Search

Purpose: To compare the efficacy of right portal vein embolization using ethylene vinyl alcohol (EVOH-PVE) compared to other embolic agents and surgical right portal vein ligation (PVL). Material and methods: Patients with right sided liver malignancies scheduled for extensive surgery and receiving induction of liver hypertrophy via right portal vein embolization/ligature between 2010-2016 were retrospectively evaluated. Treatments included were ethylene vinyl alcohol copolymer (Onyx®, EVOH-PVE), ethiodized oil (Lipiodol ® , Lipiodol/PVA-PVE), polyvinyl alcohol (PVA-PVE) or surgical ligature (PVL). Liver segments S2/3 were used to assess hypertrophy. Primary outcome was future liver remnant growth in ml/day. Results: Forty-one patients were included (EVOH-PVE n =  11; Lipiodol/PVA-PVE n =  10; PVA-PVE n =  8; PVL n =  12), the majority presenting with cholangiocarcinoma and colorectal metastases ( n =  11; n =  27). Pre-interventional liver volumes were comparable ( p =  .095). Liver hypertrophy was successfully induced in all but one patient receiving Lipiodol/PVA-PVE. Liver segment S2/3 growth was largest for EVOH-PVE (5.38 ml/d) followed by PVA-PVE (2.5 ml/d), with significantly higher growth rates than PVL (1.24 ml/d; p <  .001; p =  .007). No significant difference was evident for Lipiodol/PVA-PVE (1.43 ml/d, p =  .809). Conclusions: Portal vein embolization using EVOH demonstrates fastest S2/3 growth rates compared to other embolic agents and PVL, potentially due to its permanent portal vein embolization and induction of hepatic inflammation.

Background: Intra-arterial therapy with embolics is established for the treatment of malignancies of the liver. However, there are no studies comparing the different effects of various embolics used in clinical practice. Herein, we analyzed the effect of 3 different embolics on tumor growth in a rat model of colorectal liver metastases., Methods: Eight days after subcapsular implantation of 5 × 10 5 colorectal cancer cells (CC531) in the left liver lobe of WAG/Rij rats were randomized into 4 groups (n = 8) and underwent intra-arterial hepatic therapy. Animals received either EmboCept S®, DC Bead® or Lipiodol® Ultra-Fluid. Animals of the control group received a comparable amount of saline. Tumor growth was measured on day 8 and 11 using a three-dimensional 40 MHz ultrasound device. On day 11 tumor and liver tissue were removed for histological and immunohistochemical analyses., Results: On day 11 animals of the control group showed a tumor growth of ~ 60% compared to day 8. Application of Lipiodol Ultra-Fluid® did not significantly influence tumor growth (~ 40%). In contrast, treatment with EmboCept S® or DC Bead® completely inhibited tumor growth. Of interest, application of EmboCept S® did not only completely inhibit tumor growth but even decreased tumor size. Immunohistochemical analysis showed a significant increase of necrotic areas within the tumors after application of EmboCept S® and DC Bead® compared to Lipiodol® Ultra-Fluid., Conclusion: The present study demonstrates that an intra-arterial therapy with EmboCept S® and DC Bead®, but not Lipiodol® Ultra-Fluid, results in a complete inhibition of rat colorectal liver metastatic growth.

