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Aim: Main bile duct necrosis develops after transcatheter arterial chemoembolization (TACE) through the caudate artery (A1) and medial subsegmental artery (A4) of the hepatic artery in the treatment of hepatocellular carcinoma. The aim of this study was to evaluate the bile duct branch (BD branch) from A1 and A4., Methods: We evaluated the origin and vascular territory of the BD branch in 11 patients who underwent selective A1 and/or A4 arteriography using arteriograms, cone-beam computed tomography (CBCT) and CT obtained 1 week after TACE. Follow-up CT and/or magnetic resonance imaging were also evaluated., Results: The BD branch arose from the first branch (n = 4), the second branch (n = 1), and both the first and second branches (n = 1) of A1, and from the first branch of A4 (n = 5). It supplied the bilateral hepatic ducts and common hepatic duct (CHD) (n = 4), the right hepatic duct (RHD) and CHD (n = 2), RHD, CHD and common bile duct (n = 1), the left hepatic duct (LHD) and CHD (n = 2), and LHD alone (n = 2). Anastomosis between A1 or A4 and other branches was demonstrated in seven patients. Bile duct stricture developed in all nine patients 2-8 months after TACE of the BD branch and percutaneous transhepatic bile duct drainage and metallic stent placement was required in one because of jaundice., Conclusion: The BD branch arises from the proximal portion of A1 and A4 and mainly supplies the hepatic ducts and CHD., (© 2013 The Japan Society of Hepatology.)

Purpose: To evaluate the performance of transcatheter arterial chemoembolization guidance software that uses cone-beam computed tomography (CT) technology in identifying small hepatocellular carcinoma (HCC) tumors and feeding branches., Materials and Methods: Cone-beam CT and manual feeder vessel detection (MFD) software were used in chemoembolization of 68 HCCs 30 mm or smaller (mean ± standard deviation, 15.3 mm ± 5.2). Detectability of tumors and tumor-feeding sub-subsegmental arteries was compared versus that of nonselective digital subtraction angiography (DSA). Technical success of chemoembolization was divided into three grades according to 1-week CT findings: entire tumor embolized with at least a 5-mm-wide margin (ie, complete), tumor embolized without a margin in parts (ie, adequate), or entire tumor not embolized (ie, incomplete). All cone-beam CT data were also reanalyzed with automatic feeder vessel detection (AFD) software that was developed later., Results: Cone-beam CT could depict all tumors, including eight that were first discovered during chemoembolization. Sixty-one tumors (89.7%) were detected on CT during arterial portography and during hepatic arteriography, and seven (10.3%) were detected with one or the other. Nonselective DSA depicted 49 tumors (72.1%). Among 100 tumor-feeding vessels, 81 were identified with MFD and 38 with nonselective DSA. Detectability of tumors with CT and tumor-feeding branches with MFD was significantly better than with nonselective DSA (both P<.001). Fifty-nine tumors (86.8%) were completely embolized and nine (13.2%) were adequately embolized. AFD identified 96 feeder vessels; 88 (88%) represented true-positive findings., Conclusions: Transcatheter arterial chemoembolization guidance software with cone-beam CT technology has a sufficient performance level to detect small HCCs and their feeding branches., (Copyright © 2013. Published by Elsevier Inc.)

Purpose: To analyze the origins of the feeding arteries of hepatocellular carcinomas (HCCs) near the umbilical fissure of the left hepatic lobe., Methods: Twenty-eight HCCs with a mean ± SD tumor diameter of 3.4 ± 1.0 cm (range 1-4.4 cm) in contact with the right or left side of the umbilical fissure were treated by superselective transcatheter arterial chemoembolization (TACE). The origins of the tumor-feeding arteries were analyzed with arteriograms and computed tomography or cone-beam computed tomography images obtained during and 1 week after TACE., Results: Twenty-one HCC lesions were located in segment 3 and seven were located in segment 4. Of 21 tumors in segment 3, 13 (61.9%) were supplied by the lateral inferior subsegmental artery (A3), three (14.3%) by the medial subsegmental artery (A4), three (14.3%) by both A4 and A3, one (4.8%) by a branch arising from the left lateral hepatic artery, and one (4.8%) by a branch of the right gastric artery. In particular, all tumor-feeding branches arising from A4 were the first branch of A4. Of seven tumors in segment 4, four (57.1%) were supplied by A4 and three (42.9%) by A3. In particular, all tumor-feeding branches arising from A3 were the first branch of A3., Conclusion: This study demonstrates crossover blood supply to HCC lesions located near the umbilical fissure, in addition to direct feeding from a separate branch. In particular, the first branch of the opposite subsegmental artery may feed tumors when crossover blood supply is present.

Purpose: To evaluate the clinical features of hepatocellular carcinoma (HCC) supplied by the left internal mammary artery (LIMA)., Materials and Methods: This cohort included 12 HCCs of 12 patients supplied by the LIMA. The clinical features of these tumors were analyzed., Results: The tumor diameters were 4.2 ± 4.4 cm (mean ± SD) located at the surface of segments 4 (n = 6), 3 (n = 3), 2 (n = 2), and 4-8 (n = 1), respectively. The tumor was supplied by the phrenic branch (n = 8) or musclophrenic artery (n = 4) entirely (n = 7) or partially (n = 5). Two patients with large tumors 10 and 16 cm in diameter, respectively, received no previous treatment. Ten patients had previously undergone 5.8 ± 3.7 TACE sessions including through extrahepatic collaterals. Selective TACE could not be completed in one. No TACE-related complications developed. Of 11 embolized tumors, six did not recur at 8.8 ± 4.6 months and five recurred 4.4 ± 2.6 months later., Conclusion: The clinical features of HCC supplied by the LIMA can be divided into two categories, untreated large tumors and small tumors receiving multiple TACE sessions at the subcapsular area of the left hepatic lobe.

