Treatment patterns and outcomes of unresectable pancreatic cancer patients in real-life practice: a region-wide analysis.

BACKGROUND: FOLFIRINOX (FFX) and gemcitabine (GEM) plus nab-paclitaxel (GnP) have recently been available for treating pancreatic ductal adenocarcinoma (PDAC). We investigated trends in characteristics, treatment and outcomes of unselected patients with unresectable PDAC in real-life practice in Japan. METHODS: We retrospectively reviewed the medical records of 1085 patients diagnosed as having unresectable or recurrent PDAC in multiple centers in the Hokuriku area between January 2009 and July 2015. RESULTS: The incidence of pathologically proven PDAC had increased from 18.7% in 2009 to 56.2% in 2015. Oncological therapy was administered to 779 patients (71.8%): chemotherapy (n = 675), chemo-radiotherapy (n = 92) or radiotherapy (n = 12); the remaining patients were treated with best supportive care. Of 100 patients diagnosed in 2009, 62.0% received GEM as first-line chemotherapy; whereas 30.7% of the 75 patients diagnosed in 2015 received FFX, 25.3% GnP, 22.7% GEM and 17.3% S-1. The objective response rates of patients treated with FFX, GnP and GEM were 14.9%, 35.0% and 5.5%, respectively and the OS 10.3, 9.9 and 7.5 months after FFX, GnP and GEM, respectively. Grade 3 or greater any hematological toxicity occurred in 70.2%, 70.0% and 18.8% of the patients treated with FFX, GnP and GEM, respectively. The reasons for treatment discontinuation were adverse events in 9.8%, 26.7% and 24.1% of the patients treated with FFX, GnP and GEM, respectively. CONCLUSION: Chemotherapeutic protocols changed dramatically between 2009 and 2015. Continuous collection and analysis for our cohort with longer follow-up provides useful information about treatment selection and prediction of outcome.

Chemoembolization for the treatment of large hepatocellular carcinoma.

PURPOSE: To retrospectively evaluate the efficacy of chemoembolization for inoperable hepatocellular carcinoma (HCC) tumors larger than 5 cm in diameter. MATERIALS AND METHODS: Chemoembolization was performed in 30 patients with HCCs with a largest diameter of more than 5 cm with three or fewer lesions and no portal vein tumor thrombus. The mean maximum tumor diameter was 7.7 cm +/- 2.4. When the tumor was extremely large and had multiple feeding arteries, stepwise chemoembolization sessions at intervals of 3-10 weeks were performed. In addition, extrahepatic collateral supply was identified and embolized. Local therapeutic effects, survival rates, and complications were analyzed. RESULTS: The mean follow-up period was 33.8 months +/- 24.1. One to 13 chemoembolization sessions (mean, 4.0 sessions +/- 3.0) were performed in each patient. Additionally, 62 collateral vessels were embolized in 21 patients, including 22 vessels in 14 patients at the initial procedure. Early tumor response rate 2-3 months after treatment was 43.3% by Response Evaluation Criteria In Solid Tumors. Complete radiologic response was achieved in 19 patients. Eleven patients died between 4 and 61 months after treatment (mean, 27.2 months +/- 21.8), including four deaths unrelated to hepatic causes. Nineteen patients have survived for 6-103 months (mean, 37.5 months +/- 25.2). Overall and progression free-survival rates at 1, 3, and 6 years were 82.3% and 66.0%, 73.9% and 57.6%, and 32.9% and 34.2%, respectively. Three infectious complications developed and were managed by interventions. CONCLUSIONS: Chemoembolization was effective for large HCCs, although there is a risk of infectious complications after the procedure.

Efficient Prophylactic Management of HBV Reactivation by an Information Technology Encoding System: Results of a 6-year Prospective Cohort Study.

