Hepatocellular carcinoma detected by iodized oil

Study of repeated arterial infusion chemotherapy with a subcutaneously implanted reservoir for advanced hepatocellular carcinoma

We performed repeated arterial infusion chemotherapy (RAIC) in 114 advanced hepatocellular carcinoma (HCC) patients, using a subcutaneous reservoir implanted under ultrasonic guidance. In 60 patients, this was the initial therapy for the primary tumor and the other 54 patients being treated for recurrent tumor. One hundred and seventy-one patients with advanced HCC who had been treated by transcatheter arterial embolization (TAE) or single bolus arterial infusion chemotherapy before RAIC was available served as historical controls. In 97 patients, anticancer agents (4'-epidoxorubicin or acurarubicin) and Lipiodol emulsion were used, and in 17, anticancer agents alone were given. The response rates were 39.2% in the Lipiodol group and 17.6% in the non-Lipiodol group. The dose of Lipiodol and the degree of liver invasion were the most important factors influencing the response rate. The 1-, 2-, and 3-year survival rates were 55.0%, 30.9%, and 21.2%, respectively. The long-termsurvival was compared in relation to Child's classification and the presence or absence of portal vein tumor thrombosis (PVTT). In non-PVTT patients, the results of initial therapy and therapy for recurrence were similar, but recurrent Child's C patients showed a poorer prognosis. In PVTT patients, initial therapy had a better prognosis than treatment for recurrence, but initial Child's C patients had a poor long-termprognosis. During the observation period, no severe complications were encountered, but in Child's C patients, hepatic function sometimes deteriorated. Compared with the results in the 171 controls, RAIC was more useful for advanced HCC as initial therapy, and it was also beneficial for the treatment of recurrence after TAE.

Lipiodol uptake and retention by human hepatoma cells

Lipodol has important diagnostic and therapeutic uses in hepatoma. However, the mechanisms of its selective, prolonged retention in hepatoma cells is not well understood. Therefore, using oil-red O, light and electron microscopy and neutron activation analysis we have determined that HepG2 cells are characterized by lipiodol deposition and emulsification on the cell surface, action uptake of lipodol by endocytosis, and prolonged intracellular retention. These findings may have major clinical significance in the development of a new treatment for hepatoma patients.

Patients with ultrasonic coarse-nodular cirrhosis who are anti-hepatitis C virus-positive are at high risk for hepatocellular carcinoma

BACKGROUND

The relationship between echosonographic patterns of patients with cirrhosis who are antihepatitis C virus (HCV)-positive, the DNA synthesis of hepatocytes, and the risk for HCC were studied.

METHODS

Thirty-eight patients with anti-C-100 antibody-positive and Child's grade A posthepatitic cirrhosis were studied. DNA synthesis activity was measured by a bromodeoxyuridine (BrdU, a thymidine analogue)-labeling index (LI), using the BrdU-anti-BrdU in vitro method, and the patients were followed prospectively by frequent liver ultrasonography for 3 years. The ultrasound patterns were classified into fine, coarse, and coarse-nodular (CN) patterns, and the reproducibility of the classification in practical use also was confirmed.

RESULTS

Of the 21 patients with high DNA synthesizing cirrhosis (BrdU LI > or = 1.5%), 10 (48%) showed coarse-nodular, 5 (24%) coarse, and 6 (29%) fine pattern in ultrasonography. Conversely, of the 17 patients with low DNA synthesizing LC (BrdU LI < 1.5%), only 1 (6%) showed coarse-nodular, 2 (12%) coarse, and 14 (82%) fine pattern. A significant relationship was found between the two groups of BrdU LI and ultrasound imaging patterns (P < 0.05). The incidence of CN pattern was significantly higher (P < 0.01) in the high DNA synthesizing group than in low DNA synthesizing group. Of the 11 patients with CN pattern by ultrasound imaging, 10 (91%) were in the high DNA synthesizing group, and 9 (82%) developed HCC during the follow-up period, compared with 3 of 7 (43%) with coarse, and only one of 20 (5%) with fine pattern developed HCC. The incidence of HCC was significantly higher (P < 0.01) in patients with a CN cirrhosis pattern than in those with a fine pattern.

CONCLUSIONS

In patients with cirrhosis who are anti-HCV-positive, the CN pattern by ultrasound imaging indicates increased DNA synthesis of hepatocytes and a high risk for developing HCC.

Preparation and biodistribution of yttrium-90 Lipiodol in rats following hepatic arterial injection

In this study, we labelled Lipiodol with yttrium-90 and analysed the biodistribution in rats after intrahepatic arterial injection. An RP-18 column (E. Merck) was used to separate 90Y from strontium-90. 90Y was retained on the column, which had been pretreated with yttrium-selective extraction reagent, di(2-ethylhexyl) phosphate, while 90Sr was washed out. A hexadentate nitrogen-donor chelating ligand N,N,N',N'-tetrakis(2-benzymidazolylmethyl)-1,2-ethanediamine (EDTB) was synthesized by condensation of 1,2-benzenediamine and ethylene diamine tetra-acetic acid (EDTA). Lipiodol was covalently conjugated with EDTB. The final product was obtained by eluting the retained 90Y from the RP-18 column with EDTB-Lipiodol. Sixteen male rats (Sprague-Dawley) were sacrificed at 1 h, 24 h, 48 h and 72 h (four rats at each time) after injection of approximately 0.1 mCi 90Y-Lipiodol via the hepatic artery. Samples of liver, spleen, muscle, lung, kidney, bone, whole blood and testis were obtained and counted to calculate the tissue concentrations. In addition, labelling efficiency and in vitro stability were determined by ITLC methods. We found that at 1 h after intrahepatic injection, most of the radiotracer was retained in the liver, but it was eliminated gradually over a few days. The radioactivity level in the lung was fair at 1 h and remained at roughly the same level throughout the study. Radioactivity in the kidney and spleen reached a relatively high level at 24 h, but declined rapidly.(ABSTRACT TRUNCATED AT 250 WORDS)

Iodized oil in the treatment of hepatocellular carcinoma

When injected into the hepatic artery the contrast agent Lipiodol (iodized poppy seed oil) is selectively retained by hepatocellular carcinoma (HCC) for a prolonged period of time. Liver computed tomography (CT) performed after Lipiodol angiography is more sensitive than ordinary CT at imaging HCC. Arterial administration of cytotoxic drugs and radioisotopes conjugated to Lipiodol has been shown to be reasonably safe in patients with irresectable HCC. These therapies, often combined with embolization, provide effective palliation, better tumour response and improved survival compared with other available treatments. Their use as a preoperative adjunct to surgical resection of HCC is controversial.