The left hepatic lobe is divided into three subsegments according to anatomical landmarks; however, there are several variations in the vascular territories of the left hepatic arterial branches. Hepatocellular carcinoma (HCC) located near the umbilical fissure or at the left side of the umbilical portion of the left portal vein has frequent crossover blood supply. HCC located in the caudal aspect of the lateral segment has a variety of feeding arteries, and is infrequently supplied by the caudate artery or the medial subsegmental artery (A4), and by the lateral left hepatic arteries. HCC located in the posterior aspect of segment 4 is frequently supplied by the caudate artery or a small A4 branch arising from the caudate artery. In addition, the left inferior phrenic, right and left internal mammary, right and left gastric, cystic, and omental arteries are well known extrahepatic collateral pathways supplying HCC in the left hepatic lobe, especially when the hepatic artery is attenuated by previous transcatheter arterial chemoembolization (TACE). Interventional radiologists should have sufficient knowledge of vascular territories in the left hepatic arterial branches and extrahepatic collaterals to perform effective TACE for HCC located in the left hepatic lobe.

Purpose: To compare local control effects of superselective transcatheter arterial chemoembolization (TACE) using epirubicin (EPI) plus mitomycin C (M) and miriplatin (MPT) for hepatocellular carcinoma (HCC)., Materials and Methods: One-hundred and twenty-nine HCCs treated with superselective TACE were divided into three groups according to the type of anticancer drug; EPI-M-TACE (n = 51), MPT-TACE (n = 21), and MPT-I-TACE (MPT emulsion) (n = 57). Local recurrence, patterns of recurrence (intratumoral recurrence; IR), and follow-up angiograms were evaluated., Results: Mean tumor diameter and follow-up period for the EPI-M-TACE, MPT-TACE, and MPT-I-TACE groups were 16.9 mm and 15.5 months, 20.7 mm and 12.0 months, and 18.8 mm and 9.6 months, respectively. Local recurrence for the EPI-M-TACE, MPT-TACE, and MPT-I-TACE groups at 5, 10, and 15 months was 6.1, 47.6, and 40.1%, 23.5, 67.3, and 63.9%, and 26.2, 75.4, and 72.9%, respectively. IR for the EPI-M-TACE, MPT-TACE, and MPT-I-TACE groups was 23.1, 71.4, and 71.0%, respectively. Local recurrence and IR in the EPI-M-TACE group were significantly less than those in the MPT-TACE and MPT-I-TACE groups. Follow-up angiograms revealed less arterial damage in the MPT-TACE and MPT-I-TACE groups., Conclusion: Superselective TACE using MPT resulted in very frequent local recurrence, in particular IR, despite less arterial damage.

Recently an increase in the serum levels of a bone formation marker after anti-tumor necrosis factor (TNF)-α therapy in rheumatoid arthritis patients has been reported. However, there remains no direct evidence that TNF-α antagonist could accelerate bone formation under inflammatory condition. Cavity-induced allosteric modification (CIAM) compound, F002, is a newly developed-TNF-α antagonist, which was designed by using the structure of TNF type 1 receptor, thus preventing TNF-α-induced signaling. In this study, we examined whether the CIAM compound can promote bone formation under inflammatory condition induced by lipopolysaccharide (LPS). Thirty-six 10-week-old male mice (C57BL/6J) were used. Half of the mice received 10 mg/kg LPS, while the other half received PBS. Thereafter, incisor extraction was performed at 4 days after either LPS or PBS injection. Intraperitoneal injections of 2 mg/kg/day, 4 mg/kg/day CIAM, or vehicle (10% DMSO) were performed once a day from day 0 to day 7 after incisor tooth extraction. The mice were sacrificed at 21 days after the extraction. The regenerated bone mineral density (BMD) in the tooth socket, and the mineral apposition rate and the bone formation rate, direct evidences of bone formation, were significantly decreased in the LPS-injected group compared to the PBS-injected group. CIAM compound dose-dependently prevented the decrease of BMD under the LPS-injected condition, and promoted both the mineral apposition rate and the bone formation rate significantly compared to the LPS-injected group. We did not observe any significant differences among the PBS-injected groups. Taken together, TNF-α antagonist CIAM compound, was found to accelerate bone formation under LPS-induced inflammatory condition., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Calcifying cystic odontogenic tumors are benign tumors, characterized by the presence of ghost cells and calcified materials. We evaluated clinical characteristics of calcifying cystic odontogenic tumors in 21 cases at the Maxillofacial Surgery, Tokyo Medical and Dental University Hospital, between January 1979 and December 2006. Of the 21 lesions that were studied, 12 were observed in male patients, and 9 in female patients. The median age was 13.0 years (range, 4-69 years). Of the 21 lesions, 11 were located in the maxilla (intraosseous), 9 in the mandible (intraosseous), and 1 in the lower gingiva (extraosseous). Radiographically, 18 lesions appeared as unilocular radiolucencies, and 2 lesions as multilocular radiolucencies. Impacted teeth were observed in 15 cases. In 20 cases, the lesions were treated by enucleation. The follow-up duration ranged from 2 years, 5 months to 28 years, 8 months, and in 1 case, the lesion recurred and showed a malignant transformation 2 years 10 months after the treatment. Histopathologically, the lining epithelium consisted of cuboidal or columnar odontogenic cells. Ghost cells were frequently calcified, and the tissue was hardened. In 14 cases, the tumor was associated with odontoma.

