Multidisciplinary Taiwan consensus for the use of conventional TACE in hepatocellular carcinoma treatment.

Developed in early 1980s, transarterial chemoembolization (TACE) with Lipiodol was adopted globally after large-scale randomized control trials and meta-analyses proving its effectiveness were completed. Also known as "conventional TACE" (cTACE), TACE is currently the first-line treatment for patients with unresectable intermediate stage hepatocellular carcinoma (HCC) and delivers both ischemic and cytotoxic effects to targeted tumors. Although new technology and clinical studies have contributed to a more comprehensive understanding of when and how to apply this widely-adopted therapeutic modality, some of these new findings and techniques have yet to be incorporated into a guideline appropriate for Taiwan. In addition, differences in the underlying liver pathologies and treatment practices for transcatheter embolization between Taiwan and other Asian or Western populations have not been adequately addressed, with significant variations in the cTACE protocols adopted in different parts of the world. These mainly revolve around the amount and type of chemotherapeutic agents used, the type of embolic materials, reliance on Lipiodol, and the degree of selectiveness in catheter positioning. Subsequently, interpreting and comparing results obtained from different centers in a systematic fashion remain difficult, even for experienced practitioners. To address these concerns, we convened a panel of experts specializing in different aspects of HCC treatment to devise modernized recommendations that reflect recent clinical experiences, as well as cTACE protocols which are tailored for use in Taiwan. The conclusions of this expert panel are described herein.

Multidisciplinary Taiwan Consensus Recommendations for the Use of DEBDOX-TACE in Hepatocellular Carcinoma Treatment.

Transarterial chemoembolization (TACE) is the first-line treatment in patients with unresectable hepatocellular carcinoma (HCC). In recent years, there has been increasing clinical evidence that drug-eluting beads provide a combined ischemic and cytotoxic effect that may be superior to conventional TACE, with low systemic toxicity. The therapeutic value of TACE performed using the embolic microsphere DC Bead loaded with doxorubicin (drug-eluting bead doxorubicin [DEBDOX]) has been shown by several randomized controlled trials. Since Lencioni et al. [Cardiovasc Intervent Radiol 2012; 35: 980-985] published the first widely accepted technical recommendations on HCC embolization with DEBDOX-TACE in 2012, new studies have contributed to a better understanding of when and how to apply this new therapeutic modality, and they have yet to be incorporated into an updated guideline. Additionally, differences in the underlying liver pathology and practice of transcatheter embolization between Asian and Western populations have not been adequately addressed, and there remain significant variations in the TACE protocols adopted in different parts of the world. These mainly revolve around the number and type of chemotherapeutic agents used, type of embolic material, reliance on Lipiodol, and selectivity of catheter positioning. As a result of these issues, it has been difficult to interpret and compare results obtained from different centers in a systematic fashion. To address these concerns, we convened a panel of experts specializing in different aspects of HCC treatment to craft an updated set of recommendations that better reflect recent clinical experiences and are tailored to the use of DEBDOX-TACE in Taiwan. The conclusions of this expert panel are described in the following article.

Concurrent use of pigtail and loop snare catheters for percutaneous retrieval of dislodged central venous port catheter.

The purpose of this study was to report our experience of percutaneous retrieval of dislodged port catheters with concurrent use of pigtail and loop snare catheters. During a 5-year period at our institute (June 2005 to July 2010), a total of 23 dislodged port catheters were retrieved. The interval between port catheter implantation and dislodged catheter retrieval ranged from 43 days to 1,414 days (mean 586.7 days). The time of delayed retrieval ranged from 1 day to 45 days (mean 4.6 days). All dislodged catheters were retrieved with the concurrent use of pigtail and loop snare catheters via femoral venous route. The prevalence of port catheter dislodgement at our institute was 3.4%. All dislodged port catheters were removed successfully with pigtail and loop snare catheters together. No procedure-related complications were encountered, except for transient arrhythmia in two patients, which required no medication. In conclusion, the concurrent use of pigtail and loop snare catheters is a feasible and easy way for percutaneous retrieval of a dislodged central venous port catheter.

