Superselective Conventional Transarterial Chemoembolization for Hepatocellular Carcinoma: Rationale, Technique, and Outcome.

Conventional transarterial chemoembolization with ethiodized oil and gelatin sponge (GS) particles is a standard technique for hepatocellular carcinoma. Ethiodized oil can temporarily block tumor sinusoids, portal venules, hepatic sinusoids, and arterial microcommunications. By adding GS embolization, strong ischemic effects not only on the tumor but also on the surrounding liver parenchyma can be achieved. Superselective conventional transarterial chemoembolization is mainly indicated for patients with Child-Pugh scores of 5-8, tumors ≤ 7 cm, and ≤ 5 lesions. According to a Japanese nationwide survey, the 5-year survival rate of patients with Child-Pugh class A and a single tumor was 52%.

Treatment of Liver Tumors with Lipiodol TACE: Technical Recommendations from Experts Opinion.

Transarterial chemoembolization with Lipiodol (Lipiodol TACE), also called conventional TACE, was developed in the early 1980s and widely adopted worldwide after randomized control trials and meta-analysis demonstrated superiority of Lipiodol TACE to best supportive care. Presently, there is no level one evidence that other TACE techniques are superior to Lipiodol TACE for intermediate stage hepatocellular carcinoma (HCC), which includes patients with preserved liver function and nonsurgical large or multinodular HCC without distant metastases. In addition, TACE is part of the treatment for progressive or symptomatic liver metastases from gastroenteropancreatic neuroendocrine tumors. When injected into the hepatic artery, Lipiodol has the unique property of selective uptake and retention in hyperarterialyzed liver tumors. Lipiodol/drug emulsion followed by particle embolization has been demonstrated to improve the pharmacokinetic of the drug and tumor response. Radio opacity of Lipiodol helps to monitor treatment delivery, with retention of Lipiodol serving as an imaging biomarker for tumor response. For 30 years, Lipiodol TACE has been inconsistently referenced in many publications with various levels of details for the method of preparation and administration, with reported progressive outcomes following improvements in the technique and the devices used to deliver the treatment and better patient selection. Consequently, there is no consensus on the standard method of TACE regarding the use of anticancer agents, embolic material, technical details, and the treatment schedule. In order to develop an internationally validated technical recommendation to standardize the Lipiodol TACE procedure, a worldwide panel of experts participated in a consensus meeting held on May 10, 2014 .

Transarterial chemoembolization failure/refractoriness: JSH-LCSGJ criteria 2014 update.

In the 2010 version of the Japan Society of Hepatology (JSH) consensus-based treatment algorithm for the management of hepatocellular carcinoma (HCC), transarterial chemoembolization (TACE) failure/refractoriness was defined assuming the use of superselective lipiodol TACE, which has been widely used worldwide and particularly in Japan, and areas with lipiodol deposition were considered to be necrotic. However, this concept is not well accepted internationally. Furthermore, following the approval of microspheres, an embolic material that does not use lipiodol, in February 2014 in Japan, the phrase 'lipiodol deposition' needed to be changed to 'necrotic lesion or viable lesion'. Accordingly, the respective section in the JSH guidelines was revised to define TACE failure as an insufficient response after ≥2 consecutive TACE procedures that is evident on response evaluation computed tomography or magnetic resonance imaging after 1-3 months, even after chemotherapeutic agents have been changed and/or the feeding artery has been reanalyzed. In addition, the appearance of a higher number of lesions in the liver than that recorded at the previous TACE procedure (other than the nodule being treated) was added to the definition of TACE failure/refractoriness. Following the discussion of other issues concerning the continuous elevation of tumor markers, vascular invasion, and extrahepatic spread, descriptions similar to those in the previous version were approved. The revision of these TACE failure definitions was approved by over 85% of HCC experts.

Forcible intraarterial injection of a nonadhesive liquid embolic agent under microballoon occlusion: experimental study in swine liver.

