Stent Graft Placement for Injured Visceral Artery.

Injury of the visceral artery is a potentially fatal complication of iatrogenic procedures, trauma, and tumors. A stent graft can achieve rapid exclusion of the injured arterial portion and minimize the risk of ischemic complications by preserving arterial flow to organs. Although various types of stent grafts are available worldwide, Viabahn has only been approved for visceral arterial injury in Japan. The reported technical and clinical success rates, including cases with injured pelvic or thoracic arterial branches, are 80%-100% and 66.7%-100%, respectively. Severe ischemic complications are rare; however, fatal ischemia occurs when the stent graft is immediately occluded. The necessity of antiplatelet therapy is controversial, and a target artery diameter ≤ 4 mm is a significantly higher risk factor of stent-graft occlusion.

Protocol for a multicentre, prospective observational study of elective neck dissection for clinically node-negative oral tongue squamous cell carcinoma (END-TC study).

INTRODUCTION: In early-stage oral tongue squamous cell carcinoma (OTSCC), elective neck dissection (END) is recommended when occult lymph node metastasis is suspected; however, there is no unanimous consensus on the risks and benefits of END in such cases. The management of clinically node-negative (cN0) OTSCC remains controversial. This study, therefore, aimed to evaluate the efficacy of END and its impact on the quality of life (QoL) of patients with cN0 OTSCC. METHODS AND ANALYSIS: This is a prospective, multicentre, nonrandomised observational study. The choice of whether to perform END at the same time as resection of the primary tumour is based on institutional policy and patient preference. The primary endpoint of this study is 3-year overall survival. The secondary endpoints are 3-year disease-specific survival, 3-year relapse-free survival and the impact on patient QoL. Propensity score-matching analysis will be performed to reduce selection bias. ETHICS AND DISSEMINATION: This study was approved by the Clinical Research Review Board of the Nagasaki University. The protocol of this study was registered at the University Hospital Medical Information Network Clinical Trials Registry. The datasets generated during the current study will be available from the corresponding author on reasonable request. The results will be disseminated internationally, through scientific and professional conferences and in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER: UMIN000027875.

Percutaneous sclerotherapy using a 4 F pigtail catheter and 40 milliliters of 5% ethanolamine oleate for symptomatic large hepatic cysts.

PURPOSE We retrospectively evaluated the efficacy of percutaneous sclerotherapy using a 4 F catheter and 40 mL of 5% ethanolamine oleate (EO) for symptomatic large hepatic cysts. METHODS Twenty-four patients, including 10 with polycystic liver disease (PLD), were eligible. The mean long- and short-axis diameters of the cyst on computed tomography (CT) were 145.0 ± 35.5 mm (range, 72-216 mm) and 110.5 ± 21.4 mm (range, 63-150 mm), respectively. After aspiration of the fluid contents using a 4 F pigtail catheter, 40 mL of 5% EO was injected into the cyst for 30 min. Then, the catheter was withdrawn after EO removal. Symptomatic relief and complications were evaluated. The percentage reductions at the early (1-3 months later) and late (at the final follow-up) responses were evaluated using an estimated cyst volume calculated by using the following formula: volume = π/6 × long-axis diameter × (short-axis diameter)2 on the maximum cross-section image on CT. Spearman's rank correlation coefficient (ρ) was used to evaluate the correlation between the pretreatment estimated cyst volume and percentage reduction of early and late responses and between the percentage reduction of the late response and length of the follow-up period after sclerotherapy. RESULTS The symptoms disappeared in 23 patients and improved in 1 patient with PLD. The mean aspirated fluid volume was 1337.8 ± 845.4 mL (range, 140-3200 mL). In 1 patient, EO injection was postponed until the second procedure was performed 40 days later due to intraperitoneal leakage of contrast material. In another patient, the EO volume was reduced to 20 mL because of a small cyst size. The mean early and late percentage reductions of the treated cyst were 52.3% ± 23.8% and 87.5% ± 20.4% (mean follow-up period: 48.0 ± 42.4 months), respectively. The symptom recurred in 2 patients with PLD and 1 underwent additional sclerotherapy 14 months later due to re-enlargement of the treated cyst. Another patient underwent transarterial embolization 5 years and 4 months later for other enlarged cysts, although the treated cyst markedly shrank. There were significant negative correlations between the pretreatment estimated cyst volume and percentage reduction of early (P = .027, ρ = - 0.46) and late (P= .007, ρ = - 0.52) responses. However, there were no significant correlations between the percentage reduction and length of the follow-up period (P = .19, ρ = 0.31). Transient pain developed in 1 patient and low-grade fever in 3. CONCLUSION Sclerotherapy using a 4 F catheter and 40 mL of 5% EO is safe and effective for symptomatic large hepatic cysts.

