with apatinib (TACE-apatinib) and TACE-alone for patients with advanced hepatocellular carcinoma (HCC) with hepatic arterioportal shunts (APS).

Materials and Methods: This retrospective study evaluated the medical records of patients with advanced HCC with APS who underwent TACE-apatinib or TACE-alone from June 2015 to January 2019. The occlusion of the shunt was performed during the TACE procedure. The time to tumor progression (TTP) and overall survival (OS) of study patients were evaluated. The modified Response Evaluation Criteria in solid tumors (mRECIST) was used to evaluate the treatment response. The apatinib-related adverse events were recorded.

Results: Fifty-eight patients were included in this study. Twenty-seven patients underwent the treatment of TACE-apatinib, and 31 received TACE-alone treatment. The median overall survival (OS) and median time of tumor progression (TTP) in the TACE-apatinib group were significantly longer than those of the TACE-alone group (OS: 12.0 vs. 9.0 months, P = 0.000; TTP: 9.0 vs. 5.0 months, P = 0.041). Multivariate analysis revealed that TACE-apatinib was a protective factor for OS, and there was no independent risk factor for TTP. In the TACE-apatinib group, the grade 3 apatinib-related adverse events occurred in four patients.

Conclusion: TACE-apatinib was an efficacious and safe treatment for patients with advanced HCC with APS, and apatinib improved the efficacy of TACE in the treatment of these patients.

Comparison of Transcatheter Arterial Chemoembolization-Radiofrequency Ablation and Transcatheter Arterial Chemoembolization Alone for Advanced Hepatocellular Carcinoma with Macrovascular Invasion Using Propensity Score Analysis: A Retrospective Cohort Study

Background

To compare the efficacies of transcatheter arterial chemoembolization (TACE) with radiofrequency ablation (RFA) (TACE + RFA) and TACE alone in patients with hepatocellular carcinoma (HCC) and macrovascular invasion (MVI).

Methods

In total, 664 patients having HCC with MVI were included. Of these patients, 141 were treated with TACE + RFA, 254 with TACE alone, and 269 with supportive therapy (control group). The overall survival (OS) was compared among these groups. Propensity score matching (PSM) was performed for balancing the characteristics of the three groups.

Results

After one-to-one PSM, the 12-month OS rates were higher in the TACE and TACE + RFA groups than in the control group (p=0.0009 and p=0.0017, respectively). Furthermore, higher 12-month OS rates were observed in the TACE + RFA group than in the TACE group (p=0.0192). The 12-month OS rates of patients were remarkably higher in α-fetoprotein (AFP) < 400 ng/ml, tumor < 3, tumor diameter < 5 cm, or portal vein tumor thrombosis (PVTT) group who were treated with TACE + RFA than in those who were treated with TACE (p=0.0122, p=0.0090, p=0112, and p=0.0071, respectively).

Conclusions

TACE + RFA provides a superior survival outcome than TACE alone in HCC patients, especially in AFP <400 ng/ml, tumor <3, tumor diameter <5 cm, or PVTT group.

Safety and efficacy assessment of transarterial chemoembolization using drug-eluting beads in patients with hepatocellular carcinoma and arterioportal shunt: a single-center experience

Objective

To evaluate the feasibility and safety of transarterial chemoembolization with drug-eluting beads (DEB-TACE) in patients with hepatocellular carcinoma (HCC) and arterioportal shunts (APSs).

Materials and methods

Fifty-eight patients with unresectable HCC and APSs who were treated with DEB-TACE (n=26) or polyvinyl alcohol (PVA) plus TACE (PVA-TACE, n=32) were included in this retrospective study. The tumor response was evaluated by the modified Response Evaluation Criteria in Solid Tumors. Toxicity was graded by the Common Terminology Criteria for Adverse Events version 5.0 (CTCAE v5.0) and compared between the two groups. Survival curves were calculated by the Kaplan-Meier method and compared by the log-rank test between the two groups. The influence of potential prognostic factors on survival in the DEB-TACE group was analyzed via a multivariate Cox regression model.

Results

The disease control rate was better in the DEB-TACE group than in the PVA-TACE group. The median survival times were 346 and 274 days in the DEB-TACE group and PVA-TACE group, respectively. There was no significant difference in survival rates between the two groups (P=0.081). Patients treated with DEB-TACE were significantly less likely to have fever (P=0.048) or a low-grade (grade 1-2) increase in transaminases (P=0.046) than the patients treated with PVA-TACE. The potential predictive prognostic factors in the DEB-TACE group were tumor response, APS grading, and serum bilirubin.

Conclusion

DEB-TACE may be feasible and safe in HCC patients with APS. Survival in the DEB-TACE group was associated with tumor response, APS grading, and serum bilirubin levels.

Clinical characteristics of hepatic Arterioportal shunts associated with hepatocellular carcinoma

BACKGROUND

Hepatic arterioportal shunt (A-P shunt) is defined as the direct blood flow established between hepatic artery and portal venous system; it is frequently observed in patients with hepatocellular carcinoma (HCC). Clinically, it is important to diagnose HCC associated A-P shunts, as it may impact the treatment strategy of the patients. In the present study, we described the imaging findings of the HCC associated A-P shunts and discussed the treatments strategy of such patients. From the findings, we also discussed the potential cause of A-P shunts.

METHODS

Clinical data of HCC patients (n = 560), admitted to the hospital between April 2012 to April 2014, were reviewed. Hepatic angiography was used to examine the presence of A-P shunts. Of the 137 patients with A-P shunts, grading of the A-P shunts was performed, and statistical analysis of the different grades of A-P shunts and clinical characteristics was performed.