PURPOSE: To evaluate the feasibility and effectiveness of transcatheter embolization by forcible intraarterial injection of a mixture of ethylene vinyl alcohol copolymer (EVAL) and ethanol under microballoon occlusion compared with conventional transcatheter arterial embolization methods in nontumoral swine liver. MATERIALS AND METHODS: Nine swine were divided into three groups: embolization with EVAL/ethanol mixture (EVAL group, n = 5), with ethiodized oil (ethiodized oil group, n = 2), and with microspheres (microspheres group, n = 2). Embolization was performed at the subsegmental hepatic artery. The EVAL/ethanol mixture was injected forcibly through a microcatheter with a balloon, which was inflated to prevent backflow of the mixture during the injection. Ethiodized oil or microspheres were injected into the artery using a microcatheter without balloon occlusion. Two animals of the EVAL group were euthanized immediately after embolization, and the distribution of EVAL was assessed microscopically. The remaining seven animals were euthanized 4 weeks after embolization, and the histopathologic changes were assessed. RESULTS: All procedures were technically successful. EVAL occupied > 80% of the hepatic arterial, portal venous, and sinusoidal lumens after embolization. Ischemic coagulation necrosis was observed 4 weeks after embolization in the EVAL group. Parenchymal necrosis was not observed in the ethiodized oil and microspheres groups. CONCLUSIONS: Transcatheter embolization by forcible intraarterial injection of an EVAL/ethanol mixture under microballoon occlusion was feasible and achieved the simultaneous embolization of hepatic artery, portal vein, and sinusoids in swine liver, resulting in complete necrosis of the segment that received embolization.

Hypervascular hepatocellular carcinoma: correlation between biologic features and signal intensity on gadoxetic acid-enhanced MR images.

PURPOSE: To analyze the correlation among biologic features, tumor marker production, and signal intensity at gadoxetic acid-enhanced MR imaging in hepatocellular carcinomas (HCCs). MATERIALS AND METHODS: Institutional ethics committee approval and informed consent were obtained for this retrospective study. From April 2008 to September 2011, 180 surgically resected HCCs in 180 patients (age, 65.0 years ± 10.3 [range, 34-83 years]; 138 men, 42 women) were classified as either hypointense (n = 158) or hyperintense (n = 22) compared with the signal intensity of the background liver on hepatobiliary phase gadoxetic acid-enhanced MR images. Pathologic features were analyzed and a fetoprotein (AFP) and protein induced by vitamin K absence or antagonist-II (PIVKA-II) production were compared by means of serum analysis and immunohistochemical staining. Recurrence and survival rates were also evaluated. The Mann-Whitney and Pearson correlation tests were used for statistical analysis. RESULTS: The grade of differentiation was higher (P = .028) and portal vein invasion was less frequent in hyperintense HCCs (13.6%) than in hypointense HCCs (36.7%) (P = .039). The serum levels of AFP, Lens culinaris agglutinin reactive fraction of AFP, and PIVKA-II were lower in hyperintense than in hypointense HCCs (P = .003, .004, and .026, respectively). Immunohistochemical AFP and PIVKA-II expression were lower in hyperintense than in hypointense HCCs (both P < .001). The recurrence rate was lower in hyperintense than in hypointense HCCs (P = .039). CONCLUSION: The results suggest that hyperintense HCCs on gadoxetic acid-enhanced MR images are less aggressive than hypointense HCCs. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12120226/-/DC1.

Current status of hepatocellular carcinoma treatment in Japan: transarterial chemoembolization.

Transarterial chemoembolization (TACE) is the gold standard of treatment for intermediate-stage hepatocellular carcinoma (HCC), and involves the administration of cytotoxic drugs, with or without lipiodol, by means of a catheter directly to the hepatic artery followed by the administration of embolizing agents such as spherical gelatin or polyvinyl alcohol particles. There are currently no global guidelines regarding the dose, choice or combination of cytotoxic agents for TACE; therefore it is difficult to compare data from different TACE studies. Superselective TACE with lipiodol is the primary TACE procedure that offers satisfactory levels of local control with a lower risk of complications. Approximately 40-70% of patients with HCC with tumours sized 4-5 cm or less attained complete tumour necrosis or remained local recurrence free for 3 years or longer following TACE. The early identification of unresponsiveness to TACE is important to allow for a timely switch to alternative therapies. The use of novel embolizing materials in TACE such as drug-eluting beads and radioembolization is likely to have beneficial effects. Indeed, the increase in angiogenic activity following TACE emphasizes the potential of TACE in combination with targeted molecular therapies such as the anti-angiogenesis inhibitor, sorafenib.

Current status of hepatocellular carcinoma treatment in Japan: case study and discussion-voting system.

