Embolization for Thoracic Duct Collateral Leakage in High-Output Chylothorax After Thoracic Surgery.

PURPOSE: This study was designed to investigate thoracic duct collateral leakage and the supply route of lymphatic fluid by lymphangiography and transcatheter thoracic ductography and to evaluate the results of embolization for thoracic duct collateral leakage performed to cut off this supply route. METHODS: Data were retrospectively collected from five patients who underwent embolization for thoracic duct collateral leakage in persistent high-output chylothorax after thoracic surgery. Extravasation of lipiodol at the ruptured thoracic duct collaterals was confirmed in all patients on lymphangiography. Transcatheter thoracic ductography was used to identify extravasation of iodinated contrast agent and to identify communication between the thoracic duct and leakage site. Thoracic duct embolization (TDE) was performed using the percutaneous transabdominal approach to cut off the supply route using N-butyl cyanoacrylate (NBCA) mixed with lipiodol (1:5-1:20). RESULTS: Clinical success (drainage volume ≤10 mL/kg/day within 7 days after TDE) was achieved in all patients. The collateral routes developed as consequence of surgical thoracic duct ligation. In three patients, NBCA-Lipiodol reached the leakage site through direct communication between the thoracic duct and the ruptured lymphatic duct. In the other two patients, direct communication and extravasation was not detected on thoracic ductography, and NBCA-Lipiodol did not reach the leakage site. However, NBCA-Lipiodol did reach the cisterna chyli, lumbar trunks, and some collateral routes via the cisterna chyli or lumbar lymphatics. As a result, leakage was stopped. CONCLUSIONS: TDE was effective for the management of leakage of the collaterals in high-output chylothorax after thoracic surgery.

Intranodal lymphangiogram: technical aspects and findings.

PURPOSE: To report the technical results and imaging findings of intranodal lymphangiogram (INL). MATERIALS AND METHODS: we studied four patients (three men, one woman) who had persistent chylous leakage despite conservative treatment after esophageal cancer surgery. Their mean age was 68 years (range 61-74 years). The inguinal or femoral lymph node was punctured under ultrasound guidance using a 60-mm-long, 23-gauge needle. If the lipiodol injected via the needle showed granular nodules on fluoroscopy, lipiodol injection was continued manually at a rate of 1 mL/3 min for INL. If the cisterna chyli was detectable on the lymphangiogram, it was punctured percutaneously via the abdomen by a needle under fluoroscopy, and thoracic duct embolization was performed. RESULTS: INL was successful in all patients. Lymphaticovenous anastomoses at the femoral or pelvic region were confirmed in all four patients. In one case, a different ipsilateral lymph node was punctured because major flow of lipiodol into the veins through a lymphaticovenous anastomosis occurred. Catheter cannulation and embolization were successful for three of the four patients. In unsuccessful procedures, the cisterna chyli was not visualized, and puncture was not possible. CONCLUSIONS: INL succeeded in all patients. Lipiodol leaked into the vein through a lymphaticovenous anastomosis at the femoral or pelvic region in all patients.

Intra-arterial infusion of thrombin: animal experiments.

PURPOSE: Thrombin inhibits cadherin on vascular endothelial cells, rapidly and reversibly increasing endothelial permeability. The purpose of this study was to evaluate the feasibility of trans-arterial infusion with thrombin. MATERIAL AND METHODS: Ten rabbits with right thigh tumor were randomly divided into two groups: A thrombin group and a control group. In the thrombin group, a suspension of thrombin (300 IU), cisplatin (3 mg), lipiodol (0.3 ml) and iopamidol (0.3 ml) was infused into the right femoral artery. In the control group, a suspension of cisplatin, lipiodol and iopamidol was infused. Platinum concentrations in plasma were measured five and ten minutes after administration. Platinum concentrations were also measured in tumor specimens excised 30 minutes after infusion. RESULTS: At both five and ten minutes after infusion, platinum concentrations in plasma were significantly lower for the thrombin group than for the control group. Platinum concentration in tumor tissue was significantly higher for the thrombin group than for the control group. CONCLUSION: The present results suggest that transarterial infusion with thrombin may offer a number of pharmacological advantages.