Purpose: To report technical aspects of thrombolysis and thromboaspiration for acute thromboembolic occlusion in the upper extremity., Materials and Methods: This study included four consecutive patients with acute thromboembolic occlusion in the upper extremity (right arm, n = 3; left arm n = 1). The mean patient age was 81.3 ± 11.5 years (mean ± standard deviation; range 69-92 years) and all patients had chronic atrial fibrillation. Emergent angiography was performed via the femoral artery., Results: Thromboembolic occlusion was demonstrated in the axillary artery (n = 2), axillary and radial arteries (n = 1), and brachial, radial, and ulnar arteries (n = 1). Endovascular treatment was performed via the unaffected brachial (n = 3) or radial artery (n = 1). Thrombolysis was performed for three patients using 360,000-480,000 IU (mean 400,000 ± 69,000 IU) urokinase, including 12-h continuous infusion in one. Thromboaspiration was performed in all four patients using a 6F catheter. Recanalization was achieved in all patients and all arms were salvaged. Perforation of the small branch during guidewire manipulation was successfully managed by placement of a microcoil., Conclusion: The combination of thrombolysis and thromboaspiration is effective for acute thromboembolic occlusion in the upper extremity.

Purpose: To evaluate the arterial blood supply to the caudate lobe of the liver from the proximal branches of the right inferior phrenic artery (RIPA) in patients with recurrent hepatocellular carcinoma after transcatheter arterial chemoembolization (TACE)., Materials and Methods: Thirteen patients, including 10 who had a history of TACE of the caudate artery (A1), underwent TACE of the proximal RIPA branches. Iodized oil distribution was evaluated by computed tomography (CT) 1-week after TACE. Angiographic findings were also evaluated., Results: Previously embolized A1 was occluded (n = 15) or attenuated (n = 2). In one of three patients without A1 TACE, A1 was also attenuated. TACE was performed at the first branch of the proximal RIPA (n = 8), the first branch of the anterior branch (n = 6), and the first branch of the posterior branch (n = 1), respectively. Iodized oil was mainly distributed into the dorsal part of the Siegel lobe (SP) (n = 10), the caudate process (n = 1), and both (n = 2). In three of seven patients who had undergone serial RIPA angiography, RIPA parasitization to SP was suspected before A1 TACE., Conclusion: The proximal RIPA branches mainly supply the SP when A1 is attenuated.

Purpose: To evaluate the origins of feeders of hepatocellular carcinoma (HCC) in the caudate lobe (S1)., Materials and Methods: Eighty-eight HCCs (mean diameter 21.4 mm) were treated by chemoembolization. The tumor-feeding caudate artery was confirmed when a tumor stain was demonstrated on angiogram and iodized oil was accumulated into the HCC and S1 on computed tomography (CT). The origins were divided into R(1) (right proximal), R(2) (right distal), L(1) (left proximal), L(2) (left distal), A (anterior segmental), P (posterior segmental), M (middle hepatic or medial segmental), Ph (proper hepatic), Ch (common hepatic), and Ex (extrahepatic). The origins of feeders supplying HCCs in the Spiegel lobe (SP; n = 36), the paracaval portion (PC; n = 38), and the caudate process (CP; n = 14) were also analyzed., Results: One hundred sixteen feeders were identified: 11 (9.5%) arose from R(1); 21 (18.1%) arose from R(2); nine arose (0.9%) from L(1); 15 (12.9%) arose from L(2); 24 (20.7%) arose from A; 25 (21.6%) arose from P; seven (6.0%) arose from M; one (0.9%) arose from Ph; and three (2.6%) arose from Ex. HCCs in the SP and the PC were fed by feeders from both hepatic arteries (the ratios of right to left were 3:2 and 3:1, respectively), and HCCs in the CP were dominantly fed by feeders from the right hepatic artery., Conclusion: The caudate artery most frequently arises from the right hepatic artery, followed with almost equal frequency by the left hepatic, the anterior segmental, and the posterior segmental artery. The origins of the caudate arteries differ according to the subsegmental locations.

Aim:   To analyze the clinical features of locally progressed hepatocellular carcinoma (HCC) supplied by portal blood (PB) after transcatheter arterial chemoembolization (TACE)., Methods:   This cohort included 12 tumors (mean diameter ± SD, 1.8 ± 0.8 cm) in 10 patients. PB supply to tumors was judged by CT during arterial portography (CTAP). Imaging data and the clinical course were retrospectively evaluated., Results:   Six tumors initially had a small tumor portion supplied by PB. In four tumors, TACE was incomplete because of technical problems. PB supply to recurrent tumors was demonstrated 7.3 ± 3.7 months after TACE. On follow-up arteriography, all embolized branches were occluded or severely attenuated. Four tumors showing a partial stain were treated by additional TACE (n = 3) or TACE plus radiofrequency (RF) ablation (n = 1), one without staining was treated by RF ablation, and seven were followed-up. All tumors progressed except for one treated by RF ablation. On serial CTAP images, relatively large-diameter portal veins directly entered 11 tumors (91.7%) and connected with intratumoral vessels in nine (75%). During follow-up, partial arterial supply was demonstrated in two tumors and additional TACE was performed. Nine patients died after 31.4 ± 16.2 months due to tumor progression (n = 8), or hepatic failure (n = 1). One patient has survived for 53 months despite multiple tumors., Conclusions:   PB supply to locally progressed tumor after TACE became apparent on CTAP. Arterial damage by TACE, incomplete TACE, and preexisting tumor tissues supplied by PB may be the main causes., (© 2011 The Japan Society of Hepatology.)