The Toward Integrated Treatment of Advanced Hepatocellular Carcinoma with Nexavar (TiTAN) Symposium was held in August 2010 in Tokyo, Japan, during which the position of sorafenib (Nexavar®) in the treatment of HCC in Japan (for which it received approval in 2009) was discussed by a panel of eight expert hepatologists in a session chaired by Dr Kudo. The following article focuses on the discussion that went on during this session, including question and answer sessions regarding the experiences of the 350 conference attendees in treating patients with HCC, as well as some of the more challenging disease management issues. Since 2008, when the phase III Sorafenib Hepatocellular Carcinoma Assessment Randomized Protocol (SHARP) trial demonstrated an increase in the median overall survival (OS) for patients with unresectable HCC treated with sorafenib compared with placebo, international and Japanese guidelines recommend sorafenib as a first-line option for patients with advanced HCC Child-Pugh liver function class A who have extrahepatic metastasis. Sorafenib is also recommended for patients unresponsive to transarterial chemoembolization (TACE) or hepatic arterial infusion chemotherapy (HAIC). Importantly, if HCC is judged to be unresponsive to TACE, treatment should be switched to sorafenib in a timely manner. Almost half of the conference attendees said that they used both the Japan Society of Hepatology clinical practice guidelines and the clinical practice guidelines for HCC when determining treatment strategies for individual HCC patients. Sorafenib should currently not be used as adjuvant therapy or in combination with TACE or HAIC until evidence from ongoing clinical trials shows that it is beneficial in these settings.

Superselective transarterial chemoembolization for hepatocellular carcinoma. Validation of treatment algorithm proposed by Japanese guidelines.

BACKGROUND & AIMS: Transcatheter arterial chemoembolization with lipiodol (TACE) is widely performed in patients with hepatocellular carcinoma (HCC) unsuitable for curative treatment. It has recently been recommended for patients with 2 or 3 tumors >3 cm or ≥4 tumors in a treatment algorithm proposed by Japanese guidelines. However, the best indication and appropriateness of the algorithm for TACE are still unclear. METHODS: In 4966 HCC patients who underwent TACE, survival was evaluated based on tumor number, size and liver function; and the adequacy of the algorithm for TACE was validated. Exclusion criteria were: vascular invasion, extrahepatic metastasis, and prior treatment. The mean follow up period was 1.6 years. RESULTS: The overall median and 5-year survivals were 3.3 years and 34%, respectively. Multivariate analysis revealed that Child-Pugh class, tumor number, size, alpha-fetoprotein, and des-gamma carboxy-prothrombin were independent predictors. The survival rate decreased as the tumor number (p=0.0001) and size increased (p=0.04 to p=0.0001) in all but one subgroup in both Child-Pugh-A and -B. The stratification of these patients to four treatments in the algorithm showed potential ability to discriminate survivals of the resection and ablation (non-TACE) groups from those of the TACE group in Child-Pugh-B and partially in A. CONCLUSIONS: TACE showed higher survival rates in patients with fewer tumor numbers, smaller tumor size, and better liver function. The treatment algorithm proposed by the Japanese guidelines might be appropriate to discriminate the survival of patients with non-TACE from TACE therapy.

Arterial blood supply to the caudate lobe of the liver from the proximal branches of the right inferior phrenic artery in patients with recurrent hepatocellular carcinoma after chemoembolization.

PURPOSE: To evaluate the arterial blood supply to the caudate lobe of the liver from the proximal branches of the right inferior phrenic artery (RIPA) in patients with recurrent hepatocellular carcinoma after transcatheter arterial chemoembolization (TACE). MATERIALS AND METHODS: Thirteen patients, including 10 who had a history of TACE of the caudate artery (A1), underwent TACE of the proximal RIPA branches. Iodized oil distribution was evaluated by computed tomography (CT) 1-week after TACE. Angiographic findings were also evaluated. RESULTS: Previously embolized A1 was occluded (n = 15) or attenuated (n = 2). In one of three patients without A1 TACE, A1 was also attenuated. TACE was performed at the first branch of the proximal RIPA (n = 8), the first branch of the anterior branch (n = 6), and the first branch of the posterior branch (n = 1), respectively. Iodized oil was mainly distributed into the dorsal part of the Siegel lobe (SP) (n = 10), the caudate process (n = 1), and both (n = 2). In three of seven patients who had undergone serial RIPA angiography, RIPA parasitization to SP was suspected before A1 TACE. CONCLUSION: The proximal RIPA branches mainly supply the SP when A1 is attenuated.