Objective We started an information technology (IT) system that encodes the medical treatment status of hepatitis B virrus (HBV) with a 9-digit number, automatically checks for inappropriate situations occurring due to immunosuppression and chemotherapy that do not comply with the flowchart of the hepatitis B countermeasure guideline, and promotes correct HBV medical treatment in our hospital. We conducted a prospective study of HBV reactivation using this system. Methods Among 21,607 cases that were managed using this system, 1,206 patients who were HBs antigen-negative, HBc antibody- and/or HBs antibody-positive and in whom HBV DNA quantification was performed two times or more were examined for the occurrence of HBV reactivation. The study population included: malignant lymphoma patients using rituximab (n=40), patients with malignant tumors using anticancer agents (n=546), patients treated with steroids (n=274), rheumatoid arthritis (RA) patients (n=144), patients using immunosuppressants/biologics (n=26), and patients undergoing hepatitis C direct acting antiviral (DAA) treatment (n=176). Results HBV reactivation was observed in 27 cases undergoing treatment with the following agents: rituximab (n=6), anticancer agents (n=8), steroids (n=10), anti-RA agents (n=1), and hepatitis C DAA (n=2). Among the 40 patients who were using rituximab, 6 (18.2%) showed a high rate of reactivation. In 10 in which HBV reactivation occurred at a median of 10 (range, 4-32) months after steroid administration, 6 occurred after the 7th month, and 1 patient showed HBs antigen positivity and severe hepatitis. Conclusion Continuing of the operation of an automatic check system using coded medical information to check for the reactivation enabled this prospective study of HBV reactivation. Careful attention should be paid to patients using steroids, as well as malignant lymphoma patients who are treated with rituximab. The results of the present study suggest that the present IT encoding system would be useful for preventing HBV reactivation.

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.

The effects of ipragliflozin on the liver-to-spleen attenuation ratio as assessed by computed tomography and on alanine transaminase levels in Japanese patients with type 2 diabetes mellitus.

We assessed the effects of a 12-week ipragliflozin treatment on the liver-to-spleen attenuation ratio (L/S ratio) using computed tomography and on alanine transaminase (ALT) levels in Japanese patients with type 2 diabetes mellitus (T2DM). Sixty-two patients with T2DM [age, 56 ± 8 years; hemoglobin A1c (HbA1c) levels, 8.1 ± 0.9%; body mass index (BMI), 27.5 ± 3.3 kg/m2] were randomly assigned in a 2:1 ratio to receive ipragliflozin (50 mg/day; ipragliflozin group; n = 40) or continued treatment (control group; n = 22) for 12 weeks. The primary endpoints were changes in ALT levels; the secondary endpoints included changes in the L/S ratio and in the visceral fat area (VFA) and subcutaneous fat area (SFA) before and after 12 weeks of the treatment as assessed by computed tomography. ALT levels (-12.45 vs. +5.82 IU/l, P < 0.001), L/S ratio (+0.07 vs. -0.08, P < 0.001), SFA (-5.8 vs. +13.3 cm2, P < 0.05), and VFA (+1.4 vs. +20.4 cm2, P < 0.05) significantly changed from baseline in the ipragliflozin group compared with the values in the control group. Multiple regression analysis among all subjects revealed that the independent factor contributing to the %ΔALT and %ΔL/C ratio was treatment group alone (ipragliflozin group = 1; control group = 0; ß coefficient = -32.08, P < 0.001 and ß coefficient = 19.98, P < 0.05, respectively). Thus, ipragliflozin may lower ALT levels associated with increased L/S ratios, indicating its potential therapeutic efficacy in T2DM-associated hepatic steatosis.

Switching from atorvastatin to rosuvastatin lowers small, dense low-density lipoprotein cholesterol levels in Japanese hypercholesterolemic patients with type 2 diabetes mellitus.