RESULTS

The hepatic angiography confirmed that 99 patients had typical A-P shunts (Grade 1-3), and 38 patients had atypical A-P shunts. Embolization was the main strategy used to treat A-P shunts, in which liquid embolic agents appeared to provide a better treatment outcome. The correlation analysis showed that the grading of portal vein tumor thrombus was significantly associated with the grading of A-P shunt (p = < 0.001, Spearman correlation coefficient was 0.816 ± 0.043).

CONCLUSIONS

We characterized A-P shunts and proposed treatment strategy for treating HCC patients with various levels of A-P shunts. The findings supported the hypothesis that the formation of HCC associated A-P shunts was caused by tumor thrombus.

Carbon Dioxide Digital Subtraction Angiography in Oncological-Interventional Radiology

Aims and background

The aim of this work is to demonstrate the usefulness of carbon dioxide, used as contrast agent, in special indications in vascular interventional oncological procedures.

Methods

We studied 40 patients with digital subtraction angiography enhanced with CO2 as a contrast agent. At the same time we utilized also, in all cases, jodinated contrast agent to evaluate the different opacification gradient, the different viscosity range and the different perfusion.

Results

The low viscosity of CO2 allows demonstration of the presence of even minimal blood losses in gastrointestinal tumors and enhances arteriovenous shunts in hepatocellular carcinoma. Carbon dioxide can also be employed to assess the patency of small-sized catheters for chemotherapy infusion which do not allow easy injection of the traditional iodinated contrast agents characterized by high viscosity.

Conclusion

Carboangiographic study combined to digital subtraction angiography can clear some diagnostic problems and is further method to assess the outcome of angiographic interventional procedures in oncology.

Arterio-portal shunts in the cirrhotic liver: perfusion computed tomography for distinction of arterialized pseudolesions from hepatocellular carcinoma

OBJECTIVES

To determine perfusion computed tomography (P-CT) findings for distinction of arterial pseudolesions (APL) from hepatocellular carcinoma (HCC) in the cirrhotic liver.

METHODS

32 APL and 21 HCC in 20 cirrhotic patients (15 men; 65 ± 10 years), who underwent P-CT for evaluation of HCC pre- (N = 9) or post- (N = 11) transarterial chemoembolization, were retrospectively included using CT follow-up as the standard of reference. All 53 lesions were qualitatively (visual) and quantitatively (perfusion parameters) analysed according to their shape (wedge, irregular, nodular), location (not-/adjunct to a fistula), arterial liver perfusion (ALP), portal venous liver perfusion (PLP), hepatic perfusion index (HPI). Accuracy for diagnosis of HCC was determined using receiver operating characteristics.

RESULTS

18/32 (56 %) APL were wedge shaped, 10/32 (31 %) irregular and 4/32 (12 %) nodular, while 11/21 (52 %) HCC were nodular or 10/21 (48 %) irregular, but never wedge shaped. Significant difference between APL and HCC was seen for lesion shape in pretreated lesions (P < 0.001), and for PLP and HPI in both pre- and post-treated lesions (all, P < 0.001). Diagnostic accuracy for HCC was best for combined assessment of lesion configuration and PLP showing an area under the curve of 0.901.

CONCLUSION

Combined assessment of lesion configuration and portal venous perfusion derived from P-CT allows best to discriminate APL from HCC with high diagnostic accuracy.

KEY POINTS

• Arterio-portal shunting is common in the cirrhotic liver, especially after local treatment. • Arterial pseudolesions (APL) due to shunting might mimic hepatocellular carcinoma (HCC). • Perfusion-CT allows for qualitative and quantitative assessment of liver lesions. • Lesion configuration fails to discriminate APL from HCC in locally treated patients. • Integration of quantitative perfusion analysis improves accuracy for diagnosis of HCC.

Paralytic Ileus due to Superior Mesenteric Venous Thrombosis after Transarterial Injection for Hepatocellular Carcinoma

A 69-year-old man was admitted to hospital with abdominal pain. In the four years prior to his presentation, he had undergone repeated transarterial chemoembolizations and injections for hepatocellular carcinoma. He underwent his 8th transcatheter arterial therapy one month prior to admission. Abdominal X-rays and contrast-enhanced computed tomography showed large amounts of small intestinal gas and venous thrombosis from the portal vein to the superior mesenteric vein, respectively. The thrombosis was reduced after anticoagulation therapy (heparin, antithrombin III, danaparoid sodium and warfarin). This is the first case report of paralytic ileus due to superior mesenteric venous thrombosis after transcatheter arterial therapy for hepatocellular carcinoma with an arterioportal shunt.

Changes in arterioportal shunts in hepatocellular carcinoma patients with portal vein thrombosis who were treated with chemoembolization followed by radiotherapy

Purpose

In this study, we retrospectively investigated the prevalence of arterioportal (AP) shunts in hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT) and evaluated the changes in AP shunts after chemoembolization followed by external beam radiation therapy (EBRT).

Materials and Methods

We analyzed 54 HCC patients with PVTT who were treated with chemoembolization followed by EBRT. EBRT was uniformly delivered at a total dose of 30 to 45 Gy (median, 35 Gy), with a daily dose of 2 to 4.5 Gy. Angiographic images of chemoembolization before and after radiation therapy (RT) were reviewed to investigate the AP shunt.

Results

During the initial session of chemoembolization, 33 of 54 patients (61%) had an AP shunt. After EBRT, 32 out of 33 patients had an additional session of chemoembolization and were evaluated for a change in the AP shunt. The AP shunt decreased in 20 of 32 patients (63%) after chemoembolization followed by EBRT. The 1-year calculated overall survival (OS) rate for all patients was 52.6% and the 2-year OS was 36.4%. The median OS in all patients was 13 months. Patients with AP shunt showed poorer median OS than those without AP shunt, but there was no statistically significant difference (median, 12 months vs. 17 months).

Conclusion

The AP shunt frequently occurs in HCC patients with PVTT. This study suggests that a poor prognosis is associated with an AP shunt. Chemoembolization followed by RT may produce a decrease in AP shunts.

