Hepatocellular carcinoma detected by iodized oil

Intra-arterial administration of sodium borocaptate (BSH)/lipiodol emulsion delivers B-10 to liver tumors highly selectively for boron neutron capture therapy: experimental studies in the rat liver model

PURPOSE

Boron neutron capture therapy (BNCT) is particle radiotherapy with alpha ((4)He) particle and recoiled lithium nucleus ((7)Li) derived from a reaction of boron ((10)B) and thermal neutron. We investigated applying BNCT to malignant liver tumors. The purpose of the present study was to reveal the efficacy for administration of emulsion of a boron compound (sodium borocaptate; BSH) and lipiodol via a hepatic artery using a rat liver tumor model.

METHODS AND MATERIALS

Rat liver tumors were developed by direct injection of Walker 256 cells into the liver parenchyma. BSH (75 mg/kg)/lipiodol (0.3 mL/kg) emulsion was administered via the hepatic artery. Boron concentrations in the tumors, liver, and blood were measured at 1, 6, and 12 h after administration. Neutron capture radiography (NCR) was taken to confirm the selective accumulation of (10)B in the liver tumors.

RESULTS

Boron concentrations in the liver tumors and the tumor/liver (T/L) boron concentration ratio at 1, 6, and 12 h after administration of BSH/lipiodol emulsion (concentration: T/L ratio) were 479.2 ppm: 4.0, 197.3 ppm: 14.9, and 96.5 ppm: 6.6, respectively. Highly selective irradiation was clearly demonstrated by the NCR images.

CONCLUSIONS

Intra-arterial administration of BSH/lipiodol emulsion is effective method for delivering high concentration of (10)B selectively to the liver tumors.

Dosimetric study of boron neutron capture therapy with borocaptate sodium (BSH)/lipiodol emulsion (BSH/lipiodol-BNCT) for treatment of multiple liver tumors

PURPOSE

We performed a computational study to investigate the feasibility of borocaptate sodium (BSH)/lipiodol-boron neutron capture therapy (BSH/lipiodol-BNCT) for multiple liver tumors using Simulation Environment for Radiotherapy Applications (SERA), a currently available BNCT treatment planning system.

METHODS AND MATERIALS

Three treatment plans for BSH/lipiodol-BNCT using two or three epithermal neutron beams in one fraction were generated for 4 patients with multiple liver tumors using the SERA system. The (10)B concentrations in the tumor and the liver assumed in the study were 197.3 and 15.3 ppm, respectively; and were obtained from experimental studies in animals. The therapeutic gain factors for the liver tumors, defined as the minimum dose to the tumor/maximum dose to the liver, and the inhomogeneity index of the thermal neutron fluence for the whole of the liver, defined as the maximum neutron fluence - minimum neutron fluence/mean neutron fluence, were evaluated in each plan.

RESULTS

Three epithermal neutron beams incident on the anterior, posterior, and right side of the patient can deliver the most homogeneous distribution of thermal neutron fluence to the whole of the liver and provide the greatest therapeutic gain factors for tumors in the right lobe and approximately equal therapeutic gain factors for tumors in the left lobe, compared with the two opposed (anterior-posterior) and two orthogonal (anterior-right) beams.

CONCLUSIONS

From a dosimetric viewpoint, the BSH/lipiodol-BNCT treatment plan using three epithermal neutron beams is the most suitable for the treatment of multiple liver tumors.

Serum alanine aminotransferase levels and survival after hepatectomy in patients with hepatocellular carcinoma and hepatitis C virus-associated liver cirrhosis

We examined whether sustained alleviation of inflammation as monitored by serum alanine aminotransferase (ALT) levels was associated with longer survival in hepatectomized hepatocellular carcinoma (HCC) patients with hepatitis C virus-associated liver cirrhosis (HCV-LC). Thirty-four hepatectomized patients with HCV-LC and HCC as a single nodule, and for whom more than 5 years had elapsed after the hepatectomy, were studied. They had no histologic evidence of portal or hepatic vein invasion. They were subdivided into two groups according to their serum ALT levels in the 2 years after hepatectomy: the low ALT group comprised 13 patients whose serum ALT levels showed a sustained low level below 80 IU, and the high ALT group comprised 21 patients whose serum ALT levels showed several peaks or plateaus above 80 IU. The patients had been followed-up prospectively with frequent ultrasonography and magnetic resonance imaging or computed tomography for recurrence for > 5 years. The survival period, non-recurrence interval and number of recurrences were observed. Recurrences were treated with transcatheter chemoembolization in all cases. The cumulative survival rate in the low ALT group was significantly better than that in the high ALT group (P < 0.05). The 5-year survival in the low ALT group was as high as 92.3% (12 of 13) compared with 33.3% (7 of 21) in the high ALT group (P < 0.05). The cumulative non-recurrence rate in the low ALT group was also significantly better than that in the high ALT group (P < 0.01). The survival period correlated well with the interval until the first recurrence (r = 0.545, P = 0.006). There was a tendency for the number of recurrences in the low ALT group (1.5 +/- 0.4, mean +/- SE) to be fewer than that in the high ALT group (2.2 +/- 0.4), although this was not significant. Sustained alleviation of inflammation, as indicated by low ALT levels, provides a survival advantage mainly due to the longer non-recurrence interval, and possibly because of fewer recurrences, in hepatectomized HCC patients with HCV-LC.

Therapeutic response evaluation of malignant hepatic masses treated by interventional procedures with contrast-enhanced agent detection imaging

OBJECTIVE

To assess the usefulness of microbubble contrast-enhanced agent detection imaging in evaluating the therapeutic response of malignant hepatic masses to treatment with interventional procedures.

METHODS

Fifty-eight patients with 68 hepatocellular carcinomas and 6 metastases who were treated with interventional procedures were evaluated with SH U 508A-enhanced agent detection imaging and helical computed tomography. Helical computed tomography was also performed to help establish the outcome of therapy with unenhanced computed tomography 2 weeks after transcatheter arterial chemoembolization and with dynamic contrast-enhanced computed tomography 1 day after radio frequency ablation or percutaneous ethanol injection. The studies were reviewed separately and randomly, and the sensitivity and specificity of agent detection imaging for detection of viable tumor residue were determined by follow-up imaging performed at least 3 months later.

RESULTS

Follow-up computed tomography or magnetic resonance imaging revealed complete tumor responses in 44 (59.5%) of 74 cases after the therapeutic procedures. The sensitivity of agent detection imaging was 94.7% after transcatheter arterial chemoembolization and 72.7% after radio frequency ablation and percutaneous ethanol injection. The specificity of agent detection imaging for the detection of residual tumors was 80% after transcatheter arterial chemoembolization and 79.2% after radio frequency ablation and percutaneous ethanol injection. The false-positive rate for agent detection imaging in cases of radio frequency ablation or percutaneous ethanol injection was 20.8% (5 of 24), resulting from reactive hyperemia or vascularity within the safety margin. In the assessment of the therapeutic effects, the concordance of contrast-enhanced agent detection imaging with helical computed tomography was statistically significant after transcatheter arterial chemoembolization (P < .00001) and radio frequency ablation or percutaneous ethanol injection (P < .02).

CONCLUSIONS

Contrast-enhanced agent detection imaging proved useful and as effective as helical computed tomography for evaluating the therapeutic effects of interventional therapeutic procedures for malignant hepatic masses.

Evaluation of optimal timing of arterial phase imaging for the detection of hypervascular hepatocellular carcinoma by using triple arterial phase imaging with multidetector-row helical computed tomography

PURPOSE

We evaluated the optimal timing of arterial phase imaging for detection of hypervascular hepatocellular carcinoma by using triple arterial phase imaging with multidetector-row helical computed tomography.

MATERIALS AND METHODS

Forty-nine patients with 90 hypervascular hepatocellular carcinomas (3 to 50 mm in diameter; mean, 18.7 mm) underwent triple arterial phase imaging of the whole liver using a multidetector-row helical computed tomography. At 20 seconds, 30 seconds, and 40 seconds after intravenous administration of 100 mL of 300 mgI/mL of nonionic contrast medium at a rate of 4 mL/s, early, middle, and late arterial phase images were obtained serially during a single breath-hold with an interscan delay of 5 seconds. Detector-row configurations of 4 mm x 4, scan pitch of 5.5, and scan time of 5 seconds for each phase were used. Forty prospective reconstruction images of 5-mm thickness for each phase were obtained. The images from each phase were interpreted separately for detection of hypervascular hepatocellular carcinoma by 3 observers independently who were unaware of tumor burden in the liver. Sensitivity, positive predictive value, and area under the receiver operating characteristic curve values for each arterial phase were calculated and compared statistically.