MR findings of hepatic cavernous hemangioma after intraarterial infusion of iodized oil

Magnetic resonance (MR) imaging was performed on five tumors of three patients who had hepatic hemangiomas. Four tumors were given an intraarterial infusion of 3-8 ml of iodized oil, while one tumor was not. MR images were obtained at 2.0 or 0.5 T. A single spin echo sequence with TE of 30 ms and TR of 500 ms and a double echo sequence with TEs of 60 and 150 ms and TR of 2000 ms, were used to produce relatively T1-, T2-weighted, and heavily T2-weighted images, respectively. Follow-up MR imaging was done 1-5 months after infusion of iodized oil. On relatively T1-weighted images, hemangiomas showed iso- or hypointensity. On T2-weighted images, all tumors showed hyperintensity. However, on heavily T2-weighted images, tumors with iodized oil showed heterogeneous, slight hyperintensity, while tumors without iodized oil showed characteristic appearance of marked hyperintensity in hemangiomas. In hepatic cavernous hemangiomas with intraarterial infusion of iodized oil, familiarity with this unusual MR intensity of tumors on heavily T2-weighted images is useful to avoid the incorrect diagnosis and to reduce the frequency of inappropriate hepatic resection.

Role of increased DNA synthesis activity of hepatocytes in multicentric hepatocarcinogenesis in residual liver of hepatectomized cirrhotic patients with hepatocellular carcinoma

To examine whether the marked increase in DNA synthesis of hepatocytes in cirrhotic liver might elicit multicentric hepatocarcinogenesis, we examined the relationship between new development of hepatocellular carcinoma (HCC) and the bromodeoxyuridine (BrdU) labeling index (LI) of hepatocytes in the residual liver of hepatectomized patients with liver cirrhosis (LC) and HCC. Eighteen hepatectomized patients with LC and HCC, whose resected liver revealed neither portal nor hepatic vein invasion by histologic examination, were studied (to exclude cases with intrahepatic metastasis). DNA synthesis activity of hepatocytes from the residual cirrhotic liver was measured by a BrdU/anti-BrdU in vitro method. The incidence of HCC recurrence was studied during a 3-year follow-up period. Among 18 patients, 9 patients had recurrence and 9 did not. The average BrdU LI in the recurrent patients was 2.6 +/- 1.3% and was significantly higher than that in patients without recurrence (1.4 +/- 0.5%, P < 0.05). All five patients who had a BrdU LI of 2.4% or above showed recurrence within 3 years, as compared with 4 of 13 (30.8%) patients with BrdU LI of less than 2.4% (P < 0.05). Our data indicate that abnormally high DNA synthesis in hepatocytes in the background cirrhosis might lead to the development of multicentric carcinogenesis in human cirrhotic liver, and in the residual cirrhotic liver of hepatectomized patients with HCC and LC, it may be a predictor of new development of HCC.

Transcatheter oily chemoembolization for hepatocellular carcinoma. A 4-year study of 127 French patients

BACKGROUND

In Western countries, only a small proportion of patients with hepatocellular carcinoma (HCC) can be treated with surgical resection. For other patients, locoregional management by transcatheter oily chemoembolization seems to be useful and warrants evaluation.

METHODS

One hundred and twenty-seven French patients with an inoperable HCC were treated by transcatheter oily chemoembolization. The efficiency of the treatment was assessed by a comparison of this group with a group of 127 untreated patients. Each patient of the treated group was matched closely with an untreated patient for all the main clinical, anatomic, and biologic features that characterize the spontaneous evolution of HCC.

RESULTS

The overall probabilities of survival in the treated group were 64%, 38%, 27%, and 27% at 1, 2, 3, and 4 years, respectively; those for the untreated group were 18%, 6%, and 5% at 1, 2 and 3 years, respectively (P < 0.0001). The survival was significantly increased in patients with Okuda Stage I and II disease (P < 0.0001), but not in those with Stage III. Karnofsky and Child-Pugh scores remained stable during the follow-up period and dropped only shortly before patients died.

CONCLUSION

Transcatheter oily chemoembolization is an efficient treatment for unresectable HCC for the palliation of symptoms as well as for the prolongation of survival with a good quality of life.

Transarterial oily chemoembolization for the treatment of hepatocellular carcinoma: a multivariate analysis of prognostic factors

A total of 84 patients with hepatocellular carcinoma and cirrhosis were analyzed retrospectively to investigate prognostic factors. All patients received transarterial oily chemoembolization as the only anticancer therapy. The follow-up range was 1 to 39 mo (median, 9.5 mo). The overall actuarial survival rates at 12, 24 and 30 mo were 62%, 31% and 24%, respectively. According to univariate analysis, variables significantly associated with survival were age, Child-Pugh grade, total serum bilirubin, Okuda stage, tumor size, degree of labeling of the tumor with Lipiodol, gelatin foam use, changes with treatment in tumor size and changes with treatment in alpha-fetoprotein concentration. Two multivariate analyses were performed. When pretreatment and treatment variables were considered, parameters with independent prognostic value were age, Child-Pugh grade, total serum bilirubin, tumor size and degree of Lipiodol labeling of the tumor. When follow-up variables were also considered, we (a) confirmed the prognostic significance of all these parameters (age, Child-Pugh grade, total serum bilirubin, tumor size) and (b) found the independent prognostic value of the change in tumor size (or change in alpha-fetoprotein concentration). Both models yielded different risk coefficients for each class of each variable. Two simple prognostic indexes, based on these coefficients, are proposed: an "initial" index (including pretreatment and treatment variables) and a "follow-up" index (also including follow-up variables). According to the two indexes, the patients were classified into three groups with different prognoses: good (93% and 100% actuarial survival at 1 yr for the initial and follow-up indexes, respectively), intermediate (65% and 53%, respectively) and poor (27% for both indexes).

