Prospective trial of combined transcatheter arterial chemoembolization and three-dimensional conformal radiotherapy for portal vein tumor thrombus in patients with unresectable hepatocellular carcinoma.

PURPOSE: We conducted a prospective trial of combined transarterial chemoembolization (TACE) and three-dimensional conformal radiotherapy (3D-CRT) for portal vein tumor thrombus (PVTT) in unresectable hepatocellular carcinoma (HCC). The aim of the present study was to investigate the efficacy and toxicity of this trial regime. METHODS AND MATERIALS: Patients with unresectable HCC complicated with tumor thrombus in the first branch of portal vein were selected as eligible for this study. TACE was performed using Lipiodol, epirubicin hydrochloride, and mitomycin, followed by gelatin sponge cubes. The 3D-CRT was performed targeting the clinical target volume (CTV) defined as PVTT only to a total dose of 60 Gy using 10-MV accelerator. RESULTS: A total of 19 patients were enrolled in this study. Survival rates at 1 and 2 years were 40.6% and 10.2%, respectively. The median survival time was 7.0 months. An objective response was observed in 11 of 19 cases (57.9%). Recanalization of the first portal branches was not observed; however, the protrusion of PVTT into the main portal trunk decreased in all cases. Growth of intrahepatic metastasis outside the 3D-CRT field was observed in 12 cases (63%). Deterioration of the Child-Pugh Score was observed in 5 of 6 cases with the percent volume of the total liver receiving a dose exceeding 30 Gy (V(30)) > or =40%, vs. 2 of 13 cases with a V(30) <40% (p < 0.01). CONCLUSION: This combined therapy was feasible. Our results indicate that V(30) was a predictive test for deterioration of liver function. Further investigation of treatment modalities is needed to prevent the growth of intrahepatic metastasis.

Radiation-induced liver injury showing low intensity on T2-weighted images noted in Budd-Chiari syndrome.

PURPOSE: Although it is documented that radiation can cause density or intensity changes on computed tomography or MR imaging in the irradiated hepatic parenchyma, few researchers have reported or understood the MR presentation of changes in hepatic parenchyma following radiotherapy in the patient with Budd-Chiari syndrome. The purpose of this study was to investigate the MR appearance of hepatic radiation injury in Budd-Chiari syndrome and to consider the underlying pathophysiology. MATERIALS AND METHODS: The MR examinations of two patients with Budd-Chiari syndrome were compared with those of 11 patients without Budd-Chiari syndrome. The two groups, both of which suffered from hepatocellular carcinoma, underwent 50-72 Gy of proton-beam irradiation during a period of 14-43 days. Examinations including T1- and T2-weighted imaging, superparamagnetic iron oxide-enhanced imaging, and dynamic study were performed 3-10 weeks after the end of irradiation. RESULTS: Radiation-induced hepatic injury was observed as a low-intensity area on T2-weighted images and on delayed phase images of dynamic study in the Budd-Chiari patients, and as iso- or high-intensity areas on both images in the patients without Budd-Chiari syndrome. US-guided needle biopsy from the irradiated area in one patient with Budd-Chiari syndrome revealed mostly necrotic tissue and fibrous tissue. CONCLUSION: These MR features of hepatic radiation injury in Budd-Chiari syndrome were considered to be due to severe hepatic fibrosis.

Transcatheter arterial embolization for advanced tumor thrombus with marked arterioportal or arteriovenous shunt complicating hepatocellular carcinoma.

PURPOSE: To evaluate the efficacy and safety of transcatheter arterial embolization with gelatin sponge immersed in an anti-cancer agent (GIA-TAE) alone or combined with radiation therapy, in hepatocellular carcinoma with portal vein tumor thrombus (PVTT) or hepatic vein tumor thrombus (HVTT) complicated by marked arterioportal or arteriovenous shunts. MATERIALS AND METHODS: GIA-TAE was performed in 15 patients with PVTT and arterioportal shunts to the main portal trunk or first-order branch, and five with HVTT and arteriovenous shunts, adding radiation therapy in suitable cases. Primary efficacy, hemodynamic changes, Child-Pugh score, and survival rates were evaluated. RESULTS: GIA-TAE with or without radiation therapy was effective for tumor thrombus in 11 patients with PVTT and in four with HVTT. Treatment was effective for the main tumor in eight patients with PVTT and three with HVTT. Shunts disappeared in seven of 13 patients available for follow-up. Child-Pugh scores before and after the treatment were not significantly different. Median survival times of PVTT and HVTT groups were 8.7 and 12.2 months, respectively. One-year survival rates for both groups were about 15.6% and 50.0%, respectively. CONCLUSION: TAE with GIA alone or combined with radiation therapy is effective and safe for severe arteriovenous shunts with PVTT or HVTT, and also favors patient survival.

Metastatic Wilms' tumor causing acute hepatic-vein occlusion (Budd-Chiari syndrome).

We describe a case of Wilms' tumor in a 6-yr-old girl which extended from the right kidney and completely obstructed the inferior vena cava and hepatic veins to the level of the right atrium, producing an acute Budd-Chiari syndrome. After an initial course of chemotherapy, the primary tumor was excised and, using cardiopulmonary bypass, the tumor thrombus was removed from the inferior vena cava and hepatic veins. The Budd-Chiari syndrome resolved and after triple-drug chemotherapy and radiotherapy under the National Wilms' Tumor Study-2 protocol the child has remained disease-free for 5 yr.