Purpose of the Study: To evaluate the usefulness of C-arm computed tomography (CT) during superselective intra-arterial infusion chemotherapy for advanced head and neck carcinoma., Methods: C-arm CT was performed during superselective intra-arterial infusion chemotherapy for 11 patients with advanced head and neck carcinoma located in the hypopharynx (n = 3), maxillary sinus (n = 3), oropharynx (n = 1), larynx (n = 1), extra-auditory canal (n = 1), tonsil (n = 1) and tongue (n = 1). The usefulness of C-arm CT during superselective catheterisation was evaluated., Results: On arteriography, nine tumours showed tumour stains and two in the oropharynx or tonsil showed no obvious tumour stains. C-arm CT was performed one to four times (mean ± standard deviation, 2.5 ± 0.8) in each patient during a single procedure. C-arm CT clearly showed not only the vascular territory of the selected branch but also the tumour itself in all patients. Intra-arterial infusion chemotherapy was performed through one to three branches (mean, 1.7 ± 0.9) according to C-arm CT findings without any complications., Conclusion: C-arm CT during superselective intra-arterial infusion chemotherapy was useful to determine the arterial supply of head and neck carcinoma. C-arm CT may replace conventional CT during superselective arteriography in this procedure., (© 2011 The Authors. Journal of Medical Imaging and Radiation Oncology © 2011 The Royal Australian and New Zealand College of Radiologists.)

Cone-beam computed tomography (CBCT) using a flat-panel detector is an alternative method of obtaining cross-sectional images. This technique is now being used during transcatheter arterial chemoembolization (TACE) for inoperable hepatocellular carcinoma (HCC). Several CBCT techniques are performed to detect HCC lesions: CBCT during portography (CBCTAP), CBCT during hepatic arteriography (CBCTHA), CBCT after iodized oil injection (LipCBCT), CBCT during arteriography (CBCTA) of extrahepatic collaterals. Almost all HCC lesions can be detected using these CBCT images. Three-dimensional arteriography using maximum intensity projection from CBCTHA images can identify the tumor-feeding branch. In particular, this technique is useful when the tumor stain cannot be demonstrated on arteriography. In addition, dual-phase CBCTHA can improve the diagnostic accuracy for hypervascular HCCs because corona enhancement can be detected around the tumor. To monitor the embolized area during TACE, selective CBCTHA or LipCBCT at the embolization point is useful. Two sequential CBCT scans without and with contrast material injection is also useful to confirm each embolized area of two vessels. Furthermore, CBCTA can prevent nontarget embolization. Although the image quality of CBCT is low compared to that of conventional CT, CBCT provides useful information that helps perform TACE for HCCs safely and effectively.

Purpose: The aim of this study was to evaluate the technical aspects of embolization using microcoils through a microcatheter with a tip of 2F or smaller during abdominal vascular interventions., Materials and Methods: Coil embolization through a microcatheter with a tip of 2F or smaller was attempted in 73 procedures. Two types of microcoil-Liquid Coil (Boston Scientific, Watertown, MA, USA) and Tornado Coil (Cook, Bloomington, IN, USA)-were deployed through four types of thinner microcatheter [2F tip (n = 49) and 1.8F tip (n = 24)]. Coil jams in the microcatheter and coil migration were evaluated., Results: In total, 286 microcoils were placed (mean ± SD, 3.9 ± 4.3 coils per procedure, range 1-32 coils). In 19 procedures (26.9%), Liquid Coils were used alone. In 44 (60.3%), Tornado Coils were used alone. In 10 (13.7%), Liquid Coils and Tornado Coils were combined. There were no coil jams in the microcatheter in this series. One Tornado Coil (0.3%) delivered into the gastroduodenal artery migrated to the right hepatic artery., Conclusion: Liquid Coils and Tornado Coils can be placed through a thinner microcatheter without difficulty. However, there is a risk of coil migration in large vessels or at the proximal site because the catheter tip is not stabilized.

In this review article, the clinical and histopathological characteristics of oral premalignant lesions, and primarily oral leukoplakia, are noted and the risk factors for malignant transformation of oral leukoplakia are discussed. Malignant transformation rates of oral leukoplakia range from 0.13 to 17.5%. The risk factors of malignant transformation in the buccal mucosa and labial commissure are male gender with chewing tobacco or smoking in some countries such as India, or older age and/or being a non-smoking female in other countries. Some authors have reported that leukoplakia on the tongue or the floor of the mouth showed a high risk of malignant transformation, although others have found no oral subsites at high risk. In concurrence with some authors, the authors of this review view epithelial dysplasia as an important risk factor in malignant transformation; however, there are conflicting reports in the literature. Many authors believe that nonhomogeneous leukoplakia is a high risk factor without exception, although different terms have been used to describe those conditions. The large size of lesions and widespread leukoplakia are also reported risk factors. According to some studies, surgical treatment decreased the rate of malignant transformation; however, many review articles state that no definitive treatment including surgery can decrease the malignant transformation rate of oral leukoplakia because of the lack of randomized control trials of treatment. Tobacco chewing and smoking may be causative agents for cancerization of oral leukoplakia in some groups, and evidence for a role of human papilloma virus in the malignant transformation of oral leukoplakia is inconsistent. Further research to clarify its role in malignant transformation is warranted.