RESULTS

The mean sensitivity and positive predictive values for hypervascular hepatocellular carcinoma diagnosis of blind readers were 37% and 87% for the early arterial phase, 73% and 85% for the middle arterial phase, and 49% and 81% for the late arterial phase, respectively. The middle arterial phase imaging showed significantly superior sensitivity compared with the early and late arterial phase for detecting hepatocellular carcinoma (P < 0.05). Mean area under the receiver operating characteristic curve value of the middle arterial phase imaging (0.84) was significantly higher that that of the early (0.56) or late arterial phase (0.62; P < 0.05).

CONCLUSION

If a single arterial phase is used for diagnosis of hypervascular hepatocellular carcinoma, the middle phase (delay time of 30 seconds) is optimal.

Angiographic subsegmentectomy for the treatment of patients with small hepatocellular carcinoma

BACKGROUND

The therapeutic results of nonsurgical treatment for patients with hepatocellular carcinoma (HCC) have been poor, and improved treatments are needed. The authors recently developed a new technique called angiographic subsegmentectomy for the treatment of patients with small HCC.

METHODS

The technique includes confirming the diagnosis of small HCC using a helical computed tomography (CT) scan combined with an angiography system for identifying the tumor-feeding subsegmental hepatic artery, injecting lipiodol containing farmorubicin until it enters the portal vein in sufficient amounts, and injecting sponge particles into the hepatic artery for embolization. Occlusion of the hepatic artery with gel particles and occlusion of the portal vein by lipiodol induce infarction necrosis, which encompasses the entire tumor and the surrounding liver parenchyma.

RESULTS

The treatment was given to 23 patients with 30 HCC tumors that measured < 20 mm in greatest dimension. It was successful in all 23 patients. Serum alanine aminotransferase levels were elevated to a significant level in the majority of patients after treatment, mild ascites developed in three patients, and the patients complained of pain and fever posttreatment that were controlled readily. No patients developed hepatic failure. Only one patient developed recurrent disease posttreatment at 1.5 years, for a recurrence rate of 5% at 1 year and 6.6% at 1.5 years, a rate that has never been achieved with other treatment modalities.

CONCLUSIONS

Angiographic subsegmentectomy is a novel treatment for patients with small HCC. The results indicated that it is equivalent to undergoing small resection and is superior to conventional arterial chemoembolization.

Detection of hepatocellular carcinoma: comparison of dynamic MR imaging with dynamic double arterial phase helical CT

OBJECTIVE

Three-dimensional (3D) Fourier transformation-enhanced fast gradient-echo sequences with a special spectral inversion recovery pulse and fat suppression developed for abdominal imaging, including MR angiography, can show enhanced areas clearly. The purpose of this study was to evaluate the efficacy of dynamic MR imaging with the pulse sequences for the detection of hypervascular hepatocellular carcinoma by comparing it with that of dynamic helical CT with double arterial phase imaging.

SUBJECTS AND METHODS

Fifty-three patients with 103 hypervascular hepatocellular carcinoma nodules who underwent both dynamic MR imaging with 3D Fourier transformation-enhanced fast gradient-echo sequences with a special spectral inversion recovery pulse and dynamic helical CT with double arterial phase imaging were enrolled in the study. For dynamic MR imaging, unenhanced, arterial, portal venous, and equilibrium phase images were obtained before and approximately 19, 60, and 120 sec, respectively, after injection of gadopentetate dimeglumine. Three observers independently interpreted the images obtained with each technique in a blinded manner and in random order.

RESULTS

Mean sensitivity and positive predictive values of CT for hypervascular hepatocellular carcinoma (66% and 97%, respectively) were higher than those of MR imaging (63% and 96%, respectively), but there was no significant difference in detecting sensitivity among the observers (p < 0.05). CT and MR imaging were complementary, with some tumors undetected by CT but revealed on MR imaging. There was also no significant difference in A(z) values between CT (0.74) and MR imaging (0.71) (p < 0.05).

CONCLUSION

Dynamic MR imaging with 3D Fourier transformation-enhanced fast gradient-echo sequences with a special spectral inversion recovery pulse is recommended to improve the detection of hypervascular hepatocellular carcinoma nodules in addition to the use of dynamic helical CT with double arterial phase imaging.

Hepatic artery embolization for hepatocellular carcinoma: technique, patient selection, and outcomes

Most patients with HCC do not qualify for surgical interventions. In carefully selected patients, TACE may improve survival, reduce the rate of tumor growth, and decrease the incidence of portal vein occlusion. Since the introduction of TACE in the 1980s, the technical aspects of the procedure have significantly improved. Sophisticated angiographic equipment and techniques have made superselective arterial catheterization possible for more focused drug delivery. The use of ethiodized oil allows for more effective targeting of HCC and provides dual embolization of the hepatic artery and the portal venules supplying the tumor. Many important technical questions about TACE remain unanswered at this time: there are no reliable, standardized patient selection criteria, ideal cytotoxic agents have not yet been identified, the optimal dose of ethiodized oil has not been confirmed, and the optimal frequency and timing of repeat treatment sessions remain unknown. One major limitation of TACE--the need for repeated treatments, which can result in deterioration of liver function--may be avoided by use of a combination of interventional therapies. The combination of limited TACE with PEI or RFA may lead to improved survival and decreased risk of liver failure. More recently, two excellent randomized clinical trials have demonstrated significant survival benefit for patients treated with TACE when compared with those treated symptomatically.

Detection of hypervascular hepatocellular carcinoma by dynamic magnetic resonance imaging with double-echo chemical shift in-phase and opposed-phase gradient echo technique: comparison with dynamic helical computed tomography imaging with double arterial phase

PURPOSE

The technique of double-echo chemical shift gradient echo magnetic resonance imaging (MRI) with the fast low-angle shot (double-echo FLASH) sequence provides in-phase and opposed-phase images in a single breath hold. The purpose of this study was to evaluate the efficacy of dynamic MRI with double-echo FLASH imaging for the detection of hypervascular hepatocellular carcinoma by comparing it with dynamic helical computed tomography (CT) imaging with double arterial phase.

MATERIALS AND METHODS

Twenty-nine patients with 67 hypervascular hepatocellular carcinoma nodules who underwent both dynamic MRI with double-echo FLASH imaging (repetition time/echo time/flip angle: 160/3.6, 7.0/80 degrees ) and dynamic helical CT imaging with double arterial phase were enrolled in the study. For dynamic MRI, precontrast, arterial, portal venous, and equilibrium phase images were obtained before and approximately 19, 60, and 120 seconds, respectively, after intravenous injection of 0.1 mmol/kg of gadopentetate dimeglumine at a rate of 2 ml/s. For dynamic CT imaging, quadraphase images, including early arterial, late arterial, portal venous, and equilibrium phases, were obtained serially approximately 20, 30, 70, and 180 seconds, respectively, after intravenous administration of 2 ml/kg of 300 mgI/ml of nonionic contrast medium at a rate of 5 ml/s. Three masked observers independently interpreted images obtained with each technique in random order, separately and without patient identifiers. Sensitivity and positive predictive values as well as the area below the alternative-free response receiver operating characteristic curve (Az) for each imaging technique were calculated and compared statistically.

RESULTS

Mean sensitivity and positive predictive values of MRI for hypervascular hepatocellular carcinoma were 48% and 94%, respectively, and those of CT imaging were 47% and 91%, respectively. In 11 (38%) of the 29 patients, at least one observer judged dynamic MRI to be superior, whereas in 5 patients (17%), dynamic CT was judged to be superior. There was no significant difference in the sensitivity and positive predictive values between these techniques (p > 0.05). There was no significant difference either in mean Az values between CT (0.55) and MRI (0.57) (p = 0.61).

CONCLUSION

Dynamic MRI with double-echo FLASH imaging can detect hypervascular hepatocellular carcinoma as well as dynamic helical CT imaging with double arterial phase.