Significance of hepatocellular proliferation in the development of hepatocellular carcinoma from anti-hepatitis C virus-positive cirrhotic patients

BACKGROUND

There is a hypothesis explaining the pathogenesis of carcinoma that increased proliferation of tissue cells correlates with the development of carcinoma, presumably by increased rate of random mutations and by promotion. In this study, the significance of hepatocellular proliferation in the development of human hepatocellular carcinoma (HCC) from anti-hepatitis C virus (HCV)-positive cirrhotic patients was studied.

METHODS

Twenty-eight Child A cirrhotic patients who were anti-HCV (C-100 antibody) positive were studied. At the beginning of the study, the in vitro uptake of bromodeoxyuridine (BrdU, a thymidine analogue) by hepatocytes in biopsied liver specimens was investigated as labeling indices (LIs), and they were divided into high-DNA synthetic (BrdU LI > or = 1.5%) and low-DNA synthetic (BrdU LI < 1.5%) groups. The patients were then surveyed prospectively with frequent ultrasonography (every 3 months) for the development of HCC for 3 years.

RESULTS

The mean BrdU LI plus or minus standard deviation for 14 cirrhotic patients with high-DNA synthesis activity (BrdU LI > or = 1.5%) was 2.7 +/- 0.8%, and this was significantly (P < 0.001) higher than that for 14 cirrhotic patients with low-DNA synthesis activity (BrdU LI < 1.5%, 0.5 +/- 0.3%). Nine of 14 (64.3%) of the cirrhotic patients with high-DNA synthesis activity developed HCC in the 3-year period, in contrast to only 2 of 14 (14.3%) of the cirrhotic patients with low-DNA synthesis activity P < 0.05).

Five-year survival after transcatheter chemoembolization for hepatocellular carcinoma

The 5-year cumulative survival rate of 443 patients who underwent transcatheter chemoembolization (TCE) for non-resectable hepatocellular carcinoma (HCC) before December 1986 was 8.0%, and 29 patients survived for 5 years or more. Of these 29 patients, 25 were men and 4 were women; their mean age was 63.9 years. Macroscopic classification showed lesions of the single nodular type in 16 cases, the multiple nodular type in 10 cases, and the massive type in 3 cases; 12 of the single nodular lesions measured 5 cm or less in size. The TNM classification showed lesions of stage I in 3 cases, stage II in 14 cases, stage III in 6 cases, and stage IV in 6 cases. Lesions classified as Child A were found in 23 patients, and they were thus much more common than Child B lesions (2 patients) and Child C lesions (1 patient). The response was analyzed in relation to the use of iodized oil (Lipiodol). It was used in 215 of the patients, and the 5-year cumulative survival rate of those patients was 12.9% (23 of them survived for 5 years or more). Lipiodol was not used in 228 patients, and they showed a 5-year cumulative survival rate of 3.4%, with 6 patients surviving for 5 years or more. The 6 patients with stage III disease and the 6 with stage IV disease received Lipiodol. TCE with Lipiodol thus contributed greatly in prolonging the survival of patients with HCC complicated by intrahepatic metastases or intraportal tumor thrombi.

A randomized trial of intrahepatic arterial infusion of 4'-epidoxorubicin with Lipiodol versus 4'-epidoxorubicin alone in the treatment of hepatocellular carcinoma

We conducted a prospective randomized trial to evaluate the efficacy of Lipiodol in intrahepatic arterial infusion chemotherapy for patients with hepatocellular carcinoma (HCC). A total of 38 patients with unresectable HCCs and underlying cirrhosis were entered in this trial, and 36 of them were evaluable. Every 4 weeks, 17 patients received 70 mg of 4'-epidoxorubicin (epirubicin) alone (group A), whereas 19 patients received a Lipiodol emulsion containing the same dose of epirubicin (group B) through the hepatic artery. A tumor response (CR+PR) was observed in 12% of group A patients and in 42% of group B patients. The group B patients showed a significantly higher response rate than the group A patients. There was a tendency for an increased duration of survival (P = 0.09) in the group B patients. These results suggested that the infusion of the Lipiodol emulsion with epirubicin was more effective than epirubicin alone for the treatment of these patients with HCC.

Histopathology of portal tracts in livers after transcatheter arterial chemo-embolization therapy for hepatocellular carcinoma

To study the influence of transcatheter arterial embolization therapy (TAE) on the portal tracts, 32 cases of hepatocellular carcinoma (HCC) with a history of TAE were examined. Portal tract elements are said to be mainly supplied by hepatic arterial blood, as is HCC. The following changes were found: peribile duct fibrosis; biliary epithelial injuries; bile duct necrosis; fibrous thickening of the intima and adventitia of arteries; thrombosis or stenosis of portal vein branches; and fibrosis of portal tract itself. We failed to correlate these histopathologic changes with the frequency of TAE or the interval between TAE therapy and surgery or autopsy. Semi-quantitative assessment disclosed that vessels of the peribiliary vascular plexus (PVP) which are known to be derived from hepatic arterial branches, were considerably decreased. There was little correlation between the degree of reduction of PVP and the observed histopathologic changes of portal tracts. It is suggested that TAE causes adverse effects on the elements of portal tracts and a reduction in the PVP in the vicinity of HCC, but the relationship between them is unclear.

Outcomes of 116 patients with hepatocellular carcinoma

We studied the outcomes of 116 patients with hepatocellular carcinoma (HCC) diagnosed in our hospital between January 1980 and August 1992. The patients were divided into groups according to the principal treatment procedure. The 3-year survival rates in the patients treated by percutaneous ultrasonically guided ethanol injection (PEI), operation (hepatic resection), and transcatheter hepatic arterial embolization (TAE) were 90.9%, 53.6%, and 29.0%, respectively. None of the patients treated by one-shot injection of an anticancer agent into the hepatic artery and chemotherapy survived for more than 2 years. The outcomes of the patients treated by PEI and hepatic resection were significantly better than those of the patients treated by the other procedures. There was no significant difference when the patients were stratified according to the year of detection. The 3-year survival rate was 57.3% for 19 patients in whom HCCs were detected during clinical follow-up for chronic liver disease and 17.3% for the other 97 patients. We concluded that hepatic resection in patients with good liver function and PEI for early HCC yielded significantly better survival rates than the other procedures. Moreover, for early detection and treatment of HCC, we recommend clinical follow-up of patients with chronic liver disease.