Determination of Significant Prognostic Factors for Maxillary Gingival Squamous Cell Carcinoma in 90 Cases.

Maxillary gingival squamous cell carcinoma (MGSCC) occurs rather infrequently, compared to tongue and mandibular gingival carcinomas, among the cancers of the oral cavity. Therefore, significant numbers of MGSCC cases have not been statistically analysed. The aim of this study is to clarify the prognostic factors for MGSCC. We performed the statistical analysis of 90 MGSCC cases primarily treated in our department from 1999 to 2014. The patients (male: 36, female: 54) were aged between 38 and 93 years, and the mean age was 68.7 years. The number of patients in each tumour stage according to the TNM classification was as follows: T1: 15 cases, T2: 32 cases, T3: 13 cases, and T4: 30 cases. Forty-two patients were treated only by surgery, 5 only by radiotherapy, 3 by preoperative radiotherapy and surgery, and 40 patients were treated by combination therapy with preoperative chemoradiotherapy and surgery. Neck dissections were performed in 40 cases including 29 cases (11 primary and 18 secondary cases) of histopathologically diagnosed lymph node metastases. Extranodal extension was found in 74.3% cases with metastatic lymph nodes. The 5-year overall survival rate was 81.9%. In univariate analysis, the site of occurrence, stage of tumour, lymph node metastasis, and treatment contributed to the 5-year survival rate. Multivariate analysis demonstrated that the site of occurrence (posterior region) was an independent prognostic factor. Seventeen deaths occurred due to the primary disease, while three deaths were caused by other diseases. The posterior region cancers, according to the classification based on site of occurrence, were independent predictors of poor 5-year overall survival rate.

Efficacy of Superselective Conventional Transarterial Chemoembolization Using Guidance Software for Hepatocellular Carcinoma within Three Lesions Smaller Than 3 cm.

The indication of transarterial chemoembolization (TACE) has advanced to hepatocellular carcinoma (HCC) of Barcelona Clinic Liver Cancer (BCLC) stage A when surgical resection (SR), thermal ablation, and bridging to transplantation are contraindicated; however, TACE for small HCC is frequently difficult and ineffective because of less hypervascularity and the presence of tumor portions receiving a dual blood supply. Here, we report outcomes of superselective conventional TACE (cTACE) for 259 patients with HCCs within three lesions smaller than 3 cm using guidance software. Automated tumor feeder detection (AFD) functionality was applied to identify tumor feeders on cone-beam computed tomography during hepatic arteriography (CBCTHA) data. When it failed, the feeder was identified by manual feeder detection functionality and/or selective angiography and CBCTHA. Regarding the technical success in 382 tumors (mean diameter, 17.2 ± 5.9 mm), 310 (81.2%) were completely embolized with a safety margin (5 mm wide for HCC ≤25 mm and 10 mm wide for HCC >25 mm). In 61 (16.0%), the entire tumor was embolized but the safety margin was not uniformly obtained. The entire tumor was not embolized in 11 (2.9%). Regarding the tumor response at 2-3 months after cTACE in 303 tumors excluding those treated with combined radiofrequency ablation (RFA) or SR and lost to follow-up, 287 (94.7%) were classified into complete response, seven (2.3%) into partial response, and nine (3.0%) into stable disease. The mean follow-up period was 44.9 ± 27.6 months (range, 1-109) and the cumulative local tumor progression rates at 1, 3, 5, and 7 years were 17.8, 27.8, 32.0, and 36.0%, respectively. The 1-, 3-, 5-, and 7-year overall and recurrence-free survival rates in 175 patients, excluding those with Child-Pugh C class, who died of other malignancies, or who underwent combined RFA or hepatic resection, were 97.1 and 68.7, 82.8 and 34.9, 64.8 and 20.2, and 45.3 and 17.3%, respectively. Our results indicate the efficacy of superselective cTACE using guidance software for HCC within three lesions smaller than 3 cm.