The purpose of this study was to evaluate the detectability of corona enhancement around the hypervascular hepatocellular carcinoma (HCC) by dual-phase cone-beam computed tomography during hepatic arteriography (CBCTHA). Dual-phase CBCTHA was performed for 71 HCC lesions (mean ± SD 1.7 ± 0.9 cm), including seven presenting a nodule-in-nodule appearance and nine hypervascular pseudolesions. The first scan was performed during injection of 30-40 ml half-diluted contrast material at a rate of 1.5-2 ml/s through the hepatic artery. Scanning was initiated 7 s after the beginning of contrast material injection. The second scan was started 30 s after the end of the first scan. Detectability of corona enhancement on second-phase CBCTHA was evaluated. Thickness of corona enhancement was also analyzed as thin (≤2 mm) or thick (>2 mm). Corona enhancement was detected in 63 (88.7%) of 71 tumors (1.8 ± 0.9 cm), but it was not detected in eight tumors (1.0 ± 0.2 cm). Thin corona enhancement was seen in 18 tumors (1.2 ± 0.5 cm), and thick corona enhancement was seen in 45 tumors (2.0 ± 0.9 cm). There was a significant difference in tumor diameter between tumors with and those without corona enhancement (P = 0.0157) and between thin and thick corona enhancement (P = 0.001). In all seven early-stage tumors, corona enhancement was demonstrated around the hypervascular focus within the hypovascular tumor portion. None of the nine pseudolesions showed any corona enhancement. Dual-phase CBCTHA depicted corona enhancement in 88.7% of hypervascular HCC lesions. This technique may improve the diagnostic accuracy of HCC.

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.

There are usually multiple caudate arteries arising from the right, left, and middle hepatic arteries, and they are frequently connected to each other. Therefore, hepatocellular carcinoma (HCC) in the caudate lobe is frequently fed by multiple branches arising from different origins. HCC located in the Spiegel lobe is usually fed by the caudate arteries derived from the right and/or left hepatic artery. HCC in the paracaval portion is mainly fed by the caudate artery derived from the right hepatic artery; with low frequency, it is fed by the caudate artery derived from the left hepatic artery. HCC in the caudate process is usually fed by the caudate artery derived from the right hepatic artery. Because of the complexity and overlap of vascular territories, the tumor-feeding branch of a recurrent HCC lesion in the caudate lobe frequently changes on follow-up arteriograms. In addition, several extrahepatic collateral vessels supply the recurrent tumor. To perform effective transcatheter arterial chemoembolization (TACE) for HCC in the caudate lobe, radiologists should have sufficient knowledge of vascular anatomy supplying HCC in the caudate lobe.

The inferior phrenic artery (IPA) is the most common extrahepatic collateral vessel to hepatocellular carcinoma (HCC); however, there are many anatomical variations in its origin and branches. In addition, the IPA is frequently reconstructed through several pathways, mainly through the retroperitoneal network, because of the occlusion of its orifice due to atherosclerosis or previous catheter manipulation. Infrequently, selective catheterization into the IPA is impossible even using a microcatheter, particularly in the IPA that originates from the proximal or distal portion of the celiac trunk or from the aorta with an acute angle. In this article, we describe anatomical variations of the IPA and catheterization techniques, such as a catheter with a large side hole and a catheter with a cleft, to facilitate catheterization into the IPA that is difficult using a conventional coaxial technique. Radiologists should have sufficient knowledge of such variations and catheterization techniques to perform transcatheter arterial chemoembolization for HCCs through the IPA effectively and safely.

Purpose: This study evaluated the technical success and long-term patency of endovascular treatment for occluded native hemodialysis fistulas caused by thrombotic occlusion (TO) and nonthrombotic occlusion (NTO)., Materials and Methods: This cohort included 96 consecutive occlusions (70 TOs and 26 NTOs) at the forearm. Clinical success and patency rates of endovascular treatment were calculated and compared between the TO and NTO groups., Results: Overall clinical success rate was 91.6%; and primary, assisted primary, and secondary patency rates at 1, 2, and 3 years were 49.6%, 30.7%, and 28.3%, respectively; 73.8%, 48.3%, and 48.3%, respectively; and 80.7%, 72.3%, and 66.2%, respectively. Clinical success rates of the TO and NTO groups were 91.4% and 92.3%, respectively. The 1-, 2-, and 3-year primary, assisted primary, and secondary patency rates of the TO group were 54.4%, 29.3%, and 25.6%, respectively; 70.7%, 49.4%, and 49.4%, respectively, and 78%, 68.8%, and 64,2%, respectively. Those of the NTO group were 38.9%, 32.4%, and 32.4%, respectively; 81.2%, 47.3%, and 40.6%, respectively; and 87%, 80.3%, and 70.2%, respectively. There were no significant differences between the clinical success and patency rates of the two groups., Conclusion: Occluded native hemodialysis fistulas were restored with high frequency, without significant differences between clinical success and patency in the TO and NTO groups.

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., (Copyright (c) 2010 SIR. Published by Elsevier Inc. All rights reserved.)

