Safety of Radioembolization via the Cystic Artery in Patients with Hepatocellular Carcinoma and Parasitized Arterial Supply.

PURPOSE: To evaluate the safety and effectiveness of radioembolization through the cystic artery supplying hepatocellular carcinoma (HCC) adjacent to the gallbladder. MATERIALS AND METHODS: This retrospective, single-center study included 24 patients who underwent radioembolization via the cystic artery between March 2017 and October 2022. The median tumor size was 8.3 cm (range, 3.4-20.4 cm). Twenty-two (92%) patients had Child-Pugh Class A disease, and 2 (8%) patients had Class B cirrhosis. Technical issues, adverse events, and tumor response were analyzed. RESULTS: Infusion of radioactive microspheres was performed from the main cystic artery (n = 6), the deep cystic artery (n = 9), and small feeders from the cystic artery (n = 9). The cystic artery supplied the primary index tumor in 21 patients. The median radiation activity delivered via the cystic artery was 0.19 GBq (range, 0.02-0.43 GBq). The median total radiation activity administered was 4.1 GBq (range, 0.9-10.8 GBq). There was no case of symptomatic cholecystitis requiring invasive intervention. One patient experienced abdominal pain during injection of radioactive microspheres via the cystic artery. Eleven (46%) patients received pain medication during or within 2 days of the procedure. Twelve (50%) patients had gallbladder wall thickening on a 1-month follow-up computed tomography scan. Based on follow-up imaging, 23 (96%) patients showed an objective response (complete or partial response) of the tumor supplied by the cystic artery. CONCLUSION: Radioembolization via the cystic artery may be safe in patients with HCC partially supplied by the cystic artery.

Radioembolization for Hepatocellular Carcinoma: The Effects of Arterioportal Shunts on Nontargeted Liver Hypertrophy.

PURPOSE: To determine whether arterioportal shunting to the contralateral lobe attenuates liver function and hypertrophy of the nontargeted liver after radioembolization in patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS: The current retrospective study included 46 patients who received radioembolization for HCC contained within the right lobe between 2012 and 2020. The patients were divided into the following groups on the basis of the presence and extent of arterioportal shunting: patients with retrograde arterioportal shunting to the left lobe (contralateral group) and patients with arterioportal shunt limited to the right lobe or no arterioportal shunt (control group). Safety profiles, including adverse events, tumor response, and overall survival, were compared. With the volume of the left lateral segment used as a surrogate marker for nontarget liver, the degree of hypertrophy was compared between the 2 groups at 3 and 6 months. RESULTS: Liver function significantly deteriorated in the contralateral group in a month (P ≤ .05). Tumor response and overall survival did not significantly differ between the 2 groups. The degree of hypertrophy was significantly higher in the control group than in the contralateral group at 3 months (10.6% vs 3.5%; P = .008) and 6 months (20.7% vs 2.4%; P < .001). CONCLUSIONS: In patients with arterioportal shunting to the contralateral lobe, hypertrophy of the nontarget liver may not occur and the liver function may be worsened.

Outcomes of Venoplasty-Assisted, Peripherally Inserted Central Catheter Placement in Patients with Upper-Arm Venous Stenosis: Comparison with Midlines and Contralateral Placement.

PURPOSE: To compare the effectiveness and safety of percutaneous transluminal angioplasty and peripherally inserted central catheter (PTA + PICC), contralateral PICC, and midline catheterization (MC) in patients with venous stenosis. MATERIALS AND METHODS: A total of 7,327 PICC procedures were performed in 5,421 patients at a single institution between 2013 and 2019. Among them, 87 patients had upper-arm venous stenoses and were managed with PTA + PICC, contralateral PICC, or MC. Data on catheter-dwell time, clinical success rate, and adverse events were recorded. The procedure was considered to have clinically succeeded when a PICC was removed from the patient just before discharge or after the completion of therapy. Catheter survival time and the chance of adverse events were compared among the groups using the Kaplan-Meier method and log-rank test. RESULTS: PTA + PICC, contralateral PICC, and MC procedures were performed for 57 (65.5%, 57/87), 10 (11.5%, 10/87), and 20 (23.0%, 23/87) patients, respectively. The mean catheter-dwell time in the PTA + PICC, contralateral PICC, and MC groups was 49.7, 28.7, and 15.1 days, respectively, and the clinical success rate of each group was 86.0% (49/57), 80.0% (8/10), and 50.0% (10/20). The PTA + PICC group had a significantly longer catheter survival time than the MC group (P < .001). The chance of a catheter-related infection (P = .008) was significantly lower in the PTA + PICC group than in the MC group. CONCLUSIONS: PTA + PICC or contralateral PICC should be considered prior to ipsilateral MC when venous stenosis is encountered during PICC procedures.