General rules for clinical and pathological studies on oral cancer (2nd edition): a synopsis.

For doctors and other medical staff treating oral cancer, it is necessary to standardize the basic concepts and rules for oral cancer to achieve progress in its treatment, research, and diagnosis. Oral cancer is an integral part of head and neck cancer and is treated in accordance with the general rules for head and neck cancer. However, detailed rules based on the specific characteristics of oral cancer are essential. The objective of this article was to contribute to the development of the diagnosis, treatment, and research of oral cancer, based on the correct and useful medical information of clinical, surgical, pathological, and imaging findings accumulated from individual patients at various institutions. Our general rules were revised as the UICC was revised for the 8th edition and were published as the Japanese second edition in 2019. In this paper, the English edition of the "Rules" section is primarily presented.

Excretion of Necrotic Hepatocellular Carcinoma Tissues into Hepatic Lymphatic Vessels after Conventional Transarterial Chemoembolization.

We report a case of necrotic hepatocellular carcinoma tissue excretion into the hepatic lymphatic system after conventional transarterial chemoembolization (cTACE) in an 80-year-old man with liver cirrhosis. A tumor measuring 19 mm in diameter in segment 5 was successfully treated with superselective cTACE. Hepatic lymphatic vessels were not opacified with iodized oil during the procedure. Computed tomography (CT) performed 1 week after cTACE showed dense accumulation of iodized oil in the tumor and in the surrounding liver without opacification of the hepatic lymphatics. Excretion of necrotic tumor tissues containing iodized oil into the lymphatic system was initially observed on CT 9 months after cTACE and the amount of excreted tumor tissues had increased 2 years and 2 months after cTACE without tumor recurrence or any clinical symptoms.

Cerebral Embolism as a Rare Complication of Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Varices: A Case Report.

We report a case of cerebral embolism caused by balloon-occluded retrograde transvenous obliteration (BRTO) for gastric varices in a 77-year-old woman with liver cirrhosis. Balloon-occluded retrograde venography demonstrated multiple collaterals between the efferent and systemic veins, and some of them could not be embolized with metallic coils. Therefore, they were embolized with ethanol, 50% glucose solution, gelatin sponge particles, and ethanolamine oleate, and BRTO was completed. After BRTO, however, the patient complained of mild aphagia and paralysis of the right fingers, and magnetic resonance imaging demonstrated cerebral embolism. The symptoms gradually improved after the administration of ozagrel sodium and rehabilitation. The varices were also completely thrombosed. Patent foramen ovale was suspected as a cause of cerebral embolism.

Fibrin Glue in Interventional Radiology: How to Use It.

A fibrin glue kit consists of separate solutions of fibrinogen and thrombin that instantly coagulate when mixed together and can be used as an embolic agent and tissue adhesive in several interventional procedures, such as the closure of enterocutaneous, postoperative pancreatic, and bronchopulmonary fistulas, embosclerosis of biloma, and portal vein embolization. Separate and simultaneous injections of fibrinogen and thrombin solutions at the target site are necessary; therefore, insertion of two catheters or a balloon catheter with multiple lumen is required. The combined use of metallic coils is also effective for a large fistula as the coils can provide a matrix for retaining the fibrin glue, in addition to partially occluding the fistulous tract. Mixing contrast medium or iodized oil with a thrombin solution is also key to achieving radiopacity.