Detection of hypervascular hepatocellular carcinoma: comparison of SPIO-enhanced MRI with dynamic helical CT

PURPOSE

The purpose of this study was to compare the diagnostic performance of superparamagnetic iron oxide (SPIO)-enhanced MRI for the detection of hypervascular hepatocellular carcinoma (HCC) with dynamic helical CT.

METHODS

SPIO-enhanced MR and dynamic helical CT images obtained from 41 patients with 52 hypervascular HCCs (5-130 mm; mean, 27 mm) were retrospectively analyzed. MRI were obtained with 1.5 T scanners using T2-weighted and proton density-weighted spin-echo (or fast spin-echo) sequences for all cases and a T2*-weighted gradient echo sequence for 36 cases. Four blinded observers reviewed images independently. Diagnostic accuracy was evaluated using alternative-free response receiver operating characteristic (AFROC) method. Sensitivities and positive predictive values (PPV) were also evaluated.

RESULTS

The areas under the AFROC curves for each observer were greater for MR than for CT (means, 0.81 and 0.76; p < 0.05). The mean sensitivities for MR and CT were 0.75 and 0.71, respectively (p = 0.13). The mean PPVs were 0.83 and 0.79 (p = 0.21).

CONCLUSION

SPIO-enhanced MRI showed slightly better diagnostic performance than dynamic helical CT for the detection of hypervascular HCCs.

Transient peritumoral enhancement during dynamic MRI of the liver: cavernous hemangioma versus hepatocellular carcinoma

PURPOSE

The purpose of this work was to compare the incidence and pattern of transient peritumoral parenchymal enhancement for cavernous hemangioma and hepatocellular carcinoma during dynamic MRI of the liver.

METHOD

Two hundred seven hemangiomas and 155 hepatocellular carcinomas up to 4 cm in size were retrospectively assessed. The peritumoral enhancement was comparatively analyzed in terms of the shape, extent, signal intensity, and dependence on the size and degree of contrast enhancement of each tumor.

RESULTS

For small lesions (<2 cm), hemangiomas (16/141; 11.3%) showed a higher incidence (p = 0.026) of peritumoral enhancement than hepatocellular carcinomas (3/87; 3.5%). For larger lesions (2-4 cm), there was no significant difference (p > 0.05) in the incidence of peritumoral enhancement of hemangiomas (15/66; 22.7%) and hepatocellular carcinomas (15/68; 22.1%). Nineteen (61.3%) of the 31 hemangiomas showed contrast agent filling the entire tumor volume at the phase of peritumoral enhancement.

CONCLUSION

In spite of the limited specificity, for a <2 cm small focal lesion with homogeneous contrast enhancement on early phase dynamic MR images in the liver, peritumoral enhancement could suggest a higher possibility of hemangioma rather than hepatocellular carcinoma.

Close association between high serum alanine aminotransferase levels and multicentric hepatocarcinogenesis in patients with hepatitis C virus-associated cirrhosis

BACKGROUND

Multicentric development of hepatocellular carcinoma (HCC) is a characteristic feature of hepatitis C virus (HCV)-associated cirrhosis (HCV-LC). In this study, the objective was to determine whether the persistent elevation of the serum alanine aminotransferase (ALT) level, which represents the inflammatory necrosis of hepatocytes, is correlated with the multicentric development of hepatocellular carcinoma (HCC) in patients with early-stage HCV-LC.

METHODS

Ninety-three consecutive patients with biopsy proven HCV-LC (Child Stage A) who had been followed for > 5 years for the development of HCC were studied. They were subdivided into three groups according to their serum ALT level: Group A included 33 patients with annual average serum ALT levels that were persistently high (> or = 80 IU; high ALT group), Group B included 41 patients with annual average serum ALT levels that were persistently low (< 80 IU; low ALT group), and Group C included 19 unclassified patients. The patients had been studied prospectively with frequent ultrasonography and magnetic resonance imaging or computed tomography (CT) scans for > 5 years. When the development of HCC was suspected, angiography, infusion of lipiodol into the hepatic artery, and lipiodol-CT scans were performed in all patients to determine the number of HCC nodules.

RESULTS

In Group A, 27 patients (81.8%) developed HCC. Seventeen of 27 patients (63.0%) had multiple nodules. In contrast, in Group B, only 12 patients (29.3%) developed HCC, and only 1 of these 12 patients (8.3%) had multiple nodules. There was a significant difference between Groups A and B in the incidence of developing HCC (P < 0.001) and developing multiple nodules (P = 0.006). In addition, among the male patients, the incidence of developing multiple HCC nodules in Group A (12 of 19 patients; 63.2%) was significantly higher (P < 0.05) compared with the incidence in Group B (0 of 6 patients; 0%). The same tendency was observed among the female patients.

CONCLUSIONS

These results showed a close correlation between multicentric hepatocarcinogenesis and sustained necroinflammation of the liver in patients with HCV-LC.

Arterial embolization of unresectable hepatocellular carcinoma with use of cyanoacrylate and lipiodol

PURPOSE

To assess the potential of transarterial permanent embolization with use of a mixture of cyanoacrylate and lipiodol for treatment of unresectable primary hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

In a retrospective study, 36 patients with histologically proven HCC were treated with transarterial embolization (TAE) of the hepatic arteries. None of these patients were candidates for surgical resection and some had advanced disease with multinodular disease or bulky tumor, thrombosis of a segmental branch of the portal vein, and/or extrahepatic spread. To induce permanent and more peripheral embolization, cyanoacrylate, an adhesive polymerizing on contact with blood, was used in TAE. From 1990 to 1998, a total of 76 embolization procedures were performed. Cumulative survival rates were calculated.

RESULTS

Most of the patients presented with a self-limited postembolization syndrome. Severe procedure-related complications were found after four treatment sessions (5.2%). The 30-day perioperative mortality rate was 2.7%. The mean follow-up period was 20.3 months (range, 1-68 mo), with a median survival of 26 months. The median survival was also estimated for different Okuda stages of disease: stage II (n = 26) versus stage III (n = 5) disease (32 vs 9 months; P <.05); patients with (n = 9) or without (n = 27) extrahepatic metastasis (10 vs 26 months; P <.05); and patients with (n = 10) or without (n = 26) thrombosis of a segmental branch of the portal vein (7 versus 34 months [P <.005]).

CONCLUSION

TAE with use of cyanoacrylate and lipiodol for unresectable HCC is a feasible treatment modality. This retrospective report indicates beneficial effects on survival even in patients with advanced disease.

Value of lipiodol computed tomography and digital subtraction angiography in the era of helical biphasic computed tomography as preoperative assessment of hepatocellular carcinoma

OBJECTIVE

To compare the diagnostic accuracies of Lipiodol computed tomography (CT) and helical biphasic CT as preoperative imaging modalities for hepatocellular carcinoma (HCC).

SUMMARY BACKGROUND DATA

Lipiodol CT after digital subtraction angiography has long been used as a highly sensitive imaging modality for HCC. The recent advent of helical CT has allowed scanning the entire liver during both the arterial and portal venous phase of contrast enhancement.

METHODS

The authors analyzed data from 164 patients who underwent hepatic resection for HCC to calculate the sensitivity and specificity of these modalities. Findings of intraoperative ultrasonography followed by histologic confirmation were set as the gold standard.

RESULTS

Although sensitivity decreased with both modalities as tumors became small and well differentiated, helical CT showed a higher sensitivity than Lipiodol CT in detecting well-differentiated HCC nodules smaller than 2 cm. In contrast, Lipiodol CT was superior to helical CT for the detection of small but moderately to poorly differentiated nodules. The overall sensitivity of helical CT was higher than that of Lipiodol CT. These findings suggest that helical CT is superior in delineating early HCC, whereas Lipiodol CT is specific to the detection of intrahepatic metastases. In terms of specificity, helical CT was superior to Lipiodol CT.

CONCLUSIONS

Helical CT and Lipiodol CT are complementary modalities. At present, helical biphasic CT does not obviate the need for invasive techniques such as angiography and Lipiodol CT as preoperative examinations for HCC.