Interventional treatment for unresectable hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the sixth most common cancer and third leading cause of cancer-related death in the world. The Barcelona clinic liver cancer classification is the current standard classification system for the clinical management of patients with HCC and suggests that patients with intermediate-stage HCC benefit from transcatheter arterial chemoembolization (TACE). Interventional treatments such as TACE, balloon-occluded TACE, drug-eluting bead embolization, radioembolization, and combined therapies including TACE and radiofrequency ablation, continue to evolve, resulting in improved patient prognosis. However, patients with advanced-stage HCC typically receive only chemotherapy with sorafenib, a multi-kinase inhibitor, or palliative and conservative therapy. Most patients receive palliative or conservative therapy only, and approximately 50% of patients with HCC are candidates for systemic therapy. However, these patients require therapy that is more effective than sorafenib or conservative treatment. Several researchers try to perform more effective therapies, such as combined therapies (TACE with radiotherapy and sorafenib with TACE), modified TACE for HCC with arterioportal or arteriohepatic vein shunts, TACE based on hepatic hemodynamics, and isolated hepatic perfusion. This review summarizes the published data and data on important ongoing studies concerning interventional treatments for unresectable HCC and discusses the technical improvements in these interventions, particularly for advanced-stage HCC.

Hepatic epithelioid angiomyolipoma with arterioportal venous shunting mimicking hepatocellular carcinoma: report of a case

A patient with hepatic epithelioid angiomyolipoma (Epi-AML) with arterioportal venous shunting, who was successfully treated by a laparoscopic left lateral sectionectomy, is presented herein. AML is an uncommon benign neoplasm of the liver. Tumors composed predominantly of epithelioid cells have been subcategorized into Epi-AML, and the treatment strategy for Epi-AML is currently undetermined. There are no reports describing Epi-AML with arterioportal venous shunting to date. An arterioportal venous shunting of the liver tumor was suggested to be one of the malignant signs of the liver tumor. It would be important to differentiate Epi-AML with arterioportal venous shunting from hepatocellular carcinoma and hypervascular metastatic tumors. Minimally invasive resection, such as laparoscopic hepatectomy, for patients having Epi-AML with arterioportal venous shunting may be recommended.

Efficacy of TACE in TIPS patients: comparison of treatment response to chemoembolization for hepatocellular carcinoma in patients with and without a transjugular intrahepatic portosystemic shunt

PURPOSE

To compare treatment response after transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) in patients with and without a transjugular intrahepatic portosystemic shunt (TIPS).

MATERIALS AND METHODS

A retrospective review of patients who underwent conventional TACE for HCC between January 2005 and December 2009 identified 10 patients with patent TIPS. From the same time period, 23 patients without TIPS were selected to control for comparable Model for End-Stage Liver Disease and Child-Pugh-Turcotte scores. The two groups showed similar distribution of Barcelona Clinic Liver Cancer and United Network of Organ Sharing stages. Target HCC lesions were evaluated according to the modified response evaluation criteria in solid tumors (mRECIST) guidelines. Transplantation rate, time to tumor progression, and overall survival (OS) were documented.

RESULTS

After TACE, the rate of complete response was significantly greater in non-TIPS patients compared with TIPS patients (74 vs. 30 %, p = 0.03). Objective response rate (complete and partial response) trended greater in the non-TIPS group (83 vs. 50 %, p = 0.09). The liver transplantation rate was 80 and 74 % in the TIPS and non-TIPS groups, respectively (p = 1.0). Time to tumor progression was similar (p = 0.47) between the two groups. OS favored the non-TIPS group (p = 0.01) when censored for liver transplantation.

CONCLUSION

TACE is less effective in achieving complete or partial response using mRECIST criteria in TIPS patients compared with those without a TIPS. Nevertheless, similar clinical outcomes may be achieved, particularly in TIPS patients who are liver-transplantation candidates.

Transcatheter arterial chemoembolization based on hepatic hemodynamics for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the sixth most common cancer and the third leading cause of cancer-related deaths in the world. The Barcelona Clinic Liver Cancer (BCLC) classification has recently emerged as the standard classification system for clinical management of patients with HCC. According to the BCLC staging system, curative therapies (resection, transplantation, and percutaneous ablation) can improve survival in HCC patients diagnosed at an early stage and offer potential long-term curative effects. Patients with intermediate-stage HCC benefit from transcatheter arterial chemoembolization (TACE), and those diagnosed at an advanced stage receive sorafenib, a multikinase inhibitor, or conservative therapy. Most patients receive palliative or conservative therapy only, and approximately 50% of patients with HCC are candidates for systemic therapy. TACE is often recommended for advanced-stage HCC patients all over the world because these patients desire therapy that is more effective than systemic chemotherapy or conservative treatment. This paper aims to summarize both the published data and important ongoing studies for TACE and to discuss technical improvements in TACE for advanced-stage HCC.

Primary liver cancer complicated with hepatic arterioportal fistula: Clinical characteristics and risk factors

AIM: To investigate the clinical characteristics of and risk factors for primary liver cancer (PLC) complicated with hepatic arterioportal fistula (HAPF).

METHODS: Clinical and imaging data for 152 patients with PLC who underwent transcatheter arterial chemoembolization (TACE) were analyzed retrospectively. These patients were divided into HAPF group and control group to analyze the clinical characteristics of and risk factors for PLC with HAPF.

RESULTS: The percentages of patients with liver function grade (B+C), upper tract hemorrhage, ascites, or portal vein thrombosis were significantly higher in the HAPF group than in the control group (t = 4.858, 4.522, 4.496, 6.024, all P < 0.05). No statistical differences were noted in liver cirrhosis, disseminated lesions in the liver, and abnormal AFP between two groups (all P > 0.05). HAPF was prone to be present in patients with massive PLC that has rich feeding vessels. Approximately 89.9% of patients had improvement of HAPF and 22.2% had remission of portal hypertension shortly after TACE treatment.