Kaposiform hemangioendothelioma arising from the maxillary sinus: a case report.

Kaposiform hemangioendothelioma is a very infrequent, locally aggressive vascular neoplasm, characterized by fascicular spindle cell proliferation. It occurs almost exclusively in infants and adolescents, and is often associated with Kasabach-Merritt phenomenon. The tumor is predominantly located subcutaneously or in the deep soft tissue of the extremities and trunk, peritoneum, or retroperitoneum. However, this tumor can sometimes be located on the head and neck. We report a case of kaposiform hemangioendothelioma of the maxillary sinus in a 4-month-old female infant presenting with cheek swelling, thrombocytopenia, anemia, and disseminated intravascular coagulation. Sinus computed tomography presented an enhancing, bone-destructing tumor. Magnetic resonance images showed an uncommon appearance as mostly low signal intensity on T2-weighted images.

Anomalous origin of the left anterior descending artery from the main pulmonary artery with multi-detector row computed tomography coronary angiography.

Anomalous origin of the left anterior descending artery from the main pulmonary artery is a rare congenital anomaly of the coronary artery. We present a case report of a 31-year-old male patient with anomalous origin of the left anterior descending artery from the main pulmonary artery that was diagnosed by multi-detector row computed tomography coronary angiography and correlated with conventional angiography. The results indicate that multi-detector row computed tomography plays an important role in the diagnosis of some rare coronary anomalies that conventional angiography cannot clarify.

Quantitative assessment of image quality in 64-slice-computed tomography of coronary arteries in subjects undergoing screening for coronary artery disease.

Accurate and consistent visualization of the entire coronary system with high-grade imaging quality is crucial for routine applications of multi-detector-computed tomography (MDCT) coronary angiography. To determine the imaging quality of 64-slice-MDCT coronary angiography, we respectively explored the quantitative parameters of imaging quality in 105 consecutive subjects (71 men, 34 women; aged 58.66 +/- 10.62 years) who underwent 64-slice-MDCT coronary angiography to screen for coronary disease. The interobserver agreement for semi-quantitative image quality, visible length, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of the coronary arteries was good. The SNR and CNR of the proximal segments of the coronary arteries were superior to that of the distal segments of coronary arteries (p < 0.001). The visible length of the stenosed right coronary artery was significantly shorter than that of the non-stenosed right coronary artery (p = 0.03). The SNR and CNR of the stenosed and non-stenosed coronary arteries revealed no significant difference (p > 0.05). Body weight and body mass index were inversely related to the SNR and CNR of the aorta (p < 0.001). In conclusion, 64-slice-MDCT coronary angiography can provide excellent imaging quality of coronary arteries in subjects undergoing screening for coronary disease, although the SNR and CNR were relatively low at the distal segments of coronary arteries.

Successful catheter ablation of typical atrial flutter in a patient with a long vertical and diverticulum-like cavotricuspid isthmus.

A long vertical vestibule with a diverticulum-like morphology of cavotricuspid isthmus (CTI) was demonstrated by right atrial angiogram in a 47-year-old male patient in whom his typical atrial flutter was difficult to be ablated. Compatible with the right atrial angiography, the diverticulum-like CTI with a long vertical vestibule, pouch-like recess, and a long transverse posterior component was also demonstrated on volume-rendering reconstruction computed tomography and the virtual endoscopy showed prominent trabeculation inside the diverticulum-like part of CTI. The bidirectional CTI conduction block was successfully achieved after ablating along the CTI guided by the right atrial angiography.

Virtual intraluminal evaluation of aortico-left ventricular tunnel by multislice computed tomography.