Dextroplantation of Left Liver Graft in Infants.

The position of the left side liver graft is important, and it could lead to complications of the hepatic vein (HV) and portal vein (PV), especially in a small child using a variant left lateral section (vLLS) graft. The purpose of this study was to evaluate the outcome of a novel technique for the implantation of a vLLS graft to the right side (dextroplantation) in infants. For 3 years, 10 consecutive infants underwent dextroplantation using a vLLS graft (group D). The graft was implanted to the right side of the recipient after 90° counterclockwise rotation; the left HV graft was anastomosed to inferior vena cava using the extended right and middle HV stump, and PV was reconstructed using oblique anastomosis without angulation. Surgical outcomes were compared with the historical control group (n = 17, group C) who underwent conventional liver transplantation using a vLLS during infancy. Group D recipients were smaller than group C (body weight <6 kg: 50.0% versus 11.8%; P = 0.03). The rate of graft-to-recipient weight ratio >4% was higher in group D (60.0%) than C (11.8%; P = 0.01). Surgical drains were removed earlier in group D than in group C (15 versus 18 postoperative days [PODs]; P = 0.048). Each group had 1 PV complication (10.0% versus 5.9%); no HV complication occurred in group D, but 3 HV complications (17.6%) occurred in group C (P > 0.05). Hospital stay was shorter in group D than in group C (20 versus 31 PODs; P = 0.02). Dextroplantation of a vLLS graft, even a large-for-size one, was successful in small infants without compromising venous outcomes, compared with conventional vLLS transplantation. We could remove the surgical drains earlier and reduce hospital stays in cases of dextroplantation.

Spectral CT-Based Iodized Oil Quantification to Predict Tumor Response Following Chemoembolization of Hepatocellular Carcinoma.

PURPOSE: To quantify iodized oil retention in tumors after transarterial chemoembolization using spectral computed tomography (CT) imaging in patients with hepatocellular carcinoma (HCC) and evaluate its performance in predicting 12-month tumor responses. MATERIALS AND METHODS: From September 2017 to December 2018, 111 patients with HCC underwent initial conventional transarterial chemoembolization. Immediately after the procedure, unenhanced CT was performed using a spectral CT scanner, and the iodized oil densities in index tumors were measured. In tumor-level analyses, a threshold level of iodized oil density in the tumors was calculated using clustered receiver operating characteristic curve analyses to predict the 12-month tumor responses. In patient-level analyses, significant factors associated with a 12-month complete response, including the presence of tumors below the threshold value (ie, suspected residual tumors), were evaluated by logistic regression. RESULTS: Forty-eight HCCs in 39 patients were included in the analyses. The lower 10th percentile of the iodine density was identified as the threshold for determining the 12-month nonviable responses. The area under the curve of the iodine density measurements in predicting the 12-month nonviable responses was 0.893 (95% confidence interval, 0.797-0.989). The threshold value of the iodine density of 10.68 mg/mL yielded a sensitivity of 82.76% and specificity of 94.74% (P < .001). In the patient-level analysis, the 12-month complete response was significantly associated with the presence of a suspected residual tumor, with an odds ratio of 72.0 (95% confidence interval, 7.273-712.770). CONCLUSIONS: Spectral CT imaging using quantitative analysis of the iodized oil retention in target HCCs can predict tumor responses after a conventional transarterial chemoembolization procedure.

Benign Biliary Stricture after Yttrium-90 Radioembolization for Hepatocellular Carcinoma.