AIMS: This open-label, randomized, parallel-group comparative study compared the efficacy of rosuvastatin (5mg/day) and atorvastatin (10mg/day) for reduction of small dense low-density lipoprotein cholesterol (sd LDL-C) levels in Japanese patients with type 2 diabetes mellitus (T2DM). METHODS: Patients with T2DM and hypercholesterolemia with detectable sd LDL-C after receiving 10mg/day atorvastatin for ≥ 24 weeks were randomly assigned to receive rosuvastatin (5mg/day; switched treatment) or atorvastatin (10mg/day; continued treatment) for 12 weeks. The primary endpoints were changes in sd LDL-C levels and sd LDL-C/total LDL-C ratio evaluated using the LipoPhor AS(®) system. RESULTS: There were no significant percent changes from baseline for LDL-C levels between the switched (n=55) and the continued treatment group (n=56). However, the former group exhibited a statistically significant reduction from baseline of sd LDL-C levels, sd LDL-C/total LDL-C ratio compared with the latter group (-3.8 mg/dL vs. -1.4 mg/dL, p=0.014; -2.3% vs. -0.6%, p=0.004, respectively). Multiple regression analysis among all subjects revealed that independent factors contributing to the reduction in sd LDL-C levels were a change in LDL-C (p=0.003) and triglyceride (TG) levels (p=0.006), treatment group (the switched group=1, the continued group=0; standard coefficient=-1.2, p=0.034) and baseline glycated hemoglobin A1c (HbA1c) (p=0.045), respectively. CONCLUSION: Switching from 10mg atorvastatin to 5mg rosuvastatin may be a useful therapeutic option to reduce sd LDL-C levels in Japanese hypercholesterolemic patients with T2DM.

Ipragliflozin lowers small, dense low-density lipoprotein cholesterol levels in Japanese patients with type 2 diabetes mellitus.

AIMS: This preliminary randomized, parallel-group comparative study evaluated the efficacy of ipragliflozin for reduction of small dense low-density lipoprotein cholesterol (sd LDL-C) levels in Japanese patients with type 2 diabetes mellitus (T2DM). METHODS: Sixty-two patients with T2DM (age, 56 ± 8 years; hemoglobin A1c levels, 8.1 ± 0.9%; BMI, 27.5 ± 3.3 kg/m2) were randomly assigned in a 2:1 ratio to receive ipragliflozin (50 mg/day) (treatment group; n = 40) or continued treatment (control group; n = 22) for 12 weeks. The primary endpoints were changes in sd LDL-C levels detected using the LipoPhor AS® system; the secondary endpoints included changes in the sd LDL-C/large buoyant LDL-C (lb LDL-C) ratio, a surrogate marker for LDL particle size, and percent changes in routine lipid parameters. RESULTS: The treatment group exhibited a statistically significant reduction from baseline for LDL-C levels (-0.37 mg/dL vs. 14.4 mg/dL, p = 0.038), sd LDL-C levels (-1.28 mg/dL vs. 2.81 mg/dL, p = 0.012), and sd LDL-C/lb LDL-C ratio (-3.20% vs. 4.58%, p = 0.040) compared with the control group. Multiple regression analysis among all subjects revealed change in TG levels (p = 0.011) and LDL-C levels (p = 0.024) as well as change in body weight (p = 0.006) as independent factors contributing to the reduction in sd LDL-C. CONCLUSIONS: Ipragliflozin may have a potential for lowering sd LDL-C levels associated with increasing LDL particle size in Japanese patients with T2DM.

Non-high-density cholesterol level as a predictor of maximum carotid intima-media thickness in Japanese subjects with type 2 diabetes: a comparison with low-density lipoprotein level.