Purpose: To compare different imaging techniques (volume perfusion CT, cone-beam CT, and dynamic gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced dynamic contrast-enhanced MR imaging with golden-angle radial sparse parallel MR imaging) in evaluation of transarterial chemoembolization of hepatocellular carcinoma (HCC) using radiopaque drug-eluting embolics (DEE)., Materials and Methods: MR imaging and CT phantom investigation of radiopaque DEE was performed. In the clinical portion of the study, 13 patients (22 HCCs) were prospectively enrolled. All patients underwent cross-sectional imaging before and after transarterial chemoembolization using 100-300 μm radiopaque DEE. Qualitative assessment of images using a Likert scale was performed., Results: In the phantom study, CT-related beam-hardening artifacts were markedly visible at a concentration of 12% (v/v) radiopaque DEE; MR imaging demonstrated no significant detectable signal intensity changes. Imaging obtained before transarterial chemoembolization showed no significant difference regarding tumor depiction. Visualization of tumor feeding arteries was significantly improved with volume perfusion CT (P < .001) and cone-beam CT (P = .002) compared with MR imaging. Radiopaque DEE led to significant decrease in tumor depiction (P = .001) and significant increase of beam-hardening artifacts (P = .012) using volume perfusion CT before versus after transarterial chemoembolization. Greater residual arterial tumor enhancement was detected with MR imaging (10 HCCs) compared with volume perfusion CT (8 HCCs) and cone-beam CT (6 HCCs)., Conclusions: Using radiopaque DEE, the imaging modalities provided comparable early treatment assessment. In HCCs with dense accumulation of radiopaque DEE, treatment assessment using volume perfusion CT or cone-beam CT may be impaired owing to resulting beam-hardening artifacts and contrast stasis. Dynamic contrast-enhanced MR imaging may add value in detection of residual arterial tumor enhancement., (Copyright © 2018 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: To address the feasibility of infusion of yttrium-90 ( 90 Y) glass microspheres directly through the right inferior phrenic artery (RIPA)., Materials and Methods: From November 2015 to May 2017, 20 patients underwent 90 Y radioembolization through the RIPA. When the systemic-to-pulmonary shunt was demonstrated on C-arm computed tomography (CT) of the RIPA, prophylactic embolization by polyvinyl alcohol (PVA) particles was performed prior to infusion of 90 Y glass microspheres. Follow-up CT scans were retrospectively reviewed for pulmonary complications. Tumor response was determined by the modified Response Evaluation Criteria in Solid Tumors., Results: Nine (45%) patients had systemic-to-pulmonary shunts on C-arm CT images of the RIPA. The feeder of the systemic-to-pulmonary shunt was the azygoesophageal branch (n = 7) and the anterior branch (n = 2). The mean activity of 90 Y glass microspheres infused into the RIPA was 0.49 GBq (range, 0.19-1.55 GBq). No patient had symptomatic radiation pneumonitis or cutaneous complications during follow-up. Seven patients had focal atelectasis (n = 5), focal ground-glass opacity (n = 2), and/or a small amount of pleural effusion (n = 2) on follow-up image. Best tumor response fed by the RIPA was complete response (n = 4), partial response (n = 9), stable disease (n = 2), progressive disease (n = 4), and unevaluable (n = 1)., Conclusion: The administration of 90 Y glass microspheres through the RIPA may be safe after embolization of a systemic-to-pulmonary shunt identified on C-arm CT., (Copyright © 2017 SIR. Published by Elsevier Inc. All rights reserved.)

Background/aim: The aim of this study was to determine whether the addition of bumetanide (BU), a glycolytic metabolism pathway inhibitor, to arterial embolization improves tumor necrosis of N1-S1 hepatocellular carcinoma in a rat model., Materials and Methods: N1-S1 tumors were surgically implanted in the liver of 14 Sprague-Dawley rats. The rats were divided into three groups: In control group (n = 5), 1 ml of normal saline was injected intra-arterially. The tumor in the transarterial embolization group (TAE, n = 4) was embolized using 10 mg of 50-150 μ polyvinyl alcohol (PVA) particles and embolization plus BU group (TAE + BU, n = 5) were embolized with 10 mg of PVA plus 0.04 mg/kg of BU. Tumor volume was measured using two-dimensional ultrasound before intervention and twice a week afterward. Relative tumor volume after the intervention was calculated as the percentage of preinterventional tumor volume. After 4 weeks of observation, the rats were sacrificed for histopathological evaluation., Results: No statistically significant difference was detected in the preintervention tumor sizes between the three groups (P > 0.05). In the control group, the relative tumor volume increased to 142.5% larger than baseline measurements. In the TAE group, the tumor volume decreased by 18.2 ± 12.2%. The tumor volume in the TAE + BU group decrease by 90.4 ± 10.2%, which was 72.2% more than in TAE only group (P < 0.0001). Histopathological evaluation demonstrated no residual tumor in the TAE + BU group., Conclusion: Tumor necrosis significantly increased in N1-S1 tumor that received BU at the time of TAE when compared to TAE alone.

Purpose: To evaluate the safety and efficacy of polyvinyl alcohol (PVA) terminal chemoembolization and to identify the prognostic factors associated with survival in hepatocellular carcinoma (HCC) patients with hepatic arteriovenous shunts (HAVS)., Materials and Methods: Of 133 patients' managements were retrospectively analyzed. HAVS was classified into three types: slow-flow, intermediate-flow and high-flow. The size of the PVA used was determined following the scheme: slow-flow HAVS: 300-500μm PVA; intermediate-flow HAVS: 500-710μm PVA; high-flow HAVS: 710-1000μm PVA. The HCCs with slow-flow and intermediate-flow HAVS were embolized by PVA plus chemotherapeutic agents lipiodol emulsion, while the high-flow HAVS were treated by PVA with chemotherapeutic agents. Survival curves were calculated by Kaplan-Meier method and compared by log-rank test. The influence of possible prognostic factors on survival were analyzed by multivariate Cox proportional-hazards method., Results: The median overall survival (OS) of 133 patients was 9.1 months. The median OS of the slow-flow type, intermediate-flow type and high-flow type patients were 10.8, 9.1 and 7.3 months, respectively. There was no statistically significant difference among different HAVS types (P=0.239). The 30-day mortality was 3.8%. Cox multivariate survival analysis revealed that initial preoperative AFP value≥400ng/ml (HR=2.105, P=0.006) was an independent risk factor. While multiple embolization (HR=0.482, P=0.011), tumor remission (HR=0.431, P=0.041) and multimodality therapy (HR=0.416, P=0.004) were independent protection factors., Conclusion: It is safe and effective for HCCs with HAVS treated by terminal chemoembolization therapy with PVA plus chemotherapeutic agents lipiodol emulsion (or PVA plus chemotherapeutic agents). The HCCs with HAVS achieves good prognosis with multiple embolization, tumor remission and multimodality therapy, while achieves poor prognosis with inital preoperative high AFP value (≥400ng/ml)., (Copyright © 2016. Published by Elsevier B.V.)