A prospective randomized controlled trial of preoperative whole-liver chemolipiodolization for hepatocellular carcinoma.

BACKGROUND: We previously reported that preoperative chemolipiodolization of the whole liver is effective for reducing the incidence of postoperative recurrence and prolonging survival in patients with resectable hepatocellular carcinoma (HCC). The present randomized controlled trial was performed to evaluate the influence of preoperative transcatheter arterial chemoembolization (TACE) on survival after the resection of HCC. METHODS: Operative results and long-term outcome were prospectively compared among 42 patients who received only selective TACE targeting the tumor (selective group), 39 patients who received TACE targeting the tumor plus chemolipiodolization of the whole liver (whole-liver group), and 43 patients without preoperative TACE or chemolipiodolization (control group). RESULTS: There were no serious side effects of TACE or chemolipiodolization and the operative outcomes did not differ among the three groups. Even though preoperative TACE induced complete tumor necrosis, there were no significant differences in the pattern of intrahepatic recurrence or the time until recurrence among the three groups. There were also no significant differences in disease-free survival or overall survival among the three groups, even among patients with larger tumor size. CONCLUSION: These results indicate that preoperative selective TACE and whole-liver chemolipiodolization plus TACE do not reduce the incidence of postoperative recurrence or prolong survival in patients with resectable HCC.

Water-soluble polyvinyl alcohol microspheres for temporary embolization: development and in vivo characteristics in a pig kidney model.

PURPOSE: To preliminarily examine whether solubility of water-soluble polyvinyl alcohol (PVA) microspheres in blood plasma changes in proportion to their degrees of saponification. The study also examined their feasibility as a temporary embolic agents in the pig renal artery. MATERIALS AND METHODS: Three types of PVA microspheres with the degrees of saponification of 97 mol% (S97), 98 mol% (S98), and 99 mol% (S99) were prepared. Seven kidneys in seven miniature pigs were embolized and divided into three groups so there would be at least two kidneys for each type of PVA. One animal in each group was euthanized immediately after angiography at 3 hours after embolization and the other one at 7 days after. In addition, one animal embolized with S99 microspheres was euthanized at 21 days after embolization. RESULTS: With S97 microspheres, the vascular network had recovered to the preembolic state by 3 hours after embolization. With S98 microspheres, blood flow in the third-order branch had been restored in the same period. With S99 microspheres, the second- and lower order branches remained occluded until 21 days. Histopathologic specimens harvested at 3 hours revealed only a trace of PVA for S97 microspheres. With S98 microspheres, the vascular lumen was still found to be filled with PVA gel. With S99 microspheres, swollen microspheres densely filled the vascular lumen even on day 21. CONCLUSIONS: Dissolution process in vitro and the duration of arterial occlusion in vivo were possibly related to the degree of saponification of PVA. This result may support feasibility of PVA microspheres as a temporary embolic agent.

Pancreatitis after transcatheter embolization of a splenic aneurysm.

A 52-year-old woman was treated for a splenic aneurysm that was found on abdominal computed tomography (CT) during a preoperative assessment for rectal cancer. The aneurysm was embolized using the "double coil-delivered microcatheter technique," and 4 ml of a mixture of N-butyl 2-cyanoacrylate (NBCA) and iodized oil (Lipiodol) (NBCA/Lipiodol = 1.0: 2.5) were injected into the aneurysm. The patient complained of left upper quadrant abdominal pain immediately after the procedure. A blood test 2 days after the procedure showed an increased white blood cell count (13,100/microl), C-reactive protein (13.36 mg/dl), and pancreatic amylase (428 U/l). Abdominal CT scan showed a huge cystic lesion at the pancreatic tail, in the center of which was a highly enhanced area due to accumulated NBCA-Lipiodol. Postembolization pancreatitis was diagnosed, and treatment with fasting and a drip infusion of nafamostat mesilate was started. The patient's abdominal pain became less severe within 3 days, and the pancreatic enzyme level had normalized 14 days after treatment. On CT, the cystic lesion at the pancreatic tail was smaller 20 days after the procedure, and it had disappeared completely 75 days after the procedure.

