Hemodynamic changes after transcatheter arterial embolization of hepatocellular carcinomas

Longitudinal Analysis of the Effect of Repeated Transarterial Chemoembolization for Liver Cancer on Portal Venous Pressure

Objectives

Investigate long-term effects of repeated transarterial chemoembolization (TACE) on portal venous pressure (PVP) using non-invasive surrogate markers of portal hypertension.

Methods

Retrospective, Institutional Review Board-approved study. 99 patients [hepatocellular carcinoma (HCC) group (n=57); liver metastasis group (n=42)] who underwent 279TACEs and had longitudinal pre-/post-therapy contrast-enhanced-MRI (n=388) and complete blood work were included. Outcomes of interest were platelet count (PC), spleen volume, ascites and portosystemic collaterals. Variables included TACE type/number, tumor type, microcatheter location, Child-Pugh, baseline tumor burden (tumor number/total/largest size), vessel invasion, alpha-fetoprotein, Eastern Cooperative Oncology Group (ECOG) performance status, and Model for End-Stage Liver Disease (MELD) score. Generalized Estimating Equations assessed the associations between TACE and outcomes. Power analysis determined the sample size was sufficient.

Results

No significant change in PC over time was observed in either groups, regardless of liver function (P>0.05). Baseline spleen volume was 226 cm³ for metastatic group, and was larger by 204 cm³ for HCC group (P<0.001). Spleen volume increased by 20 cm³ (95%CI: 8-32; P=0.001) for both groups after 1^stTACE and by 16cm³/TACE (P=0.099) over the full follow-up (up to 9TACEs). Spleen volume also tended to increase by 23cm³ (95%CI: -1–48; P=0.064) with higher tumor burden. Odds of developing moderate/severe ascites for metastatic patients was decreased by 0.5 (95%CI: 0.3–0.9; P=0.014), regardless of the Child-Pugh, and increased by 1.5 (95%CI: 1.2–1.9; P<0.001) among HCC patients with unstable Child-Pugh, whereas no change was noted with stable Child-Pugh. HCC patients with unstable Child-Pugh demonstrated a significant increase in portosystemic collaterals number over time (P=0.008). PVP-related complications such as variceal bleeding post-TACE were low (0.4%).

Conclusion

Repeated TACEs did seem to have an impact on PVP. However, the increase in PVP had marginal effects with low portal hypertension-related complications.

The incidence and predictors of post transarterial chemoembolization variceal bleeding in hepatocellular carcinoma patients

BACKGROUND & AIMS

Transarterial chemoembolization (TACE) is the standard of care for intermediate stage hepatocellular carcinoma (HCC) patients. Variceal bleeding is a life-threatening complication and may alter the initial treatment plan. This study was aimed to elucidate the risk factors for variceal bleeding in HCC patients receiving TACE treatment.

METHODS

From 2005 to 2016, a total of 1233 treatment-naive HCC patients receiving first time TACE treatment in Chang Gung Memorial Hospital, Linkou medical center were recruited. Pre-TACE status including baseline characteristics, prior history of ascites, and parameters for liver function evaluation were analyzed. All the variables were compared between patients with and without variceal bleeding.

RESULTS

Among the 1233 patients, the median age was 63.7 (range 25.8-91.5) years old, and 73.5% were male. Variceal bleeding events were documented in 19 patients (1.5%) within 3 months post TACE treatment. Patients with younger age, cirrhosis, pre-treatment ascites and advanced fibrosis status (higher MELD score, CTP score, ALBI grade, FIB-4 and APRI score) were more likely to encounter post-treatment variceal bleeding. Multivariate Cox regression analysis revealed existence of ascites (adjusted HR: 4.859 (1.947-12.124), p = 0.001), and higher FIB-4 score (adjusted HR: 4.481 (1.796-11.179), p = 0.001) were the independent predictive factors for variceal bleeding. Patients with post-TACE variceal bleeding are more likely to encounter tumor progression (42.1% vs. 20.3%, p = 0.039) and mortality owing to GI bleeding (15.8% vs. 3%, p = 0.032).