CONCLUSION: PLC complicated with HAPF is possibly associated with factors including massive tumors with rich tumor feeding vessel and portal vein thrombosis, which tend to impair liver function and aggravate portal vein hypertension symptoms. Proper TACE treatment can improve HAPF and portal hypertension symptoms in a short term.

Surgical approach to multifocal hepatocellular carcinoma with portal vein thrombosis and arterioportal shunt leading to portal hypertension and bleeding: a case report

It is reported the case of a 69 years man who presented to the Emergency Room because of pain and abdominal distension from ascites. After admission and paracentesis placement, he developed a digestive hemorrhage due to oesophageal varices from portal ipertension secondary to the formation of a portal shunt concomitant with a multifocal HepatoCellular Carcinoma (HCC) with portal vein thrombosis (PVT). The patient underwent endoscopic varices ligation, twice transarterial embolization (TAE) of arterial branches feeding the shunt and subsequent left hepatectomy. During the postoperative course he developed mild and transient signs of liver failure and was discharged in postoperative day 16. He is alive and disease free 8 months after surgery.

Low-dose hepatic computed tomography perfusion imaging and its preliminary study

OBJECTIVE

Computed tomography perfusion imaging (CTPI) is a rapid and non-invasive functional imaging method that reflects hemodynamic changes of liver diseases. However, its large radiation dosage limits its clinical application. We aimed to evaluate the feasibility of low-dose CTPI in normal liver and its preliminary application in hepatocellular carcinoma (HCC).

METHODS

CTPI was performed in 34 healthy volunteers randomly divided into three groups with different applications of tube current, including a conventional dose group, a median-dose group and a low-dose group. The perfusion parameters of each group were compared and a low-dose CTPI was performed in 13 patients with HCC.

RESULTS

Relatively satisfying images and perfusion parameters of liver CTPI were acquired with the different tube currents. There were no significant differences between the parameters of the three groups (P>0.05). The effective dosage of conventional, median and low-dose liver CTPI were 19.62 mSv, 12.61 mSv, and 7.01 mSv, respectively. The radiation dosage of low-dose liver CTPI was reduced to 64.27% compared with that of the conventional group. The hepatic blood flow, hepatic blood volume and hepatic perfusion index of HCC were higher than background liver parenchyma and normal liver.

CONCLUSIONS

Low-dose liver CTPI obtained similar perfusion parameters result to that of the conventional-dose, whereas the radiation dosage was reduced by 2/3. Low-dose liver CTPI can reflect the hemodynamic change of HCC. Low-dose liver CTPI has potential clinical value for diagnosis and differential diagnosis of liver diseases.

Contrast-enhanced ultrasonography of hepatocellular carcinoma: correlation between quantitative parameters and arteries in neoangiogenesis or sinusoidal capillarization

OBJECTIVE

The quantitative parameters in contrast-enhanced ultrasonography-time-intensity curve of hepatocellular carcinoma (HCC) were studied to explore their potential importance in monitoring the effects of anti-angiogenic therapy for HCC.

METHODS

115 HCC patients were studied with contrast-enhanced ultrasonography-time-intensity curve (CEUS-TIC) and with immunohistochemical analysis of tissue sections. The CEUS images were analyzed off-line to obtained quantitative parameters including maximum of intensity (IMAX), rise time (RT), time to peak (TTP), mean transit time (mTT), rise slope (RS), and washout time (WT). Monoclonal antibodies specific for smooth muscle actin and anti-CD34 were used to observe unpaired arteries (UAs) and microvessel area (MVA) of sinusoidal capillarization, respectively. The UAs and MVA of 82 HCC cases were successfully stained.

RESULTS

The number of UAs had moderate correlation with RT (r=-0.446), TTP (r=-0.432), and RS (r=0.431) (P<0.05), and it had mild correlation with IMAX (r=0.303) and WT (r=0.285) (P<0.05). MVA of sinusoidal capillarization had no correlation with perfusion parameters.

CONCLUSION

Quantitative CEUS-TIC parameters reflecting hemodynamics of tumors are correlated with UAs, but not with MVA, and they might be used to monitor the effects of anti-angiogenic therapy on HCC.

Distinguishing hypervascular pseudolesions of the liver from hypervascular hepatocellular carcinomas with gadoxetic acid-enhanced MR imaging

PURPOSE

To retrospectively determine findings at gadoxetic acid-enhanced magnetic resonance (MR) imaging in hypervascular pseudolesions that were observed at computed tomography (CT) during hepatic arteriography, with special focus on distinguishing these pseudolesions from hypervascular hepatocellular carcinomas (HCCs).

MATERIALS AND METHODS

The institute ethics committee deemed study approval unnecessary. The study population comprised 80 patients (55 men, 25 women) with chronic liver disease who underwent CT during hepatic arteriography and arterial portography, gadoxetic acid-enhanced MR imaging, and follow-up dynamic contrast material-enhanced CT. The diagnosis of 104 pseudolesions and 123 HCCs was confirmed by means of histopathologic or multimodality evaluation. Two radiologists assessed the MR imaging findings of HCCs and pseudolesions in consensus, including the signal intensities (SIs) of the lesions on T2-weighted, diffusion-weighted (DW), and contrast-enhanced hepatocyte-phase images. The findings of nodular pseudolesions and HCCs were compared with the Fisher exact test. Additionally, the hepatocyte-phase SI ratio (ratio of lesion SI to liver SI) for HCCs and pseudolesions was compared by means of the Mann-Whitney U test.