Purpose: To report outcomes after portal vein embolization (PVE) and right hepatectomy in patients receiving embolization with N-butyl cyanoacrylate (NBCA) glue + central AMPLATZER Vascular Plug (AVP; glue group) or polyvinyl alcohol (PVA) particles ± coils (PVA group)., Materials and Methods: Between March 2008 and August 2013, all patients having PVE with NBCA + AVP or PVA ± coils before right hepatectomy were retrospectively reviewed; 85 patients underwent PVE with NBCA + AVP (n = 45) or PVA ± coils (n = 40). The groups were compared using Mann-Whitney U and χ 2 tests., Results: Technical success of embolization was 100%. Degree of hypertrophy (16.2% ± 7.8 vs 12.3% ± 7.62, P = .009) and kinetic growth rate (3.5%/wk ± 2.0 vs 2.6%/wk ± 1.9, P = .016) were greater in the glue group versus the PVA group. Contrast volume (66.1 mL ± 44.8 vs 189.87 mL ± 62.6, P < .001) and fluoroscopy time (11.2 min ± 7.8 vs 23.49 min ± 11.7, P < .001) were significantly less during the PVE procedure in the glue group. Surgical outcomes were comparable between groups, including the number of patients unable to go onto surgery (P = 1.0), surgical complications (P = .30), length of hospital stay (P = .68), and intensive care unit admissions (P = .71). There was 1 major complication (hepatic abscess) in each group after PVE., Conclusions: PVE performed with NBCA + AVP compared with PVA ± coils resulted in greater degree of hypertrophy of the future liver remnant, less fluoroscopic time and contrast volume, and similar complication rates., (Copyright © 2016 SIR. Published by Elsevier Inc. All rights reserved.)

To assess the value of transarterial embolization/chemoembolization (TAE/TACE) therapy via adrenal artery for patients with hepatocellular carcinoma (HCC). Patients with HCC who underwent TAE/TACE therapy via adrenal artery between May 2003 and October 2015 across 4 medical centers were identified. Clinical information, procedural data, and imaging data were analyzed to assess technical success, disease control, and survival rates. A t test was used to compare the differences in serum alpha-fetoprotein before and after treatment. A total of 23 patients (23 men; mean age, 54.6 ± 7.5 years; range, 37-72 years) were included in this study. All tumors were located under the capsule of the liver and adjacent to the adrenal gland (median tumor diameter, 8.2 cm). Lesions fed by the adrenal artery were demonstrated during initial TAE/TACE in 7 patients and during repeat TAE/TACE in 16 patients. The superior, middle, and inferior adrenal arteries were involved in 14, 3, and 6 patients, respectively. The technical success rate was 100%. The disease control rate at 3 months was 100%, with partial tumor response seen in 16 (69.6%) patients and stable disease seen in 7 (30.4%) patients. The cumulative survival rate from the time of TAE/TACE was 100% at 1 year. There were no embolization-related complications. TAE/TACE therapy via the adrenal arteries can improve the therapeutic efficacy of TAE/TACE and reduce the incidence of HCC recurrence and/or presence of residual HCC., Competing Interests: The authors have no conflicts of interest to disclose.

