Combined peripheral and central chemoembolization of liver tumors. Experience with lipiodol-doxorubicin and gelatin sponge (L-TAE)

Patients with primary and a few with secondary liver tumors were embolized through the hepatic artery. Lipiodol and doxorubicin occluded peripherally, which was immediately followed by central embolization with gelatin sponge cubes. Preoperative embolizations were made for diagnostic and possible surgical adjuvant purposes. Extensive postembolization necrosis was common in tumors less than 5 cm in diameter, and tumor markers usually decreased temporarily after treatment. There were moderate side effects of pain, fever and nausea, and an acceptable complication and mortality rate with no deaths after embolization alone. This warrants further research on the method, which also seemed to improve the detection rate for small hepatocellular carcinomas.

Liver injury with perivenular fibrosis and alcoholic hyalin after pancreatoduodenectomy for pancreatic carcinoma

We describe a patient who developed progressive hepatic failure one year after pancreatoduodenectomy for pancreatic carcinoma and died of gastrointestinal bleeding. He suffered from progressive weight loss after surgery, even though obstruction or stenosis of the gastrointestinal tract was excluded. At autopsy, the liver showed extensive perivenular fibrosis associated with variable loss of hepatocytes, perisinusoidal fibrosis, alcoholic hyalin and a lack of parenchymal regenerative activity, all of which closely resembled severe alcoholic liver disease. Stricture of both the main pancreatic duct and the pancreaticojejunostomy with almost complete loss of exocrine acini was also found, and the recurrent tumor was seen to have caused portal venous obstruction and hepatic arterial stenosis. A combination of these nutritionally unfavorable circumstances and prolonged ischemia appeared to have been responsible for the liver injury in this non-alcoholic patient.

Hepatocellular carcinoma: treatment with intraarterial iodized oil with and without chemotherapeutic agents

Thirty-one patients with hepatocellular carcinoma (HCC) were given either an intraarterial injection of iodized poppyseed oil (Lipiodol) alone (group A, n = 6), an emulsion of iodized oil and doxorubicin hydrochloride (Adriamycin) (group B, n = 15), or chemoembolization with the same emulsion followed by gelatin sponge (Gelfoam) particles (group C, n = 10). Hepatic resection was subsequently performed. The frequencies of complete necrosis of tumor in the main lesion, daughter tumors, tumor thrombus, and foci of intracapsular invasion were evaluated in the cut surface of the resected specimen. Group C demonstrated the best therapeutic effects, showing complete necrosis of the main lesion in 83% (P less than .01), daughter tumors in 53% (P less than .01), tumor thrombus in 17%, and foci of intracapsular invasion in 67%. These results are superior to those reported previously for chemoembolization without iodized oil. Group B showed better results than group A, but the difference was not significant. Iodized oil alone (group A) had practically no therapeutic effect but was helpful in differentiating small HCC from regenerative nodules.

Imaging characteristics of large lipoma and angiomyolipoma of the liver. Case reports

A large lipoma and a large angiomyolipoma of the liver, one case each, are described. In the first case, a 24 X 14-cm homogeneous mass demonstrated a fatty density (-96H) on computed tomography (CT), echogenicity on sonography, and fine neovascular vessels on angiography in the right lobe of the liver. Histopathologic diagnosis of the resected specimen was lipoma. The second case showed a 9-cm fatty mass (-66H) with some enhanced interior nodules in the left lateral area of the liver on CT. Sonography disclosed a large echogenic mass with echolucent nodules, which were seen as stains on the angiogram. Angiomyolipoma was the histopathologic diagnosis. Among these diagnostic modalities, the CT scan provided the most specific and reliable findings. Both patients are doing well more than 2 years and 9 months after resection.

Computed tomography findings of hepatic lesions in human fascioliasis: report of two cases

Two patients with hepatic fascioliasis are presented. Computed tomography demonstrated multiple low density areas located in the center and periphery of the liver. In one patient a spontaneous decrease in the size of the low-density areas occurred but the abdominal symptoms were persistent before bithionol treatment. After the treatment both patients became asymptomatic. The computed tomography scan can be a useful tool for the diagnosis and follow-up of the patients with hepatic fascioliasis.