RESULTS

There were 62 wedge-shaped, 32 nodular, and 10 linear pseudolesions. On gadoxetic acid-enhanced hepatocyte-phase MR images, 15% of pseudolesions (16 of 104) were hypointense compared with surrounding liver tissue. The mean hepatocyte-phase SI ratio of HCCs (0.65 +/- 0.14 [standard deviation]) was significantly lower (P < .01) than that of the nodular pseudolesions (0.95 +/- 0.11). The optimal cutoff value of hepatocyte-phase SI ratio for distinguishing between HCC and nodular pseudolesion was 0.84. No nodular pseudolesions were visible on DW images.

CONCLUSION

Gadoxetic acid-enhanced hepatocyte-phase MR imaging and DW imaging could be used to distinguish hypervascular pseudolesions from hypervascular HCCs; a hepatocyte-phase SI ratio below 0.84 and visibility on DW images were findings specific for HCCs rather than pseudolesions.

Surgical treatment of hepatocellular carcinoma with severe intratumoral arterioportal shunt

We report a case of hepatocellular carcinoma (HCC) that caused a severe arterioportal shunt (APS). A 49-year-old man was admitted to hospital due to esophagogastric variceal hemorrhage and HCC, and underwent endoscopic variceal ligation (EVL) and endoscopic injection sclerotherapy (EIS). He was then referred to our hospital. Abdominal computed tomography revealed a low-density lesion in the posterior segment of the liver and an intratumoral APS, which caused portal hypertension. Although the patient underwent EVL, EIS, Hassab’s operation, and transcatheter arterial embolization for APS, he vomited blood due to rupture of esophagogastric varices. Right hepatectomy was performed for the treatment of HCC and APS, although the indocyanine green retention value at 15 min after intravenous injection was poor (30%). The patient’s postoperative course was uneventful. Eventually, APS disappeared and the esophagogastric varices improved.

Nontumorous arterioportal shunts in the liver: CT and MRI findings considering mechanisms and fate

The intrahepatic non-tumorous arterioportal shunt (APS) is one of the important causes of transient hepatic enhancement differences (THED) on dynamic CT or MRI. Most small APSs are located in the peripheral portion of the liver. Because of the parenchymal distortion in the advanced cirrhotic liver, many small APSs tend to show an amorphous or nodular appearance, making them difficult to distinguish from hypervascular tumors. In addition to the use of dynamic CT or MRI, iso-attenuation densities or iso-intensities on pre-contrast and equilibrium phases, MRI using a liver-specific contrast agent can be useful to characterize the hypervascular pseudolesions. Because there is no difference in water diffusion in the hepatic parenchyma in the region of the APS, diffusion-weighted MRI also has great potential to distinguish non-tumorous shunts from true focal lesions. Larger (>2 cm) APSs of direct arterio-portal venous fistulas from extrinsic insults show typical subcapsular wedge-like THEDs that are only temporarily depicted several months after the traumatic event; most of these THEDs gradually decrease in size or vanish completely. By understanding the nature of non-tumorous APSs, radiologists will be able to provide a more accurate assessment of many THEDs during daily interpretations of CT or MR images of the liver.

Initial experience of transcatheter arterial chemoembolization during portal vein occlusion for unresectable hepatocellular carcinoma with marked arterioportal shunts

The purpose of this study was to assess the clinical effects of transcatheter arterial chemoembolization (TACE) during the corresponding portal vein occlusion (TACE-PVO) in patients with hepatocellular carcinoma (HCC) and marked arterioportal (AP) shunts. This was a prospective, nonrandomized study of TACE-PVO in patients with HCC who had marked AP shunts. The subjects were 21 patients with unresectable HCC and marked AP shunts who underwent shunt embolization with the use of coils and/or gelatin-sponge particles (group A: n = 7) or by TACE-PVO (group B: n = 14). Clinical parameters and data on embolization of AP shunts and on tumor response were assessed prospectively. No major procedure-related complication occurred in either group. Effectiveness of AP-shunt treatment was significantly better in group B than in group A in terms of both immediate results (P = 0.009) and subsequent results (P = 0.028). Tumor response in the therapeutic target area was significantly (P = 0.002) better in group B than in group A. Survival was significantly better in group B than in group A (P = 0.008). TACE-PVO may be a safe and useful therapy for selected patients with unresectable HCC and marked AP shunts.

Transcatheter arterial chemoembolization of hepatocellular carcinoma with hepatic arteriovenous shunt after temporary balloon occlusion of hepatic vein

PURPOSE

Hepatocellular carcinoma with hepatic artery to hepatic vein (AV) shunt has increased risk of pulmonary complications during transcatheter arterial chemoembolization (TACE). The purpose of this study is to assess temporary balloon occlusion as a means of preventing pulmonary complications during TACE of hepatocellular carcinoma with AV shunt.

MATERIALS AND METHODS

Eleven hepatocellular carcinoma patients (M: F = 9:2; mean age, 48 years) with angiographically evident AV shunt underwent TACE with occlusion of the shunt-draining hepatic veins using temporary occlusion balloon catheters. All tumors were in the right lobe, and all AV shunts were between the right hepatic artery and right hepatic vein. The occlusion balloon was inserted via femoral (n = 6) or jugular (n = 5) venous access. The balloon diameter ranged from 8.5 to 11.5 mm and time of ballooning was 3 to 15 minutes (mean, 9.5 minutes). TACE was performed using emulsion of iodized oil and doxorubicin, followed by Gelfoam embolization. The balloon was deflated immediately after chemoembolization, and physical examination and chest radiography were performed. Follow-up computed tomography was performed within 2 weeks after TACE to evaluate the result and pulmonary complications.

RESULTS

The technical success rate was 100%. There was no symptom, sign, or radiographic evidence of pulmonary complication. Follow-up computed tomography revealed complete iodized oil uptake by the tumor in eight patients and incomplete uptake by the tumor in three patients. There was no iodized oil uptake in the lungs.

CONCLUSIONS

Temporary balloon occlusion of the hepatic vein in hepatocellular carcinoma with AV shunt allowed completion of TACE using conventional method while preventing pulmonary complications.