New trends in hepatocellular carcinoma

This review discusses the etiological association of hepatitis C virus with hepatocellular carcinoma and recent progress in the understanding of early histopathological changes that occur in cirrhotic livers leading to hepatocarcinogenesis. In some parts of the world (for example Japan) hepatitis C virus infection is becoming a more important etiological factor in the pathogenesis of hepatocellular carcinoma than infection with hepatitis B virus. Biopsy-proven adenomatous hyperplasia often progresses to hepatocellular carcinoma and adenomatous hyperplasia should be treated as a potentially malignant lesion.

Intrahepatic distant metastasis and metachronous multicentric occurrence in solitary hepatocellular carcinoma of less than five centimeters in diameter

During the 7 years from 1984 to 1990, 36 patients underwent liver resection for solitary hepatocellular carcinoma (HCC) measuring less than 5 cm in diameter, with no intrahepatic vascular invasion on imaging diagnoses and no macroscopic infiltration into the tumor capsule or surrounding tissues. Although HCC is less likely to cause intrahepatic adjacent metastasis to the cut liver surface, an analysis revealed the possibility of intrahepatic distant metastasis and metachronous multicentric occurrences, even after complete removal of the primary tumor. The 5-year cumulative survival rate was 53%, while the 5-year cumulative recurrence-free survival rate was 19%. Of the 36 patients, 18 (50%) had suffered a recurrence by April, 1992, one with extrahepatic metastasis. Recurrence of intrahepatic metastasis was multifocal in 5 patients, single and adjacent in 1, and single (or a few) and distant in 11. Multifocal recurrence was observed within 1 year after liver resection. The sole single and adjacent metastatic case occurred in one of eight patients in the recurrent group in whom distance of the surgical margin was less than 1 cm [TW(+)]. Multicentric occurrence was found in 6 of 13 patients (46%) whose recurrent tumors were examined histologically, and all belonged to the "single (or a few) and distant" type of recurrence. In this report, we also present two typical cases of metastasis, one being multifocal metastasis occurring within 3 months after liver resection and the other being intrahepatic metastasis occurring after a 4-year-dormant state, to demonstrate the complicated nature of the intrahepatic metastatic pattern.

The male preponderance in incidence of hepatocellular carcinoma in cirrhotic patients may depend on the higher DNA synthetic activity of cirrhotic tissue in men

BACKGROUND

The relationship between the DNA synthetic activity of hepatocytes from cirrhotic liver tissue and the incidence of hepatocellular carcinoma (HCC) during a 3-year follow-up period was studied in male and female patients with posthepatitic cirrhosis.

METHODS

The bromodeoxyuridine labeling index (BrdU LI) of hepatocytes was estimated in 38 cirrhotic patients (Child A stage, 23 men and 15 women) using a BrdU/anti-BrdU in vitro method. The incidence of HCC was compared between male and female cirrhotic patients during a 3-year follow-up period.

RESULTS

Sixteen of 23 (69.6%) male patients belonged to the high-DNA synthesis group (BrdU LI > or = 1.5%), and only 7 (30.4%) were in the low-DNA synthesis group (BrdU LI < 1.5%). Among female patients, only 5 of 15 (33.3%) were in the high-DNA synthesis group, and 10 of 15 (66.7%) were in the low-DNA synthesis group (P < 0.05). Eleven of 23 (47.8%) male patients and 3 of 15 (20.0%) female patients had HCC develop. In the high-DNA synthesis group, 10 of 16 (62.5%) of the men and 3 of 5 (60.0%) of the women had HCC develop during the follow-up period. In contrast, only one of seven (14.3%) male patients and none of ten (0%) female patients in the low-DNA synthesis group had HCC develop.

CONCLUSIONS

It was concluded that HCC developed frequently (about 60% of the time within 3 years) in patients of both sexes who were in a high-DNA synthesis group. Thus, the larger proportion of men in the high-DNA synthesis group compared with the number of women in the group (69.6% versus 33.3%) might be one possible reason for the male predominance in the development of HCC in cirrhotic patients.

Evaluation of preoperative transcatheter arterial embolization in the treatment of resectable primary liver cancer

The effects of preoperative transcatheter arterial embolization (TAE) and intra-arterial injection of Lipiodol were retrospectively evaluated in patients with resectable hepatocellular carcinoma experienced during two different periods of time. In the TAE study, there were 31 patients with TAE and 107 patients without TAE. In the Lipiodol study, 60 patients had received Lipiodol injection and 68 patients served as controls. Curative hepatic resection was performed in all cases. As such preceding treatments had been performed at other hospitals, two comparing groups were fairly randomized in both the TAE and the Lipiodol study. Preoperative TAE did not influence the postoperative morbidity and mortality rates, cause of late death, and long-term survival rate in overall patients, but seemed to produce a better survival in noncirrhotic patients. Antitumor effect by Lipiodol injection was found in that the cancer free survival rate was significantly better in the group with Lipiodol injection. However, the overall 5-year survival rate was significantly better in the group without Lipiodol (67%) than in the group with Lipiodol (26%). The present study may indicate that preoperative TAE or Lipiodol injection should not be routinely performed. Such treatments may produce a substantial benefit only in selected patients with good hepatic functional reserve.

Usefulness of hepatic artery injection of iodized oil and 131I-labeled iodized oil before the therapeutic decision in hepatocellular carcinoma

This study assesses the usefulness of intra-arterial injection of iodized oil (Lipiodol) as a tool for evaluating the therapeutic choice in a series of 72 consecutive patients with hepatocellular carcinoma (HCC). In 52 of these patients a scintigraphic study of the biodistribution of iodized oil was done, using 131I-iodized oil injection. A single tumor was detected in only 17 cases; 18 patients had a tumor involving only 1 lobe; in 7 cases CT scan disclosed a minute nodule in the opposite lobe of the main tumor. Eighteen patients had a portal thrombosis; in 12 of these cases CT scan showed iodized oil in the tumor emboli. The degree of intratumoral retention of iodized oil depended on the size of tumors and on the presence of arterioportal shunts. Our study demonstrates that only a few patients (4%) with HCC might benefit from curative surgery. The therapeutic benefit of methods using iodized oil injection might be estimated by means of its biodistribution variables (CT and/or scintigraphic data).