The aortico-left ventricular tunnel (ALVT) is a rare abnormal channel that arises from the right coronary sinus through the right ventricular outflow tract to enter the left ventricle below the aortic valve. The unique ability of multislice computed tomography (CT), as applied in the virtual coloscopy, has not been well established in patients with cardiovascular diseases. We herein investigate the virtual intraluminal image in a patient with an ALVT. An 18-year-old male was admitted with a 6-month-long history of progressive exertional dyspnea. He was diagnosed to suffer from ALVT at 5 months of age and received prosthetic patch closure of the aortic opening of the tunnel with mild residual aortic regurgitation. On admission this time, physical examination revealed a grade 3/6 diastolic murmur over the right upper sternal border. A 16-row multislice CT angiography demonstrated an ALVT. In the 3D reconstructed images, the orifice and intraluminal structure of ALVT were clearly visualized at different levels, similar to a real intracardiac endoscopic images. The patient was then referred for aortic valve replacement due to heart failure caused by severe degenerative aortic insufficiency. Our case displayed successfully not only the entire location of ALVT but also demonstrated the virtual intraluminal imaging mimicking endoscopy. This technique provides the virtual visualization of the entire inner image of AVLT, which may not be possible with other imaging modalities.

Septum hematoma: a complication of retrograde wiring in chronic total occlusion.

In spite of the remarkable technological innovation and improved outcomes with percutaneous coronary intervention (PCI), chronically total occlusion in coronary arteries (CTO) remains a formidable challenge for coronary interventionalist. Recently Japanese interventionists have proposed a retrograde wiring technique which provides another way to resolve such difficulties. The retrograde wire in the distal CTO vessel can then be used as a clear landmark in the distal true lumen, facilitating antegrade wiring and possibly increasing the success rate of CTO-PCI. Reported here is a patient who experienced retrograde wire technique but suffered from a complication with septum hematoma and myocardial infarction. The patient had a complete recovery of chest symptoms and resolution of septum hematoma in 1 month. Retrograde wire manipulation should be used as a last resort and via a large collateral vessel in the treatment of CTO.

Early response of hepatocellular carcinoma to transcatheter arterial chemoembolization: choline levels and MR diffusion constants--initial experience.

PURPOSE: To prospectively investigate the apparent diffusion coefficient (ADC) and choline levels measured at hydrogen 1 ((1)H) magnetic resonance (MR) spectroscopy, to monitor therapeutic responses of hepatocellular carcinoma (HCC) to transcatheter arterial chemoembolization (TACE). MATERIALS AND METHODS: Institutional review board approval was obtained, and all patients and control subjects provided informed consent. Histologically proved large HCCs (>3 cm in diameter) were evaluated in 20 patients (16 men and four women; mean age, 59 years; range, 34-80 years) before TACE and 2-3 days after TACE. A control group of eight adults (five men and three women; mean age, 43 years; range, 24-76 years) with normal livers was examined by using the same protocol. Hepatic choline levels were measured by means of an external phantom replacement method, quantifying the peak at 3.2 ppm at (1)H MR spectroscopy. ADCs were measured for all lesions. A Wilcoxon rank sum test was used to compare absolute choline concentrations and ADCs at baseline between HCCs and normal liver parenchyma. Changes in choline levels and ADCs in the tumors before and after TACE were analyzed by using the Wilcoxon signed rank test. RESULTS: The median preoperative choline level in patients with HCC (measured in 18 of the 20 patients) was 4.0 mmol/L (range, 0.0-17.2 mmol/L), which was significantly higher than that in patients with normal livers (n = 8) (median, 1.6 mmol/L; range, 0.0-2.1 mmol/L; P < .01). Among 18 patients with HCC, choline levels decreased significantly from before TACE to after TACE (P < .01). A significant increase in ADC from before TACE to after TACE in the 20 patients with HCC was also found (P < .01). CONCLUSION: Hepatic choline levels and ADCs may allow monitoring of therapeutic responses of HCC to TACE although larger, more definitive and quantitative studies with clinical end points are needed.