Transcatheter arterial chemoembolization: current technique and future promise

Transarterial chemoembolization is the mainstay of catheter based interventional oncologic therapies. This article describes the history of the procedure, selection of appropriate candidates, technical aspects of procedure performance, results, complications, and appropriate follow-up. In addition, the limitations and challenges of the procedure are outlined. Finally, the reader is introduced to novel and promising techniques and devices that hold future promise for transarterial therapy of malignancies.

Polyvinyl alcohol embolization adjuvant to oily chemoembolization in advanced hepatocellular carcinoma with arterioportal shunts

OBJECTIVE

To assess the feasibility and safety of polyvinyl alcohol (PVA) embolization adjuvant to transarterial oily chemoembolization (P-TACE) in advanced hepatocellular carcinoma (HCC) with arterioportal shunts (APS).

MATERIALS AND METHODS

Nineteen patients who underwent PVA embolization for APS before a routine chemoembolization (TACE) procedure were retrospectively reviewed. 10 of these 19 patients underwent follow-up TACE or P-TACE after P-TACE (Group A), but nine patients underwent only initial P-TACE because of progression of HCC and/or underlying liver cirrhosis (Group B). Hepatic function tests, APS grades, and portal flow directions were evaluated before and after P-TACE sessions. Complications after procedures and survival days were also evaluated.

RESULTS

In group A, APS grade was improved in eight patients and five of six patients with hepatofugal flow showed restored hepatopetal flow postoperatively. No immediate complication was developed in either group. Transient hepatic insufficiency developed in eight (42.1%) of 19 patients after P-TACE, and seven (87.5%) of these eight recovered within two weeks under conservative care. The mean and median survival time all study subjects was 280 days and 162 days.

CONCLUSION

P-TACE is feasible and safe in advanced HCC patients with APS.

Effects of Location and Extension of Portal Vein Tumor Thrombus on Long-Term Outcomes of Surgical Treatment for Hepatocellular Carcinoma

BACKGROUND

The role of surgical resection and thrombectomy for hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) is controversial. This study aimed to evaluate the effects of the location and extent of PVTT on the long-term outcomes of surgical treatment for HCC.

METHODS

A total of 438 patients with HCC and PVTT underwent liver resection with or without thrombectomy. These 438 patients were divided into 2 groups: in group A, PVTT was located in the hepatic resection area or protruded into the first branch of the main portal vein beyond the resection line for < 1 cm (286 patients), and in group B, PVTT extended into the main portal vein (152 patients). Concomitant thrombectomy was performed in 147 patients (51.4%) of group A and in all patients of group B.

RESULTS

PVTT recurrence within 6 months after surgery in group B was significantly higher than that in group A: 76.9% vs. 11.3%. Remnant liver recurrence within 1 year after surgery was 45.0% in group A and 78.8% in group B. The cumulative 1-, 2-, 3-, and 5-year overall survival rates were 58.7%, 39.9%, 22.7%, and 18.1% for group A and 39.5%, 20.4%, 5.7%, and 0% for group B, respectively. The overall survivals were significantly better in group A than group B (P < .02).

CONCLUSIONS

Liver resection with thrombectomy yielded better outcomes in the HCC patients with PVTT confined to the first or second branch of the main portal vein compared with PVTT extending into the main portal vein.

Severe gastrointestinal tract bleeding in a two-month-old infant due to congenital intrahepatic arterioportal fistula

A 2-month-old boy was referred for assessment of severe upper gastrointestinal tract bleeding and melena. On physical examination, a continuous murmur was heard over the right upper quadrant of the abdomen. A splenomegaly and dilated veins were also noted on the abdominal wall. Liver functions were normal. There was no history of trauma or jaundice. Doppler ultrasonography, magnetic resonance arteriography and angiography suggested the presence of an intrahepatic arteriovenous fistula between the phrenic artery and the portal vein. Management consisted of successful embolization by coiling of the phrenic artery. To our knowledge this is the first documented case report of a congenital fistula between the phrenic artery and the portal vein.

Angiographic considerations in patients undergoing liver-directed therapy

The rapid evolution and increasing complexity of liver-directed therapies has forced the medical community to further advance its understanding of hepatic arterial anatomy. The anatomy of the mesenteric system, and particularly the hepatic arterial bed, has been demonstrated to have a high degree of variation. This is important when considering presurgical planning, catheterization, and transarterial hepatic therapies. Although anatomic variants have been well described, the characterization and understanding of regional hepatic perfusion is also required to optimize endovascular therapy and intervention. Although this is true for patients undergoing bland embolization or chemoembolization, drug delivery, and hepatic infusional pump therapy, it is particularly true for intraarterial brachytherapy. The purpose of this review is to provide historical perspective in angiographic aspects of liver-directed therapy, as well as a discussion of normal vascular anatomy, commonly encountered variants, and factors involved in changes to regional perfusion in the presence of liver tumors. Methods of optimizing the safety and efficacy of liver-directed therapies with use of percutaneous techniques will be discussed. This review is based on the experience gained in treating more than 500 patients with transarterial liver-directed therapies. Although the principles described in this article apply to all liver-directed therapies such as chemoembolization and administration of drug-coated microspheres, they apply particularly to intraarterial brachytherapy.

A review of the sonographic assessment of tumor metastases in liver and superficial lymph nodes

Diagnostic imaging techniques are an important part of the diagnostic workup and staging of cancer patients. Ultrasound is of particular interest in this respect. In so far as tumor metastases are concerned, ultrasonography of regional lymph nodes and of the liver can provide valuable information. In humans many criteria, some of them objective, have been evaluated as indicators of malignancy. The most diagnostically helpful of these include the short/long axis ratio of the lymph node, the pattern of distribution of the blood vessels within the lymph node, and to some extent the calculated values for resistive and pulsatility indices. Putative objective criteria to improve the specificity of ultrasound for metastases detection in the liver have also been evaluated. These include perfusion indices, primarily using analysis of Doppler frequencies (Doppler perfusion index) and hepatic venography using an ultrasound contrast agent. Contrast-enhanced ultrasonography is a new and promising area to help the initial diagnosis and characterization of malignancy, particularly for focal lesions in the liver. This review discusses the use of ultrasound for detection of metastases and presents material from four veterinary cases.