Efficacy of cone-beam computed tomography during transcatheter arterial chemoembolization for hepatocellular carcinoma.

Cone-beam computed tomography (CBCT) using a flat-panel detector is an alternative method of obtaining cross-sectional images. This technique is now being used during transcatheter arterial chemoembolization (TACE) for inoperable hepatocellular carcinoma (HCC). Several CBCT techniques are performed to detect HCC lesions: CBCT during portography (CBCTAP), CBCT during hepatic arteriography (CBCTHA), CBCT after iodized oil injection (LipCBCT), CBCT during arteriography (CBCTA) of extrahepatic collaterals. Almost all HCC lesions can be detected using these CBCT images. Three-dimensional arteriography using maximum intensity projection from CBCTHA images can identify the tumor-feeding branch. In particular, this technique is useful when the tumor stain cannot be demonstrated on arteriography. In addition, dual-phase CBCTHA can improve the diagnostic accuracy for hypervascular HCCs because corona enhancement can be detected around the tumor. To monitor the embolized area during TACE, selective CBCTHA or LipCBCT at the embolization point is useful. Two sequential CBCT scans without and with contrast material injection is also useful to confirm each embolized area of two vessels. Furthermore, CBCTA can prevent nontarget embolization. Although the image quality of CBCT is low compared to that of conventional CT, CBCT provides useful information that helps perform TACE for HCCs safely and effectively.

Phase III study of sorafenib after transarterial chemoembolisation in Japanese and Korean patients with unresectable hepatocellular carcinoma.

BACKGROUND: In Japan and South Korea, transarterial chemoembolisation (TACE) is an important locoregional treatment for patients with unresectable hepatocellular carcinoma (HCC). Sorafenib, a multikinase inhibitor, has been shown effective and safe in patients with advanced HCC. This phase III trial assessed the efficacy and safety of sorafenib in Japanese and Korean patients with unresectable HCC who responded to TACE. METHODS: Patients (n=458) with unresectable HCC, Child-Pugh class A cirrhosis and ≥25% tumour necrosis/shrinkage 1-3 months after 1 or 2 TACE sessions were randomised 1:1 to sorafenib 400mg bid or placebo and treated until progression/recurrence or unacceptable toxicity. Primary end-point was time to progression/recurrence (TTP). Secondary end-point was overall survival (OS). FINDINGS: Baseline characteristics in the two groups were similar; >50% of patients started sorafenib>9 weeks after TACE. Median TTP in the sorafenib and placebo groups was 5.4 and 3.7 months, respectively (hazard ratio (HR), 0.87; 95% confidence interval (CI), 0.70-1.09; P=0.252). HR (sorafenib/placebo) for OS was 1.06 (95% CI, 0.69-1.64; P=0.790). Median daily dose of sorafenib was 386 mg, with 73% of patients having dose reductions and 91% having dose interruptions. Median administration of sorafenib and placebo was 17.1 and 20.1 weeks, respectively. No unexpected adverse events were observed. INTERPRETATION: This trial, conducted prior to the reporting of registrational phase III trials, found that sorafenib did not significantly prolong TTP in patients who responded to TACE. This may have been due to delays in starting sorafenib after TACE and/or low daily sorafenib doses.

Angiographic evaluation of feeding arteries of hepatocellular carcinoma in the caudate lobe of the liver.

PURPOSE: To evaluate the origins of feeders of hepatocellular carcinoma (HCC) in the caudate lobe (S1). MATERIALS AND METHODS: Eighty-eight HCCs (mean diameter 21.4 mm) were treated by chemoembolization. The tumor-feeding caudate artery was confirmed when a tumor stain was demonstrated on angiogram and iodized oil was accumulated into the HCC and S1 on computed tomography (CT). The origins were divided into R(1) (right proximal), R(2) (right distal), L(1) (left proximal), L(2) (left distal), A (anterior segmental), P (posterior segmental), M (middle hepatic or medial segmental), Ph (proper hepatic), Ch (common hepatic), and Ex (extrahepatic). The origins of feeders supplying HCCs in the Spiegel lobe (SP; n = 36), the paracaval portion (PC; n = 38), and the caudate process (CP; n = 14) were also analyzed. RESULTS: One hundred sixteen feeders were identified: 11 (9.5%) arose from R(1); 21 (18.1%) arose from R(2); nine arose (0.9%) from L(1); 15 (12.9%) arose from L(2); 24 (20.7%) arose from A; 25 (21.6%) arose from P; seven (6.0%) arose from M; one (0.9%) arose from Ph; and three (2.6%) arose from Ex. HCCs in the SP and the PC were fed by feeders from both hepatic arteries (the ratios of right to left were 3:2 and 3:1, respectively), and HCCs in the CP were dominantly fed by feeders from the right hepatic artery. CONCLUSION: The caudate artery most frequently arises from the right hepatic artery, followed with almost equal frequency by the left hepatic, the anterior segmental, and the posterior segmental artery. The origins of the caudate arteries differ according to the subsegmental locations.