Ischemic bile duct injury as a serious complication after transarterial chemoembolization in patients with hepatocellular carcinoma

BACKGROUND

Bile duct injuries after transarterial chemoembolization (TACE) have been reported; however, the exact pathogenic mechanisms and clinical implications of the injuries remain to be clarified.

STUDY

A total of 950 consecutive patients with hepatocellular carcinoma (HCC) were studied. Among them, 807 were treated with TACE and the remaining 143 were treated with transarterial chemoinfusion (TACI) of cisplatin.

RESULTS

None of 143 patients with HCC treated with TACI were found to have any radiographic evidence of biliary injury. In contrast, of the 807 patients treated with TACE, 17 (2%) developed biliary complications. Of all complications, 12 (71%) were subcapsular bilomas; 3 (17%), focal strictures of the common hepatic duct or common bile duct; and 2 (12%), diffuse mild dilatation of the intrahepatic bile ducts. Interestingly, 2 of the 12 bilomas were found in the lobe that was not embolized with gelatin sponge particles. The median numbers of TACE tended to be greater in the patients with focal stricture than in those with bilomas (6.0 vs. 2.5; p = 0.08). All 3 patients with focal strictures and 4 of the 12 patients with bilomas had associated serious bacterial infections at presentation.

CONCLUSIONS

Bilomas seem to be caused by iodized oil rather than gelatin sponge particles; focal strictures of large bile ducts seem to be caused by gelatin sponge particles. We suggest that adjustments in the amounts of iodized oil or gelatin sponge particles and in the sites of embolization may reduce ischemic biliary injuries after TACE.

Lipiodol accumulation in focal peliosis hepatis with sinusoidal dilatation

Peliosis hepatis is a rare benign condition that is histologically characterized by multiple cystic blood-filled spaces in the liver. Although the cause is unknown, the condition occurs in association with several diseases or medications. We report a patient who was found to have a lesion with lipiodol accumulation in the liver 2 months after its intraarterial injection. The lesion was diagnosed and treated as a small hepatocellular carcinoma. However, subsequent right hepatic lobectomy and histologic examination confirmed the diagnosis of focal peliosis hepatis.

SMANCS and polymer-conjugated macromolecular drugs: advantages in cancer chemotherapy

This review discusses the development and therapeutic potential of prototype macromolecular drugs for use in cancer chemotherapy, in particular the development and use of SMANCS, a conjugate of neocarzinostatin and poly(styrene-comaleic acid). The various topics covered include a brief description of the chemistry and polymer conjugation, the binding of the conjugate to albumin and the biological behaviour in vitro and in vivo after arterial injection in animals, including plasma half-life, and the lipid solubility of SMANCS in medium chain triglycerides and Lipiodol, a lipid contrast medium suitable for use in X-ray-computed tomography. The biological response-modifying effects and the tumor-targeting mechanism of SMANCS and other macromolecular drugs are also discussed. The latter mechanism is accounted for in terms of a tumor 'enhanced permeability and retention' (or EPR) effect. A principal advantage in the use of SMANCS or other macromolecular drugs is the potential for a reduction or elimination of toxicity. Macromolecular drugs such as a pyran copolymer-NCS conjugate show a marked reduction in bone marrow toxicity normally associated with the use of NCS. This is believed to be due to a hypothetical blood-bone marrow 'barrier' which, relative to NCS, restricts or limits access of the macromolecular drug to the bone marrow. In addition, the clinical possibilities for SMANCS are discussed, including the suggestion that angiotensin II-induced hypertension has clinical potential in improving the selective delivery of macromolecular drugs (i.e. SMANCS) to tumors. Aqueous SMANCS formulations have been tested in pilot studies in patients with solid tumors of the ovary, esophagus, lung, stomach, adrenal gland and in the brain. Formulations based on SMANCS/Lipiodol have been shown to be effective both as a diagnostic tool and for therapeutic use in solid tumors where the formulations are given arterially via a catheter. In a pilot study in primary unresectable hepatoma, an objective reduction in tumor size was observed for about 90% of cases when an adequate amount of the macromolecular drug was administered. A patient receiving such treatment with no active liver cirrhosis and tumor nodules/lesion confined within one liver segment might expect to have a 90% chance of survival after treatment for at least 5 years.

Dysplastic nodules and hepatocellular carcinoma: sensitivity of digital subtraction hepatic arteriography with whole liver explant correlation

PURPOSE

The purpose of this work was to determine the sensitivity of hepatic digital subtraction arteriography (DSA) for the detection of hepatocellular carcinoma (HCC) and dysplastic nodules (DNs) when compared with pathological findings from whole liver explants.

METHOD

Twenty-one patients 30-72 years old (mean 54 years) with cirrhosis and known or clinically suspected HCC (20 prior to chemoembolization) underwent hepatic DSA with subsequent transplantation within 80 days (mean 32 days). The prospective DSA report was compared with pathologic findings from explanted livers.

RESULTS

Overall, DSA detected 31 of 95 HCC lesions for a sensitivity of 33%. Of these 31 lesions, 28 were hypervascular and 3 were hypovascular. DSA detected all six HCCs measuring >5 cm, all six HCCs measuring 3-5 cm, and all five HCCs 2-3 cm, resulting in a sensitivity of 100% (17/17) for HCC >2 cm. DSA detected 7 of 18 HCCs measuring 1-2 cm (sensitivity 39%) and 7 of 60 HCCs < or =1 cm (sensitivity 12%). Overall sensitivity for DSA in detection of HCC < or =2 cm was 18% (14/78 lesions). None of 17 DNs (0.2-1.5 cm in size) was identified on DSA.

CONCLUSION

DSA is insensitive to small HCC (< or =2 cm), carcinomatosis arising within nodules, and DN.

Hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is increasing in many countries as a result of an increase in hepatitis C virus (HCV) infection since World War II. The epidemiology of HCC varies with the global region. There have been conflicting observations from different parts of the world concerning the frequency of HCC in patients who in the distant past had post-transfusion non-A, non-B hepatitis. The genetic basis of hepatocarcinogenesis is still poorly understood. In hepatitis B virus (HVB) associated HCC, codon 249 mutation in the p 53 gene seems more related to exposure to aflatoxin B1 than to hepatocarcinogenesis itself. HCC that occurs in children in high HBV endemic regions could be associated with germ-line mutations, but little information is available; not much is known about chemical hepatocarcinogens in the environment other than aflatoxins. The X gene of HBV seems to play an important role in HBV-associated hepatocarcinogenesis. There are preliminary observations on the molecular mechanism of HCV-associated HCC, such as HCV core protein inducing HCC in transgenic mice and the NS3 genome transforming NIH 3T3 cells. Pathological distinction between preneoplastic and very early transformed lesions still depends on classical morphology, and a more genetically oriented differential diagnosis is required. Clinical diagnosis based on modern imaging has improved greatly, but is still unsatisfactory in the differential diagnosis of preneoplastic and early transformed nodules, because the vasculature changes that occur within the nodule are not accurately discerned with the current imaging. Use of sensitive des-gamma-carboxy prothrombin (PIVKA II) assay, and lectin affinity chromatography separating HCC specific subspecies of AFP molecules with a more practical biochemical technique will further improve diagnosis. Early diagnosis and transplantation are the best treatment at the moment, but transplantation is not widely available because of the donor shortage. Despite successful resection, the remnant cirrhotic liver frequently develops new HCC lesions, seriously curtailing long-term survival. All-out efforts should be directed to the prevention of HCC, through prevention of viral hepatitis, prevention of acute hepatitis from becoming chronic, prevention of chronic hepatitis from progressing to cirrhosis, and prevention of the cirrhotic liver from developing HCC (chemoprevention). At the moment, very few such studies exist.

Monitoring response to treatment in liver tumours

New imaging techniques offer better ways of measuring response to treatment and remain central to the formal assessment of response in clinical trials and routine clinical practice. Increasing tumour size is consistently associated with progressive disease. However, there is evidence that the designation 'partial response', as determined by conventional imaging techniques, may not always accurately reflect the degree of treatment-induced tumour necrosis. Thus, responses classified as partial on imaging grounds have, in some cases, been shown to be complete pathological responses after surgical resection, implying that residual tumour and necrotic/fibrotic tumour remnants cannot always be accurately distinguished by imaging. In this situation, serological tumour markers such as alphafetoprotein may be useful in measuring the true degree of response. While radiological imaging is likely to remain the main method of assessing response in phase II trials of drugs for the treatment of liver cancer, it may in some instances be useful to apply additional parameters such as alphafetoprotein level.