Purpose: To evaluate changes in T-cell populations in peripheral blood after bland hepatic artery embolization (HAE)., Materials and Methods: Bland HAE was performed in 12 patients to treat primary (n = 5) or metastatic (n = 7) liver tumors, using microspheres and polyvinyl alcohol (n = 8) or microspheres alone (n = 4). Patient peripheral blood samples were collected within 1 month before HAE, within 1 week after HAE (early period after HAE), and 2-8 weeks after HAE (follow-up period). Peripheral blood populations of cytotoxic T lymphocytes, CD4(+) T cells, type 1 helper T cells (Th1) and type 2 helper T cells (Th2), and regulatory T cells (Treg) were evaluated using flow cytometry. Changes in T-cell populations before and after bland HAE were compared using paired t tests., Results: Peripheral blood CD4(+) T-cell populations decreased significantly in the early period after HAE (44.0% ± 2.2 to 34.4% ± 3.6, P < .01) and in the follow-up period (44.0% ± 2.2 to 36.3% ± 3.0, P < .01). Among the individual CD4(+) T-cell subtypes, Treg (2.5% ± 0.3 to 1.7% ± 0.2, P < .02) and Th1 (8.1% ± 1.8 to 5.6% ± 1.6, P < .02) decreased significantly in the early period after HAE only. The presence of extrahepatic disease was associated with decreasing Treg (P < .04)., Conclusions: After HAE, the peripheral blood T-cell environment is changed with decreases in Treg and Th1., Competing Interests: No author has any conflict of interest related to this study., (Copyright © 2016 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: We aimed to compare the effect of using different embolic agents such as gelfoam and polyvinyl alcohol (PVA) on survival, tumor response, and complications in transarterial chemoembolization (TACE) of hepatocellular carcinoma (HCC) patients., Materials and Methods: We retrospectively reviewed the medical records of 38 inoperable HCC patients who underwent TACE between August 1998 and April 2007. A total of 50 TACE sessions were performed using PVA (n=18) or gelfoam particles (n=20), following the application of 60 mg doxorubicin with 10-20 mL lipiodol emulsion. The PVA and gelfoam groups were compared based on clinical, laboratory and demographic variables. Survival rates were calculated starting from the first TACE session using the Kaplan-Meier analysis., Results: There was no significant difference between the survival rates of PVA and gelfoam groups (P = 0.235). Overall survival rates at 12, 24, 36, 48, and 60 months were 55%, 36%, 15%, 7%, and 5%, respectively. Tumor response, age, lipiodol accumulation type, number of HCC foci, complications and serum alpha-fetoprotein level were significant factors for survival in all patients., Conclusion: Use of gelfoam or PVA as the embolic agent did not have a significant impact on survival. Complete tumor response, intensive lipiodol accumulation in tumor, older age (<60 years), fewer (≤3) HCC foci, low serum alpha-fetoprotein level (≤400 ng/mL) were found to improve cumulative survival significantly.

A hybrid composite made up of superparamagnetic iron oxide nanoshells encapsulating the anticancer drug doxorubicin and bound together by poly(vinyl alcohol) was developed. Transcatheter arterial delivery in an in vivo liver tumor model led to embolization of the liver tumor blood vessels. Embolization was followed by disassembly of the composite. The nanoshells were then able to pass through the leaky tumor vasculature into the tumor tissue, thereby leading to slow and sustained release of the drug. As well as being relatively noncytotoxic, the composite was responsive to magnetic resonance imaging, thus making it a potentially useful theranostic agent., (© 2014 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Background & Aims: Neo-adjuvant transarterial therapies are commonly used for patients with HCC in the waiting list for liver transplantation (LT) to delay tumour progression, however, their effectiveness is not well-established. We studied the effect of pre-LT transarterial therapies on post-LT HCC recurrence, using the explanted liver histology to assess therapeutic efficacy and the predictors of response to these therapies., Methods: We included 150 consecutive patients from our prospectively compiled database, listed for liver transplantation using the Milan criteria. Transarterial embolization without chemotherapeutic agents was the transarterial therapy used as standard of care. PVA particles were the embolizing agent of choice., Results: Sixty-seven (45%) patients had TAE as bridging therapy to liver transplantation, of which 60 were transplanted after 2001. The majority of patients (36, 54%) had partial tumour necrosis after transarterial therapy, whereas 22 (33%) had complete tumour necrosis and 9 (13%) had no necrosis. HCC post-transplant recurrence was independently associated with no neo-adjuvant transarterial therapy (OR 5.395, 95% CI 1.289-22.577; P = 0.021) and the total radiological size of HCC nodules (OR 1.037, 95% CI 1.006-1.069; P = 0.020)., Conclusions: Pre-transplant TAE with the more permanently occluding PVA particles significantly reduces post-transplant HCC recurrence in patients within the Milan criteria., (© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Unresectable colorectal liver metastases have a 1- and 2-year survival of 55% and 33% with current systemic therapies. The authors evaluated response and survival after transarterial chemoembolization., Methods: Chemoembolization with cisplatin, doxorubicin, mitomycin C, ethiodized oil, and polyvinyl alcohol particles was performed at monthly intervals for 1 to 4 sessions. Cross-sectional imaging and clinical and laboratory evaluation were performed before treatment, 1 month after treatment, and then every 3 months. A second cycle was performed for intrahepatic recurrence. Toxicity was assessed using National Cancer Institute's Common Toxicity Criteria version 3.0. Response was evaluated using Response Evaluation Criteria in Solid Tumors criteria. Progression and survival were estimated with Kaplan-Meier analysis., Results: A total of 245 treatments were performed over 141 cycles on 121 patients. Ninety-five of 141 treatment cycles were evaluable for response: 2 (2%) partial response, 39 (41%) stable disease, and 54 (57%) progression. Median time to disease progression (TTP) in the treated liver was 5 months, and median TTP anywhere was 3 months. Median survival was 33 months from diagnosis of the primary colon cancer, 27 months from development of liver metastases, and 9 months from chemoembolization. Survival was significantly better when chemoembolization was performed after first- or second-line systemic therapy (11-12 months) than after third- to fifth-line therapies (6 months) (P = .03). Presence of extrahepatic metastases did not adversely affect survival (P = .48)., Conclusions: Chemoembolization provided local disease control of hepatic metastases after 43% of treatment cycles. Median survival was 27 months overall, and 11 months when initiated for salvage after failure of second-line systemic therapy., (Copyright © 2010 American Cancer Society.)