Hepatic intra-arterial lipiodol ultrasound guided biopsy in the management of hepatocellular carcinoma

One hundred and fifty-one consecutive new patients with suspected hepatocellular carcinoma (HCC) were investigated from 1989 to 1990. Ultrasound showed the tumours to be inoperable in 111 patients. Selective hepatic angiography revealed 17 more patients with inoperable HCC. Hepatic intra-arterial lipiodol (HIAL) was injected in the remaining 23 patients. In 16 of them, a clinical decision could be reached basing on the radiological findings. Hepatic intra-arterial lipiodol ultrasound (HIAL/USG) guided biopsy was done in seven patients with suspicious lesions. Histology obtained with this method revealed hyperplastic cirrhotic nodules in four patients (two with suspected HCC and two with suspected secondaries). In another two patients, the suspected lesions were confirmed to be malignant. In the last patient who had received chemotherapy for extensive HCC, HIAL/USG guided biopsy revealed necrotic tissue only. At laparotomy, diffuse infiltrative abnormality was found and repeated biopsy confirmed residual malignancy in the necrotic tumour. We conclude that when there is radiological uncertainty as to the nature and extent of the HCC, HIAL/USG guided biopsy can help the clinician to make important decisions.

Development of hepatocellular carcinoma associated with increases in DNA synthesis in the surrounding cirrhosis

The relationship between DNA synthesis activity in hepatocytes from cirrhotic tissue and development of hepatocellular carcinoma was studied in 33 posthepatitic patients with Child's grade A cirrhosis. DNA synthesis activity was measured by a bromodeoxyuridine (a thymidine analogue) labeling index, using the bromodeoxyuridine-antibromodeoxyuridine in vitro method, and the patients were followed up prospectively with frequent liver ultrasonography for 2 years. During the 2-year follow-up, 11 of the 33 cirrhotic patients developed hepatocellular carcinoma; they included 8 of the 15 patients (53%) in the high labeling index (greater than 1.5%) group compared with only 3 of the 18 patients (17%) in the low labeling index (less than 1.5) group (P less than 0.05). Five of the latter 18 subsequently had increased synthesis activity. Of these 20 patients who showed high synthesis activities either initially or subsequently, 10 (50%) developed hepatocellular carcinoma, in contrast to 1 of 13 (8%) with persistently low activities (P less than 0.05). Thus, hepatocellular carcinoma seems to develop or may become detectable when DNA synthesis in the background cirrhosis is increasing or remains high.

Disposition of epirubicin in an oily contrast medium after intravenous and intrahepato-arterial administration in liver cancer: a preliminary report

The present study reports findings on the disposition of epirubicin after an intrahepato-arterial administration of the Lipiodol-drug complex, prepared by mixing the drug-aqueous phase with the iodized oil by ultra-sonification, in 14 patients with histologically proven hepatoma or hepatomegaly with serum alpha-fetoprotein level above 500 micrograms.l-1. The volume of Lipiodol used was 5 ml and the epirubicin dose was 50 mg.m-2. Blood samples were obtained at various time intervals up to 72 h post-dose. Serum concentrations of epirubicin were measured by liquid chromatography with fluorometric detection. The area under serum concentration-time curve (AUCinfinity0) was higher in the Lipiodol-epirubicin group (n = 8) while the clearance was faster and elimination t1/2 and mean residence time shorter in the plain epirubicin group (n = 3). However, interindividual variation in metabolism of epirubicin would affect serum level of the drug. In three patients who were given intravenous and intrahepato-arterial injections (90 mg.m-2) of plain epirubicin and Lipiodol-drug complex, the relative bioavailability of Lipiodol-epirubicin complex (F = 0.76 and 0.45) was lower than that of plain epirubicin (F = 0.80 and 0.73) in two patients while it was approximately 100% (F = 1.06 and 1.20) in one patient. It is likely that liver function of the patients might be modified by the disease state over a period of 3 months in the cross-over study. Further studies with larger patient samples are required to confirm if there is a targeting effect of the Lipiodol-drug complex toward hepatoma using a better formulation of the drug in Lipiodol.

Therapeutic ethanol injection of hepatocellular carcinomas undetectable by angiography and Lipiodol computed tomography

Seven smaller than 2 cm in diameter hepatocellular carcinomas (HCC) undetectable by hepatic arteriography and computed tomography (CT) after intraarterial injection of iodized oil (Lipiodol CT) were diagnosed by ultrasonography-guided fine-needle biopsy in 6 patients. All lesions were treated by percutaneous ethanol injection (PEI) in 1-3 weekly intervals. No recurrences have been demonstrated after 7-15 months. The treatment of HCCs undetectable by angiography and Lipiodol CT presents a problem as transcatheter arterial embolization is considered ineffective due to poor vascularity. PEI appears to be an excellent treatment for these small HCCs.

Evaluation of oil-soluble FUdR ester for transcatheter arterial treatment of hepatomas

From January 1987 to December 1989, we performed a prospective study of transcatheter arterial chemoembolization therapy with iodized oil (Lipiodol) mixed with an anticancer agent. A new oil-soluble modification of FUdR, FUdR-C8 ester, was developed and dissolved in Lipiodol as an embolic material, which was administered to 36 patients with hepatomas. Water-soluble adriamycin emulsified in Lipiodol was used as control in 67 patients with hepatomas. Initial effects on tumors were observed as decrease of tumor size in 25.0% for the FUdR group and 17.9% for the control group. Alpha-fetoprotein decreased more than half in 41.9% of the FUdR group, and 16.1% of the ADM group. Six-month and one-year survivals were 74.2% and 46.8% for the FUdR group (median survival 317 days), whereas the control group yielded 61.0% and 28.3% survivals, respectively (median survival 191 days).