Complex comprised of dextran magnetite and conjugated cisplatin exhibiting selective hyperthermic and controlled-release potential.

We developed a dextran-magnetite conjugated cisplatin (DM-Cis) complex for use in thermal ablation and as a chemotherapeutic drug. To produce DM-Cis we reacted Cis with 1 mL DM (56 mg/mL iron). The temperature rise of DM-Cis was measured in vitro and in vivo under a portable induction-heating (IH) device. Platinum desorption from DM-Cis over 24 hours was measured in bovine serum. In in vivo accumulation and magnet and exothermic experiments we used four rat groups. In group 1 we delivered DM-Cis intraperitoneally (ip) and placed magnets subcutaneously (sc). In group 2 we injected saline (ip) and placed magnets (sc). In group 3 we injected DM-Cis (ip) and placed a sc incision (sham). The control (group 4) received an ip injection of saline. Rectus abdominis muscle tissue was stained with hematoxylin-eosin and iron-stained tissue areas (µm(2)) were calculated. The maximum platinum concentration in DM-Cis was approximately 105.6 µg/mL. Over 24 hours, 33.48% of platinum from DM-Cis was released. There was a significant difference (P < 0.05) in the iron-stained area between group 1 and the other groups. The temperature in muscle tissue registered a maximum of 56°C after about 4 min. DM-Cis may represent a magnetically-accumulated anticancer drug with hyperthermic effects.

Advanced hepatocellular carcinoma treated effectively with irinotecan via hepatic arterial infusion followed by proton beam therapy.

We report a 48-year-old man with hepatocellular carcinoma (HCC) treated with hepatic arterial infusion (HAI) chemotherapy followed by proton beam therapy. The HCC lesion in this patient was 88 mm in diameter, with portal vein tumor thrombosis in the right lobe of the liver. He was first treated with 5-fluorouracil, cisplatin, and isovorin, administered by HAI, combined with interferon-alpha, and he was subsequently treated with epirubicin and mitomycin-C administered by HAI. However, no definite efficacy of either of these treatments was observed. Then, after 3 weeks' continuous administration of irinotecan by HAI, the tumor size decreased to 68 mm in diameter. However, 3 months after reduction of the tumor, the tumor had become enlarged to 100 mm in diameter and intrahepatic metastases were prominent. Angiographic findings indicated that the HCC was fed not only from the right hepatic artery but also from the left gastric and right and left subphrenic arteries. After rearrangement of the arteries, and 3 months' continuous HAI chemotherapy with irinotecan, plus hyperthermia, the tumor size had decreased to 50 mm in diameter. The reduction rate of the main tumor according to the Response Evaluation Criteria in Solid Tumors was 43%; therefore, the efficacy of this treatment was judged as a partial response. Two months after reduction of the tumor, the patient's serum alpha-fetoprotein (AFP) level was elevated, and so docetaxel was administered by HAI instead of irinotecan. The liver tumors showed gradual enlargement during the administration of docetaxel, although the AFP level was suppressed. Proton beam therapy was instituted and the liver tumors showed necrosis after this therapy. The patient died of hepatic failure and distant metastases 6 years after the onset of HCC. As far as we know, this is the first case report of HCC treated effectively with irinotecan administered by HAI followed by proton beam therapy in which tumor suppression and the long-term survival of the patient were observed.

Selective induction hyperthermia following transcatheter arterial embolization with a mixture of nano-sized magnetic particles (ferucarbotran) and embolic materials: feasibility study in rabbits.