Purpose: To evaluate hepatic arterial patency after serial bland particle embolization procedures in patients with hepatocellular carcinoma (HCC)., Materials and Methods: All patients with HCC who underwent five or more hepatic artery bland embolization procedures with permanent particulate and spherical embolic agents between September 1996 and December 2007 were retrospectively reviewed. Data analyzed included patient demographics, vessels embolized, embolic agent used, and duration of arterial patency., Results: Forty-three patients were identified who underwent five or more bland embolization procedures in the same arterial distribution. Of the 43 patients examined, 83% (n = 36) showed no change in the hepatic arterial tree after repeated bland embolization (mean treatment period of 48 months +/- 23). Six patients (13%) exhibited occlusion of a fifth-order or more distal vessel after an average of 5 embolizations +/- 2 over a period of 34 months +/- 27. A single case of vascular occlusion of a fourth-order vessel was observed after five embolizations over a period of 52 months., Conclusions: Repeated bland embolization of the hepatic arteries in HCC preserves patency of the hepatic arterial vasculature despite the fact that embolization is carried out to complete stasis., (Copyright 2010 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the survival of patients with hepatocellular carcinoma (HCC) treated with a standardized method of transcatheter arterial embolization (TAE) with small embolic particles intended to impart terminal vessel blockade, and to evaluate prognostic factors that impact overall survival., Materials and Methods: A total of 322 patients with HCC who underwent 766 embolizations from January 1997 to December 2004 were retrospectively reviewed. Selective embolization of vessels feeding individual tumors was performed with small (50 microm) polyvinyl alcohol or spherical embolic particles (40-120 microm) intended to cause terminal vessel blockade. Repeat embolization was performed in cases of evidence of persistent viable tumor or development of new lesions. Patient, tumor, and treatment characteristics were prospectively recorded and tested for prognostic significance by univariate and multivariate analysis., Results: The median survival time was 21 months, with 1-, 2-, and 3-year overall survival rates of 66%, 46%, and 33%, respectively. In patients without extrahepatic disease or portal vein involvement by tumor, the overall 1-, 2-, and 3-year survival rates increased to 84%, 66%, and 51%, respectively. Okuda stage, extrahepatic disease, diffuse disease (> or =5 tumors), and tumor size were independent predictors of survival on multivariate analysis. There were 90 complications (11.9%) in 75 patients, including eight deaths (2.5%), within 30 days of embolization., Conclusions: Hepatic arterial embolization with small particles to cause terminal vessel blockade is an effective treatment method for patients with unresectable HCC. These data support our hypothesis that particles alone may be the critical component of catheter-directed embolotherapy.

Objective: To assess the feasibility and safety of polyvinyl alcohol (PVA) embolization adjuvant to transarterial oily chemoembolization (P-TACE) in advanced hepatocellular carcinoma (HCC) with arterioportal shunts (APS)., Materials and Methods: Nineteen patients who underwent PVA embolization for APS before a routine chemoembolization (TACE) procedure were retrospectively reviewed. 10 of these 19 patients underwent follow-up TACE or P-TACE after P-TACE (Group A), but nine patients underwent only initial P-TACE because of progression of HCC and/or underlying liver cirrhosis (Group B). Hepatic function tests, APS grades, and portal flow directions were evaluated before and after P-TACE sessions. Complications after procedures and survival days were also evaluated., Results: In group A, APS grade was improved in eight patients and five of six patients with hepatofugal flow showed restored hepatopetal flow postoperatively. No immediate complication was developed in either group. Transient hepatic insufficiency developed in eight (42.1%) of 19 patients after P-TACE, and seven (87.5%) of these eight recovered within two weeks under conservative care. The mean and median survival time all study subjects was 280 days and 162 days., Conclusion: P-TACE is feasible and safe in advanced HCC patients with APS.