Clinicopathological study on combination therapy consisting of arterial infusion of lipiodol-dissolved SMANCS and transcatheter arterial embolization for hepatocellular carcinoma

Combination therapy (LpTAE) consisting of arterial infusion of a lipophilic anticancer drug, SMANCS, dissolved in an oily lymphographic agent, lipiodol (LPD), and transcatheter arterial embolization (TAE) for hepatocellular carcinoma (HCC) was studied with special reference to the pathological findings. A total of 32 patients were subjected to surgical resection after LpTAE. The pattern of LPD deposition in the tumor was examined by CT scan (Lipiodol CT, LpCT) at 7 days and/or 1 month after LpTAE. The resected materials were examined radiographically with soft X-rays and histologically. LPD was deposited in tiny daughter nodules with a diameter of less than 5 mm and in tumor thrombi as well as in the main tumors, which showed necrotic change. Part of the LPD flowed out from the main tumor via the drainage vein and was deposited in the capsular invasion, resulting in necrosis. LPD accumulated almost exclusively within the blood spaces of trabecular-type HCC, creating a pattern corresponding to a cast of the tumor vessels, which showed prominent necrosis. On the other hand, LPD was not deposited in scirrhous, compact, or well-differentiated HCC, which showed little or no necrosis. It was demonstrated that LpCT images, which accurately depicted the existence and the extent of LPD deposition and necrosis in the tumor, were useful for precise evaluation of the therapeutic effect. Our findings indicate that LpTAE and LpCT are valuable for the diagnosis and treatment of HCC and should play a central role in systemic therapeutic approaches to this disease.

Treatment of hepatocellular carcinoma by transcatheter hepatic arterial injection of radioactive iodized oil solution

After 12 days of culture, VX2 carcinoma cells were inoculated into the liver of 16 rabbits; 14 days later, 131I-labeled iodized oil ([131I]-Lp) suspended in lipiodol was injected into the hepatic artery. Selective accumulation of the contrast material in the tumor for an extended time was evident on X-rays and hepatic scintiphotographs. The antitumor effect was remarkable. [131I]-Lp agents warrant further examination for their clinical usefulness. Internal radiation therapy by transcatheter hepatic arterial injection of [131I]-Lp (group A) was evaluated in 9 patients with hepatocellular carcinoma (HCC, tumor stage III or IV) associated with liver cirrhosis (LC) and compared with combination therapy of Lp-TAE (group B) in 18 patients with HCC (tumor stage III or IV) associated with LC. In group A, serum AFP levels dropped rapidly in eight of the nine patients who had an elevated initial level of more than 500 ng/ml. The average reduction in tumor size was 50% in eight cases as determined by computed tomography. Histological examination of one resected liver specimen at 3 months after the third injection of [131I]-Lp revealed microscopic features highly suggestive of a radiation effect in the [131I]-Lp-containing area. The 1-year survival value for patients with HCC was estimated at 49.0% using the Kaplan-Meier method. The survival of patients treated with internal radiation therapy tended to be better than that of those treated with Lp-TAE (P = 0.119).

Comparison of the anticancer effect of ADMOS alone and ADMOS with CDDP in the treatment of hepatocellular carcinoma by intra-arterial injection

A total of 135 patients with hepatocellular carcinoma (HCC) were treated by intra-arterial injection of an Adriamycin/mitomycin C oil (lipiodol) suspension (ADMOS) alone or of ADMOS plus cis-diammine-dichloroplatinum (CDDP). In all, 59 patients were treated with ADMOS alone and 76 were treated with ADMOS plus CDDP. A reduction of more than 25% in the tumor size was obtained in 13 of 38 (34%) evaluable patients in the former group and in 39 of 76 (51%) evaluable patients in the latter group. Serum alpha-fetoprotein (AFP) levels decreased by more than 50% in 10 of 17 (59%) and 23 of 33 (70%) patients in the respective groups whose pretreatment AFP level was estimated to be over 200 ng/ml. Overall, the 1-year survival value was 68% and the 2-year value was 41% as determined by the Kaplan-Meier method. No statistically significant difference in survival was observed between the two groups. The initial tumor response correlated with the survival value. No severe complication was encountered except for one case of liver abscess formation. No serious change in the laboratory data was observed following treatment with these regimens. Although the tumor response was significantly better in patients treated with ADMOS combined with CDDP injection than in those treated with ADMOS alone (P < 0.05), no significant difference in survival was found between the two groups.

Analysis of prognostic factors in patients with hepatocellular carcinoma treated by transcatheter arterial embolization

We studied 240 cases of unresected hepatocellular carcinoma (HCC) using Cox's proportional hazard model to elucidate which factors would be closely related with the survival period after treatment by transcatheter arterial embolization (TAE) in the presence or absence of iodized oil. The results were as follows. The cumulative survival values obtained after TAE were 67.5% for 1 year, 32.0% for 2 years, and 20.5% for 3 years. The most significant prognostic factor was the degree of extension of tumor embolus in the portal vein or its branch. The tumor extension and the tumor type were also important factors. Age, sex, and AFP, HBsAg, and HCV Ab values were not useful as prognostic factors. This study provides a rational background for the selection of treatment for HCC. Furthermore, knowledge of the prognostic factors is useful for the management of patients, particularly in maintaining their good quality of life.

Treatment of inoperable hepatocellular carcinoma by intra-arterial lipiodol and 4'-epidoxorubicin

A total of 30 patients presenting with inoperable hepatocellular carcinoma (HCC) were treated with intrahepatic arterial Lipiodol (5 ml) and 4'-epidoxorubicin (90 mg/m2) once every 4 weeks. The treatment results included no complete response, 2 partial responses, 6 cases of static disease and 19 cases of progressive disease. The median survival was 18.9 weeks. All patients had died by the time of this writing, with survival duration ranging from 4.1 to 87.3 weeks. Toxicities were minimal and included anaemia and alopecia. As compared with a historic control group that had received the same dose of intravenous 4'-epidoxorubicin, the treatment group showed similar response rates but developed fewer toxicities. There was no significant survival benefit over the control group. We concluded that although this form of treatment had comparable activity and produced fewer side effects, it provided no survival benefit over intravenous treatment. The slight prolongation of survival achieved in the treatment group as compared with the control arm might have been due to case selection.

Outcome of localized hepatocellular carcinoma treated with segmental arterioportal chemoembolization

When lipiodol is injected into the hepatic artery at a dose exceeding a certain level, it flows into the portal vein. On the basis of this feature, an emulsion of Adriamycin with lipiodol was injected into a segmental or subsegmental artery such that it was delivered to the portal vein of the same segment, and the artery was then embolized with Gelfoam. This segmental arterioportal chemoembolization (cement therapy) was performed in 50 patients with localized hepatocellular carcinoma. A posttreatment CT scan showed that almost 100% of the lesions were occupied by lipiodol. The cumulative survival values determined for the 50 patients were very high: 83.4% after 1 year and 62.7% after 2 years.