Hepatic intraarterial 131I iodized oil for treatment of hepatocellular carcinoma in patients with impeded portal venous flow

PURPOSE

To evaluate the efficacy and safety of intraarterial hepatic iodine 131 iodized oil for treatment of hepatocellular carcinoma in patients with impeded portal venous flow.

MATERIALS AND METHODS

Twenty-four patients (mean age, 61 years) with hepatocellular carcinoma underwent 38 courses of 131I iodized oil (one to three per patient), with a mean dose of 2,146 MBq injected into the proper hepatic artery. Hepatocellular carcinoma manifested as single nodules (n = 8; mean, 7.75 cm), multiple nodules (n = 13; mean, 5.46 cm), or a mass (n = 3) occupying more than two hepatic segments. Portal venous thrombosis was complete (n = 10), right (n = 9), left (n = 2), or multisegmental (n = 1). Two patients had hepatofugal portal flow.

RESULTS

Among the 23 patients with evaluable results, response to treatment was partial in three, and disease was stable in 12 and progressive in eight. Estimated actuarial survival rates were 70%, 33%, 12%, and 6% at 3, 6, 9, and 12 months, respectively, with two patients alive at 9 and 11 months. The median survival time was 147 days. Adverse events were the early death of one patient owing to hepatic failure and transient symptomatic hepatic failure after 12 courses in nine patients.

CONCLUSION

In this preliminary experience, intraarterial hepatic 131I iodized oil did not demonstrate high efficacy in the treatment of hepatocellular carcinoma in patients with portal venous thrombosis, as side effects were not rare.

Association between high serum alanine aminotransferase levels and more rapid development and higher rate of incidence of hepatocellular carcinoma in patients with hepatitis C virus-associated cirrhosis

BACKGROUND

Many studies have demonstrated in animal experiments that persistent inflammation may accelerate the development of carcinoma. In this article, the question of whether the persistent elevation of serum alanine aminotransferase (ALT) levels (which represents the inflammatory necrosis of hepatocytes) correlates with the development of hepatocellular carcinoma (HCC) was studied in patients with early stage hepatitis C virus (HCV)-associated cirrhosis.

METHODS

Sixty-nine consecutive patients with biopsy proven HCV-associated cirrhosis (mostly Child's Stage A) who had been followed for >5 years for the development of HCC were studied. They were subdivided into 3 groups according to their serum ALT levels: Group A was comprised of 28 patients whose annual average serum ALT level was persistently high (>/= 80 IU) (high ALT group), Group B was comprised of 28 patients whose annual average serum ALT level was persistently low (< 80 IU) (low ALT group), and Group C was comprised of 13 unclassified patients. The patients had been studied prospectively with frequent ultrasonography and magnetic resonance imaging or computed tomography for > 5 years.

RESULTS

In the high ALT group HCC developed in 71.4% of patients compared with 25.0% in the low ALT group over the observation period (P < 0.005). The 5-year rate of incidence of HCC in the high ALT group was as high as 53.6% compared with only 7.1% in the low ALT group (P < 0.001). The expected interval between the diagnosis of cirrhosis and the development of HCC was 6.0 +/- 0.7 years (mean +/- standard error) in the high ALT group and 12.7 +/- 1.2 years in the low ALT group (P < 0.001).

CONCLUSIONS

The results of the current study demonstrated that the development of HCC was more rapid in the high ALT group with HCV-associated cirrhosis.

Imaging of hepatocellular carcinoma

Recent improvements in the treatment of hepatocellular carcinoma (HCC) have resulted in a need to identify the disease at an early stage. The wide range of imaging techniques available reflects the difficulty in demonstrating small HCC, particularly in the cirrhotic liver. This article reviews the current imaging techniques available for the diagnosis of HCC.

Sensitivity of double-phase helical CT during arterial portography for detection of hypervascular hepatocellular carcinoma

PURPOSE

The purpose of our work was to determine the usefulness of double-phase helical CT during arterial portography (CTAP) for the detection of hypervascular hepatocellular carcinoma (HCC).

METHOD

Eighty-four patients with 176 hypervascular HCC nodules underwent double-phase CTAP. Hypervascular HCCs were diagnosed by iodized oil CT after transcatheter arterial chemoembolization (TACE). The first-phase images were obtained 30 s after the initiation of injection of a nonionic iodinated contrast medium into the superior mesenteric artery or splenic artery, and the second-phase images were obtained after 70 s. These images were interpreted separately for detection of HCC.

RESULTS

The double-phase CTAP detected two nodules and six nodules that were missed by the first- and second-phase images, respectively. The sensitivity for hypervascular HCC nodules was 89% for the first phase, 91% for the second phase, and 93% for the first phase and second phase combined. The double-phase CTAP showed significantly superior sensitivity to the first-phase CTAP for detecting HCC nodules (p < 0.05). However, there was no statistically significant difference between the sensitivities of the double-phase CTAP and the second-phase CTAP. The positive predictive values of the double-phase images were inferior to those of either the first-phase or the second-phase images alone.

CONCLUSION

Double-phase helical CTAP was found to be no better than second-phase CTAP alone for the detection of hypervascular HCC nodules.

The usefulness of determining des-gamma-carboxy prothrombin by sensitive enzyme immunoassay in the early diagnosis of patients with hepatocellular carcinoma

BACKGROUND

Measurements of serum concentrations of des-gamma-carboxy prothrombin (DCP) are widely used for diagnosing hepatocellular carcinoma (HCC). However, the DCP is not always sensitive enough to detect small HCCs. In the current study, the authors investigated the usefulness of DCP in the early diagnosis of HCC, using a more sensitive enzyme immunoassay than is conventionally employed.

METHODS

The authors examined 148 serum samples with DCP concentrations from a conventional assay of less than 100 mAU (arbitrary unit)/mL from 91 patients with HCC and 57 with cirrhosis. DCP concentrations were determined by a more sensitive enzyme immunoassay (ED-036 kit, Eisai Laboratory, Tokyo, Japan) with a minimal detection level of 10 mAU/mL. Ninety-one HCC patients had 43 solitary small HCCs (with a greatest dimension of less than 2 cm). Of these 43 HCCs, 12 were well differentiated.

RESULTS

The mean serum concentration of DCP in HCC (48.3 +/- 24.3, mean +/- standard deviation [SD]) was higher than in cirrhosis (20.3 +/- 10.3); this difference was statistically significant. When the tentative cutoff level of 40 mAU/mL (almost corresponding to the mean value + 2SD in patients with cirrhosis) was used as the level of discriminating HCC from cirrhosis, 62% of patients (56 of 91) with HCC had DCP values above this level (sensitivity). However, only three patients with cirrhosis had higher DCP levels. Thus, the specificity of this test was 95% (54 of 57 patients). The total accuracy was 74% (56 + 54/91 + 57). Twenty-three of 43 solitary small HCCs (53%) had DCP values above the cutoff level. Furthermore, 7 of 12 (58%) small, well-differentiated HCCs less than 2 cm in greatest dimension had higher DCP values.

CONCLUSIONS

The results of this study indicate that DCP determination by sensitive enzyme immunoassay is useful in the early diagnosis of HCC because a high specificity is maintained.

Diagnostic value and tolerance of Lipiodol-computed tomography for the detection of small hepatocellular carcinoma: correlation with pathologic examination of explanted livers

BACKGROUND/AIMS

This study aimed to assess the tolerance and the real sensitivity of Lipiodol-computed tomography in the detection of small hepatocellular carcinoma by comparison with pathological examination of the explanted livers.

METHODS

Seventy-two patients with cirrhosis (Child A=8, B=36, C=28) awaiting orthotopic liver transplantation underwent Lipiodol-computed tomography to determine the presence, number and location of possible hepatocellular carcinoma nodules. Before liver transplantation six patients had a presumed single hepatocellular carcinoma diagnosed by biopsy. Liver transplantation was performed a mean of 6 months after Lipiodol-computed tomography. Explanted livers were sectioned at 0.8- to 1-cm intervals. Lipiodol-computed tomography staging and pathologic findings were compared.