Usefulness of virtual parenchymal perfusion software visualizing embolized areas to determine optimal catheter position in superselective conventional transarterial chemoembolization for hepatocellular carcinoma.

AIM: To determine the optimal catheter position during superselective conventional transarterial chemoembolization (cTACE) for hepatocellular carcinoma (HCC) using virtual parenchymal perfusion software. METHODS: Patients who had newly developed HCC nodules ≤6 cm and five or fewer lesions were eligible. The virtual catheter tip was placed on a tumor-feeder identified by TACE guidance software using cone-beam computed tomography during hepatic arteriography to minimize the virtual embolized area (VEA), including the tumor with a safety margin. Conventional transarterial chemoembolization was then carried out at the same position. The VEA and real embolized area where iodized oil was retained on cone-beam computed tomography after cTACE were compared using the dice similarity coefficient, linear regression analysis, and mean surface distance. Technical success of cTACE and therapeutic effects by the modified Response Evaluation Criteria in Solid Tumors were also evaluated. RESULTS: Ninety-one tumors in 56 patients were embolized. The mean dice similarity coefficient values in 80 VEAs and real embolized areas were 0.78 ± 0.01. Both volumes were well correlated (r = 0.957, p < 0.001) with a mean surface distance of 2.78 ± 2.11 mm. Eighty-four (92.3%) tumors were embolized with a safety margin. Regarding the early response of 82 tumors, complete response was achieved in 72 (87.8%), partial response in six (7.3%), and stable disease in four (4.9%). Regarding responses of 81 tumors during the follow-up (mean, 20 ± 4.9 months), complete response was maintained in 62 (76.5%), whereas 19 (23.5%), including six that were incompletely embolized, locally progressed. CONCLUSION: Virtual parenchymal perfusion software can determine the optimal catheter position in superselective cTACE.

Blood supply to the caudate lobe of the liver from the right inferior phrenic artery: observation by cone-beam computed tomography during arteriography.

PURPOSE: To retrospectively evaluate blood supply to the caudate lobe of the liver from the right inferior phrenic artery (RIPA) using cone-beam computed tomography during arteriography (CBCTA-RIPA). METHODS: CBCTA-RIPA examinations during transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) were collected from 2448 procedures in 787 patients. The exclusion criteria were (1) major artifacts, (2) TACE of hepatic arterial branches before performing CBCTA-RIPA, and (3) repeated CBCTA-RIPA studies in the same patient. Blood supply to three subsegments, the Spiegel lobe (SP), paracaval, and caudate process, was evaluated on CBCTA-RIPA images. The origins and routes of branches supplying the caudate lobe were also evaluated by three-dimensional vessel-tracking software. RESULTS: Forty-seven CBCTA-RIPA examinations in 47 patients (38 with a history of TACE [repeated TACE group] and nine without it [initial TACE group]) were eligible, including five who had previously undergone hepatectomy. Seven had caudate lobe HCCs. Blood supply to the caudate lobe was demonstrated in 21 (44.7%) patients: in 50% (19/38) and 22.2% (2/9) of the repeated and initial TACE groups, respectively. The caudate arteries had previously been embolized in eight patients, the RIPA branch in three, and both in one. Forty-one proximal branches mainly supplied the dorsal part of the SP. All branches but five reached there through the inferior vena cava (IVC) ligament. The RIPA supplied eight of nine caudate lobe HCCs, totally (n = 7) or partially (n = 1). CONCLUSION: The proximal RIPA branches mainly supply the dorsal SP through the IVC ligament, especially in the repeated TACE group.

Intraoperative Bile Duct Disruption Treated Using Intrahepatic Biliary Ablation with Ethanol: A Report of Two Cases.

