Balloon-Occluded Trans-Arterial Chemoembolization Technique with Alternate Infusion of Cisplatin and Gelatin Slurry for Small Hepatocellular Carcinoma Nodules Adjacent to the Glisson Sheath.

OBJECTIVE: It is difficult to control small hepatocellular carcinoma (HCC) nodules adjacent to the Glisson sheath (GS) by trans-arterial chemoembolization (TACE) probably due to multiple small tumor feeders directly branching from the trunk artery. The purpose of this study was to conduct a retrospective evaluation of a new TACE technique called the repeated alternate infusion of cisplatin solution and gelatin slurry distal to balloon occlusion (RAIB-TACE), for the treatment of small HCC nodules adjacent to GS. MATERIALS AND METHODS: Small nodules less than 4 cm attached to proximal portion of the subsegmental to lobar level portal branch were retrospectively selected. Between January 2011 and April 2014, 29 nodules in 29 patients were treated by super-selective lipiodol TACE/balloon-occluded TACE (B-TACE) (Lip-TACE group). Since April 2014, treatment protocols for small nodules adjacent to GS were changed, and 14 nodules in 12 patients were treated by RAIB-TACE (RAIB-TACE group). In RAIB-TACE group, alternate infusion of cisplatin solution and sparse gelatin slurry (mixture of 80 mg of gelatin fragments and 20 mL of contrast medium) were repeated until arterial flow was ceased. In Lip-TACE group, lipiodol was used as drug carrier and dense gelatin slurry (mixture of 80 mg of gelatin fragments and 2 mL of contrast medium) as embolization material. Dynamic CT/MRI was obtained 1-3 months after TACE, and response of each nodule was evaluated basing on modified RECIST criteria. RESULTS: In RAIB-TACE group, all 14 nodules (100%) were diagnosed as CR or PR. In Lip-TACE group, 18 of 29 (62.1%) were diagnosed as CR or PR. There was a statistically significant difference in objective response ratio between the groups (p=0.008, Fisher's test). Biloma (n=1) and benign stricture of the right hepatic duct (n=1) were seen in RAIB-TACE group. The biloma shrunk without treatment and the patient had no symptom, but the patient with biliary stricture repeated cholangitis and was treated by administration of antibiotics. CONCLUSION: The study results show that RAIB-TACE is more effective than lipiodol TACE/B-TACE for small hepatocellular carcinoma adjacent to GS. We speculate that one of the reasons to explain why Lip-TACE is inferior to RAIB-TACE is that viscous lipiodol or dense gelatin slurry could not flow into small tumor feeders effectively.

Development of Conventional Transarterial Chemoembolization for Hepatocellular Carcinomas in Japan: Historical, Strategic, and Technical Review.

OBJECTIVE: This article reviews the development of transarterial chemoembolization (TACE) in Japan, particularly ethiodized oil-based conventional TACE, from historical, strategic, and technical points of view. We also present the current status of standardized conventional TACE. CONCLUSION: Conventional TACE has been developed toward a more-selective and hemodynamic-conscious method, along with technical innovation and knowledge accumulation. Standardization of this method is necessary for further scientific evaluation.

Dense accumulation of lipiodol emulsion in hepatocellular carcinoma nodule during selective balloon-occluded transarterial chemoembolization: measurement of balloon-occluded arterial stump pressure.

PURPOSE: To reveal the mechanism of dense accumulation of lipiodol emulsion (LE) in hepatocellular carcinoma (HCC) during selective balloon-occluded transarterial chemoembolization (B-TACE). METHODS: Balloon-occluded arterial stump pressure (BOASP) at the embolization portion was measured during selective B-TACE for 43 nodules in 42 patients. Fluoroscopy and digital subtraction angiography were prospectively observed during selective B-TACE to note whether dense LE accumulation in HCC occurred. The LE concentration ratio of HCC to embolized liver parenchyma (LECHL ratio) was also calculated for each treatment on the basis of the computed tomographic scan obtained immediately after selective B-TACE. The relationships between degree of LE accumulation and the BOASP, as well as the LECHL ratio, were analyzed. RESULTS: Arterial flow beyond the catheter tip was maintained even after balloon inflation. In 39 of 43 treatments, LE inflow into the nontumorous liver parenchyma ceased immediately after LE droplets were filled in arteries of the nontumorous liver parenchyma while LE inflow into the HCC nodule continued (group 1). More dense LE accumulation in HCC nodule was obtained in these 39 treatments. In four treatments, LE inflow both into the nontumorous liver parenchyma and into the HCC nodule continued, and no dense LE accumulation in HCC nodule was observed (group 2). In these four treatments, thick anastomotic vessels with collateral artery were noted. The BOASP in group 1 was (mean ± SD) 33.8 ± 12.8 mmHg (range 13-64 mmHg) and that in group 2 was 92.3 ± 7.4 mmHg (range 83-100 mmHg). There was a statistically significant difference in BOASP between groups (p = 0.00004, Welch's t test). The LECHL ratio in group 1 was 18.3 ± 13.9 (range 2.9-54.2) and that in group 2 was 2.6 ± 1.1 (range 1.7-4.2). There was a statistically significant difference in the LECHL ratio between the groups (p = 0.000034, Welch's t test). CONCLUSION: Selective B-TACE induced dense LE accumulation in HCC nodules in 39 (91 %) of 43 treatments in which BOASP was 64 mmHg or less.