[Multiple rectal carcinoids--with special reference to the histogenesis of these lesions]

A 61 year-old man was diagnosed prior to surgery as having multiple carcinoids of the rectum. Postoperative histological examination revealed 52 carcinoids, 1-6 mm in diameter, invading the submucosal layer, and innumerable endocrine cell micronests, less than 0.1 mm in diameter, were present in the rectum. A careful examination revealed several argyrophil cell micronests "budding from" the basis of the glands. Most of the tumor cells showed a positive reaction for Grimelius stain and some immunoreactivities for GLI, PP, PYY, insulin and NSE by the PAP method. Moreover, PYY cell hyperplasia was detected in the rectal mucosa, markedly in the areas surrounding the carcinoids. The authors suggest that (initiative) progenitor cells may develop into these lesions due to unknown factors.

[HCG-producing intrahepatic cholangiocarcinoma]

The serum level of human chorionic gonadotropin (hCG) in a 60-year-old man with intrahepatic cholangiocarcinoma was found to be abnormal (44.6 mIU/ml) at the diagnosis. The patient underwent right hemihepatectomy, and the high serum hCG returned to normal 28 days postoperatively. Six months after the operation, the cholangiocarcinoma recurred in the remnant liver and the hCG level was again elevated to 268 mIU/ml. The patient died of liver failure eight months after the operation. Immunohistochemical studies of the resected tumor showed hCG-positive cells in the cancer nest. In this case, it is (believed) that the intrahepatic cholangiocarcinoma produced hCG and secreted it to the serum.

Selective portal branch occlusion by balloon catheter during liver resection

An intraoperative ultrasonographically guided introduction of a balloon catheter into labor or smaller branches of the portal vein within the liver parenchyma made it possible to temporarily occlude them and perform regional staining during resection for tumors. The technique minimized blood loss without hilar dissection for vascular control, and the presence of the catheter facilitated intraparenchymal dissection of the portal stalk to the part of the liver to be resected.

Necrosis of hepatocellular carcinoma as a result of subintimal injury incurred by hepatic angiography: report of two cases

This report described two patients with hepatocellular carcinoma in whom angiographic procedure caused an inadvertent subintimal injury of the hepatic artery, resulting in tumor necrosis. In the first case of a 38-year-old male, complete obstruction of the common hepatic artery occurred on the initial angiography. It was followed by marked reduction of the tumor vessels on repeat angiography, and necrosis of about half of the tumor as confirmed by computed tomography. In the other 58-year-old female, severe subintimal injury occurred in the proper hepatic artery followed by obstruction of the feeding arteries. Subsequent computed tomography scan disclosed necrosis of the tumor. Both patients presented the postembolization syndrome that consisted of a transient fever and elevation of blood enzymes. When spontaneous regression or reduction of hepatocellular carcinoma is observed, special attention should be paid regarding whether or not hepatic angiography was performed and clinical symptoms followed it.

Clinical and radiologic features of hepatocellular carcinoma originating in the caudate lobe

Five patients with hepatocellular carcinoma in the caudate lobe were evaluated. Computed tomography (CT) scan and/or angiography clearly demonstrated multiple intrahepatic metastases in four (80%), and tumor thrombi in the portal vein in two (40%), and in the inferior vena cava in one. Even though there was no recognizable lung metastasis, metastases were found in the orbita in one patient, and in the ribs and thoracic vertebrae in two patients. Four patients died after a mean period of 5.5 months from the initial diagnosis. The mechanism for early invasion into the vessels and multiple intrahepatic metastases of hepatocellular carcinoma arising from the caudate lobe is discussed.