Background: The authors evaluated the impact of bland particle embolization on survival in patients with metastatic sarcoma to the liver., Methods: Twenty-four patients with liver-dominant metastases from sarcoma were treated with particle embolization from 1996 to 2002. Primary tumors included 16 gastrointestinal stromal tumors (GISTs), 7 intestinal leiomyosarcomas, and 1 liposarcoma. Thirteen patients had known extrahepatic disease. Embolization was performed by using polyvinyl alcohol or trisacryl microspheres to effect stasis in the target vessel(s). Follow-up images to assess response were obtained 4 weeks after the procedure. Decrease in the size of the target lesion by >25% or development of >50% necrosis on follow-up imaging was considered a treatment response., Results: Nineteen patients had metachronous liver metastases, and the median disease-free interval was 22 months (range 10-156 months) from resection of the primary tumor. Ten patients underwent prior liver resection for metastatic disease. Of 15 evaluable patients, 9 patients (60%) had a radiographic response. The median follow-up for all patients was 21 months. The median follow-up for surviving patients was 59 months. Overall survival from the time of initial embolization was 62% at 1 year, 41% at 2 years, and 29% at 3 years. Patients who had radiographic evidence of response survived significantly longer than patients who did not respond (63 months vs. 19 months; P < .007). Patients with GIST survived significantly longer than patients with visceral leiomyosarcoma (median, 36 months vs. 18 months; P < .03)., Conclusions: Bland embolization was efficacious in some patients with metastatic sarcoma to the liver. Radiographic evidence of response was correlated with improved survival. This regional therapy may enter the treatment algorithm for patients who have unresectable disease or disease that has failed conventional therapies., ((c) 2006 American Cancer Society.)

Purpose: The optimal embolic agent for transhepatic arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) has not been identified. This study reports outcomes of TACE for HCC with Gelfoam powder and polyvinyl alcohol (PVA)., Materials and Methods: Eighty-one patients underwent 152 TACE sessions with Gelfoam powder (n = 41) or polyvinyl alcohol (PVA) and Ethiodol (n = 40) as the embolic agent. Chemotherapeutic drugs were the same for all patients (50 mg cisplatin, 20 mg doxorubicin, 10 mg mitomycin-c). The groups were compared based on number of TACE sessions, maximum tumor size, bilirubin level, aspartate and alanine aminotransferase levels, Child-Pugh score, Model for End-stage Liver Disease score, and hepatitis B or C virus positivity. The number of cases of each Child class in each group was also evaluated. Survival starting from the first TACE session was calculated according to Kaplan-Meier analysis. Forty-eight patients died during the study period, 19 received transplants, and 14 were alive at the end of the study period., Results: The groups were statistically similar in all categories regarding liver function, Child-Pugh score, tumor size, hepatitis status, and percentage of patients with Child class A, B, and C disease. The number of TACE sessions was significantly greater for the Gelfoam powder group (mean, 2.2) versus the PVA group (mean, 1.6; P = .01). Overall survival was similar between groups whether patients who received transplants were included in the analysis (mean, 659 days +/- 83 with Gelfoam powder vs 565 days +/- 71 with PVA; P = .42) or were excluded (mean, 519 days +/- 80 with Gelfoam powder vs 511 days +/- 75 with PVA; P = .93)., Conclusion: In similar patient groups, survival after treatment of HCC with TACE with Gelfoam powder or PVA and Ethiodol was similar.

The purpose of this study was to determine whether transcatheter arterial chemoembolization (TACE) protocol affects the total volume of chemotherapy injected into the liver as well as subsequent arterial patency. A total of 160 patients with primary or secondary liver cancer were treated with 3 different chemoembolization protocols at a single institution. Data were analyzed retrospectively. Group 1 (n = 36) consisted of slurry of chemotherapy, oil and polyvinyl alcohol particles (PVA), group 2 (n = 91), chemotherapy and oil followed by PVA, and group 3 (n = 33), chemotherapy and oil followed by Gelfoam pledgets. The total volume of chemotherapy injected into the liver was recorded. Arterial patency was determined during subsequent chemoembolizations. The mean percentage of total intended chemotherapy dose administered was 54.6% for group 1, 75.3% for group 2, and 80.6% for group 3. Arterial patency at follow-up angiography was 56% for group 1, 74% for group 2, and 81% for group 3. The slurry protocol (group 1) significantly reduced arterial patency and injectable volume of chemotherapy during TACE.