Percutaneous vein graft reanastomosis with use of a covered stent to salvage a thrombosed hemodialysis graft.

Technical success rates for percutaneous restoration of thrombosed arteriovenous grafts are high. However, in thrombosed grafts without restorable original outflow veins, percutaneous salvage is usually not possible. In this situation, patients are referred for bypass grafting or recreation of their vascular access sites. This report describes a patient in whom the original outflow vein at the venous anastomosis was completely obliterated and in whom vascular access was successfully salvaged by percutaneously reanastomosing the venous stump of the thrombosed graft with an adjacent patent vein. This procedure is technically feasible for the salvage of a thrombosed graft.

Supraumbilical skin rash and fat necrosis after transcatheter arterial chemoembolization: a case report.

We report the case of a 63-year-old female who had chronic hepatitis C and who was diagnosed with hepatocellular carcinoma. Hepatic angiography showed one visible and tortuous falciform artery arising as the terminal branch of the left hepatic artery. Transcatheter arterial chemoembolization (TACE) was performed via the left hepatic artery. The patient developed supraumbilical skin rash with local tenderness on the following day. After supportive treatment by a dermatologist, the skin rash subsided gradually with sequelae of irregular skin surface and one small subcutaneous nodule. Skin biopsy of the lesion 1 year later showed fat necrosis with foreign body reaction and fibrosis. We discuss this rare complication of TACE and review the literature.

In vivo proton magnetic resonance spectroscopy of large focal hepatic lesions and metabolite change of hepatocellular carcinoma before and after transcatheter arterial chemoembolization using 3.0-T MR scanner.

PURPOSE: To investigate the value of in vivo proton magnetic resonance spectroscopy (MRS) in the assessment of large focal hepatic lesions and to measure the metabolite change of hepatocellular carcinoma (HCC) after transcatheter arterial chemoembolization (TACE) using 3.0-T scanner. MATERIALS AND METHODS: In this prospective study, 43 consecutive patients with large (not less than 3 cm in diameter) hepatic tumors and eight normal volunteer were included. MRS of the lesions in addition to uninvolved liver parenchyma was carried out using a whole-body 3.0-T scanner. Among the patients with proven HCC, eight lesions were evaluated before and two to five days after TACE. The choline-to-lipid (cho/lipid) ratio was measured by dividing the peak area of choline at 3.2 ppm by the peak area of lipid at 1.3 ppm. The sensitivity and specificity profiles of MRS in the diagnosis of malignant hepatic tumors were determined by plotting empirical receiver operating characteristic (ROC) curve. The mean cho/lipid ratios in different groups before and after TACE were also measured. RESULTS: The technical success rate for MRS was 90% (53/59). The ROC curve showed proton MRS has moderate discriminating ability in diagnosing malignant hepatic tumors, although the sensitivity was less than 50% while 1-specificity was less than 20%. The area under the curve was 0.71 (P < 0.05). The mean +/- 1 standard error (SE) of cho/lipid ratios for uninvolved liver (N = 8), benign tumor (N = 8), and malignant tumor (N = 21; 19 HCC, one angiosarcoma, and one lymphoma) were 0.06 +/- 0.02, 0.02 +/- 0.02, and 0.17 +/- 0.05, respectively. A significantly statistical difference (ANOVA planned contrast test, P = 0.01 and Games-Howell procedure, P = 0.03) was achieved in the mean cho/lipid ratio between malignant and benign tumors. The mean cho/lipid ratios were significantly decreased from 0.23 +/- 0.11 before TACE to 0.01 +/- 0.00 after the treatment (t = 2.01, P < 0.05, one-tail paired t-test; z = -2.37, P < 0.05, Wilcoxon Signed Ranks Test). CONCLUSION: In vivo proton MRS is technically feasible for the evaluation of focal hepatic lesions. The technique has potential in the detection of early metabolite change in malignant liver tumors after TACE but limitation still exists in clear differentiation between normal liver and benign and malignant tumor.