[A study of malignancy in gastro-intestinal carcinoids with special reference to the association of the prognosis and peptide hormone or oncofetal protein producing pattern]

It is difficult to differentiate malignant carcinoid tumors from benign ones early in the course of the illness. We investigated retrospectively a series of thirty-nine gastro-intestinal carcinoids not only for primary tumor anatomic site, macroscopic type, tumor size, histological depth, vessel invasion and mitosis, but also for peptide, ectopic hormone and oncofetal proteins by immunohistochemistry. Carcinoids primary in the appendix or rectum rarely metastasize, but those primary in the stomach or colon grow rapidly. Those greater than 2 cm in diameter and Borrmann's type had a poor prognosis. Carcinoids with deep penetration, vessel invasion or mitosis easily metastasize to lymph nodes or to the liver. Peptide hormone producing carcinoids were present in 21 of 39 (54%) tumors, but there were no correlation between the prognosis and peptide hormone producing patterns. Carcinoids producing carcinoembryonic antigen (CEA) were demonstrated in 11 of 37 (29%) tumors. These tumors were greater in size, more deeply penetrating and had more remarkable vessel invasion and mitosis than CEA non-producing ones. These results show that CEA producing carcinoids grow rapidly and easily metastasize. We concluded that these findings in carcinoid tissue appeared to be a reliable markers for metastasis and poor prognosis.

Angiography of small hepatocellular carcinomas: analysis of 105 resected tumors

One hundred five hepatocellular carcinomas less than 5 cm in diameter were resected in 75 patients. The tumors were studied with respect to their detection rate by angiography and their angiographic features. Angiography identified 86 (82%) of the 105 lesions, missing 19 (18%). The findings included tumor vessels (70%) and tumor staining (76%). Pathologic analysis of the 19 undetected lesions showed that 74% of them were smaller than 2 cm in diameter and that they were well-differentiated carcinomas. Forty percent of 100 lesions were in the anterosuperior subsegment of the right lobe.

Hepatic lobar atrophy following obstruction of the ipsilateral portal vein from hilar cholangiocarcinoma

Gross deformity of the liver associated with hilar carcinoma is rare. In 17 patients with hilar cholangiocarcinoma and intrahepatic bile duct dilatation, the relationships between lobar or segmental atrophy, compensatory hypertrophy, and patency of portal vein branches were evaluated with computed tomography (CT) and angiography. All six patients with obstructed or narrowed portal veins (group A) had lobar or segmental atrophy on CT scans and angiograms. Compensatory hypertrophy was observed in the unaffected lobe with a patent portal vein in five. In contrast, neither hepatic atrophy nor hypertrophy was demonstrated in the other 11 patients with patent portal veins. All group A patients had differences in hepatic attenuation on CT scans or dense opacification during the hepatogram phase of angiography. Biliary decompression was optimized when the bile duct selected for percutaneous drainage paralleled a patent portal vein. Knowledge of radiologic findings will assist in determining the primary site along the bile duct from which carcinoma has arisen.

Peripheral low-density area of hepatic tumors: CT-pathologic correlation

To aid in the distinction between colorectal cancer metastasis to the liver and hepatocellular carcinoma, findings on computed tomographic (CT) scans taken more than 5 minutes after contrast material administration ("late-enhanced CT scans") and pathologic findings were compared. Late-enhanced CT scans of metastatic adenocarcinoma showed a peripheral low-density area (PLDA) that corresponded to viable tumor and a central high-density area that represented fibrous connective tissue. This phenomenon was recognized in 15 of 20 (75%) patients with metastatic adenocarcinoma and in one of 50 (2%) patients with hepatocellular carcinoma. Late-enhanced CT scans may be useful in distinguishing between metastatic nonmucinous colorectal cancer and hepatocellular carcinoma.