CONCLUSION

The incidence of post-TACE variceal bleeding was 1.5%. Patients with post-TACE variceal bleeding have poorer TACE treatment response. The pre-treatment ascites and FIB-4 score are the independent predictors for post-TACE variceal bleeding.

Short- and long-term effects of transarterial chemoembolization on portal hypertension in patients with hepatocellular carcinoma

Background

Transarterial chemoembolization (TACE) affects hepatic perfusion, and might have an impact on portal pressure in patients with hepatocellular carcinoma (HCC).

Objective

The objective of this article is to report the secondary outcome “hepatic hemodynamics” from the AVATACE trial, a prospective randomized, placebo-controlled trial on the efficacy of conventional TACE in combination with bevacizumab or placebo.

Methods

Hepatic venous pressure gradient (HVPG) was measured at baseline (prior to first TACE), within nine days (“acute effects”), two months (“intermediate effects”) and six months (“long-term effects”) after the first TACE.

Results

Of 28 patients with early-intermediate stage HCC, n = 20 (71%) had clinically significant portal hypertension (CSPH, HVPG ≥ 10 mmHg) at baseline (median, 12 (interquartile range (IQR): 9–19) mmHg). TACE had neither “acute effects” nor “intermediate effects” on HVPG. However, in 13 patients with available HVPG measurement at month 6, there was a significant increase in HVPG (median, 16 (IQR: 11–19) mmHg) compared with baseline (median, 10 (IQR: 5–12) mmHg; p = 0.007). Portal hypertension-related complications occurred exclusively in patients with CSPH (8 (40%) vs 0).

Conclusions

Repeated TACE was associated with a significant long-term increase in HVPG. This should be considered when deciding whether to continue with TACE or switch to systemic treatment, since CSPH drives the development of complications.

Genital tract cavernous hemangioma as a rare cause of postpartum hemorrhage

Cavernous hemangiomas rarely involve the female genital tract. It is difficult to identify vascular malformations when these lesions are concealed in the vagina or deep vulva area. We present a rare case of vaginal cavernous hemangioma in a 30-year-old primiparous woman with an early severe postpartum hemorrhage (PPH) and delayed continuous bleeding from the episiotomy site. She was treated successfully with transarterial embolization of the left vaginal artery. To our knowledge, this is the first reported case of PPH caused by rupture of a vaginal hemangioma during vaginal delivery in English literature.

Volume perfusion computed tomography (VPCT)-based evaluation of response to TACE using two different sized drug eluting beads in patients with nonresectable hepatocellular carcinoma: Impact on tumor and liver parenchymal vascularisation

OBJECTIVE

Response monitoring of transarterial chemoembolization (TACE) with the help of volume perfusion computed tomography (VPCT) at day one post-TACE and analysis of TACE-impact on tumor and uninvolved liver parenchymal perfusion by using different particles sizes and epirubicin dose.

MATERIALS AND METHODS

Institutional review board approved this prospective study. VPCT was performed in the baseline, post-interventional (FU1; 24 h post-TACE) and at follow-up (FU2; median, 81 days) in 45 consecutive patients. 100-300 μm (n=17) and 300-500 μm (n=28) drug eluting beads (DEB) using an epirubicin dose of (<=25 vs. >25) were administered. VPCT was performed for 40-s using 80 kV, 100/120 mAs, 64×0.6 mm collimation, 26 consecutive measurements, IV injection (50 ml iodinated contrast), flow rate (5 ml/s). Blood flow (BF), blood volume (BV) and k-trans were registered as average and max values in the tumor. Arterial liver perfusion (ALP), portal-venous perfusion (PVP) and the hepatic perfusion index (HPI) were registered both in tumor and non-involved liver parenchyma. Response to TACE was classified by VPCT as complete (CR), partial (PR) or no response (NR).

RESULTS

A significant reduction of viable tumor tissue was found in all patients between baseline and FU1 (p<0.001) being independent on particle size and epirubicin dose (p>0.05). PPV/NPV/sensitivity/specificity of post-interventional VPCT (FU1) results for prediction of the mid-term tumor course (FU2) were 100%/70%/76%/100%. There was generally a significant increase of the ALP between baseline and FU1 in the liver parenchyma coupled by a significant subsequent decrease (normalization) of ALP and HPI between FU1 and FU2.