We report two cases of intraoperative bile duct disruption. In case 1, an isolated bile duct in the remnant of the anterosuperior liver segment after right hepatic lobectomy for cholangiocarcinoma caused bile leakage. In case 2, bile leakage continued from a disrupted accessory hepatic duct during pancreaticoduodenectomy for pancreatic carcinoma. In both patients, a mixture of ethanol and iodized oil at a 10:1 ratio was injected into the disrupted bile duct under balloon occlusion. In case 1, the mixture was injected through a balloon catheter under balloon occlusion overnight. No severe complications developed in either case. Bile leakage stopped postoperatively and did not recur until the patients' death from tumor progression 14 and 16 months after surgery, respectively.

Transarterial Interventional Therapy for Non-functioning Hemodialysis Access.

Transarterial vascular access interventional therapy (VAIVT) for non-functioning hemodialysis access has advantages over the venous approach because natural venous outflow through the fistula as well as the stump at the fistula site in total occlusion can be observed, and most strictures and/or occlusions can be treated via one access route. The brachial arterial approach is essential, but the radial arterial approach at the wrist is also necessary for certain patients. The transarterial approach can be applied to all VAIVTs; however, additional venous access is necessary in cases requiring a large device and those with unsuccessful traversal of the occluded segment via the arterial route. The high origin of the radial artery is a disadvantage of the transbrachial approach, and local hematomas are the most frequent complications.

Outcomes of conventional transarterial chemoembolization for hepatocellular carcinoma ≥10 cm.

AIM: To retrospectively evaluate the outcomes of conventional transarterial chemoembolization (cTACE) for hepatocellular carcinoma (HCC) ≥10 cm. METHODS: Twenty-five patients with naïve HCC ≥10 cm (mean maximum tumor diameter, 130 ± 27.6 mm; single [n = 12], 2-9 [n = 6], and ≥10 [n = 7]) without extrahepatic spread treated with cTACE were eligible. Five (20%) had vascular invasion. Two to three stepwise cTACE sessions using iodized oil ≤10 mL in one cTACE session were scheduled. When the tumor recurred, additional cTACE was repeated on demand, if possible. Overall survival (OS) rates were calculated using the Kaplan-Meier method. The prognostic factors were evaluated using uni- and multivariate analyses. RESULTS: Stepwise cTACE sessions were completed for 20 (80%) patients, but could not be completed for four (16%). In the remaining (4%) patient, the whole tumor was embolized in one session. Additional treatment, mainly cTACE, was undertaken for 19 (76%) patients. The OS rates at 1, 3, and 5 years were 68, 34.7, and 23.1%, respectively. A tumor number of three was a significant prognostic factor (P = 0.020) and the 1-, 3-, and 4-year OS rates in patients with ≤3 and ≥4 tumors were 81.3 and 33.3, 55.6 and 11.1, and 38.9% and 0%, respectively. Whole tumor embolization and the serum level of protein induced by vitamin K absence or antagonist-II were also significant prognostic factors (P < 0.001 and P = 0.042, respectively). Bile duct complications requiring additional interventions developed in two (8%) patients. CONCLUSION: Conventional TACE is safe and effective for huge HCCs, but has limited effects in cases with four or more tumors.

Outcomes of Patients with Hepatocellular Carcinoma Treated with Conventional Transarterial Chemoembolization Using Guidance Software.