The purpose of this study was to evaluate changes in vascular supply to hepatocellular carcinoma (HCC) located in the bare area of the liver in patients who were mainly treated with chemoembolization. Twenty-six patients with HCC showing a mean diameter of 3.1 +/- 1.4 cm (mean +/- standard deviation) were mainly treated with chemoembolization. All patients underwent 2.7 +/- 2.3 chemoembolization sessions over 40.1 +/- 25.2 months. Tumor feeding branches demonstrated in each chemoembolization session were retrospectively evaluated. Initially, 18 tumors (59.2%) were supplied by the hepatic artery (H) and 8 (30.8%) by both the hepatic and the extrahepatic arteries (H + C). Fourteen tumors (53.8%) recurred at the posterior aspect of the tumor and were supplied by H (n = 4), H + C (n = 5), and extrahepatic collaterals (C) (n = 5). Several tumors recurred despite repeated chemoembolization, and these were supplied by H (n = 1), H + C (n = 7), and C (n = 2) at the second recurrence, by H (n = 1), H + C (n = 2), and C (n = 3) at the third, by H + C (n = 2) and C (n = 2) at the fourth, by H + C (n = 2) and C (n = 2) at the fifth, and by H (n = 1) and C (n = 1) at the sixth. One tumor was supplied by H at the seventh and by H + C at the eighth recurrence. As the number of local recurrences increased, the feeding vessel shifted from H to C. Especially, the right inferior phrenic artery (IPA) and renal capsular artery (RCA) supplied the tumor early, while the small right RCAs, adrenal arteries, and intercostal and lumbar artery supplied late recurrences in turns. In conclusion, HCCs located in the bare area are frequently supplied by extrahepatic vessels initially, while recurrence after chemoembolization is mainly due to extrahepatic blood supply. The right IPA and RCA are common feeding vessels demonstrated early, while other extrahepatic collateral supply from the retroperitoneal circulation occurs in turns during the later course.

Transcatheter arterial chemoembolization (TACE) is effective for hepatocellular carcinoma (HCC) with intrabile duct thrombus. After TACE, intraductal tumor thrombi occasionally detach from the intrahepatic tumor and drop into the bottom of the common bile duct, causing clinical symptoms similar to the impaction of choledocholithiasis. The investigators describe three cases of sloughing of HCC intraductal tumor thrombi after selective TACE. In each of the three cases, the necrotic tumor cast was successfully removed endoscopically, and the patient's symptoms were dramatically improved. Two patients survived without recurrence of the intraductal tumor thrombus for 8 and 11 months after TACE, respectively.

This study evaluated the clinical features of hepatocellular carcinoma (HCC) supplied by the right lumbar artery. Eleven patients with HCC supplied by the right lumbar artery were treated with chemoembolization. The patients' medical records were retrospectively analyzed. All patients underwent 6.7 +/- 3.7 (mean +/- SD) chemoembolization sessions, and the hepatic arterial branches were noted as being attenuated. The right inferior phrenic artery (IPA) was also embolized in 10 patients. The interval between initial chemoembolization and chemoembolization of the lumbar artery supply was 53.2 +/- 26.9 months. Mean tumor diameter was 3.1 +/- 2.4 cm and was located at the surface of S7 and S6. The feeding-branch arose proximal to the bifurcation of the dorsal ramus and muscular branches (n = 8) or from the muscular branches (n = 3) of the right first (n = 10) or second lumbar artery (n = 1). The anterior spinal artery originated from the tumor-feeding lumbar artery in one patient. All feeders were selected, and embolization was performed after injection of iodized oil and anticancer drugs (n = 10) or gelatin sponge alone in a patient with anterior spinal artery branching (n = 1). Eight patients died from tumor progression 10.1 +/- 4.6 months later, and two patients survived 2 and 26 months, respectively. The remaining patient died of bone metastases after 32 months despite liver transplantation 10 months after chemoembolization. The right lumbar artery supplies HCC located in the bare area of the liver, especially in patients who undergo repeated chemoembolization, including chemoembolization by way of the right IPA. Chemoembolization by way of the right lumbar artery may be safe when the feeder is well selected.

To determine whether staining with iodine solution provides an efficient criterion for determining the area of resection for the lesions surrounding squamous cell carcinoma (SCC) and leukoplakia of the tongue, we determined the optimum density of iodine solution and staining procedure and analyzed the color of lightly stained lesions (LSLs) in relation to the histopathologic findings. Sixty-five patients with SCC or leukoplakia of the tongue were divided into two groups: lesions stained with 3% Lugol solution and restained with either 5% Lugol solution (n=38) or 10% iodine glycerin (n=27). Among the lesions stained with 5% Lugol solution, significant differences were found in all color values. Color difference values (DeltaE*ab) using 3% and 5% Lugol solutions were significantly different between epithelial hyperplasia/mild epithelial dysplasia and moderate to severe dysplasia (P < 0.05). According to the evaluations of five clinicians in 46 LSLs, a distinctive boundary was most often obtained using 5% Lugol solution. These results suggest that the most effective method for obtaining a clear boundary and distinguishing moderate to severe dysplasia from mild or no epithelial dysplasia according to the measured color value was to stain with 3% followed by 5% Lugol solution.