CONCLUSION

VPCT accurately measures impact of TACE on liver tumor and hepatic parenchymal perfusion. The former proved not to be significantly dependent on particle size and epirubicin dose. There was no persistent perfusion deficit in the liver after TACE.

Effect of renal angioembolization on post-traumatic acute kidney injury after high-grade renal trauma: a comparative study of 52 consecutive cases

BACKGROUND

Acute kidney injury (AKI) is associated with unfavourable outcomes and higher mortality after trauma. Renal angioembolization (RAE) has proved efficiency in the management of high-grade renal trauma (HGRT), but inevitably expose to unavoidable ischaemic areas or contrast medium nephrotoxicity which may impair renal function in the following hours. The aim of this study was to assess the potential acute impact of RAE on renal function in a consecutive series of HGRTs treated nonoperatively.

MATERIALS AND METHODS

Of 101 cases of renal trauma admitted to our Regional Trauma Center between January 2005 and January 2010, 52 cases of HGRT were treated nonoperatively; they were retrospectively classified into 2 groups according to whether RAE was used. Incidence and progression of AKI (RIFLE classification), maximum increase in serum creatinine (SCr), level since admission and recovery of renal function at discharge were compared between the groups. Multivariable analysis was performed to determine the role of RAE as an independent risk factor of AKI.

RESULTS

RAE was performed in 10 patients within the first 48h. The RAE and no RAE groups were comparable in terms of severity score, renal injury grade, and level of SCr on admission. AKI incidence (RIFLE score Risk or worse) after 48 and 96h was 33% and 10%, respectively and did not differ significantly between groups at 48h (p=1.00) or 96h (p=1.00). The median maximum increase in SCr was significantly higher in no RAE than RAE group (30.4% vs. 6.9%, p=0.04). RAE was not found to be a significant variable in a multiple linear regression analysis predicting maximum SCr rise (p=0.34). SCr at discharge was >120% of baseline in only 5 patients, with no difference according to RAE (p=0.24).

CONCLUSION

In a population of nonoperatively treated HGRT, the incidence of AKI decreased from almost 30% to 10% at 48h and 96h. RAE proceeding did not seem to affect significantly the occurrence and course of AKI or renal recovery. The decision to use RAE should probably not be restricted by fear of worsening renal function.

Metastatic insulinoma - prolonged survival after multimodal approach

Background

Metastatic insulinoma is a disease associated with a poor life expectancy.

Case Report

The case of a presently 68 year old female with malignant, metastatic insulinoma is reported. Due to severe clinical symptoms surgical tumor mass reduction was conducted. Furthermore the patient underwent a chemotherapy using streptozotocine and fluorouracil. After two years without any symptoms, the remaining hepatic metastases increased in size and again hypoglycemias occurred. To reachieve an asymptomatic state and further reduction in tumor mass, the decision was made for transarterial chemoembolization with streptozotocine. After the first treatment the patient was hypoglycemia – free for 3 months, after another more extensive chemoembolization the patient is presently symptom free for 8 months.

Conclusions

Since the diagnosis of extended disease was established, the patient has survived for 36 months. We regard this as the result of a multimodal approach and the extensive use of local tumor therapy. The different therapeutic options for local tumor therapy are reported and discussed.

Transcatheter arterial chemoembolization for hepatocellular carcinoma in cirrhosis: influence on portal hypertension

BACKGROUND

Transcatheter arterial chemoembolization (TACE) is a routine treatment for hepatocellular carcinoma in cirrhotic patients. Whether TACE influences the degree of portal hypertension remains uncertain. AIM AND PATIENTS: We retrospectively analyzed the clinical course of 283 TACE to investigate the incidence of variceal bleeding and ascites after the procedure. We also prospectively evaluated portal pressure by hepatic venous portal gradient (HVPG) before and within 3 days by TACE in a group of 15 patients.