Use of Yttrium-90 glass microspheres (TheraSphere) for the treatment of unresectable hepatocellular carcinoma in patients with portal vein thrombosis

PURPOSE

Intra-arterial injection of Yttrium-90 glass microspheres ((90)Y- microS; TheraSphere, MDS Nordion, Ottawa, Canada) is indicated for treatment of unresectable hepatocellular carcinoma (HCC) in the presence of acceptable liver function. This study presents hepatic toxicity results after unilobar and bilobar intra-arterial administration of (90)Y- microS in patients with unresectable HCC who had known portal vein thrombosis (PVT) without evidence of cavernous transformation.

MATERIALS AND METHODS

Fifteen patients with unresectable HCC and PVT of one or both first order and related segmental portal venous branches received a total of 29 infusions of (90)Y- microS for treatment of HCC. All patients had pretreatment evaluation including: computed tomography (CT) imaging, alpha-fetoprotein (AFP) levels, liver function tests, technetium-99m macroaggregated albumin ((99)Tc-MAA) scan for evaluation of lung and visceral shunting, and angiography with visualization into the portal venous phase. (90)Y- micro S dose was based on lobar hepatic volume with adjustment for lung shunt activity. Liver toxicity was assessed by serum total bilirubin graded for severity according to the NIH NCI Clinical Toxicity Criteria (CTC version 2.0). Other adverse events were reported according to the standards established by the Society of Interventional Radiology.

RESULTS

There were no procedural complications with delivery of (90)Y- microS, and treatment was well tolerated by all patients. Increased post-treatment bilirubin levels were observed across all treatments in five patients, four of whom had CT or AFP evidence of intrahepatic disease progression. After initial treatment, two patients developed bilirubin toxicity (grades 1 and 2); one patient demonstrated an increment in bilirubin toxicity grade (grade 1 to grade 3) and one patient had an improvement in grade after initial treatment. There were no new treatment-related toxicities in nine patients after a second treatment.

CONCLUSIONS

(90)Y- microS treatment was well tolerated and appears to be safe to use in patients with compromised portal venous flow in one or both first order and related segmental portal venous branches and no evidence of cavernous transformation. In patients who did not exhibit disease progression, there appeared to be no clinically significant change in bilirubin.

Arterioportal shunt: prevalence in small hemangiomas versus that in hepatocellular carcinomas 3 cm or smaller at two-phase helical CT

PURPOSE

To compare the prevalence of arterioportal (AP) shunting associated with (a) small (< or =3 cm) hemangiomas and (b) hepatocellular carcinomas (HCCs) (< or =3 cm) at two-phase helical computed tomography (CT).

MATERIALS AND METHODS

Two-phase helical liver CT was performed in 107 patients (61 men, 46 women; age range, 25-73 years; mean, 48.6 years) with 169 small hemangiomas and in 384 patients (292 men, 92 women; age range, 18-82 years; mean, 58.3 years) with 598 HCCs 3 cm or smaller. Diagnosis of HCC was verified with histologic findings (n = 30) or typical imaging and clinical findings (n = 568); that of all hemangiomas was verified with typical imaging and clinical findings. Three radiologists retrospectively reviewed all CT images in consensus. Contrast material-enhanced CT scans were obtained during the hepatic arterial and portal venous phases. AP shunt was considered to be present when wedge-shaped or irregularly shaped homogeneous enhancement peripheral to tumor appeared at hepatic arterial phase CT and isoattenuation or slight hyperattenuation in that area appeared at portal phase CT. The prevalence of AP shunting associated with hemangiomas and that associated with HCCs were compared with multivariate model testing. Speed of lesion enhancement (rapid enhancement, when extent of intratumoral enhancement at hepatic arterial phase CT was >50%; slow enhancement, when extent of intratumoral enhancement was < or =50%) and presence of AP shunt were correlated with chi2 or Fisher exact testing.

RESULTS

AP shunts were more frequently found in hemangiomas (36 lesions [21.3%]) than in HCCs (25 lesions [4.2%]) (P <.001). Twenty-four (38%) of the 64 hemangiomas with rapid enhancement had AP shunts, whereas only 12 (11.4%) of the 105 hemangiomas with slow enhancement had AP shunts (P <.001). There was no significant difference between prevalence of AP shunt in the 573 HCCs with rapid enhancement (24 lesions, 4.2%) and that in the 25 HCCs with slow enhancement (one lesion, 4.0%).

CONCLUSION

AP shunts were more frequently seen at two-phase helical CT in small hepatic hemangiomas than in HCCs and thus represent a suggestive but not specific finding of hemangioma. Small hemangiomas with AP shunts tend to show rapid rather than slow enhancement.

Imaging features of hepatocellular carcinoma

This pictorial review concentrates on the imaging features of hepatocellular carcinoma as revealed by ultrasonography, computed tomography, magnetic resonance imaging and angiography. Understanding of the pathomorphological characteristics of the disease is important to precise image interpretation.

Comparison of long-term effects between intra-arterially delivered ethanol and Gelfoam for the treatment of severe arterioportal shunt in patients with hepatocellular carcinoma

AIM: To evaluate long-term effect of ethanol embolization for the treatment of hepatocellular carcinoma (HCC) with severe hepatic arterioportal shunt (APS), compared with Gelfoam embolization.