PURPOSE: To evaluate the outcomes of conventional transarterial chemoembolization using guidance software for hepatocellular carcinoma (HCC) patients. MATERIALS AND METHODS: One hundred two patients with treatment-naïve HCC with ≤ 7-cm and ≤ 5 lesions treated with conventional transarterial chemoembolization using guidance software were selected. Technical success was classified into 3 grades by computed tomography performed 1 week after transarterial chemoembolization: (i) A, complete embolization with a safety margin; (ii) B, entire tumor embolization without a safety margin; and (iii) C, incomplete embolization. Intrahepatic tumor recurrence was classified into 2 categories: local tumor progression (LTP) and intrahepatic distant recurrence (IDR). Overall survival (OS) and tumor recurrence rates were calculated by the Kaplan-Meier method. Additionally, the incidences of LTP between grade A and B tumors, IDR with/without LTP, and OS with/without LTP were compared by the log-rank test. RESULTS: One hundred fifty-six (82.1%) tumors were determined to be grade A, 26 (13.7%) were determined to be grade B, and 8 (4.2%) were determined to be grade C. The 1-, 3-, and 5-year LTP and IDR rates were 31.7%, 49.4%, and 59.4% and 33.9%, 58.2%, and 73.3%, respectively. LTP developed more frequently in grade B tumors than grade A tumors (P = .0016). IDR developed more frequently in patients with LTP than without LTP (P = .0004). The 1-, 3-, and 5-year OS rates were 96.1%, 71.1%, and 60%, respectively; the 1-, 3-, and 5-year OS rates in patients with/without LTP were 95.7%, 69.8%, and 59.3% and 96.2%, 71.6%, and 59.4%, respectively (P = .9984). CONCLUSIONS: Transarterial chemoembolization guidance software promotes the technical success of transarterial chemoembolization and excellent OS in HCC patients.

Usefulness of dual-phase cone-beam computed tomography during arteriography and automated tumour-feeder detection software in transarterial embolization for obscure arterial bleeding in the abdomen.

We report the usefulness of dual-phase cone-beam computed tomography during angiography (CBCTA) and automated tumour-feeder detection software (AFD) in transarterial embolization (TAE) for three consecutive cases of obscure arterial bleeding in the abdomen. Two patients presented with lower gastrointestinal bleeding and one showed bleeding into the pancreatic pseudocyst. Superior mesenteric or common hepatic angiography did not demonstrate extravasation, but dual-phase CBCTA and AFD could identify extravasation and an access route to the bleeding point. TAE with gelatin sponge particles and a microcoil was successfully performed under AFD guidance in all patients without any complication, and haemostasis could be achieved.

Does a Vascularized Fibula Free Bone Grafted Immediately After Hemimandibulectomy in a Child Grow or Relapse During Adolescence?

For young growing children before the end of skeletal maturity, the growth activity of the grafted bone after hemimandibulectomy is not well-known. After an adolescence, such a patient may have facial deformity because the anterior growth point of the mandible is in the condylar neck. A 13-year-old boy was performed hemimandibulectomy with immediate mandibular reconstruction by fibula free flap (FFF) because of a huge ameloblastic fibroma. The authors evaluated the length of FFF on the images of computed tomography (CT) at 5 and 60 months after the operation and compared them by calculating growth rates. Five years after surgery, his facial appearance was symmetry and mandibular function was satisfaction. Although the mandibular bone in the contralateral side grew during 5-year follow-up, the vascularized FFF grafted in the child patient did not significantly grow. Moreover, spontaneous regeneration (SR) and the gradual osteosclerosis were confirmed on the left distal edge of the FFF on the CT imaging. The arrival of SR at the left distal edge of the FFF was considered a part of the reason to compensate the unchanging growth rate of the grafted FFF and contribute for the postoperative good functional and esthetic results.

Reliability and Validity of the MD Anderson Dysphagia Inventory Among Japanese Patients.

This study aimed to validate the Japanese version of a dysphagia-specific quality of life questionnaire, the MD Anderson Dysphagia Inventory (MDADI-J), and to verify trends between MDADI-J and Functional Oral Intake Scale (FOIS) scores. The original 20 MDADI items were translated using a forward-backward method following accepted cultural adaptation guidelines. Seventy-two patients with a history of head and neck cancer treatment completed the MDADI-J between October 2015 and August 2016. Concurrent validity was determined by correlations with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Head and Neck 35 (EORTC QLQ-H&N35) instruments. Discriminant validity was examined using cancer stage grouping between stages I-II and III-IV. Additionally, trends between the FOIS and the MDADI-J total scores were analyzed using a trend test. The Cronbach's α coefficient of the MDADI-J total score was 0.92, indicating high internal consistency. The average inter-item correlation coefficients ranged from 0.39 to 0.49. ICC, an indicator of test-retest reliability, was 0.84 for the total score, and 0.58 to 0.81 for individual subscales. The total score and all subscales were significantly associated with the scores for each factor of the EORTC QLQ-C30 and EORTC QLQ-H&N35. The total score and all subscales were significantly different between clinical tumor stages I-II and III-IV. The total scores all increased with the progress of the FOIS. In conclusion, this study validated the Japanese version of the MDADI and showed that as FOIS scores deteriorate, MDADI-J scores tend to constantly decrease.