RESULTS

Before TACE, esophageal varices were present in 125 patients. Variceal bleeding occurred in three (1.5%) and ascites in two (1%) patients during the follow-up post-TACE. Patients with variceal bleeding were significantly older (P=0.019). In 15 patients who underwent portal pressure measurement before and within 3 days by TACE, HVPG was unchanged (mean 13.1 vs. 12.8 mmHg, P>0.05).

CONCLUSION

In our series portal hypertension-related complications after TACE were rare and did not result in higher mortality. As TACE did not influence HVPG, the preventive ligation of esophageal varices before TACE does not seem justified.

Therapeutic options for gastrointestinal carcinoids

Although wide surgical resection is the optimal curative therapy for carcinoid tumors, in most patients the presence of metastatic disease at diagnosis usually renders excision a palliative procedure. This nevertheless decreases tumor burden, facilitates symptom control, and prevents complications caused by bleeding, perforation, or bowel obstruction resulting from fibrosis. In the stomach (types I and II) and rectum endoscopic excision may be adequate provided the lesion(s) are local. Long-term therapy is focused on symptom alleviation and improvement of quality of life using somatostatin analogues, particularly in a subcutaneous depot formulation. In some instances interferons may have a role but their usage often is associated with substantial adverse events. Conventional chemotherapy and external radiotherapy either alone or in a variety of permutations are of minimal efficacy and should be balanced against the decrease in quality of life often engendered by such agents. Hepatic metastases may be amenable to surgery, radiofrequency ablation, or embolization either alone or in combination with chemotherapeutic agents or isotopically loaded microspheres. Rarely hepatic transplantation may be of benefit although controversy exists as to its actual use. Peptide-receptor-targeted radiotherapy for advanced disease using radiolabeled octapeptide analogs (111In/90Yt/177Lu-octreotide) appear promising but data are limited and its status remains investigational. A variety of antiangiogenesis and growth factor-targeted agents have been evaluated, but as yet have shown little promise. The keystone of current therapy remains the long-acting somatostatin analogues that alleviate symptomatology and substantially improve quality of life with minimal adverse effects.

Chemoembolization and other ablative therapies for liver metastases of gastrointestinal endocrine tumours

Hepatic metastases are frequent in patients with gastroentero-pancreatic (GEP) endocrine tumours; their presence significantly influences overall prognosis. Surgery, although the treatment of choice for hepatic metastases, is frequently impossible due to disease extent. Systemic chemotherapy in patients with diffuse and/or progressive liver metastases yields disappointing results especially in patients with metastases from midgut origin. In addition, in patients with carcinoid syndrome, the efficacy of somatostatin analogues wanes due to disease progression and development of tachyphylaxis. Locoregional strategies with vascular occlusion inducing ischemia in these highly vascular GEP tumours are indeed other options and may be performed using either surgical or radiological techniques (e.g. surgical ligation of the hepatic artery, transient hepatic ischemia, or sequential hepatic arterialization). Trans-catheter arterial chemoembolization is efficacious in both the control of hormonal symptoms and yields reliable objective tumour responses. Treatments aimed at regional destruction either alone or in combination with surgery include radiofrequency ablation and cryotherapy and may also be considered in certain circumstances.

Surgical treatment of non-functioning pancreatic islet cell tumors

Pancreatic endocrine tumors (PETs) are rare neoplasms originating from the amine precursor uptake and decarboxylation (APUD) stem cells. Although the majority of PETs are sporadic, they frequently occur in familial syndromes. PETs may cause a variety of functional syndromes or symptoms of local progression if they are non-functional. General neuroendocrine tumor markers are highly sensitive in the diagnostic assessment of a PET. Imaging studies for tumor localization and staging include computer tomography (CT) scan, magnetic resonance imaging (MRI), In(111)-octreotide scan, MIBG, and endoscopic ultrasonography (EUS). Treatment of PETs often requires a multi-modality approach; however, surgical resection remains the only curative therapy for localized (non-metastatic) disease. Treatment of metastatic disease includes biologic agents, cytotoxic chemotherapy, and liver-directed therapies.