AIM: To determine whether non-high-density lipoprotein cholesterol (non-HDL-C) level, in comparison with low-density lipoprotein cholesterol (LDL-C) level, is useful for predicting the values of various surrogate atherosclerosis markers in Japanese subjects with type 2 diabetes (T2DM). METHODS: Data were retrieved from medical records of 265 subjects with T2DM who underwent laboratory tests to evaluate for atherosclerosis by using the following parameters: brachial-ankle pulse wave velocity, mean and maximum carotid intima-media thickness (mean CIMT and max-CIMT), and ankle-brachial index, with simultaneous fasting blood sampling for routine lipid parameters. RESULTS: In a multiple stepwise regression analysis, non-HDL-C level, but not LDL-C level, positively correlated with max-CIMT (ß coefficient = 0.14, F = 6.84). Stepwise logistic regression analysis revealed that a 0.26 mmol/L (10 mg/dL) increase in non-HDL-C level, but not LDL-C level, was significantly associated with high risk of max-CIMT (≥1.1 mm; odds ratio, 1.096; 95 % confidence interval, 1.003-1.202; p = 0.046). However, in a receiver operating characteristic curve (ROC) analysis, the addition of non-HDL-C level to the three significant independent variables obtained from the stepwise analyses did not significantly increased the area under the ROC curve (from 0.7789 to 0.7864, p = 0.4343). CONCLUSIONS: Non-HDL-C levels may be non-inferior to LDL-C level for the prediction of high-risk max-CIMT in Japanese subjects with T2DM.

Chronic hyperglycemia may attenuate the serum-uric-acid-lowering effect of low-dose febuxostat in Japanese patients with type 2 diabetes mellitus.

AIMS: This study investigated the independent predictors of the serum uric acid (sUA)-lowering effect of low-dose febuxostat, a novel xanthine oxidase inhibitor, in Japanese patients with type 2 diabetes mellitus (T2DM). MATERIALS AND METHODS: Data of 130 T2DM patients who had been taking febuxostat 10 mg once daily for elevated sUA (≥7 mg/dl) for at least 12 weeks were retrieved from medical records. Spearman's rank correlation coefficients were calculated to determine the correlations between sets of two independent continuous variables. Multiple stepwise linear regression analysis was used to determine independent predictors of the percent change of sUA levels after 12 weeks of febuxostat treatment (%ΔsUA). RESULTS: Among all patients, %ΔsUA was significantly correlated with age (ρ = 0.192, P = 0.030) and mean glycated hemoglobin (HbA1c) level (ρ = -0.186, P = 0.036). Multiple stepwise linear regression analysis of all patients revealed that major independent factors contributing to %ΔsUA were mean HbA1c (ß = -3.14, P = 0.022) and mean glycated albumin (ß = -0.743, P = 0.013) levels. CONCLUSIONS: High HbA1c and glycated albumin levels significantly attenuated the sUA-lowering effect of low-dose febuxostat in Japanese patients with T2DM. Further detailed analysis using a larger population is warranted to confirm these findings.

Obesity may attenuate the HbA1c-lowering effect of sitagliptin in Japanese type 2 diabetic patients.

UNLABELLED: Aims/Introduction: The aim of the present study was to assess the independent predictors of the HbA1c-lowering effect of sitagliptin in Japanese type 2 diabetic patients. MATERIALS AND METHODS: Data were retrieved from the medical records of 151 type 2 diabetic patients who had been taking sitagliptin 25 or 50 mg once daily for inadequate glycemic control for at least 12 weeks, with or without other oral hypoglycemic agents. Spearman's rank correlation coefficients were calculated to investigate correlations between two independent continuous variables. Multiple stepwise regression analysis was used to identify independent predictors of reductions in HbA1c levels after 12 weeks of sitagliptin treatment (ΔHbA1c). RESULTS: In all patients combined, Spearman's rank correlation coefficients showed that ΔHbA1c was significantly correlated with baseline HbA1c alone (r = 0.371, P < 0.0001). However, multiple linear regression analysis among all patients using baseline variables revealed that the independent factors contributing to ΔHbA1c, in order of importance, were method of prescribing (P < 0.0001), baseline HbA1c (P < 0.0001), body mass index (BMI; P = 0.004), and duration of diabetes (P = 0.024). CONCLUSIONS: Our analysis may provide novel evidence that increased BMI contributes, in part, to attenuation of the HbA1c-lowering effect of sitagliptin in Japanese type 2 diabetic patients. Analysis of a larger population over a longer period of time is warranted to confirm these findings. (J Diabetes Invest, doi: 10.1111/j.2040-1124.2011.00156.x, 2011).