Objectives: In cancer treatment, arterial blood flow reduction by embolization combined with intra-arterial chemotherapy may be advantageous by achieving high and prolonged drug concentrations in the tumor, and lower systemic drug exposure. The pharmacokinetics of intra-arterial mitomycin C (MMC) was investigated in patients with liver metastases undergoing chemoembolization treatment., Methods: The chemoembolization treatment consisted of the use of polyvinylalcohol microspheres (ITC-Contour, diameter 150-250 micro m, irreversible vessel occlusion, 20 mg MMC, 15 patients) followed by sealing of the supplying artery with Ethibloc. Alternatively, starch microspheres (Spherex, diameter 45 micro m, biologically degradable, 10 ml of suspension containing 60 mg starch/ml, 20 mg MMC in 7 patients, 15 mg/m2 body surface in 3 patients) were used. MMC was infused over 6 min into the artery supplying the tumor. Serum MMC concentrations were determined from peripheral venous blood samples [protein precipitation with acetonitrile, reverse-phase HPLC with ultraviolet detection (C18 column, elution with 0.01 M, pH 6.5 phosphate buffer/methanol, v/v 70:30, 365 nm)]. The pharmacokinetic parameters were computed assuming an open two-compartment model and linear kinetics., Results: The disposition parameters for MMC in patients treated with polyvinylalcohol microspheres were comparable to data from the literature (C(max)=913+/-98 ng/ml, T(max)=7.7+/-0.3 min, V(c)=0.27+/-0.03 l/kg, V(ss)=0.59+/-0.07 l/kg, Cl=757+/-67 ml/min, T(1/2 alpha)=5.8+/-0.8 min, T(1/2 beta)=50.4+/-4.1 min). There was no significant difference in the disposition parameters for MMC between patients treated with polyvinylalcohol microspheres and those treated with starch microspheres ( P>0.05). In particular, there was no significant difference in the standardized AUC between the groups; this implies that the systemic toxicity of MMC is comparable when polyvinylalcohol microspheres and ethibloc (AUC 1472+/-123 microg min/l per 1 mg MMC) or starch microspheres (AUC: 1448+/-172 microg min/l per 1 mg MMC) are used., Conclusion: The AUC values found in this study do not indicate a reduction in the systemic toxicity of MMC if applied intra-arterially in combination with embolizing microspheres, when compared to the AUC values in the literature for intra-arterial application without embolization, or intravenous MMC application. The amount of starch microspheres may have been too small to cause marked effects. On the other hand, there is a very wide range of AUC values reported in the literature for different application modes, and the use of such historical controls is not adequate for detecting more subtle advantages of the chemoembolization procedure, which may, however, exist.

Purpose: Postembolization syndrome (PES) occurs in the majority of patients undergoing hepatic chemoembolization, and is the major reason for hospitalization after the procedure. The ability to identify which groups of patients are at increased or decreased risk of PES would be useful to better counsel patients, to minimize toxicity, and to plan inpatient versus outpatient therapy., Materials and Methods: Seventy hepatic chemoembolization procedures were performed in 29 patients using cytotoxic drugs mixed with Ethiodol and polyvinyl alcohol. The following procedural variables were retrospectively assessed and evaluated for association with PES and length of postprocedural hospitalization: gallbladder embolization, lobe embolized, percentage liver volume embolized, percentage embolized volume occupied by tumor, previous embolization of the same territory, and dose of chemoembolic emulsion. Logistic regression was used to quantify the relative effect of each procedural variable., Results: Gallbladder embolization and dose administered were associated with an increased risk of PES and an extended hospitalization, with odds ratios of 2.8 and 3.0, and 3.0 and 4.6, respectively. Previous embolization was associated with a decreased risk of both PES and extended hospitalization, with odds ratios of 0.5 and 0.4, respectively. There was a statistical trend toward significance for gallbladder embolization (P = .06), dose administered (P = .07), and previous embolization (P = .14)., Conclusion: Clinically relevant predictors of the severity of PES and length of postprocedural hospitalization may exist. Avoiding embolization of the gallbladder reduces the risk of PES. Re-embolization of previously treated vessels is associated with decreased toxicity and may assist in selecting patients for treatment on an outpatient basis, especially when a reduced dose is required.

Purpose: To evaluate the response to and survival after chemoembolization with cisplatin, doxorubicin, mitomycin-C, Ethiodol, and polyvinyl alcohol for patients with sarcomas metastatic to the liver that are surgically unresectable., Materials and Methods: Sixteen patients were treated. Primary tumors included 11 gastrointestinal leiomyosarcomas, two splenic angiosarcomas, one leiomyosarcoma of the broad ligament, one leiomyosarcoma of the inferior vena cava, and one malignant fibrous histiocytoma of the colon. Chemoembolization with cisplatin, doxorubicin, mitomycin-C, Ethiodol, and polyvinyl alcohol particles was performed 1-5 times at approximately monthly intervals (mean, 2.8). Pre- and posttreatment cross-sectional imaging was performed 1 month after completion of treatment and then every 3 months. Thirty-day response was graded according to World Health Organization/Eastern Cooperative Oncology Group criteria. Survival was calculated with use of Kaplan-Meier analysis., Results: Two patients (13%) exhibited partial morphologic response, 11 patients (69%) were morphologically stable, and three (19%) demonstrated progression of disease 30 days after completion of treatment. Among the 13 responders, two underwent partial hepatectomy after initial treatment. Seven developed intrahepatic progression at a mean of 10 months and a median time of 8 months. The remaining four patients had no documented intrahepatic progression at the time of last imaging follow-up. Nine patients developed extrahepatic progression at a mean time of 6.3 months and a median time of 6 months, of whom four underwent additional surgical resection. Response to therapy was based on time of first intervention. Cumulative survival from time of diagnosis with use of Kaplan-Meier analysis was 81% at 1 year, 54% at 2 years, and 40% at 3 years. Median survival time was 20 months. Cumulative survival from initial chemoembolization was 67% at 1 year, 50% at 2 years, and 40% at 3 years, with a median survival time of 13 months. The thirty-day mortality rate was zero., Conclusion: Durable tumor response with chemoembolization is possible in this form of metastatic disease, which is highly resistant to systemic chemotherapy.