Surgical results after preoperative chemoradiation therapy for patients with pancreatic cancer.

OBJECTIVES: The results of surgical therapy alone for pancreatic cancer are disappointing. We explored surgical results after neoadjuvant chemoradiation therapy (NACRT) for patients with pancreatic cancer that extended beyond the pancreas. METHODS: Sixty-eight consecutive patients with pancreatic cancer who underwent pancreatic resection were included. Twenty-seven patients underwent surgical resection after NACRT (NACRT group). The other 41 patients were classified as surgery-alone group. Surgical results were compared in patients who underwent curative resection (R0/1) who were followed up for at least 25 months and underwent no adjuvant therapy. RESULTS: A lower frequency of lymph node metastasis was observed in the NACRT group (P < 0.05). The frequency of residual tumor grading in the NACRT group was significantly different from that in surgery-alone (R0/1/2%, 52/15/33 vs 22/51/27; P = 0.0040). In R0/1 cases, overall survival and disease-free survival rates in the NACRT group (n = 18) were significantly longer than in surgery-alone (n = 30, P < 0.05). The rate of local recurrence in the NACRT group was significantly less than in surgery-alone (11% vs 47%, P = 0.0024). CONCLUSIONS: This single-institution experience indicates that NACRT is able to increase the resectability rate with clear margins and to decrease the rate of metastatic lymph nodes, resulting in improved prognosis of curative cases with pancreatic cancer that extended beyond the pancreas.

A case of spontaneous regression of hepatocellular carcinoma with multiple lung metastases.

Spontaneous regression of hepatocellular carcinoma (HCC) is a rare phenomenon. We present herein the case of a patient with hepatocellular carcinoma with multiple lung metastases in whom malignancy spontaneously regressed after taking Pheliinus linteus Mycelium. A 79-year-old man consulted our hospital complaining of epigastric discomfort. Abdominal MRI and CT revealed a 3 cm diameter tumor in the liver, and chest CT showed numerous nodular lesions. The levels of alpha-fetoprotein (AFP) and protein induced by vitamin K deficiency or antagonist-II (PIVKA-II) were very high. We diagnosed HCC with multiple lung metastases, and no therapy was performed. Independently he took exact from Phellinus linteus Mycelium for one month, and 6 months later the tumors appeared to be in complete regression. The mechanism underlying this intriguing phenomenon remains unknown.

Preoperative chemolipiodolization of the whole liver for hepatocellular carcinoma.

BACKGROUND: Preoperative transarterial chemoembolization is not routinely recommended before hepatectomy for resectable hepatocellular carcinoma. This study evaluated the effect of preoperative whole-liver chemolipiodolization. PATIENTS AND METHODS: A retrospective comparison of background characteristics, operative results and long-term outcome was performed between 36 patients with chemolipiodolization confined to the tumor (selective group) and 23 patients with chemolipiodolization also involving the noncancerous liver (whole-liver group). RESULTS: There were no serious side-effects in either group and the operative outcome did not differ between the two groups. Tumor diameter was significantly greater in the selective group, but other pathological characteristics were comparable. The 5-year disease-free and overall survival rates for the selective and whole-liver groups were 11.9% and 33.0% (p=0.0191) and 44.9% and 73.2% (p=0.0121), respectively. CONCLUSION: These results indicate that preoperative whole-liver chemolipiodolization reduces postoperative recurrence and prolongs survival in patients undergoing resection of hepatocellular carcinoma.