RESULTS

Pathologic studies showed 24 hepatocellular carcinoma nodules (diameter, 2-42 mm) not diagnosed before liver transplantation in 14 of the 72 livers. Lipiodol-computed tomography detected 6 of these 24 nodules, but none of the daughter lesions (n=9) in the six patients with a presumed single hepatocellular carcinoma. Lesion-by-lesion analysis revealed a sensitivity of 37%. Lipiodol-computed tomography falsely detected three additional nodules not confirmed by pathologic examination (1 haemangioma, 2 nondysplastic regenerating nodules). One Child C patient developed variceal bleeding within 2 days after injection of Lipiodol.

CONCLUSIONS

Tolerance of this procedure was satisfactory, even in Child C patients. Lipiodol-computed tomography has a low sensitivity in the detection of small hapatocellular carcinoma. These results must be considered when liver resection or liver transplantation is proposed for the treatment of hepatocellular carcinoma.

Modification of arterial and portal hemodynamics after injection of iodized oils and different emulsions of iodized oils in the hepatic artery: an experimental study

PURPOSE

A strong embolic effect of iodized oil/drug mixtures injected in the hepatic artery appeared to be an efficient way of prolonging the contact time between drugs and tumor tissue. Therefore, the authors evaluated arterial and portal embolic effects after hepatic intra-arterial injection of iodized oils and various emulsions of iodized oil.

MATERIALS AND METHODS

Twenty-five pigs were monitored for the Doppler resistance index (DRI) in the hepatic artery and wedge hepatic vein pressure (WHVP) during 1 hour after injection of pure iodized oil, ultra-fluid or fluid, and four different emulsions of iodized oil ultra-fluid, into the hepatic artery.

RESULTS

Mean area under the curve (AUC) values of DRI increases varied from 20.3 to 24.2 after injection of pure iodized oils or water-in-oil emulsions, and were 13.2 for large-droplet oil-in-water emulsion and 8.2 for small-droplet oil-in-water emulsion. Mean AUC values of WHVP increases varied from 151.6 to 195.6 after injection of pure iodized oils or water-in-oil emulsions, and were 105.5 for large-droplet oil-in-water emulsion and 8.5 for small-droplet oil-in-water emulsion. There was a significant difference in DRI and WHVP modifications between small-droplet oil-in-water emulsions and all other products (P = .001), between the two oil-in-water emulsions and the two water-in-oil emulsions (P = .004), and between the two oil-in-water emulsions and pure iodized oils (P = .002).

CONCLUSION

After hepatic intra-arterial injection, water-in-oil emulsions and pure iodized oils provided a stronger embolic effect than oil-in-water emulsion, both in the hepatic artery and in the portal vein.

Influence of preoperative transarterial lipiodol chemoembolization on resection and transplantation for hepatocellular carcinoma in patients with cirrhosis

OBJECTIVE

To investigate the impact of preoperative transarterial lipiodol chemoembolization (TACE) in the management of patients undergoing liver resection or liver transplantation for hepatocellular carcinoma.

PATIENTS AND METHODS

TACE was performed before surgery in 49 of 76 patients undergoing resection and in 54 of 111 patients undergoing liver transplantation. Results were retrospectively analyzed with regard to the response to treatment, the type of procedure performed, the incidence of complications, the incidence and pattern of recurrence, and survival.

RESULTS

In liver resection, downstaging of the tumor by TACE (21 of 49 patients [42%]) and total necrosis (24 of 49 patients [50%]) were associated with a better disease-free survival than either no response to TACE or no TACE (downstaging, 29% vs. 10% and 11 % at 5 years, p = 0.08 and 0.10; necrosis, 22% vs. 13% and 11% at 5 years, p = 0.1 and 0.3). Five patients (10%) with previously unresectable tumors could be resected after downstaging. In liver transplantation, downstaging of tumors >3 cm (19 of 35 patients [54%]) and total necrosis (15 of 54 patients [28%]) were associated with better disease-free survival than either incomplete response to TACE or no TACE (downstaging, 71 % vs. 29% and 49% at 5 years, p = 0.01 and 0.09; necrosis, 87% vs. 47% and 60% at 5 years, p = 0.03 and 0.14). Multivariate analysis of the factors associated with response to TACE showed that downstaging occurred more frequently for tumors >5 cm.

CONCLUSIONS

Downstaging or total necrosis of the tumor induced by TACE occurred in 62% of the cases and was associated with improved disease-free survival both after liver resection and transplantation. In liver resection, TACE was also useful to improve the resectability of primarily unresectable tumors. In liver transplantation, downstaging in patients with tumors >3 cm was associated with survival similar to that in patients with less extensive disease.

Laparoscopic prediction of hepatocellular carcinoma in cirrhosis patients

Previously, laparoscopic studies have not been successful in predicting the occurrence of small hepatocellular carcinoma because cirrhotic patients had not been separated into groups of those who developed small hepatocellular carcinoma under 3 cm in diameter, and those who did not. Retrospective examination with better separation of the two groups gave improved results. Of the 26 laparoscopic findings, only the presence of large complex regenerative nodules was closely associated with the occurrence of subclinical small hepatocellular carcinoma. The study of other cirrhotic patients with and without large complex regenerative nodules gave a cumulative hepatocellular carcinoma occurrence rate of 73% for patients who had these nodules by the third year after laparoscopy. In contrast, the rate for patients without such nodules was 6%, showing a significant difference (P < 0.05) between the two groups. We concluded that the laparoscopic finding of large complex regenerative nodules of liver cirrhosis can be used to predict the occurrence, or a complication, of subclinical small hepatocellular carcinoma.

Relationship between the recurrence of hepatocellular carcinoma (HCC) and serum alanine aminotransferase levels in hepatectomized patients with hepatitis C virus-associated cirrhosis and HCC

BACKGROUND

The relationship between the recurrence of hepatocellular carcinoma (HCC) and the serum alanine aminotransferase (ALT) level was studied in hepatectomized patients with hepatitis C virus (HCV)-associated cirrhosis and HCC.

METHODS

Twenty-six hepatectomized patients with HCV-associated cirrhosis and HCC whose resected specimens showed neither portal vein nor hepatic vein invasion by HCC histologically were divided into 2 groups: 15 patients who had no recurrence 3 years after surgery (Group A) and 11 patients whose disease recurred 1-3 years after surgery (Group B). The patients' serum ALT levels during this period were examined.

RESULTS

In Group A, serum ALT generally showed sustained low levels < 80 international units (INU) in 12 patients (80%). In contrast, ALT levels in Group B showed several peaks or plateaus > 80 INU in all patients except 2. The recurrence rate of HCC in the hepatectomized patients with sustained low levels of ALT was 14.3% (2 of 14 patients) at 3 years, and was significantly lower (P < 0.01) than that in those patients whose ALT levels showed several peaks or plateaus > 80 INU (9 of 12 patients; 75.0%). The average level of mode of ALT in Group A (48.8 +/- 26.0 INU) was significantly smaller than that in Group B (101.1 +/- 47.3 INU) (P < 0.005).

CONCLUSIONS

The importance of hepatocytic necrosis in the recurrence of HCC in hepatectomized patients with cirrhosis and HCC of HCV origin was demonstrated and the significance of subsiding hepatic necroinflammatory process in the prevention of HCC recurrence suggested.

Sequential transarterial chemoembolization for unresectable advanced hepatocellular carcinoma

PURPOSE

The aim of this prospective study was to evaluate the feasibility, safety, and efficacy of sequential transarterial chemoembolization (TACE) for patients with unresectable advanced hepatocellular carcinoma (HCC).

METHODS

Twenty-one consecutive patients with unresectable T3 and T4 HCC were treated by sequential TACE (median time interval between treatments 7 weeks) up to six times with an emulsion of lipiodol, epirubicin, and cisplatin. All TACE procedures were performed as unilobar or whole-liver chemoembolization.

RESULTS

An average of 3.9 TACE procedures were performed per patient. One primary and two secondary technical failures occurred. No procedural death was observed. After exclusion of the patient with the primary technical failure and 3 patients with extrahepatic disease, the survival rates for the remaining 17 patients at 6, 12, 18, and 24 months were 70.6%, 52.9%, 44.1%, and 33.1%, respectively.