PURPOSE: To determine the frequency and possible causative factors of benign biliary stricture after radioembolization in patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS: This retrospective study comprised 232 patients with HCC who underwent yttrium-90 radioembolization between October 2015 and September 2019. Benign biliary stricture was defined as biliary ductal dilatation of segmental or lobar biliary ducts on follow-up images. Clinical and radiologic characteristics were compared using χ2 test or independent t test. RESULTS: Mean target perfused tissue dose was 224.6 Gy ± 106.8 (median, 205.7 Gy; range, 47.0-694.7 Gy). Of 232 patients, 15 (6.5%) had benign biliary stricture, which was detected from 3 weeks to 10.3 months (mean, 3.9 months; median, 3.2 months). Whereas 5 patients did not have any symptoms or signs associated with benign biliary stricture, 10 patients had cholangitis and/or laboratory abnormality requiring biliary drainage procedures and intravenous antibiotic therapy. Selective radioembolization through a caudate artery was performed in 55 (23.7%) patients. The incidence of benign biliary stricture was 16.4% (9/55) and 3.4% (6/177) in patients with and without selective radioembolization through a caudate artery, respectively (P = .002). CONCLUSIONS: Benign biliary stricture following yttrium-90 radioembolization may be common among patients receiving selective treatment via a caudate artery.

Iatrogenic Arterioportal Fistula Caused by Radiofrequency Ablation of Hepatocellular Carcinoma: Clinical Course and Treatment Outcomes.

PURPOSE: To analyze the clinical course and treatment outcomes of patients with iatrogenic arterioportal fistula (APF) caused by radiofrequency (RF) ablation of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Among the 1,620 hepatocellular carcinoma patients treated by RF ablation between January 2012 and August 2017, 99 who developed APF after RF ablation were included in this retrospective study. Depending on the extent of portal vein enhancement on arterial phase images, APF was classified as massive or nonmassive. The patients' clinical course was investigated and statistically evaluated by univariable and multivariable analyses. RESULTS: Thrombocytopenia (odds ratio [OR] = 3.939; 95% confidence interval [CI], 1.141-13.598) was the only risk factor for developing massive APF. Eleven patients underwent embolotherapy (technical success rate, 90.9%) and no patients experienced serious adverse events within 30 days of the procedure. Patients with massive APF (66.7%) had a significantly higher chance of a Child-Pugh score increase than did the patients with nonmassive APF (13.6%) (P < .001). Massive APF had a significantly lower chance of natural regression than did nonmassive APF (P < .001). Child-Pugh B (OR = 17.739; 95% confidence interval, 2.361-133.279) and massive APF without treatment (OR = 11.061; 95% confidence interval, 1.257-97.341) were independent risk factors for liver failure that led to death of liver transplant within 1 year after RF ablation. CONCLUSIONS: Massive APF caused by RF ablation is mostly irreversible and significantly worsens patients' outcomes, but may be effectively treated with embolotherapy.

The Value of Preprocedural MR Imaging in Genicular Artery Embolization for Patients with Osteoarthritic Knee Pain.

PURPOSE: To determine the value of preprocedural MR imaging in genicular artery embolization (GAE) for patients with osteoarthritic knee pain. MATERIALS AND METHODS: This single-center study retrospectively analyzed 28 knees in 18 patients who underwent GAE for intractable knee pain < 1 month after MR imaging. The pain experienced in each knee was evaluated on a 100-mm visual analog scale (VAS) at baseline and 1- and 3-month after GAE. "GAE responders" were defined as knees that exhibited greater than 30% reduction of VAS pain scores from baseline at both follow-up visits. Musculoskeletal radiologists evaluated MR images of the affected knee compartment regarding cartilage defects, osteophytes, subchondral cysts, bone marrow lesions (BMLs), meniscal injury, and joint effusion. The performances of Kellgren-Lawrence (KL) grading and MR findings in predicting GAE responders was estimated based on receiver operating characteristic curves. RESULTS: The mean VAS pain score was 84.3 mm. BML (area under the curve [AUC], 0.860; P < .001), meniscal injury (AUC, 0.811; P = .003), and KL grading (AUC, 0.898; P < .001) were significantly associated with GAE outcome. To predict GAE responders, KL grade ≤ 2 yielded a sensitivity of 87.5% and a specificity of 60.9%, BML grade ≤ 1 yielded a sensitivity of 75.0% and a specificity of 69.6%, and meniscal injury grade ≤ 2 yielded a sensitivity of 83.3% and a specificity of 72.7%. CONCLUSIONS: Large BMLs and severe meniscal injuries on MR imaging, as well as high KL grades, indicated poor responses to GAE.