Fluorodeoxyglucose accumulation in the left atrial appendage of a patient with paroxysmal atrial fibrillation.

A 69-year-old man with a history of paroxysmal atrial fibrillation (PAF) and subsequent cerebral infarction was referred to our hospital because of an abnormal accumulation of 18F-fluorodeoxyglucose (FDG) in the left atrial appendage (LAA) that was detected on positron emission tomography-computed tomography (PET-CT) imaging during a health screening. Transesophageal echocardiography (TEE) demonstrated thrombus formation in the LAA. Even after the thrombus disappeared by strictly guided oral anticoagulant therapy, intense abnormal FDG uptake in the LAA on PET-CT imaging persisted. In low-risk patients such as this, inflammation may have played some role in LAA thrombus formation.

Main bile duct stricture occurring after transcatheter arterial chemoembolization for hepatocellular carcinoma.

The purpose of this study was to evaluate the clinical course of main bile duct stricture at the hepatic hilum after transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). Among 446 consecutive patients with HCC treated by TACE, main bile duct stricture developed in 18 (4.0%). All imaging and laboratory data, treatment course, and outcomes were retrospectively analyzed. All patients had 1 to 2 tumors measuring 10 to 100 mm in diameter (mean ± SD 24.5 ± 5.4 mm) near the hepatic hilum fed by the caudate arterial branch (A1) and/or medial segmental artery (A4) of the liver. During the TACE procedure that caused bile duct injury, A1 was embolized in 8, A4 was embolized in 5, and both were embolized in 5 patients. Nine patients (50.0%) had a history of TACE in either A1 or A4. Iodized oil accumulation in the bile duct wall was seen in all patients on computed tomography obtained 1 week later. Bile duct dilatation caused by main bile duct stricture developed in both lobes (n = 9), in the right lobe (n = 3), in the left lobe (n = 4), in segment (S) 2 (n = 1), and in S3 (n = 1). Serum levels of alkaline phosphatase and γ-glutamyltranspeptidase increased in 13 patients. Biloma requiring drainage developed in 2 patients; jaundice developed in 4 patients; and metallic stents were placed in 3 patients. Complications after additional TACE sessions, including biloma (n = 3) and/or jaundice (n = 5), occurred in 7 patients and were treated by additional intervention, including metallic stent placement in 2 patients. After initial TACE of A1 and/or A4, 8 patients (44.4%), including 5 with uncontrollable jaundice or cholangitis, died at 37.9 ± 34.9 months after TACE, and 10 (55.6%) have survived for 38.4 ± 37.9 months. Selective TACE of A1 and/or A4 carries a risk of main bile duct stricture at the hepatic hilum. Biloma and jaundice are serious complications associated with bile duct strictures.

Association of serum glycated albumin to haemoglobin A1C ratio with hepatic function tests in patients with chronic liver disease.

BACKGROUND: In patients with chronic liver disease (CLD), glycated haemoglobin (HbA(1C)) levels have been shown to be apparently lower than real values, whereas serum glycated albumin (GA) levels are apparently higher. The present study was aimed to examine whether both glycaemic indices are influenced by hepatic function. METHODS: Subjects consisted of 82 patients with CLD. Various indicators for hepatic function as well as HbA(1C) and GA were also measured. Estimated HbA(1C) values were calculated from the mean plasma glucose levels. Two hundred and two type 2 diabetic patients without CLD were studied as controls. RESULTS: Although GA was strongly correlated with HbA(1C) in patients with CLD as well as diabetic patients, GA levels in patients with CLD were relatively higher than those in diabetic patients. In patients with estimated HbA(1C) < or = 5.8%, GA levels significantly increased but HbA(1C) levels decreased as a function of decreasing hepaplastin test (HPT). The ratio of GA/HbA(1C) (G/H ratio) increased as a function of decreasing HPT. In patients with estimated HbA(1C) > 5.8%, in contrast, GA levels were independent of HPT levels. In the patients with CLD, GA and HbA(1C) were associated with mean plasma glucose levels and some indicators for hepatic function. The multivariate analysis revealed a significant association of G/H ratio with HPT, cholinesterase and direct bilirubin. The G/H ratio was not associated with the mean plasma glucose but with HPT and cholinesterase levels. CONCLUSIONS: The G/H ratio correlates with hepatic function but not with plasma glucose levels. Therefore, CLD should be suspected for diabetic patients with an elevated G/H ratio.