Background: To evaluate the detectability of hepatocellular carcinoma (HCC) by computed tomography during arterial portography (CTAP) using cone-beam CT technology (CBCTAP) by comparing it with conventional CTAP., Methods: Forty-four HCC lesions (mean diameter 1.9 +/- 1.1 cm) of 24 patients who sequentially underwent conventional CTAP and CBCTAP during the same angiography session were evaluated. CBCTAP findings of each tumor were classed into three grades as compared to conventional CTAP: optimal; suboptimal; and nondiagnostic., Results: All CBCTAP images had image artifacts from the catheter placed in the superior mesenteric artery and enhanced portal veins. Additionally, the contrast between HCC lesion and surrounding liver parenchyma of CBCTAP images was less than that of CTAP images. Of the 44 tumors, findings of 31 nodules (mean 2.2 +/- 1.2 cm) (70.5%) were classed as optimal. Eight nodules (mean 1.4 +/- 0.8 cm) (18.2%) were classed as suboptimal. Five nodules (mean 1.0 +/- 0.1 cm) (11.4%) including two located in the outside of field of view were classed as nondiagnostic., Conclusion: CBCTAP had sufficient image quality to detect almost all small HCC lesions compared to conventional CTAP and could depict approximately 89% of HCC nodules, including eight suboptimal lesions.

Aim: To evaluate the histopathologic findings in the surgical specimen of hepatocelluar carcinoma after transcatheter arterial chemoembolization (TACE) at the most distal portion of the sub-subsegmental artery of the liver (ultraselective TACE)., Methods: Histolopathologic findings from nine tumors with a mean diameter of 3.1 cm +/- 1.7 from patients who underwent hepatectomy after ultraselective TACE were evaluated, especially with regard to the relationship between peritumoral liver parenchymal necrosis and portal vein visualization during TACE. Portal vein visualization was classified into three grades by a spot digital radiograph obtained just after TACE: 0, no obvious portal vein visualization; 1, visualization of the portal vein adjacent to the tumor; and 2, visualization in the whole embolized area or extending into the surrounding non-embolized areas. Unenhanced computed tomography (CT) was obtained 1 week later and surgical resection was performed 37 +/- 6.3 days after ultraselective TACE., Results: Portal vein visualization during TACE was classed as grade 1 in 5 tumors and grade 2 in 4. Histopathologically, complete tumor necrosis was observed in 7 tumors (77.8%). In 2 tumors (1 of grade 1, the other grade 2), a small viable portion or viable daughter nodule was seen. Macroscopic parenchymal necrosis adjacent to the tumor was observed in all 4 grade 2 tumors including gas-containing areas on CT obtained 1 week after TACE., Conclusions: Ultraselective TACE induces not only complete tumor necrosis but also peritumoral parenchymal necrosis, similar to that after radiofrequency ablation, when the portal veins are markedly visualized during the TACE procedure.

This study evaluated the usefulness of cone-beam computed tomography (CBCT) during ultraselective transcatheter arterial chemoembolization (TACE) for hepatocellular carcinomas (HCC) that could not be demonstrated on angiography. Twenty-eight patients with 33 angiographically occult tumors (mean diameter 1.3 +/- 0.3 cm) were enrolled in the study. The ability of CBCT during arterial portography (CBCTAP), during hepatic arteriography (CBCTHA), and after iodized oil injection (LipCBCT) to detect HCC lesions was retrospectively analyzed. The technical success of TACE was divided into three grades: complete (the embolized area included the entire tumor with at least a 5-mm wide margin), adequate (the embolized area included the entire tumor but without a 5-mm wide margin in parts), and incomplete (the embolized area did not include the entire tumor) according to computed axial tomographic (CAT) images obtained 1 week after TACE. Local tumor progression was also evaluated. CBCTAP, CBCTHA, and LipCBCT detected HCC lesions in 93.9% (31 of 33), 96.7% (29 of 30), and 100% (29 of 29) of patients, respectively. A single branch was embolized in 28 tumors, and 2 branches were embolized in five tumors. Twenty-seven tumors (81.8%) were classed as complete, and 6 (18.2%) were classed as adequate. None of the tumors were classed as incomplete. Twenty-five tumors (75.8%) had not recurred during 12.0 +/- 6.2 months. Eight tumors (24.2%), 5 (18.5%) of 27 complete success and 3 (50%) of 6 adequate success, recurred during 10.1 +/- 6.2 months. CBCT during TACE is useful in detecting and treating small HCC lesions that cannot not be demonstrated on angiography.

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.

Purpose: We evaluated iodized oil accumulation in the hypovascular portion of early-stage hepatocellular carcinoma (HCC) after ultraselective transcatheter arterial embolization (TACE)., Materials and Methods: Forty-seven HCC lesions with hypovascular portions were treated by TACE at the distal level of the sub-subsegmental artery of the liver. Portal blood in the hypovascular portion was classed in two grades by computed tomography (CT) during arterial portography: decreased and preserved. Iodized oil accumulation was classed into three grades on CT obtained 1 week after TACE: (1) dense accumulation in the almost entire tumor, including the hypovascular portion (grade 2); (2) dense accumulation in hypervascular portions but sparse accumulation in hypovascular portion (grade 1); and (3) sparse accumulation or no accumulation (grade 0). Findings on serial follow-up CT images were also analyzed., Results: Portal blood in the hypovascular portion was decreased in 32 lesions, and preserved in 15 lesions. On CT 1 week after TACE, 32 tumors (68.1%)-23 with decreased portal blood and 9 with preserved portal blood-were classed as grade 2. Twelve tumors (25.5%), six with decreased portal blood and six with preserved portal blood, were classed as grade 1. Three tumors (6.4%) with decreased portal blood were classed into grade 0. In total, 25 tumors (53.2%), 22 in grade 2 and 3 in grade 1, were well controlled by ultraselective TACE during the mean follow-up of 15.8 months., Conclusions: Iodized oil accumulation and retention in the hypovascular portion of early-stage HCC was frequently observed after ultraselective TACE, mainly in the hypovascular portion with decreased portal blood.