Atypical radiographic findings in hepatic cavernous hemangioma: correlation with histologic features

Three cases of cavernous hemangioma of the liver having atypical imaging features are described. In the first case, an 11 x 10 cm hypervascular mass with a central hypovascular area supplied by many large tortuous vessels was demonstrated on angiography, CT, and sonography. The mass had a central cavity that contained fluid. In the second case there was a 2-cm isoechoic mass with a peripheral halo, despite the presence of typical features of hemangioma on angiography. The halo was shown histologically to be fibrous tissue surrounding the tumor. In the third case, a 6.5 x 4.3 cm mass exhibited slight peripheral enhancement on CT but was not detectable by angiography. Histologically, the tumor was hyalinized with only scattered small foci of hemangioma within it.

[Multidisciplinary therapy of hepatocellular carcinoma--TAI. TAE treatment by intra-arterial catheterization]

Two hundred sixty-six cases of hepatocellular carcinoma (HCC) were treated between June 1980 and October 1985 (4 years and 4 months) at our hospital. Hepatectomy was performed in 118 patients, 82 of which had received transcatheter arterial embolization with iodized oil (Lipiodol) 58 of then with an intraarterial catheter. HCC tumors were often multiple when they were combined with liver cirrhosis and smaller than 3 cm in diameter. For this reason treatment of HCC by surgery alone has limitations for prolongation of life. A multidisciplinary treatment is therefore necessary. We have found hepatectomy and transarterial embolization to be the most effective treatment for HCC. In order to perform repeated embolizations after hepatectomy, we developed a heparinized catheter with notches to permit safe fixation. This is suitable for long-term intraarterial use. While previous arterial catheters only permitted infusion of drugs due to their small diameters, our new catheter can be used for embolizations with Lipiodol and Gelfoam and for angiography. It is inserted through the right gastroepiploic artery into the gastroduodenal artery so that its tip lies at the level of the hepatic artery. It is brought out through the abdominal skin and flushed at two-week intervals with heparin-urokinase. The indications for the use of the catheter have been repeated embolizations 1) for prevention of tumor recurrence (surgical adjuvant therapy), and 2) after absolutely non-curative operations. For the first indication, we have found that multiple tumors and tumors larger than 5 cm frequently recur within 1 year after surgery. We have, since July 1983, used the catheter treatment to prevent recurrence in 30 such cases. Embolization with Lipiodol + Adriamycin followed by Gelfoam cubes is performed at three-month intervals for one year after surgery, starting one month after surgery, as a rule. The preliminary results indicate an improved survival rate after the treatment.

A system for measuring leaf gas exchange based on regulating vapour pressure difference

A system for measurement of leaf gas exchange while regulating leaf to air vapour pressure difference has been developed; it comprises an assimilation chamber, leaf temperature controller, mass flow controller, dew point controller and personal computer. A relative humidity sensor and air and leaf temperature sensors, which are all used for regulating the vapour pressure difference, are mounted into the chamber. During the experiments, the computer continuously monitored the photosynthetic parameters and measurement conditions, so that accurate and intenstive measurements could be made.When measuring the light-response curve of CO2 assimilation for single leaves, in order to regulate the vapour pressure difference, the leaf temperature and relative humidity in the chamber were separately and simultaneously controlled by changing the air temperature around the leaf and varying the air flow rate through the chamber, respectively. When the vapour pressure difference was regulated, net CO2 assimilation, transpiration and leaf conductance for leaves of rice plant increased at high quantum flux density as compared with those values obtained when it was not regulated.When measuring the temperature-response curve of CO2 assimilation, the regulation of vapour pressure difference was manipulated by the feed-forward control of the dew point temperature in the inlet air stream. As the vapour pressure difference was regulated at 12 mbar, the maximum rate of and the optimum temperature for CO2 assimilation in rice leaves increased 5 μmolCO2 m(-2) s(-1) and 5°C, respectively, as compared with those values obtained when the vapour pressure difference took its own course. This was reasoned to be due to the increase in leaf conductance and the decrease in transpiration rate. In addition, these results confirmed that stomatal conductance essentially increases with increasing leaf temperature under constant vapour pressure difference conditions, in other words, when the influence of the vapour pressure difference is removed.This system may be used successfully to measure inter- and intra-specific differences and characteristics of leaf gas exchange in plants with a high degree of accuracy.