Purpose: To report cutaneous complications occurring after chemoembolization of hepatic tumors via extrahepatic collaterals., Methods: Five patients underwent chemoembolization via the internal mammary (n = 3), intercostal (n = 1), or multiple extrahepatic collateral vessels supplying liver metastases., Results: Painful induration and discoloration of the skin in the distribution of the superior epigastric or intercostal arteries occurred in four patients, with transmural necrosis in two. One required surgical excision. One patient developed a radiation burn after 12 procedures and eventually developed a squamous cell carcinoma at the site, which required resection and skin grafting., Conclusion: Cutaneous injury can occur after chemoembolization of extrahepatic collaterals. Scrupulous technique is required to avoid nontarget embolization of chemotherapeutic drugs. High cumulative radiation doses to localized areas of skin can occur in patients undergoing multiple procedures.

Purpose: To evaluate response and survival after hepatic chemoembolization with cisplatin, doxorubicin, mitomycin-C, Ethiodol, and polyvinyl alcohol in a U.S. population of patients with hepatocellular carcinoma., Materials and Methods: Thirty-eight consecutive patients were treated: 35% stage I, 62% stage II, 3% stage III. Fifty-one percent had cirrhosis. Chemoembolization was performed at approximately monthly intervals for one to seven sessions (mean, 2.2). Pretreatment and posttreatment cross-sectional imaging and alpha-fetoprotein (AFP) levels were obtained prospectively 1 month after treatment and then every 3 months. Thirty-day response was calculated by means of the the World Health Organization/Eastern Cooperative Oncology Group criteria., Results: One patient was lost to follow-up. In seven patients, lesions became resectable after chemoembolization. Among 13 evaluable patients with initially elevated AFP level, 70% had a partial biologic response (>50% decrease in AFP), 15% had a minor response (25-50% decrease), and the remaining 15% remained stable. Among 25 patients evaluable for morphologic response, 36% had a partial response, 32% had a minor response, and 32% remained stable. No patients had progression of disease while receiving therapy. The cumulative survival was 60% at 1 year, 41% at 2 years, and 16% at 3 years. Two patients developed progressive hepatic failure. Thirty-day mortality was 3% (one patient)., Conclusion: These results compare favorably to published response and survival data for chemoembolization of advanced hepatocellular carcinoma from Asia and Europe.

Purpose: To evaluate treatment outcome with respect to the indication for treatment in patients with neuroendocrine tumors metastatic to the liver undergoing hepatic artery embolization with polyvinyl alcohol (PVA) particles., Materials and Methods: Charts and radiographs were reviewed of 35 patients undergoing 63 separate sessions of embolotherapy between January 1993 and July 1997. Patient demographics, tumor type, indication for embolization, and complications were recorded. Symptomatic and morphologic responses to therapy were noted, as well as duration of response., Results: Fourteen men and 21 women underwent embolization of 21 carcinoid and 14 islet cell tumors metastatic to the liver. These patients underwent 63 separate episodes of embolotherapy. Of 48 episodes that could be evaluated, response to treatment was noted following 46 episodes (96%). The duration of response was longest in patients treated for hormonal symptoms with (17.5 months) or without (16 months) pain, and was shortest (6.2 months) when the indication was pain alone. Complications occurred after 11 of the 63 embolizations (17%), including four (6%) deaths. Cumulative 5-year survival following embolotherapy was 54%., Conclusion: Hepatic artery embolization with PVA particles is beneficial for patients with neuroendocrine tumors metastatic to the liver and may be used for control of pain as well as hormonal symptoms. This therapy should be used cautiously when more than 75% of the hepatic parenchyma is replaced by tumor.

Cavernous hemangiomas are usually asymptomatic; however, a small percentage may cause symptoms. This case report discusses palliation by transcatheter arterial embolization with polyvinyl alcohol particles.

Purpose: To prospectively identify patients with collateral internal mammary artery (IMA) supply to hepatic tumors, and to embolize the IMA as part of palliative hepatic artery embolization (HAE)., Methods: Over a 4-year period, 222 patients were enrolled in an HAE protocol for inoperable liver tumors. All underwent abdominal computed tomography (CT) prior to preembolization diagnostic hepatic arteriography. When anterior subcapsular hepatic tumor was seen on the CT scan, patients underwent IMA arteriography as well. All arteries supplying tumor were embolized., Results: Six patients had anterior subcapsular lesions identified on CT. IMA catheterization revealed that these lesions drew blood supply directly or indirectly from one or both IMAs in all six patients. All IMAs were embolized., Conclusion: When an hepatic tumor is identified in an anterior subcapsular location prior to HAE, the IMA should be examined and, if significant tumor supply is demonstrated, these branches should be embolized.