Hepatic haemodynamics and microvascular architecture after portal venular embolization in the rat

To clarify the relationship between hepatic damage and alterations of hepatic microvascular architecture and haemodynamics following portal venule occlusion, the present study was performed in rats which had been injected into the portal vein with 700,000 plastic beads (30-35 microns in diameter). When the occluded segment of the portal venule was short, infarction did not occur because of the prompt development of vascular channels bypassing the obstructed venules. On the other hand, when the occluded segment was long, infarction usually occurred. In this case, formation of collateral vascular channels began as dilatation of the sinusoids in the vicinity of the occluded portal venules and increased in diameter and developed into new portal venules in 5 days. Increased portal vascular resistance after embolization was normalized after 5 days in parallel with the progression of reconstruction of vascular channels. Reduced bile production returned to a normal level 3 days after embolization. Necrotic tissue was resorbed completely and replaced by fibroblasts 5 days after embolization. These findings indicate that the development of infarct following portal venule occlusion depends on the length of the occluded segment, and that hepatic microvasculature has a great capacity for adaptation and rapid reconstruction of vascular channels which leads to speedy recovery from hepatic circulatory disturbances and resulting hepatic damage.

Intraoperative sonography of hepatocellular carcinoma: detection of lesions and validity in surgical resection

Eighty-six hepatocellular carcinomas (HCCs) in 67 patients were examined by intraoperative sonography. Sensitivity for detecting tumors with intraoperative sonography was compared with sonography, computed tomography (CT), hepatic angiography, and CT after intraarterial injection of iodized poppy-seed oil (Lipiodol-CT). The overall sensitivities were 76% with sonography, 86% with CT, 89% with angiography, 96% with Lipiodol-CT, and 98% with intraoperative sonography. The differences in sensitivity between intraoperative sonography and sonography (p less than 0.01), CT (p less than 0.01), and angiography (p less than 0.05) were significant. In 35 lesions smaller than 2 cm, the sensitivities of Lipiodol-CT and intraoperative sonography were high (91 and 94%, respectively). In operating field, tumors were invisible in 36 (42%) and nonpalpable in 31 of 86 cases (36%). In 35 tumors smaller than 2 cm, invisible tumors were 66% and nonpalpable tumors were 63%. However, 84 of 86 cases (98%) could be localized with intraoperative sonography. These results suggest that intraoperative sonography is the final diagnostic imaging procedure before surgical resection of tumors and in cases of invisible and nonpalpable tumors in the operating field, this procedure is mandatory to improve surgical results.

Staging of hepatocellular carcinoma by ultrasonography, computed tomography, and angiography: the role of CT combined with arterial portography

A series of 60 patients with hepatocellular carcinoma (HCC) were evaluated over a 2-year period of ultrasonography (US), computed tomography (CT), and angiography. The angiographic studies carried out with intraarterial digital technology were compared to both US and CT of the liver. In 16 of 60 patients, we observed discordance of the findings obtained with angiography, CT, and US. We therefore compared these three methodologies in those cases where diagnostic discordance was noted. In our experience, US had a sensitivity of 73.4%, 76.7% for CT, and 95% for angiography. In 13 of 60 patients, we performed CT with arterial portography (CTAP) which demonstrated a better resolution than conventional CT. In view of the sensitivity of US - comparable to that of CT - and for the even greater sensitivity of intraarterial digital angiography, we performed an US study of patients at risk of HCC. CT was found to play a diagnostic/staging role after angiographic study has been performed, especially when enhanced by arterial portography.

Case report: persistence of lipiodol for 13 months in metastatic deposits in the liver on computed tomography

The computed tomography (CT) findings in a 17-year-old male student with liver metastases from a primary adenocarcinoma of the rectum are presented. Lipiodol-enhanced CT 4 days after lipiodol infusion demonstrated several metastases not visible on conventional CT. A repeat CT 13 months later showed lipiodol to have been retained within the original lesions and also demonstrated new metastatic deposits free of lipiodol. Although persistence of lipiodol for up to a year has been reported by workers in Japan imaging hepatocellular carcinoma (Yumoto et al., 1985) this experience has not been confirmed in the UK (Raby et al., 1989). There are relatively few reports investigating metastatic adenocarcinoma (Nakakuma et al., 1985), none of which refers to persistence of lipiodol over 1 year. This case report demonstrates the ability of lipiodol-enhanced CT to detect occult metastases and also to facilitate their follow-up and differentiation from newer lesions.

Intrahepatic recurrence after resection of hepatocellular carcinoma complicating cirrhosis

To determine whether a careful evaluation of tumor extension by preoperative computed tomography scan after intra-arterial injection of ultrafluid lipiodol and by intraoperative ultrasound examination reduced the recurrence rate of hepatocellular carcinoma after resection, a series of 47 cirrhotic patients with a single tumor operated on from 1984 was studied. Alphafetoprotein level was less than 100 ng/mL in 26 patients (55%), size of the tumor was less than 5 cm in 28 patients (59%), and capsule was present in 30 patients (63%). The resection was performed with free margin measuring 1 cm or more. The overall cumulative survival rates at 3 and 5 years were 35% and 17%, respectively. Intrahepatic recurrence was observed in 28 patients (60%), located less than 2 cm from the resection margin in only four patients. The cumulative intrahepatic recurrence rate at 3 years was 81% and was significantly higher in patients with tumor greater than or equal to 5 cm and in patients with preoperative alphafetoprotein level of greater than or equal to 100 ng/mL. In this series the cumulative intrahepatic recurrence rate at 5 years was 100%. This high recurrence rate after resection, even with careful evaluation of tumor extension, indicates that liver transplantation might be envisaged for the treatment of cirrhotic patients with resectable hepatocellular carcinoma.