The diagnosis and medical management of advanced neuroendocrine tumors

Neuroendocrine tumors (NETs) constitute a heterogeneous group of neoplasms that originate from endocrine glands such as the pituitary, the parathyroids, and the (neuroendocrine) adrenal, as well as endocrine islets within glandular tissue (thyroid or pancreatic) and cells dispersed between exocrine cells, such as endocrine cells of the digestive (gastroenteropancreatic) and respiratory tracts. Conventionally, NETs may present with a wide variety of functional or nonfunctional endocrine syndromes and may be familial and have other associated tumors. Assessment of specific or general tumor markers offers high sensitivity in establishing the diagnosis and can also have prognostic significance. Imaging modalities include endoscopic ultrasonography, computed tomography and magnetic resonance imaging, and particularly, scintigraphy with somatostatin analogs and metaiodobenzylguanidine. Successful treatment of disseminated NETs requires a multimodal approach; radical tumor surgery may be curative but is rarely possible. Well-differentiated and slow-growing gastroenteropancreatic tumors should be treated with somatostatin analogs or alpha-interferon, with chemotherapy being reserved for poorly differentiated and progressive tumors. Therapy with radionuclides may be used for tumors exhibiting uptake to a diagnostic scan, either after surgery to eradicate microscopic residual disease or later if conventional treatment or biotherapy fails. Maintenance of the quality of life should be a priority, particularly because patients with disseminated disease may experience prolonged survival.

Hepatic venous congestion after living donor liver transplantation with right lobe graft: two-phase CT findings

PURPOSE

To describe and determine clinical importance of two-phase computed tomographic (CT) findings of hepatic venous congestion after living donor liver transplantation (LDLT) with right lobe graft.

MATERIALS AND METHODS

Forty-eight patients underwent two-phase (hepatic arterial phase and portal venous phase [PVP]) CT at 1, 2, and 4 weeks after LDLT. Images were evaluated for hepatic attenuation difference in areas of hepatic venous congestion, opacification of hepatic and peripheral portal veins in those areas, and changes in findings at follow-up CT. CT findings were correlated with serum bilirubin level. Fisher exact test and mixed model were applied. Histopathologic specimens were obtained in six patients.

RESULTS

Thirty patients (62%) had attenuation difference in segments V and VIII of right lobe transplant at initial CT scanning. Opacification of hepatic or peripheral portal veins was seen in 17 (63%) and 27 (100%) hyperattenuating areas of congestion during PVP and in none and three (19%) of 16 hypoattenuating areas, respectively. At 4-week follow-up CT, attenuation difference decreased in volume in 11 of 16 patients with hypoattenuation during PVP. All 14 patients with hyperattenuation showed no change in volume, but attenuation difference had decreased or disappeared. Histopathologic specimens showed evidence of hepatic venous congestion in all six patients. Hypoattenuation was seen at PVP CT in all three patients with severe hepatic venous congestion at histopathologic examination. Serum bilirubin level was significantly different between patients with hypoattenuation and those with hyperattenuation during PVP (P =.035) and between patients with hypoattenuation and those without attenuation difference (P =.009).

CONCLUSION

Areas possibly related to hepatic venous congestion after LDLT have variable attenuation at CT; decreased enhancement during PVP correlates with increased postoperative serum bilirubin level, which indicates severity of hepatic venous congestion.

Ablative therapies for liver metastases of gastroenteropancreatic endocrine tumors

Hepatic metastases are frequent in patients with gastroenteropancreatic (GEP) endocrine tumors. The presence of hepatic metastases affects overall prognosis and quality of life especially in the presence of debilitating functional syndromes. Surgery, although the method of choice for hepatic metastases, is usually impossible due to disease extent. Results of systemic chemotherapy are also disappointing especially in patients with metastases from midgut GEP tumors. These latter patients usually have carcinoid syndrome which can be controlled by somatostatin analogues. Other therapeutic options in the treatment of highly vascular liver metastases from GEP tumors are locoregional strategies by inducing vascular occlusion resulting in ischemia and necrosis of tumoral tissue. Surgical ligation of the hepatic artery or transient hepatic ischemia has been replaced by transcatheter arterial chemoembolization (TACE). TACE has proven effective in controlling symptoms and gives objective tumor response in about half of patients. Other regional destructive methods, used either alone or in combination with surgery, include radiofrequency ablation and cryotherapy. The latter strategies are poorly evaluated to date and are usually adjuncts to surgery and reserved for limited disease.