Cone-Beam CT-Guided Chemoembolization in Patients with Complete Response after Previous Chemoembolization but Subsequent Elevated α-Fetoprotein without Overt Hepatocellular Carcinoma.

PURPOSE: To evaluate the performance of C-arm computed tomography (CT)-guided chemoembolization in patients with hepatocellular carcinoma (HCC) with serum α-fetoprotein (AFP) level > 20 ng/mL but with no overt tumor on CT and/or magnetic resonance imaging. MATERIALS AND METHODS: From May 2010 to May 2017, 34 patients with HCC (25 men and 9 women; mean age, 59.7 y) who had elevated serum AFP levels (> 20 ng/mL) but no overt tumor on 6-mo imaging studies and had shown complete response (CR) after previous chemoembolization underwent C-arm CT-guided conventional chemoembolization. Three radiologists retrospectively reviewed the imaging studies (preprocedural images, C-arm CT scans, and follow-up images) in consensus, and clinical data including AFP levels were retrospectively obtained. Tumor detection by C-arm CT and treatment response after chemoembolization were assessed. RESULTS: HCC was imaged at the time of chemoembolization in 24 of 34 patients (70.6%). C-arm CT detected tumors in 25 patients (73.5%); 23 detections were true positives, 2 were false positives, and 1 was a false negative (diaphragm metastasis). Among the 23 patients with true-positive results, the first follow-up enhanced imaging studies showed CR (n = 17), partial response (n = 1), progressive disease (n = 4), and indeterminate status (n = 1; treated by percutaneous ethanol injection). CONCLUSIONS: C-arm CT-guided chemoembolization may help to detect and treat recurrent tumors in patients who have shown CR after previous chemoembolization but subsequently, during follow-up surveillance, had serum AFP levels > 20 ng/mL without an overt tumor evident on imaging studies.

The Efficacy of Lymph Node Embolization Using N-Butyl Cyanoacrylate Compared to Ethanol Sclerotherapy in the Management of Symptomatic Lymphorrhea after Pelvic Surgery.

PURPOSE: To compare the efficacy of lymph node (LN) embolization using N-butyl cyanoacrylate versus ethanol sclerotherapy in the management of symptomatic postoperative pelvic lymphorrhea. MATERIALS AND METHODS: Thirty-three patients with 40 instances of symptomatic postoperative lymphorrhea were treated with either LN embolization or sclerotherapy at Seoul National University Hospital from January 2009 to July 2017 and were retrospectively included (LN embolization group: 24 lymphoceles of 19 patients, mean age of 59.29 years; sclerotherapy group: 16 lymphoceles of 14 patients, mean age of 60.95 years). The types of operations were hysterectomy and bilateral oophorectomy with pelvic lymph node dissection (n = 9), radical prostatectomy (n = 3), and renal transplantation (n = 2) for the sclerotherapy group and radical prostatectomy (n = 10) and hysterectomy and bilateral oophorectomy with pelvic lymph node dissection (n = 9) for the LN embolization group. The 3 most common indications of treatment were lower extremity edema (n = 11), pain (n = 11), and fever (n = 8). The amount of leak before treatment (initial daily drainage) and clinical outcomes, including the clinical success rate in 3 weeks, treatment period, and complication rate were compared between both groups. RESULTS: LN embolization showed a higher 3-week clinical success rate than sclerotherapy in a univariate analysis (83.3% and 43.8%, P = .026). There was no statistically significant difference in the treatment period and the complication rate (7.1 days and 12.3 days, P = .098; 8.3% and 25.0%, P = .184). CONCLUSIONS: LN embolization is more effective for treating postoperative pelvic lymphorrhea than sclerotherapy with similar safety.

Portal hypertension is associated with poor outcome of transarterial chemoembolization in patients with hepatocellular carcinoma.