CONCLUSION

Sequential TACE is a safe procedure in patients with unresectable advanced HCC and feasible in most cases. It seems to prolong the survival time compared with historical series of untreated patients.

Regional Transcatheter Therapy of Hepatic Neoplasms

BACKGROUND: Surgical resection of hepatocellular carcinomas and metastases to the liver cannot always be performed, and systemic therapies for these entities are of limited value. The techniques of chemoembolization and hepatic artery infusion have been used for patients who are not candidates for surgery. METHODS: Chemoembolization uses percutaneous intra-arterial infusion of chemotherapeutic agents and embolic material. This provides longer contact of the agents with the tumor cells and induces ischemia. Hepatic arterial chemoinfusion uses the knowledge that hepatic cancers are supplied predominantly by the hepatic artery. RESULTS: Chemoembolization using Lipiodol, doxorubicin, and Gelfoam has promoted necrosis of unresectable hepatocellular tumors and may have prolonged patient survival. Hepatic arterial infusion with fluorinated pyrimidines produces more objective responses than systemic chemotherapy but probably does not alter survival. CONCLUSIONS: The nonsurgical treatments of chemoembolization and hepatic arterial infusion of chemotherapy have expanded our armamentarium to manage many primary and metastatic tumors in the liver. Additional approaches are needed.

Disposition of epirubicin after intraarterial administration in Lipiodol to patients with hepatocellular carcinoma

Delivering emulsions of anthracycline drugs in Lipiodol, an iodinated poppy-seed oil, via the hepatic artery for the treatment of hepatocellular carcinoma (HCC) has become increasingly popular. However, investigations to determine the extent to which the Lipiodol sequesters the anthracycline in the liver have been limited. Concern has been expressed that such emulsions are not stable and that the anthracycline is, therefore, released rapidly into the circulation. We studied the pharmacokinetics of epirubicin (50 mg m-2) in five patients with nonresectable primary hepatocellular carcinoma after infusion of an epirubicin/Lipiodol emulsion via the hepatic artery. We used a reliable and specific high-performance liquid chromatography assay that allows quantitation of plasma concentrations of epirubicin, epirubicinol, epirubicin glucuronide, and epirubicin aglycone. Although a large interpatient variability in pharmacokinetics was observed, our results were similar to historical data after epirubicin intravenous therapy. Only the results from one patient provided evidence of significant retention of the drug in the liver. It would appear that more stable formulations of epirubicin/Lipiodol are required to increase the efficacy of this form of treatment. We suggest that pharmacokinetic studies should accompany clinical evaluation of emulsions of epirubicin/Lipiodol for the treatment of HCC.

Iodized-oil retention within hepatic hemangioma: characteristics on iodized-oil CT

OBJECTIVE

The purpose of this study was to describe the characteristic computed tomographic (CT) appearance of iodized-oil retention in hepatic hemangioma and to evaluate the duration of the retention of iodized oil on follow-up CT.

METHODS

Seventeen hepatic hemangiomas of 14 patients were studied with CT performed 1-3 weeks after injection of 2-9 ml of iodized oil (iodized-oil CT) for the characterization of focal hepatic lesions, which needed differential diagnosis with hepatocellular carcinoma in 10 patients, for therapy in two patients, and for chemoembolization therapy of accompanying hepatocellular carcinomas in two. Twelve patients had 1-7 follow-up CT scans within an interval of 1-38 months.

RESULTS

In all cases, iodized-oil CT showed iodized-oil retention within the tumor, regardless of tumor size, shape, location, and amount of injected iodized oil. The distribution was incomplete and predominantly peripheral in all cases. Central retention was also seen in seven cases, in which a relatively large amount of iodized oil was injected, but retention of iodized oil in the tumor was incomplete even in two cases in which a large amount of iodized oil was injected to relieve symptoms and in three cases in which prominent uptake of surrounding liver parenchyma was seen. Patterns of retention were predominantly spotty in five, predominantly nodular in four, and mixed in eight patients. Retention materials slowly washed out but persisted for at least 3 months and up to 38 months (mean = 18.1 months), and complete washout was not seen in any cases at follow-up CT.

CONCLUSION

In all cases of hepatic hemangiomas, iodized oil was retained, and retention persisted over several months. Distribution and patterns of retention were characteristically peripheral, spotty, and nodular at iodized-oil CT. Knowledge of the iodized-oil CT appearance of hepatic hemangioma would be helpful to interpret follow-up CT studies of patients who have undergone iodized-oil chemoembolization procedures.

Surgical treatment of hepatocellular carcinoma originating from the caudate lobe

Hepatocellular carcinoma (HCC) originating from the caudate lobe is rare, and its surgical management is difficult because of its unique anatomic location. We have seen six such cases at our hospital. For patients with fair to excellent liver reserve, we advocated caudate lobectomy combining other types of hepatic resection. For patients with marked liver cirrhosis and poor liver reserve or a small HCC, we advocated simple partial caudate lobectomy (limited hepatic resection). There was no operative mortality or major operative morbidity. We conclude that such approaches are safer, less time-consuming, and less technique-demanding, and they produce a fair survival result compared with the approaches of other procedures. With such approaches, it is our experience that patients with HCC from the caudate lobe have a prognosis comparable to that of patients with HCC in other parts of the liver.

Detection of hepatocellular carcinoma by intraarterially enhanced ultrasonography with CO2 microbubbles. Comparison with DSA, dynamic CT, and Lipiodol CT

PURPOSE

To evaluate the diagnostic value of contrast-enhanced US with CO2 microbubbles (EU) for HCCs. Detectability was compared with DSA, dynamic CT, and Lipiodol CT.

MATERIAL AND METHODS

Forty-seven histologically proven HCCs detected with US were evaluated with EU, DSA, and dynamic CT. In 23 patients (35 lesions), Lipiodol CT was also performed. The size of the tumors ranged from 8 to 71 mm (average 28.1 mm); 24 lesions were smaller than 20 mm and 23 lesions were larger than 20 mm.

RESULTS

Overall detection was possible in 40 of 47 lesions (85%) by EU, in 32 of 47 (68%) by DSA, in 33 of 47 (74%) by dynamic CT, and in 27 of 35 (77%) by Lipiodol CT. In tumors smaller than 20 mm, detection was possible in 21 of 24 lesions (88%) by EU, 14 of 24 (58%) by DSA, 14 of 24 (58%) by dynamic CT, and 11 of 17 (65%) by Lipiodol CT.

CONCLUSION

EU has significant diagnostic value for detection of HCCs, particularly tumors smaller than 20 mm.

Lipiodol accumulation in hepatic hemangioma. Detection with osmium postfixation

Lipiodol has been used to increase the detectability of small primary neoplasms in the liver. We report a patient who was found to have lipiodol deposits in the liver one month after intra-arterial injection. The region was resected, under ultrasound control, because of the impression that the lesion was malignant. The specimen contained two small hemangiomas as well as many small dysplastic nodules (adenomatous hyperplasia) in a noncirrhotic parenchyma. To locate the lipiodol deposit in this case, the tissue was radiographed, postfixed in osmium tetroxide, and embedded in paraffin. Black osmium-stained deposits were found within the cavities of the hemangiomas but not in the dysplastic nodules. Most of the deposits were extracellular multivesiculated bodies with a small focus of lipid droplets engulfed by multinucleated foreign-body type giant cells. This report reinforces that hepatic lipiodol retention is not specific for hepatocellular carcinoma. We present, for the first time, the histologic appearance of lipiodol accumulation in an hemangioma. The value of osmium tetroxide postfixation for the detection of lipiodol is also demonstrated.