Excretion of necrotic hepatocellular carcinoma tissues into the biliary system after transcatheter arterial chemoembolization.

AIM: To evaluate the incidence and condition of necrotic tumor excretion into the biliary system in patients with hepatocellular carcinoma (HCC) >5 cm treated with conventional transcatheter arterial chemoembolization (TACE). METHODS: Eighty-three patients who underwent TACE for newly developed HCC >5 cm without an intraductal tumor thrombus and were followed-up by computed tomography for longer than 6 months were eligible. According to the location, the maximum tumors were divided into central (in contact with the left or right hepatic duct, n = 39) or peripheral (not in contact with them, n = 44). When high-density material in the biliary system that was not seen on pretreatment computed tomography was identified, it was determined as excreted necrotic tumor tissue containing iodized oil. The incidence, interval between TACE and occurrence of the necrotic tumor excretion, and clinical course were evaluated. RESULTS: Tumor excretion into the biliary system was identified in nine (10.8%) patients with a central tumor (mean diameter, 85.0 ± 29.6 mm) 28-433 days (mean, 219.3 ± 128.2) after the initial TACE. In one patient, the necrotic tumor cast caused cholangitis 1203 days after the initial TACE, and was endoscopically removed. Infection of the embolized tumor developed in two cases and percutaneous drainage was carried out 105 and 158 days later, respectively. CONCLUSIONS: Excretion of necrotic tumors into the biliary system after TACE was not rare in patients with centrally located HCC >5 cm. The detached tumor rarely caused symptoms and the communication between the tumor and bile duct caused the infection of tumors.

Performance of novel virtual parenchymal perfusion software visualizing embolized areas of transcatheter arterial chemoembolization for hepatocellular carcinoma.

AIM: To evaluate the performance of novel virtual parenchymal perfusion (VPP) software in conventional transcatheter arterial chemoembolization (cTACE) for hepatocellular carcinoma. METHODS: VPP was retrospectively applied to 43 hepatocellular carcinomas treated with cTACE. The virtual embolized area (VEA) was estimated after positioning a virtual injection point on images of non-selective cone-beam computed tomography during hepatic arteriography, at the same position in superselective cTACE. The real embolized area (REA) was defined as the area where iodized oil was retained on 1-week computed tomography after cTACE. Three dimensions across the tumor (maximum [a] and minimum [b] in the axial and craniocaudal [c]) directions, and the volume of the VEA and REA were compared using linear regression analysis. It was also evaluated whether an adequate safety margin ≥5 mm could be predicted by VPP. RESULTS: The mean lengths of a, b, and c of the VEA and REA were 54.6 ± 15.9 mm (range 24.9-91.0 mm) and 55.0 ± 15.7 mm (range 23.9-92.8 mm; r = 0.9448, P < 0.001), 35.4 ± 11.7 mm (range 16.1-66.0 mm) and 35.4 ± 13.2 mm (range 12.2-69.2 mm; r = 0.9369, P < 0.001), and 42.1 ± 11.6 mm (range 25.0-75.7 mm) and 42.9 ± 11.7 mm (range 25.7-78.7 mm; r = 0.9092, P < 0.001), respectively. The mean volume of the VEA and REA was 71.8 ± 44.8 mL and 75.5 ± 46.9 mL, respectively (r = 0.9913, P < 0.0001). VPP showed no safety margins in seven tumors, including all three actually embolized without safety margins. CONCLUSION: The VEA estimated using VPP showed a good correlation with the REA of cTACE.