OBJECTIVES: To determine whether clinically relevant portal hypertension (CRPH) influences outcome and whether it may serve as a prognostic marker in patients treated with transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). METHODS: One hundred and forty-seven patients underwent conventional TACE as a first-line treatment for a single HCC. CRPH was graded as 0, 1, or 2. The influence of CRPH, together with other factors, on local tumour progression (LTP) and overall survival (OS) were analysed using Cox proportional hazards regression. RESULTS: A higher CRPH grade (grade 1, p = 0.005, hazard ratio [HR] = 3.282; grade 2, p < 0.001, HR = 7.144) and less selective catheterization (p = 0.009, HR = 1.951) were significantly associated with early LTP. Regarding OS, older age, (p < 0.001, HR = 1.050), CRPH grade 2 (p = 0.024, HR = 2.058), and a larger tumour (p < 0.001, HR = 1.454) were significantly associated with early death. CONCLUSIONS: Portal hypertension was significantly associated with poor outcome after TACE, and non-invasive CRPH grading may be a useful prognostic marker of TACE. KEY POINTS: • Portal hypertension was significantly associated with poor outcome after TACE. • Grading portal hypertension non-invasively can help predict TACE outcome in HCC patients. • CRPH grading can aid in selecting optimal candidates for TACE.

Chemoembolisation for hepatocellular carcinoma with bile duct invasion: is preprocedural biliary drainage mandatory?

PURPOSE: To determine the necessity of preprocedural biliary drainage prior to chemoembolisation for hepatocellular carcinoma (HCC) with bile duct invasion. MATERIALS AND METHODS: The study included 52 patients who received chemoembolisation for unresectable HCC invading bile duct and causing hyperbilirubinemia (>3 mg/dL). Patients were divided into three groups according to biliary drainage and its effect: effective drainage (n=21), ineffective drainage (n=17), and non-drainage (n=14). Thirty-day mortality, length of hospitalisation, adverse events recorded using Common Terminology Criteria for Adverse Events (CTCAE), survival, and tumour response was compared among three groups. RESULTS: Thirty-day mortality rates were 14.3% (n=3), 17.6% (n=3), and 7.1% (n=1) for effective, ineffective, and non-drainage groups, respectively, and did not differ significantly among groups (p=0.780). The mean length of hospitalisation was shorter in non-drainage group compared to ineffective drainage group (12.1±11.4 vs 34.1±29.6 days, p=0.012). Mean differences in CTCAE grade for laboratory parameters before and after chemoembolisation were not significantly different among three groups. Survival among three groups was not significantly different (p=0.239-0.825). The tumour response was also not significantly different among three groups (p=0.679). CONCLUSION: Biliary drainage may not be mandatory prior to chemoembolisation in patients with HCC invading the bile duct. KEY POINTS: • Chemoembolisation without biliary drainage can be performed for icteric HCC. • Chemoembolisation without biliary drainage is not accompanied by increased adverse events. • Preprocedural biliary drainage may not be mandatory for chemoembolisation for icteric HCC.

Chemoembolization with Vascular Disrupting Agent CKD-516 Dissolved in Ethiodized Oil in Combination with Doxorubicin: A VX2 Tumor Model Study.

PURPOSE: To assess feasibility and efficacy of CKD-516, a vascular disrupting agent, in transarterial chemoembolization in a liver tumor model. MATERIALS AND METHODS: A VX2 carcinoma strain was implanted in rabbit liver (n = 40) and incubated for 2 weeks. After confirmation of tumor growth using computed tomography, transarterial chemoembolization was performed. CKD-516 was dissolved in ethiodized oil, and animals were allocated to 4 treatment groups (n = 10 in each): group A, ethiodized oil; group B, ethiodized oil/CKD-516; group C, ethiodized oil + doxorubicin; group D, ethiodized oil/CKD-516 + doxorubicin. To assess hepatic damage, serum aspartate transaminase and alanine transaminase levels were measured on day 1, 3, and 7 after delivery. To assess tumor necrosis, animals were euthanized on day 7, and explanted tumors were stained with hematoxylin and eosin and a terminal deoxynucleotidyl transferase deoxyuridine triphosphate nick end labeling assay. Percentage areas of viable tumors were calculated using digitalized histopathologic specimen images. RESULTS: Tumor viability rates were 47.1% ± 11.4%, 27.5% ± 13.6%, 14.4% ± 12.5%, and 0.7% ± 1.0% in groups A, B, C, and D (P < .001). Liver enzyme levels were elevated after drug delivery but recovered during follow-up. Significant between-group differences were observed on days 1, 3, and 7 (aspartate transaminase and alanine transaminase: P = .0135 and P = .0134, P = .0390 and P = .0084, and P = .8260 and P = .0440). CONCLUSIONS: Treatment with a combination of CKD-516 and conventional transarterial chemoembolization showed therapeutic benefit in a liver tumor model.