Radiolabelling of Lipiodol with generator-produced 188Re for hepatic tumor therapy

In this study we prepared and analyzed the biodistribution of 188Re-labelled Lipiodol ([188Re]-Lipiodol) in rats after intrahepatic arterial injection. EDTB was synthesized by condensation of 1,2-benzenediamine and ethylenediaminetetraacetic acid (EDTA). The labelling efficiency of [188Re] Lipiodol was determined to be greater than 97% by ITLC developed with n-hexane. Following incubation of the [188Re] Lipiodol with an equal volume of serum at 37 degrees C for 48 h, ITLC indicated good in vitro stability. Approximately 7.4 MBq [188Re] Lipiodol was injected in each rat via the hepatic artery and samples of liver, spleen, muscle, lung, kidney, bone, whole blood and testis were obtained. [188Re] Lipiodol tissue concentrations showed that after 1 h intrahepatic injection most of the radiotracer was retained in the liver, and was eliminated slowly with a biological half-life of 33.5 h. Radioactvity levels in the lung, kidney and blood were moderate at 1 h, and declined rapidly over time. In the spleen, muscle, testis and bone, radiation levels were insignificant. These initial results indicate that -188Re- Lipiodol may be a potential radiopharmaceutical agent for the treatment of liver tumors.

Superselective intra-arterial radiometabolic therapy with I-131 lipiodol in hepatocellular carcinoma

Superselective transcatheter arterial radioembolization with radioiodinated lipiodol and gelatin sponges was evaluated in 11 patients with nodular hepatocellular carcinoma. Thirteen tumor nodules were treated using 3-5 ml of lipiodol labeled with 259 to 2220 MBq of I-131 followed by gelatin sponge with the following results: 1) there was elevated uptake in 12 tumor nodules with high tumor-to-background ratios: 2) there was excellent clinical tolerance to the treatment (stable cirrhosis in 5 patients and cirrhosis progression in 2 cases); 3) there was good disease control with size reduction in five tumor lesions (41%) and no increase in seven lesions (59%) followed for 2 years; 4) there was a 2-year survival rate of 70%; and 5) three deaths due to hepatic failure at 2, 3, and 20 months after therapy. Superselective arterial radioembolization with I-131 lipiodol is a useful palliative approach to inoperable hepatocarcinoma, providing long-term local control without severe complications in the progression of cirrhosis.

Biodistribution of rhenium-188 Lipiodol infused via the hepatic artery of rats with hepatic tumours

The purpose of this study was to analyse the biodistribution of rhenium-188 Lipiodol in rats with hepatic tumours following intrahepatic arterial injection to assess the potential of 188Re-Lipiodol as a radiopharmaceutical for the treatment of hepatic tumours in humans. Twelve male rats with hepatic tumours were killed at 1h, 24h and 48h after injection of approximately 7.4MBq of 188Re-Lipiodol via the hepatic artery. Samples of various organs were obtained and counted to calculate the tissue concentration. Radioactivity in the hepatic tumours was very high throughout this study, with a biological half-life of 122.9h. Radioactivity in the normal liver tissue was also high, but was significantly lower than in the tumour. The biological half-life in the normal liver tissue was 31.7h. The ratio of tumour concentration to the normal liver tissue concentration was 5.15 at 1h and rose to 7.7 at 24h and 10.84 at 48h. The level of radioactivity in the lung was high at 1h, and declined rapidly over time. The level of radioactivity in the kidney was moderate throughout the study. The radiation concentrations in muscle, spleen, testis, bone and whole blood were insignificant. We conclude that 188Re-Lipiodol should be considered as a potential radiopharmaceutical for the intra-arterial treatment of hepatic tumours.

Development of a de novo tumorous necrotic lesion in the liver after transcatheter arterial embolization combined with iodized oil infusion: report of a case

We report herein the case of a 69-year-old woman in whom a hepatic tumorous necrotic lesion was discovered following transcatheter arterial embolization combined with iodized oil infusion (Lp-TAE) for a hepatoma. The lesion, which had not been evident prior to the Lp-TAE, was resected and analyzed pathologically. The portal area distribution in the necrotic lesion was the same as that in the surrounding hepatic tissue, suggesting that the lesion was derived from the nonneoplastic hepatic tissue. Moreover, extensive wall thickening and obstruction were observed in the intrahepatic portal vein and hepatic artery. These findings suggest that the lesion was a focus of hepatic infarction triggered by Lp-TAE.

Secondary prevention of hepatocellular carcinoma

Two decades have gone by since the earlier trials of alpha-fetoprotein (AFP) screening for hepatocellular carcinoma (HCC) were conducted in Africa and China. It is accepted that early detection, diagnosis and treatment of HCC remains an important target to be achieved before a breakthrough appears on the primary prevention of HCC. In the present study, screening investigations were performed in a high risk population of HCC, defined as persons who had hepatitis, blood transfusions, a family history of HCC, and were hepatitis B virus carriers. Ultrasonography combined with AFP serosurvey was accepted as an effective screening procedure to detect small HCC. Early diagnosis of HCC was not difficult if tumour markers and medical imaging were combined. Early resection has been proven to prolong survival of patients with small HCC. Repeated intralesional ethanol injection is an alternative treatment to surgery, while transcatheter arterial embolization is a less effective alternative. Re-resection of subclinical recurrence after curative resection has proven of merit in prolonging survival even further. Resection of small HCC remains an important approach in getting long-term HCC survival and to improving 5-year survival rates. It is more effective than treatment of large HCC. Studies on the secondary prevention of HCC have stimulated research into tumour markers, the natural history and cellular origin of HCC and oncogenes. However, the issue of 'cost-effectiveness' remains to be evaluated.

Conversion of unresectable to resectable liver cancer: an approach and follow-up study

In the last decade, significant improvement has been achieved in the treatment of hepatocellular cancer by combining therapies from different disciplines, and using effective biologic response modifiers to improve response to existing therapy. While operative resection remains the only curative modality, a select group of patients with unresectable fibrolamellar or nodular variant, can be converted from unresectable status to resectable by combining chemotherapy and radiotherapy. We reviewed the recent experience with intra-arterial chemotherapies and use of external beam radiotherapy and isotopic immunoglobulin-directed radiotherapy in the treatment of unresectable hepatocellular cancer. While significant tumor response can be achieved with these therapies they are short-lived, and long-term survival is poor. When combined with operative resection, however, a significant survival advantage is achieved. The expected survival of the unresectable patient is then altered from 18 to 24 months for chemotherapy or radiation alone, or when used in combination, to 44 months for patients converted to resectable status. We conclude that the need for more effective chemotherapy is imperative, and the major role for chemotherapy or radiotherapy in hepatocellular cancer is to convert an unresectable patient to resectable status.

Transcatheter arterial chemoembolization (TACE) in the treatment of unresectable liver cancer

Basis, techniques, and recent strategies and results of interventional treatments for hepatoma were reviewed. The basic experimental researches indispensable to justify clinical technique and dosage have been accomplished. A total of 1310 unresectable cases underwent transcatheter arterial chemoembolization (TACE) and/or related therapies. The related therapies are several modified or strengthened TACE such as Lipiodol-TACE and subsegmental TACE. The therapies for unembolizable cases are balloon occluded arterial infusion, Lipiodol-SMANCS infusion and percutaneous direct injection chemotherapy, that reinforces the effect of TACE. As for the resectable cases, postoperative TACE was proved to be beneficial because it increased survival rates; however, preoperative TACE was not beneficial. The TACE and related interventional radiologic therapies for the hepatoma can be an equal or superior therapy by virtue of targeting chemotherapy.

Carbohydrate-based measurements on alpha-fetoprotein in the early diagnosis of hepatocellular carcinoma

Serum alpha-fetoprotein (AFP) is a useful marker for the diagnosis of hepatocellular carcinoma (HCC), although this protein also increases moderately in benign liver diseases. The serum concentration of AFP in HCC at the time of initial diagnosis is now lower than before because of advancements in techniques for imaging the liver. The AFP concentration alone cannot distinguish between HCC and benign liver diseases, especially when it is less than 1000 ng ml-1. These circumstances lead to the need to discriminate between these diseases. This has been achieved by determining the carbohydrate structures of AFP by its reactivity with Lens culinaris agglutinin (LCA). The percentage of LCA-reactive species of AFP is significantly higher in HCC than in benign liver diseases. The fucosylation of the sugar chain at the innermost N-acetylglucosamine is the molecular basis of this variation. Therefore, the term 'fucosylation index' has been introduced to express the percentage of LCA-reactive species of AFP. This index is useful for the diagnosis of HCC even if the carcinoma is at an early stage. Furthermore, it can predict the development of HCC in the follow-up of chronic liver diseases. Thus, the qualitative and quantitative measurements of carbohydrate in AFP provide us with very valuable information for the differential diagnosis of various liver diseases.