Effect of transcatheter arterial chemoembolization on kidney hemodynamics and function in patients with cirrhosis and hepatocellular carcinoma

BACKGROUND/AIMS

Transcatheter arterial chemoembolization (TACE) may have deleterious effect on the kidney in patients with cirrhosis and hepatocellular carcinoma. The aim of the study was to test this hypothesis.

METHODS

Twenty-four patients with cirrhosis and hepatocellular carcinomas were included. They consisted of 16 patients undergoing a single TACE and eight patients undergoing diagnostic angiography. Doppler ultrasonography was used to measure hepatic artery pulsatility index (HA-PI) and renal artery pulsatility index (RA-PI) before and 1 day and 10 days after the procedure. Similarly, kidney function was assessed by measuring creatinine clearance. In addition, plasma renin activity, noradrenaline, and endothelin-1 were also measured.

RESULTS

In patients receiving diagnostic angiography, no significant changes in HA-PI were observed after the procedure. In contrast, HA-PI increased significantly 1 day after the procedure (19%, p<0.01) in patients undergoing TACE, although it returned to baseline value 10 days after the procedure. In patients undergoing diagnostic angiography, no significant changes in RA-PI were observed after the procedure. Similarly, no detectable changes in RA-PI were noted in patients undergoing TACE. A transient small reduction in creatinine clearance was noted after the procedure in patients undergoing diagnostic angiography (-12%, p<0.05) and in those undergoing TACE (-11%, p<0.05). However, the effect was similar in the two groups (two-way ANOVA, p=0.72). No significant changes in plasma renin activity, noradrenaline, and endothelin-1 were observed after either diagnostic angiography or TACE.

CONCLUSIONS

These results suggest that TACE per se has no deleterious effect on the kidney hemodynamics and function in patients with cirrhosis and hepatocellular carcinoma.

Transcatheter arterial chemoembolization for hepatocellular carcinoma in patients with Child's grade A or B cirrhosis: a multivariate analysis of prognostic factors

We evaluated factors affecting long-term survival after transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) complicating cirrhosis. One hundred eighty-two patients with Child's class A or B cirrhosis and an HCC, not amenable to surgery or percutaneous ethanol injection, underwent 346 TACEs (mean 1.9) with epirubicin, iodized oil, and gelatin sponge. Many prognostic factors were subjected to univariate analysis and thereafter, when significant, to the Cox's hazard proportional model. Finally, the significant indices in the Cox's model were used to estimate the accuracy of the probability of death with computation of the area under the receiving operative characteristic (ROC) curve. The cumulative survival rates at 1, 2, 3, and 5 years were 0.83, 0.52, 0.40, and 0.16, respectively. According to Cox's model, the factors associated with significantly worse survival were the presence of ascites (p = 0.0027), elevated bilirubin levels (p = 0.0163), elevated alpha-fetoprotein (alphaFP) values (p = 0.0067), a tumor greater than 5 cm in diameter (p = 0.0001), and the absence of a tumor capsule-like rim (p = 0.0278). According to these parameters, the accuracy of the probability of death estimated with ROC analysis was 0.63. Minor and major complications occurred in 82 patients (45%) and caused death in 2 patients. Long-term prognosis after TACE for HCCs in patients with Child's class A or B cirrhosis depends on the presence of ascites, the bilirubin level, the alphaFP value, the diameter of the tumor, and the presence of a tumor capsule-like rim. However, when considered altogether, these variables are poor predictors to evaluate survival, and other factors should be investigated to identify subjects more responsive to TACE. Complications occur in a high percentage of patients, but they do not affect long-term prognosis.