Arteries of the falciform ligament on C-arm CT hepatic arteriography: The hepatic falciform artery and the Sappey's superior artery.

BACKGROUND AND AIM: To investigate the prevalence, anatomy and distribution of the hepatic falciform artery (HFA) and Sappey's superior artery (SSA) using C-arm CT hepatic arteriography (C-arm CTHA). MATERIALS AND METHODS: From January 2011 to December 2012, 220 patients who underwent C-arm CTHA during initial transarterial treatment for hepatocellular carcinoma were included in this retrospective study. The HFAs and SSAs prevalence and origin were evaluated using axial images of C-arm CTHA. A 5-point scale for HFAs and a 4-point scale for SSAs were used to designate the radiologically conspicuous arteries. RESULTS: The prevalences of the total HFAs and SSAs were 95 % (n=209) and 22 % (n=49), while those of radiologically conspicuous HFAs and SSAs were 62 % (n=137) and 10 % (n=22), respectively. Thirty HFAs (22 % of radiologically conspicuous HFAs and 14 % of the total study population) were distributed in the subcutaneous layer of the anterior abdominal wall, while the majority of SSAs ran through the superior part of the falciform ligament in the left-anterior direction and anastomosed with left inferior phrenic artery. CONCLUSION: Our study using C-arm CTHA revealed that the prevalence of the HFA is higher than the existing knowledge and proved the existence of the SSA radiologically for the first time. KEY POINTS: • Prevalence of hepatic falciform artery is 95 %, higher than previously known. • 22 % of conspicious hepatic falciform arteries distributed in subcutaneous tissue around umbilicus. • The existence of Sappey's superior artery was proved with a radiological method.

Transarterial chemoembolization of hepatocellular carcinoma with segmental portal vein tumour thrombus.

OBJECTIVES: To evaluate the clinical outcome and safety of transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) with segmental or subsegmental portal vein tumour thrombus (sPVTT) in patients with preserved hepatic function, and to address the efficacy of additional chemoinfusion after TACE (TACE+CI). METHODS: From January 2003 to December 2012, TACE was conducted on 81 patients with Child-Pugh score ≤7 who had HCC with sPVTT. Thirty-one of them underwent TACE+CI. The overall survival (OS) and serious adverse events (SAEs) were evaluated. The efficacy of TACE+CI was appraised after adjustment with inverse probability of treatment weighting (IPTW). RESULTS: The OS after TACE (median, 15.5 months) was significantly related with aspartate aminotransferase (hazard ratio [HR], 1.011), modified Barcelona Clinic Liver Cancer (BCLC) stage D (HR, 2.841), extrahepatic spread (HR, 4.862), and TACE+CI (HR, .367). The SAE incidence was significantly associated with modified BCLC stages (HR, 10.174 [proper-C] and 24.000 [D]). After IPTW adjustment, TACE+CI significantly improved OS (p = .028; HR, .511), but the SAE incidence was not significantly altered (p = .737; HR, .819). CONCLUSIONS: TACE can be an effective and safe treatment option for HCC with sPVTT in patients with preserved hepatic function. Furthermore, additional chemoinfusion can enhance the therapeutic efficacy while maintaining the safety. KEY POINTS: • TACE is effective and safe for treating HCC with sPVTT. • Modified BCLC stages can stratify the risk and benefit of TACE. • Additional chemoinfusion can enhance the therapeutic efficacy while maintaining the safety.

Superselective Embolization for Arterial Upper Gastrointestinal Bleeding Using N-Butyl Cyanoacrylate: A Single-Center Experience in 152 Patients.