Pharmacokinetics and toxicity of intraarterial adriamycin for hepatocellular carcinoma: effect of coadministration of lipiodol

To determine the effect of coadministration of lipiodol on the pharmacokinetics and systemic toxicity of intraarterial Adriamycin in patients with hepatocellular carcinoma, nine patients were studied in detail. Each received two courses of a bolus injection of Adriamycin (60 mg/m2), in one of which the Adriamycin was mixed with 10 ml of lipiodol. Analysis of the paired data, and additional 'non-paired' data from a further seven patients, showed that there was no significant difference in the area under the concentration-time curve for Adriamycin or adriamycinol or, in the case of Adriamycin, the terminal half-life. Likewise the fall in haemoglobin concentration, white cell count and platelet count following treatment, and the degree of nausea and vomiting were not significantly different. Comparison with a series of 12 patients receiving intravenous Adriamycin, in the same dose schedule, revealed no difference in terms of pharmacokinetic parameters or toxicity with intraarterial administration of Adriamycin, with or without lipiodol.

A radiological-pathological correlation of hepatocellular carcinoma (HCC)

The histological distribution of lipiodol within hepatocellular carcinoma (HCC) was correlated with that seen on computed tomography (CT), arteriography and high resolution plain films of 15 resected specimens. By means of special stains, the arterially administered lipiodol was shown to be maximally distributed at the periphery of large tumours and nodules. The centre of large lesions often remained unopacified. In multinodular tumours some nodules were heavily stained while others contained little or no contrast medium. In small tumours there was a more uniform distribution. In large tumours, those areas where there are large arteries (and slow flow) contained little or no lipiodol. There was also no consistent match of areas of angiographic blush with lipiodol deposition. The lipiodol patterns were poorly shown by CT when compared with high resolution films taken on a mammography unit. We conclude from this study that lipiodol on its own as an embolic agent or as a chemotherapeutic carrier has great limitations because of its peripheral and otherwise haphazard distribution in large tumours. However, such treatments might be more effective in small tumours where a greater concentration of lipiodol is likely. Nevertheless, lipiodol staining of tumours remains a useful diagnostic aid as small HCC can be difficult to visualize both on arteriography and conventional CT.

Diethylnitrosamine-induced metastasizing hepatocellular carcinomas in New Zealand white rabbits. A tumor model for clinical investigations

The aim of this study was to produce large liver tumors reliably, and to diagnose the tumors during development. Therefore, New Zealand white rabbits were treated with N-nitrosodiethylamine orally three times per week by gavage and were examined by clinical-chemical assay at regular intervals during the average treatment period of 14 months. The total cumulative dose was 1200 mg N-nitrosodiethylamine over 14 months. After a short treatment period the initial dose of 3 mg/kg had to be reduced to 1.5 mg/kg. In all 11 treated animals (100%) liver tumors were seen at the end of the study. Four control animals did not show any neoplastic changes. Clinical parameters investigated were for an assessment of liver function, total protein, urea, creatinine, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, albumin and neuraminic acid as well as some serum electrolytes. The in vivo diagnosis of liver tumors based on changes in these parameters proved to be relatively unreliable. The liver enzyme tests and urea concentration only yielded significant changes when the liver tumors were very large. Changes in neuraminic acid levels were the most reliable indicator for the presence of a liver tumor in this animal model. In the 11 treated animals, serum values of this marker increased towards the end of the study by an average of 300 mg/dl. The induced tumors were mainly hepatocellular carcinomas. Only in 1 animal was a hepatocellular adenoma found. Further primary tumors diagnosed were six adenomas in the kidneys and two uterus adenomas, as well as nasal cavity tumors (two papillomas, one carcinoma, one adenoma and one adenocarcinoma). In 70% of the treated rabbits the hepatocellular carcinomas had metastasized to the lungs.

Trans-catheter hepatic arterial injection of lipiodol soluble anti-cancer agent SMANCS and ADR suspension in lipiodol combined with arterial embolization and local hyperthermia for treatment of hepatocellular carcinoma

The clinical effect and safety of Lp-TAE alone and combined with radiofrequency (RF) capacitive hyperthermia (HT) were evaluated in 20 patients with hepatocellular carcinoma (HCC) associated with cirrhosis of the liver. After the oily carcinostatic agents were administered by Lp-TAE, HT, at a temperature of greater than 42.5 degrees C, was induced for 40 min, twice a week by an RF of 8 MHz for a total of 10 to 38 times. The response rate was 40% in the 10 cases that were treated with Lp-TAE combined with HT and 20% in the 10 cases that were treated with Lp-TAE. The patients who were treated with Lp-TAE combined with HT had a tendency to have better survival rates than those of the Lp-TAE group (p less than 0.099). The main side-effects of Lp-TAE combined with HT were low-grade fever, localized pain, myelo-suppression and liver dysfunction, but these were transient and eventually disappeared.

Lipiodol computerized tomography: how sensitive and specific is the technique in the diagnosis of hepatocellular carcinoma?

Computerized tomography (CT) following the intra-arterial injection of Lipiodol (Lipiodol-CT) was performed on 60 patients suspected of having a hepatocellular carcinoma (HCC). Four main patterns of uptake of the Lipiodol within the liver were seen on CT. Of the 14 well circumscribed lesions with dense homogeneous uptake of Lipiodol, 13 were confirmed to be HCCs. Of the 25 lesions with dense patchy uptake of Lipiodol at the periphery and/or in the centre, 19 were confirmed to be HCCs. In 18 patients, in whom only ill defined faint patchy uptake of Lipiodol was present in the liver, or in whom no hepatic uptake was present at all, only one patient was found later to have an HCC. Of the three hypodense lesions in the liver with no Lipiodol uptake, one was found to be necrotic HCC, one a cholangiocarcinoma and one a regenerative nodule. In the diagnosis of HCC, Lipiodol-CT had an overall sensitivity of 97.1%, an accuracy of 88.3% and a specificity of 76.9%. Of the 34 patients with HCC, only 23 were solitary at diagnosis. The size of the HCCs ranged from 0.8 cm to 11 cm in diameter with the median size at 2.2 cm. Eleven of 34 HCCs (32.3%) were resectable. We conclude that, as part of a screening programme for high risk patients. Lipiodol-CT is useful in the early detection of HCCs. The technique also plays an important role in determining whether the tumour should be resected or managed with chemotherapy. By detecting HCCs while still small, the resectability rate can also be improved.