Hepatic damage induced by transcatheter arterial chemoembolization elevates serum concentrations of macrophage-colony stimulating factor

AIMS/BACKGROUND

This study was undertaken in order to characterize the liver injury induced by transcatheter arterial chemoembolization therapy (TACE) for hepatocellular carcinoma (HCC) and to elucidate-mechanisms involved in the growth of mononuclear phagocytes in injured human liver in vivo.

PATIENTS AND METHODS

The serum levels of macrophage-colony stimulating factor (M-CSF) along with clinical parameters were examined in 43 patients with HCC who underwent TACE. Ten patients who underwent angiography alone served as controls.

RESULTS

Serum M-CSF increased and peaked on the third day after TACE showing significant correlations (p < 0.001, respectively) with the increases in serum alanine aminotransferase (ALT) and type IV collagen-7S (IVcol-7S). The lipopolysaccharide-stimulated production of interleukin (IL)-1 beta, IL-6, and tumor necrosis factor (TNF)-alpha in peripheral whole blood increased and peaked on the first or on the third day after TACE. In effective cases of TACE, significantly (p < 0.05) greater increases in serum M-CSF were noted as compared with those in ineffective cases.

DISCUSSION

The serum levels of M-CSF increased after TACE in correlation with hepatic inflammation and necrosis and increased production of IL-1 beta, TNF-alpha and IL-6 in peripheral whole blood. These results suggest a mechanism by which hepatic injury enhances the production of M-CSF via a cytokine cascade, which results in the proliferation of liver macrophages in vivo.

Hepatic microcirculatory changes induced by hepatic artery embolization in rats: original investigation

RATIONALE AND OBJECTIVES

To evaluate the effects of hepatic artery embolization (HAE), hepatic microcirculatory changes induced by HAE were assessed quantitatively in rats.

METHODS

Using in vivo microscopy, the blood-flow velocity (BFV) through terminal portal venules (TPVs) and terminal hepatic venules (THVs) was measured during HAE with gelatin sponge powder (GSP), iodized oil (Lipiodol, 0.1, 0.2, and 0.4 mL/kg), or 0.1 mL/kg Lipiodol followed by GSP.

RESULTS

After HAE with GSP, BFV through TPVs decreased significantly, but BFV through THVs did not decrease. After HAE with Lipiodol (0.2 and 0.4 mL/kg), BFV through TPVs decreased significantly, but BFV through THVs did not. After HAE with Lipiodol followed by GSP, BFV through both TPVs and THVs decreased significantly.

CONCLUSIONS

Neither GSP nor Lipiodol adversely affects hepatic microcirculation when administered alone; however, HAE with a combination of Lipiodol and GSP does adversely affect hepatic microcirculation.

Hepatic perfusion changes after transcatheter arterial embolization (TAE) of hepatocellular carcinoma: measurement by dynamic computed tomography (CT)

We observed the hemodynamic changes at the level of the hepatic parenchyma induced by transcatheter arterial embolization (TAE) for hepatocellular carcinoma in 22 patients. TAE was performed by administration of a mixture of iodized oil, adriamycin, and mitomycin C, followed by injection of gelatin sponge particles (1-mm pieces). Perfusion measurements (arterial and portal) were done by dynamic computed tomography (CT). Arterial perfusion was increased two to six days after TAE (0.146 +/- 0.073 ml/min/ml, P < 0.0002) compared with that before TAE (0.064 +/- 0.039), but decreased again one month after TAE (0.086 +/- 0.038). Portal perfusion was decreased two to six days after TAE (0.541 +/- 0.180, P < 0.001) compared with that before TAE (0.733 +/- 0.263) and was grossly unchanged one month after TAE (0.651 +/- 0.214). We suspected that these perfusion changes were due to acute inflammatory responses. Quantification of tissue perfusion by dynamic CT was useful for studying hemodynamic changes after TAE.

Short-term effects of transcatheter arterial chemoembolisation on metabolic activity of the liver of cirrhotic patients with hepatocellular carcinoma

BACKGROUND

Transcatheter arterial chemoembolisation, a procedure for the treatment of hepatocellular carcinoma, provokes a pronounced but transient increase in hepatic cytolysis parameters. A definite evaluation of the impairment of liver function after this treatment, performed by adequate techniques, is still lacking.