Purpose: To analyze visualization of hepatic lymphatic vessels during transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC)., Materials and Methods: Retrospective review was conducted of 255 tumors in 161 patients treated by TACE with catheterization of the most distal portion of the tumor-feeding branches. All TACE procedures were performed with use of a mixture of iodized oil and anticancer drugs followed by gelatin sponge particles. Arteriograms and spot radiographs obtained during TACE were reviewed to determine whether hepatic lymphatic vessels appeared. Serial computed tomography (CT) images after TACE were evaluated along with clinical symptoms in cases that exhibited lymphatic vessel visualization., Results: Hepatic lymphatic vessels were demonstrated in eight tumors (3.1%) in eight patients during TACE. The mean tumor diameter was 1.7 cm +/- 0.7 (range, 1.0-3.3 cm), and mean volume of injected iodized oil was 1.7 mL +/- 1.0 (range, 1-4 mL). Lymphatic vessels were demonstrated followed by marked portal vein visualization (n = 5) or extravasation of a small amount of contrast material (n = 2). In the remaining patient, these were depicted during the early stage of the TACE procedure. On CT after 1 week, iodized oil in the lymphatic systems in the hepatoduodenal ligament was seen in six patients, and it was shown to have been retained in four of these patients on follow-up CT performed 2, 7, 11, and 21 months later, respectively. None of these patients presented any clinical symptom other than postembolization syndrome., Conclusions: Hepatic lymphatic vessels were demonstrated in 3.1% of tumors treated by ultraselective TACE. Iodized oil in the lymphatic vessels may be retained for a relatively long time without specific symptoms.

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.

Objective: To evaluate the diagnostic accuracy of cone-beam CT compared with panoramic images in predicting neurovascular bundle exposure during extraction of impacted mandibular third molars., Study Design: Cone-beam CT and panoramic images of 142 impacted mandibular third molars were prospectively evaluated to assess tooth relationship to the mandibular canal. These interpretations were then correlated with intraoperative findings. The sensitivity and specificity of the 2 modalities in predicting neurovascular bundle exposure at extraction were calculated and compared. The diagnostic criterion for panoramic images was defined using multivariate logistic regression analysis., Results: In predicting the exposure, the sensitivity and specificity were 93% and 77% for cone-beam CT, and 70% and 63% for panoramic images, respectively. Cone-beam CT was significantly superior to panoramic images in both sensitivity and specificity., Conclusion: Cone-beam CT was significantly superior to panoramic images in predicting neurovascular bundle exposure during extraction of impacted mandibular third molar teeth.

The purpose of this study was to elucidate the role of the superior thyroid artery in intra-arterial infusion chemotherapy for laryngeal and hypopharyngeal cancers. Thirty-nine patients with laryngeal cancer and 29 patients with hypopharyngeal cancer underwent intra-arterial infusion chemotherapy. We performed a retrospective analysis of the feeding arteries confirmed by computed tomography during selective arteriography and compared the results with the extent of the tumors. In 14 of 39 laryngeal and 15 of 29 hypopharyngeal cancers, the tumor did not cross the midline (group 1). In the remaining 25 and 14 cancers, respectively, the tumor crossed the midline or located in the center (group 2). For 13 of 14 laryngeal and 7 of 15 hypopharyngeal cancers in group 1 and for 6 of 25 laryngeal cancers in group 2, the entire tumor was contrast enhanced by the ipsilateral superior thyroid and/or superior laryngeal artery. For 12 of 25 laryngeal and 1 of 14 hypopharyngeal cancers in group 2, the entire tumor was contrast enhanced by the bilateral superior thyroid artery. For the other patients, infusion via the other arterial branches such as the inferior thyroid and the lingual arteries were needed to achieve contrast enhancement of the entire tumor. Superselective intra-arterial chemotherapy for laryngeal cancer from the superior thyroid artery is appropriate, whereas that for hypopharyngeal cancer is less sufficient. To accomplish contrast enhancement of the entire tumor, additional intra-arterial infusion from other arteries such as the inferior thyroid artery is often necessary.

Purpose: This study evaluates the efficacy of imaging for diagnosing extracapsular invasion by metastatic cervical lymph nodes., Methods: The subjects were 47 patients with squamous cell carcinoma of the oral cavity examined by both ultrasonography and computed tomography. All subjects had undergone neck dissection, and histopathologic examination confirmed the presence of one or more metastatic cervical lymph nodes in each of them., Results: Histopathologic examination confirmed extracapsular invasion in 25 of 48 metastatic nodes; in the remaining 23 nodes, the tumor was confined within the capsule. Average short-axis diameters of the lymph nodes of these groups differed significantly (17.4 ± 10.6 and 12.7 ± 4.4 mm, respectively; P = 0.046). The diagnostic sensitivity, specificity, and accuracy of ultrasonography for detecting macroscopic extracapsular invasion were 80%, 74%, and 77%, respectively. The corresponding values for computed tomography were 85%, 83%, and 84%., Conclusion: Diagnostic images are effective for the preoperative diagnosis of extracapsular invasion of metastatic cervical nodes of carcinoma of the oral cavity.