PURPOSE: To evaluate the possibility of selective hyperthermia following transcatheter arterial embolization (TAE) with ferucarbotran using a newly developed inductive heating (IH) device. MATERIALS AND METHODS: Twelve Japanese white rabbits were separated into four groups: those treated with TAE using a mixture of ferucarbotran and lipiodol (F-L group); those treated with ferucarbotran and gelatin sponge powder; those treated with saline and lipiodol; and a control group. These four groups received IH. Nine rabbits with renal VX2 carcinoma were separated into three groups: IH after TAE (IH-TAE tumor), TAE without IH (TAE tumor), and no treatment (control tumor). The temperature of the tumor was kept at 45 degrees C for 20 min. The therapeutic effect was pathologically evaluated by TUNEL staining. RESULTS: In the heating rates of the kidney, the F-L group showed significantly greater values than the group in which iron was not used. In the IH-TAE tumor group, tumors could be selectively heated. In TUNEL staining, the IH-TAE tumor and TAE tumor groups showed significantly greater values of apoptosis rate than in the control tumor group. CONCLUSION: IH following TAE with a mixture of ferucarbotran and lipiodol was capable of inducing selective hyperthermia with our device. However, further investigation is needed to confirm its safety and effectiveness in the treatment of malignant neoplasms in humans.

Ultraselective transcatheter arterial chemoembolization with a 2-f tip microcatheter for small hepatocellular carcinomas: relationship between local tumor recurrence and visualization of the portal vein with iodized oil.

PURPOSE: To retrospectively evaluate the relationship between local tumor recurrence and iodized oil deposition in the portal vein by using ultraselective transcatheter arterial chemoembolization (TACE) for small hepatocellular carcinoma. MATERIALS AND METHODS: One-hundred twenty-three tumors smaller than 5 cm in diameter (mean diameter, 1.9 cm; median diameter, 1.6 cm) were treated with TACE by using a 2-F tip microcatheter at a distal portion of the subsegmental artery of the liver. Portal vein visualization at spot radiography during TACE was divided into three grades, as follows: 0 = not visualized, 1 = limited near the tumor, and 2 = whole or extended to the embolized area. Local recurrence rates of each grade group were compared. The recurrent pattern was divided into intratumoral and peritumoral recurrence. Complications were also analyzed. RESULTS: Of the 123 tumors, 53 (43.1%) were classified as grade 2, 52 (42.3%) were classified as grade 1, and 18 (14.6%) tumors were classified as grade 0. Overall local recurrence rates at 12, 24, and 36 months were 25.6%, 34.7%, and 34.7%, respectively. The local recurrence rates for the grades 2, 1, and 0 groups were 7.9%, 24.8%, and 85.7%, respectively, at 12 months and 17.7%, 38.9%, and 85.7% at 24 months. Recurrence rates in the grade 2 group were significantly lower than those in the grades 1 and 0 groups (P = .0485 and P < .0001, respectively). Intratumoral recurrence was observed in 21 tumors, most of which were in the grade 0 group. Peritumoral recurrence was noted in 16 tumors, most of which were in the grade 2 group. There were no major complications. CONCLUSION: Ultraselective TACE was safe and effective in a significant number of tumors. In particular, local recurrence was significantly lower when a greater degree of portal vein visualization was demonstrated during TACE.

Bronchial artery aneurysm embolization with NBCA.

We present a case of asymptomatic bronchial artery aneurysm that formed a fistula with part of the pulmonary artery (there was no definite fistula with the pulmonary vein). We were able to catheterize the feeding vessel but could not reach the aneurysm. We therefore injected a mixture of N-butyl-2-cyanoacrylate (NBCA; Histoacryl, B. Braun, Melsungen, Germany) and iodized oil (Lipiodol; Guerbet, Aulnay-sous-Bois, France) from the feeding vessel. The fistula, aneurysm, and feeding vessel were almost totally occluded. After embolization, the patient coughed a little; there were no other definite side effects or complications. One and 3 months later, on chest CT, the aneurysm was almost completely occupied with hyperattenuating NBCA-Lipiodol embolization. NBCA is a liquid embolization material whose time to coagulation after injection can be controlled by diluting it with Lipiodol. It is therefore possible to embolize an aneurysm, feeding vessels, and efferent vessels (in our case, it was a fistula) by using an NBCA-Lipiodol mixture of an appropriate concentration, regardless of whether the catheter can reach the aneurysm or not.