Characteristics of undiagnosed diabetes mellitus in a population undergoing health screening in Japan: target populations for efficient screening.

AIMS: To estimate the prevalence of undiagnosed diabetes mellitus and its relationship with various risk factors in a population undergoing health screening in Japan. METHODS: Oral glucose tolerance tests were carried out in a total sample of 14,674 Japanese subjects undergoing health screening, aged 20-83 years and without known diabetes. The prevalence of glucose tolerance categories (1999 WHO criteria) was adjusted for sample probabilities. The optimal FPG cut-off point for screening diabetes was estimated using ROC curve analysis for the continuous value of FPG corresponding to a 2-h PG of 200 mg/dl. The number needed to screen (NNTS) to identify one person with undiagnosed diabetes with various risk factors was estimated using the following equation: the number of undiagnosed diabetic plus nondiabetic subjects/the number of undiagnosed diabetic subjects. RESULTS: The prevalence of undiagnosed diabetes among men and women was 6.4% (NNTS 15.7) and 3.2% (NNTS 31.7), respectively. The optimal FPG cut-off point for screening diabetes among men and women was 105 and 106 mg/dl, respectively. NNTS was lower in individuals with more risk factors, e.g. aging (> or =50), BMI (> or =25), hypertension (SBP> or =140 mmHg and/or DBP> or =90 mmHg) and dyslipidemia (TC> or =220 and/or HDL-C<40 and/or TG> or =150 mg/dl), resulting in the lowest NNTS in individuals having all four risk factors among men (6.1) and women (6.7), respectively. CONCLUSIONS: In Japan, screening for diabetes may be more efficient among individuals having an FPG of more than 105-106 mg/dl and with more risk factors, especially in men.

Acute cholecystitis caused by malignant cystic duct obstruction: treatment with metallic stent placement.

We report the successful management of acute cholecystitis using cystic duct stent placement in 3 patients with inoperable malignant cystic duct obstruction (2 cholangiocarcinoma and 1 pancreatic carcinoma). All patients underwent stent placement in the bile duct, using an uncovered stent in 2 and a covered stent in 1, to relieve jaundice occurring 8-184 days (mean 120 days) before the development of acute cholecystitis. The occluded cystic duct was traversed by a microcatheter and a stent was implanted 4-17 days (mean 12 days) after cholecystostomy. Acute cholecystitis was improved after the procedure in all patients. Two patients died 3 and 10 months later, while 1 has survived without cholecystitis for 22 months after the procedure to date.

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.

Efficacy of covered metallic stents in the treatment of unresectable malignant biliary obstruction.

We evaluated the efficacy of covered stents for malignant biliary obstruction. We studied 62 patients with obstruction distal to the hilar confluence who survived longer than 10 weeks and divided them into a covered stent group (group 1, n = 22), a Z stent group (group 2, n = 19), and a mesh stent group (group 3, n = 21), according to their type of the stent. Patency rates of each group were compared. Early stent revision was required after 3 days in 18% (4/22) of group 1, 26% (5/19) of group 2, and 0% (0/21) of group 3. The 10, 20, and 40-week primary patency rates were 77%, 77%, and 59% (group 1), 42%, 25%, and 8% (group 2), and 76%, 71%, and 55% (group 3), respectively. Primary patency rates of groups 1 and 3 were significantly higher than those of group 2 (p < 0.05), and there was no statistically difference between those of group 1 and group 3. The 10, 20, and 40-week assisted primary (secondary) patency rates were 96%, 96%, and 96% (group 1), 68%, 49%, and 39% (group 2), and 86%, 74%, and 58% (group 3), respectively. Assisted primary patency (secondary) rates of group 1 were significantly higher than those of groups 2 and 3 (p < 0.01 and p < 0.05, respectively). Our study suggests that the primary patency rates of the covered stents are equal to those of mesh stents, but these may be improved further if covered stents, which avoid the need for early revision, are used.