AIMS

To assess and quantify the impairment of liver metabolic activity after arterial chemoembolisation in patients with cirrhosis. The variations of hepatic vein pressure gradient provoked by this procedure were evaluated.

PATIENTS

15 patients with cirrhosis (Child's class A and B) and hepatocellular carcinoma.

METHODS

17 transcatheter arterial chemoembolisations with epirubicin, iodised oil, and gelfoam were performed; liver function was assessed before, the following day, and after seven days measuring galactose elimination capacity; aminopyrine breath test was also performed in six patients before the procedure and seven days after. In 10 patients intrinsic hepatic clearance of indocyanine green and hepatic vein pressure gradient were measured by hepatic vein catheterisation before and 30 minutes after chemoembolisation.

RESULTS

Intrinsic hepatic clearance of indocyanine green decreased significantly from (mean (SEM)) 355 (140) ml/min to 277 (98) ml/min after the procedure (p = 0.0007). Galactose elimination capacity did not show significant changes, being 4.00 (0.90) mg/min/kg body weight at baseline, 4.20 (0.90) mg/min/kg body weight after one day, and 3.95 (0.87) mg/min/kg body weight seven days after chemoembolisation. Aminopyrine breath test was 2.31 (1.09)% and remained unchanged after treatment, being 2.39 (2.04)% at day 7. Baseline hepatic vein pressure gradient was 17.0 (5.5) mm Hg, and 14.4 (3.7) mm Hg 30 minutes after chemoembolisation (p = 0.09).

CONCLUSIONS

A single transcatheter chemoembolisation in cirrhotic patients was detected by galactose elimination capacity and aminopyrine breath test one and seven days after the procedure. Therefore it can be considered a safe therapeutic tool for hepatocellular carcinoma in Child's class A and B cirrhotic patients.

Malignant insulinoma: permanent hepatic artery embolization of liver metastases--preliminary results

PURPOSE

To evaluate permanent hepatic artery embolization of liver metastases of malignant insulinoma as a therapeutic procedure.

METHODS

Three female patients had persistent severe hypoglycemia after distal pancreatectomy because of a malignant insulinoma. Computed tomography (CT) and CT-portography (CTAP) were used for tumor assessment and follow-up and demonstrated multiple hypervascular metastases 0.5-3 cm in diameter in both lobes of the liver. Unilobar sequential transcatheter embolization of the hepatic artery was performed with an interval of 1-2 months between the procedures. Permanent occlusion was achieved by using a mixture of n-butyl-2-cyanoacrylate and ethiodized oil as an embolizing agent.

RESULTS

In all patients, embolization of the hepatic artery was technically feasible and complete occlusion could be obtained. In two patients, collaterals originating from the right inferior phrenic artery were embolized superselectively 3 months after bilobar embolization. CTAP at that time revealed marked decrease in tumor size of more than 50%. All patients responded to the treatment as confirmed by normalization of measurable hormone levels, glucose levels, and disappearance of symptoms. Two patients are still alive after 24 and 31 months from the time of the first embolization. Current investigations revealed normal laboratory data and no further tumor progression in the liver. The third patient died 15 months after the first embolization; she also had developed ileus due to local recurrence of the primary tumor and lymph node metastases.

CONCLUSION

Hepatic arterial embolization appears to be an effective means of palliation for liver metastases of malignant insulinoma. Long-term improvement seems most likely to be the result of extensive ischemia from permanent occlusion.

Hepatic artery chemoembolization therapy for hepatic tumors

Patients with hepatocellular carcinomas who undergo chemoembolization therapies require skilled perioperative nursing care that addresses their knowledge deficits about chemoembolization techniques, their anxieties related to chemoembolization procedures and adverse effects, and their impaired mobility resulting from the presence of arterial lines and the progression of the cancer. Perioperative nursing participation in chemoembolization procedures is an example of the expanded role of today's OR nurse.