Extrahepatic blood supply to hepatocellular carcinoma: angiographic demonstration and transcatheter arterial chemoembolization.

PURPOSE: To evaluate the incidence of each extrahepatic collateral pathway to hepatocellular carcinoma (HCC) and to assess technical success rates and complications of transcatheter arterial chemoembolization (TACE) through each collateral. METHODS: We retrospective evaluated extrahepatic collateral pathways to HCC on angiography in 386 procedures on 181 consecutive patients. One hundred and seventy patients had previously undergone TACE. TACE through extrahepatic collaterals using iodized oil and gelatin sponge particles was performed when a catheter was advanced into the tumor-feeding branch to avoid nontarget embolization. RESULTS: A single collateral was revealed in 275 TACE procedures, two were revealed in 74, and three or more were revealed in 34. Incidences of collateral source to HCC were 83% from the right inferior phrenic artery (IPA), 24% from the cystic artery, 13% from the omental artery, 12% from the right renal capsular artery (RCA) and left IPA, 8% from the right internal mammary artery (IMA) and right intercostal artery (ICA), and 7% from the right inferior adrenal artery (IAA). Technical success rates of TACE were 53% in the right ICA, 70% in the cystic artery, 74% in the omental artery, 93% in the left IPA, 96% in the right IPA, and 100% in the right RCA, right IMA, and right IAA. Complications included skin necrosis after TACE through the right IMA (n = 1), cholecystitis after TACE through the cystic artery (n = 1), and ulcer formation after TACE through the right gastric artery (n = 1), in addition to pleural effusion and basal atelectasis after TACE through the IPA and IMA. CONCLUSION: Our study suggests that TACE through extrahepatic collaterals is possible with high success rates, and is also relatively safe.

Arterial blood supply to the posterior aspect of segment IV of the liver from the caudate branch: demonstration at CT after iodized oil injection.

PURPOSE: To retrospectively evaluate the arterial blood supply to the posterior aspect of segment IV of the liver with computed tomography (CT) after transcatheter arterial chemoembolization (TACE) with iodized oil through the caudate arterial branch of the liver for treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Institutional review board approval and patient informed consent were not required for this retrospective study. Twenty-four patients (11 men and 13 women; mean age, 68 years) with HCC originating in the caudate lobe (n = 23) or posterior aspect of segment IV (n = 1) were selected. TACE of the caudate arterial branch was performed in all patients, including one patient with HCC in the posterior aspect of segment IV who underwent TACE of the caudate arterial branch after CT helped confirm that iodized oil was not distributed in the tumor after TACE of the medial segmental artery. The distribution of iodized oil in the posterior aspect of segment IV was analyzed with CT 1 week after TACE. The number and origin of all arteries supplying the caudate lobe and the number of arteries embolized were determined. RESULTS: Thirty-three caudate arterial branches were embolized. Twenty-nine branches were derived from the right hepatic artery and four were derived from the left hepatic artery. A single branch was seen in 17 patients, two branches were seen in five, and three branches were seen in two. Eight patients simultaneously underwent additional TACE of branches of the right hepatic artery (n = 6) or right inferior phrenic artery (n = 2). At CT, iodized oil was seen to be distributed entirely (n = 19) or partially (n = 5) in the caudate lobe. Distribution of iodized oil at the posterior aspect of segment IV was observed in 16 patients (67%), including 13 (54%) whose caudate arterial branches were derived entirely from the right hepatic artery. CONCLUSION: The results of this study suggest that the caudate arterial branch, which is mainly derived from the right hepatic artery, frequently supplies the posterior aspect of segment IV. This knowledge is important for managing HCC in the posterior aspect of segment IV by means of TACE.

Combined use of an occlusion balloon catheter and a microcatheter for embolization of the unselectable right inferior phrenic artery supplying hepatocellular carcinoma.

We report the combined use of an occlusion balloon catheter and a microcatheter for transcatheter arterial embolization (TAE) of hepatocellular carcinoma (HCC) fed by the unselectable right inferior phrenic artery (IPA). In one case, HCC was fed by the reconstructed right IPA via a small branch arising from the proximate portion of the celiac artery. In another, the tumor was fed by the right IPA that had been previously embolized with coils. TAE was successfully performed through a microcatheter placed in the celiac artery immediately proximal to the occluding balloon catheter of the celiac trunk and coil embolization of the left gastric artery.