PURPOSE: To evaluate 30-day safety and efficacy of superselective embolization for arterial upper gastrointestinal bleeding (UGIB) using N-butyl cyanoacrylate (NBCA). MATERIALS AND METHODS: This single-center retrospective 10-year study included 152 consecutive patients with UGIB (gastric, n = 74; duodenal, n = 78) who underwent embolization with NBCA for angiographically positive arterial bleeding. The primary endpoint was clinical success rate defined as achievement of hemostasis without rebleeding or UGIB-related mortality within 30 days after embolization. Mean systolic blood pressure and heart rate were 121.2 mm Hg ± 27.4 and 97.9 beats/minute ± 22.5; 31.1% of patients needed intravenous inotropes, and 36.6% had coagulopathy. The etiology of bleeding was ulcer (80.3%) or iatrogenic injury (19.7%). Statistical analysis was performed to identify predictive factors for outcomes. RESULTS: Technical success rate was 100%. Clinical success, 1-month mortality, and major complication rates were 70.4%, 22.4%, and 0.7%. There were significant differences in the clinical success rates between gastric and duodenal bleeding (79.4% vs 62.2%; P = .025). The need for intravenous inotropes at the time of embolization was a significant negative predictive factor in both gastric (odds ratio [OR] = 0.091, P = .004) and duodenal (OR = 0.156, P = .002) bleeding. The use of a microcatheter with a smaller tip (2 F) was associated with better outcomes in duodenal bleeding (OR = 7.389, P = .005). CONCLUSIONS: Superselective embolization using NBCA is safe and effective for angiographically positive arterial UGIB.

Cone Beam CT-Guided Chemoembolization of Probable Hepatocellular Carcinomas Smaller than 1 cm in Patients at High Risk of Hepatocellular Carcinoma.

PURPOSE: To evaluate the effectiveness and safety of cone-beam computed tomography (CT)-guided chemoembolization for probable hepatocellular carcinomas (HCCs) smaller than 1 cm in patients at high risk for HCC. MATERIALS AND METHODS: From December 2009 to May 2014, 57 patients (43 male and 14 female; mean age, 61.1 y) at high risk for HCC underwent cone-beam CT-guided conventional chemoembolization for 79 treatment-naive probable HCCs < 1 cm. Probable HCCs were diagnosed when hepatic nodules showed arterial enhancement and washout on dynamic CT or magnetic resonance images. The Kaplan-Meier method and Cox proportional-hazards regression were used to evaluate the time to local progression (TTLP), time to progression (TTP), and overall survival (OS). RESULTS: Initial follow-up images obtained 2-3 months after chemoembolization showed complete response in all 79 tumors. The 1-, 2-, and 3-year local progression rates were 10.4%, 21.7%, and 35.7%, respectively. Subsegmental catheterization (P < .001; hazard ratio [HR] = .041) and segmental catheterization (P = .001; HR = .049) were significantly associated with longer TTLP. The 1-, 2-, and 3-year progression rates were 40.5%, 66.7%, and 78.6%, respectively. Tumor multiplicity (P = .004; HR = 2.612) was a significant risk factor for shorter TTP. The 1-, 2-, and 3-year OS rates were 100%, 98.2%, and 88.5%, respectively. Child-Turcotte-Pugh class B disease (P = .029; HR = 5.989) was significantly associated with shorter OS. No complications occurred after chemoembolization. CONCLUSIONS: Cone-beam CT-guided chemoembolization can be a useful and safe option for probable HCCs < 1 cm in patients at high risk for HCC.

Korean Multicenter Registry of Transcatheter Arterial Chemoembolization with Drug-Eluting Embolic Agents for Nodular Hepatocellular Carcinomas: Six-Month Outcome Analysis.