Transcatheter arterial chemoembolization for hepatocellular carcinoma fed by the reconstructed inferior phrenic artery: anatomical and technical analysis.

PURPOSE: To evaluate reconstructed patterns of occluded inferior phrenic artery (IPA) and determine the technical success rate and complications of transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) fed by the occluded IPA through the anastomosing branch. MATERIALS AND METHODS: In 19 patients, 24 IPAs, including two that had been previously embolized, were demonstrated through collateral pathways. The incidence of each collateral circulation was evaluated. Thirteen IPAs in 12 patients fed the tumor and TACE was attempted. TACE was performed only if the catheter could be advanced into the anastomosing branch so that the nontarget branches were avoided. RESULTS: A reconstructed unilateral IPA was observed in 14 patients (11 right IPAs and three left IPAs) and two reconstructed IPAs were observed in five. The IPA was demonstrated through the dorsal pancreatic artery (n = 13), inferior or middle adrenal artery (n = 7), left gastric artery (n = 2), contralateral IPA (n = 2), lumbar artery (n = 1), and small branch derived from the celiac trunk (n = 1). Five IPAs (21%) were demonstrated through more than two separate arteries, including two demonstrated through both dorsal pancreatic arteries arising from the celiac and superior mesenteric artery. The IPA opacified through the lumbar artery had been previously embolized. TACE of the reconstructed IPA was possible in 10 of 13 IPAs (77%). Complications related to the procedure were a small amount of pleural effusion (n = 4) and basal atelectasis (n = 2). CONCLUSION: The IPA is reconstructed mainly through the retroperitoneal anastomosing branch in the upper abdomen. TACE of the reconstructed IPA can be performed with a high success rate without major complications.

Transcatheter arterial chemoembolization for unresectable hepatocellular carcinoma fed by the cystic artery.

PURPOSE: To evaluate the safety, technical success rate, and effectiveness of transcatheter arterial chemoembolization (TACE) for unresectable hepatocellular carcinoma (HCC) fed by the cystic artery. MATERIALS AND METHODS: Treatment of 27 tumors in 25 patients fed by the cystic artery was attempted with TACE. Twenty-two patients had previously undergone one to eight TACE sessions (mean, four sessions), and the duration after initiation of treatment of HCC was 4-69 months (mean, 24). In three patients, parasitization of the cystic artery was revealed at initial angiography. TACE was performed only when the microcatheter could be inserted into the tumor feeding branch and the stain of the gallbladder wall disappeared. The therapeutic effects and complications were retrospectively analyzed. RESULTS: Seventeen tumors were completely fed by the cystic artery and 10 were fed by both the hepatic artery and cystic artery. Attenuation or occlusion of the hepatic artery was observed in 56%. The tumor feeding branch arising from the cystic artery could be successfully embolized in 18 tumors (67%) of 16 patients without severe complications. Adequate iodized oil accumulation was achieved in 14 tumors (52%) of 12 patients. Percutaneous therapy (n = 7), radiation (n = 4), and TACE after cholecystectomy (n = 1) were added for tumors with incomplete or unsuccessful TACE. Local progression was observed in three (21%) of 14 tumors treated by TACE alone during a mean follow-up period of 18 months. CONCLUSION: TACE via the cystic artery was safe and technically possible in 67% of patients. If adequate iodized oil accumulation is obtained, which was only achieved in 52% of patients, sufficient therapeutic effect may be expected.