METHODS: Sixty-four patients (ethanol group) and 33 patients (Gelfoam group) with HCC and APS were respectively treated with ethanol and Gelfoam for APS before the routine interventional treatment for the tumor. Frequency of recanalization of shunt, complete occlusion of the shunt, side effects, complications, and survival rates were analyzed between the two groups.

RESULTS: The occlusion rate of APS after initial treatment in ethanol group was 70.3%(45/64), and recanalization rate of 1 month after embolization was 17.8%(8/45), and complete occlusion rate was 82.8%(53/64). Those in Gelfoam group were 63.6%(21/33), 85.7%(18/21), and 18.2%(6/33). There were significant differences in recanalization rate and complete occlusion rate between the two groups (P < 0.05). The survival rates in ethanol group were 78% at 6 months, 49% at 12 months, 25% at 24 months, whereas those in Gelfoam group were 58% at 6 months, 23% at 12 months, 15% at 24 months. The ethanol group showed significantly better survival than Gelfoam group (P < 0.05). In the ethanol group, there was a significant prolongation of survival in patients with monofocal HCC (P < 0.05) and Child class A (P < 0.05). There were no significant differences in survival rate in the Gelfoam group with regard to the number of tumor and Child class (P > 0.05). The incidence rate of abdominal pain during procedure in ethanol group was 82.8%. There was no significant difference in postembolization syndromes between two groups. Procedure-related hepatic failure did not occur in ethanol group.

CONCLUSION: Ethanol embolization for patients with HCC and severe APS is efficacious and safe, and may contribute to prolongation of the life span versus Gelfoam embolization.

Hepatic arterial infusion chemotherapy for hepatocellular carcinoma with tumor thrombosis of the portal vein tumor thrombosis

AIM: Hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) is associated with poor prognosis. The aim of this prospective study was to evaluate the efficacy of hepatic arterial infusion chemotherapy (HAIC) for patients with this disease.

METHODS: Eighteen HCC patients with PVTT were treated with HAIC via a subcutaneously implanted injection port. A course of chemotherapy consisted of daily cisplatin (10 mg for one hour) followed by 5-fluorouracil (250 mg for five hours) for five continuous days within a given week. The patients were scheduled to receive four consecutive courses of HAIC. Responders were defined in whom either a complete or partial response was achieved, while non-responders were defined based on stable or progressive disease status. The prognostic factors associated with survival after treatment were analyzed.

RESULTS: Six patients exhibited partial response to this form of HAIC (response rate = 33%). The 3, 6, 9, 12 and 18-month cumulative survival rates for the 18 patients were 83%, 72%, 50%, 28%, and 7%, respectively. Median survival times for the six responders and 12 non-responders were 15.0 (range, 11-18) and 7.5 (range, 1-13) months, respectively. It was demonstrated by both univariate and multivariate analyses that the therapeutic response and hepatic reserve function were significant prognostic factors.

CONCLUSION: HAIC using low-dose cisplatin and 5-fluorouracil may be a useful alternative for the treatment of patients with advanced HCC complicated with PVTT. There may also be survival-related benefits associated with HAIC.

Hyperdynamic hemangioma with proximal arterioportal shunting: a rare manifestation

Arterioportal shunting, when associated with hemangioma, is usually small, peripherally located, and without hemodynamic significance. Proximal arterioportal shunting occurring in hemangioma has rarely been reported. Herein we report a patient with renal cell carcinoma who simultaneously was found to have a hyperdynamic hemangioma in the liver. The imaging features were confusing and evoked diagnostic difficulty before operation.

Hepatic arterial infusion chemotherapy for advanced hepatocellular carcinoma with portal vein tumor thrombosis: analysis of 48 cases

BACKGROUND

The prognosis of patients with hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) is extremely poor. The aim of this study was to elucidate the efficacy of hepatic arterial infusion chemotherapy (HAIC) for patients with advanced HCCs.

METHODS

Forty-eight HCC patients with PVTT were treated by HAIC via a subcutaneously implanted injection port. Of these, 14 had PVTT in the second portal branch and 34 patients had PVTT in the first portal branch or in the main portal trunk. One course of chemotherapy consisted of daily cisplatin (7 mg/m(2) for 1 hour on Days 1-5) followed by 5-fluorouracil (170 mg/m(2) for 5 hours on Days 1-5). Patients were scheduled to receive four serial courses of HAIC. Responders were defined as having either a complete response (CR) or partial response (PR) and nonresponders were defined as exhibiting stable disease or progressive disease. The prognosis after HAIC and factors related to survival were analyzed.

RESULTS

Following HAIC, 4 and 19 patients exhibited a CR and PR, respectively (response rate = 48%). The 1, 2, 3, and 5-year cumulative survival rates of 48 patients treated with HAIC were 45%, 31%, 25%, and 11%, respectively. Median survival periods for 23 responders and 25 nonresponders were 31.6 (range, 8.3-76.9) months and 5.4 (1.9-29.0) months, respectively. Therapeutic effect (P < 0.001) and hepatic reserve capacity (P = 0.021) were identified as significant prognostic factors by univariate analysis. Multivariate analysis identified only therapeutic effect as being significantly related to survival.

CONCLUSIONS

HAIC using low-dose cisplatin and 5-fluorouracil may be a useful therapeutic option for patients with advanced HCC with PVTT. HCC patients with PVTT who respond to HAIC could certainly have survival benefits.

Hemodynamic characterization of focal nodular hyperplasia using three-dimensional volume-rendered multidetector CT angiography

OBJECTIVE

The goal of this study was to show the ability of three-dimensional multidetector CT angiography to display the angioarchitecture of focal nodular hyperplasia.

CONCLUSION

CT angiography with volume rendering shows the anomalous feeding artery and hepatic draining veins that are characteristic of focal nodular hyperplasia. These features may be helpful in distinguishing focal nodular hyperplasia from other lesions.