PURPOSE: To assess the efficacy and safety of transcatheter arterial chemoembolization with drug-eluting embolic (DEE) agents for nodular hepatocellular carcinoma (HCC). MATERIALS AND METHODS: The study design was a prospective multicenter registry-based, single-arm clinical trial that included 152 patients. One hundred three (67.8%) had a Child-Pugh class/score of A5, 114 (75.0%) had a performance status of 0, and 77 (50.7%) had Barcelona Clinic Liver Cancer (BCLC) stage A disease. The DEE chemoembolization procedures were performed with DC Bead particles loaded with doxorubicin solution. The primary endpoint of the study was 6-month tumor response assessed per modified Response Evaluation Criteria In Solid Tumors. Secondary endpoints were treatment safety and overall survival. RESULTS: At 1-month posttreatment assessment, complete response (CR) and objective response (OR; ie, CR or partial response) rates were 40.1% and 91.4%, respectively. At 6-month assessment, 121 patients remained for analysis, and CR and OR rates were 43.0% and 55.4%, respectively. The cumulative progression-free survival (PFS) rate at 6 months was 65.0%. Child-Pugh score, tumor multiplicity, and tumor size were independent predictors of PFS (P = .020, P = .029, and P = .001, respectively). There was no 30-day mortality. The overall 6-month survival rate was 97.4%. There were no grade 4 adverse events or laboratory changes. Serious adverse events were reported in 7.2% of patients, and persistent deterioration of liver function was observed in 3.9%. Prominent biliary injury was demonstrated in 19.7% of patients. No liver abscess was observed. CONCLUSIONS: DEE chemoembolization for nodular HCC had an acceptable safety profile and acceptable 6-month tumor response and survival rates.

Split liver transplantation for retroperitoneal immature teratoma masquerading as hepatoblastoma.

Extragonadal teratoma originating from the retroperitoneum represents less than 5% of all teratomas and accounts for less than 10% of all pediatric retroperitoneal neoplasms. To date, there has been no report of teratoma managed with LT. This study reports an infant aged 3 months with retroperitoneal immature teratoma involving the hepatic hilum, refractory to chemotherapy and treated with LT. The patient was referred to our hospital for management of a growing abdominal mass. Histopathology of a fine needle biopsy of the lesion suggested the possibility of a hepatoblastoma with teratoid features. Cisplatin-based chemotherapy was initiated, but rapid growth of the tumor encasing the hepatic artery proper was detected, even after two cycles of chemotherapy. A split LT was carried out, and pathological examination of the explanted liver revealed the involvement of numerous neuroepithelial components, confirming the diagnosis of a Norris grade 3 immature teratoma. The patient recovered well and was discharged on day 19 post-LT. As on date, on postoperative day 240, he has completed seven cycles of a 12-cycle vinblastine and doxorubicin-based adjuvant chemotherapy.

Sloughing of biliary tumour ingrowth of hepatocellular carcinoma after chemoembolization.

PURPOSE: To describe the imaging findings and clinical course of sloughing of biliary tumour ingrowth of hepatocellular carcinoma (HCC) after chemoembolization. MATERIALS AND METHODS: We reviewed 12 patients who experienced sloughing of biliary tumour ingrowth after chemoembolization. We evaluated the patients' characteristics, clinical manifestations and treatment modalities. We also reviewed computed tomography (CT) scans to determine the characteristics of the sloughed tumour including length, attenuation and appearances during follow-up. RESULTS: The length of the sloughed tumour ranged from 0.6-7.8 cm. Their Hounsfield units ranged from 35-729. Sloughed tumours were misreported as biliary stones in four patients, and were not reported in the initial CT report in one patient. At the time of sloughing, seven patients complained of cholestatic symptoms, while the other five had no symptoms. Four patients underwent sphincterotomy and tumour removal under endoscopic retrograde cholangiopancreaticography (ERCP), two underwent percutaneous transhepatic biliary drainage (PTBD) and one underwent PTBD followed by ERCP. The remaining five were managed conservatively. Five sloughed tumours were removed by ERCP, six disappeared spontaneously within 3 months, and one patient had no follow-up image. CONCLUSIONS: Sloughing of biliary tumour ingrowth may be misinterpreted as biliary stone, and may or may not cause cholestatic symptoms. KEY POINTS: • Migration of intraductal tumour ingrowth of HCC after chemoembolization occurs more commonly than reported. • The sloughed tumour is often misinterpreted as biliary calculi. • It can make cholestasis and be managed by ERCP or PTBD. • In some asymptomatic cases, a wait-and-see approach can be taken.