Hepatocellular Carcinoma: Transcatheter Arterial Chemoembolization of the Gonadal Artery

Evaluation of extrahepatic collateral arteries in hepatocellular carcinoma in three independent groups in a single center

To improve the efficacy of transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC), this study evaluated the prevalence and causes of extrahepatic arteries (EHAs) and identified feeding arteries in HCCs in three independent clinical groups in a single inverventional radiology center. Between November 2011 and September 2012, 942 cases of HCC were included in this retrospective study. The patients were treated in three independent groups of 285, 301 and 356 patients, respectively. Enhanced computed tomography, enhanced magnetic resonance imaging and digital subtraction angiography were reviewed retrospectively and correlations between the presence of tumor-feeding EHAs and tumor number, size and location in the liver, number of repeat TACE procedures and complications were assessed. There were 698 EHAs in the 942 cases of HCC, with 182, 233 and 283 EHAs in the three independent groups, respectively. Tumor size was associated with EHA formation; the percentages of patients with EHAs were 2.7±3.0, 5.5±0.5, 43.2±4.0, 61.8±5.2 and 93.4±1.8% with tumor sizes of 2-3, 3-5, 5-7, 7-9 and >9 cm, respectively. There were 159±19 EHAs in each group feeding tumors in peripheral locations in the liver, but only 48.7±6.8 in the central zone. The most common EHA was the right inferior phrenic artery, with a mean of 101.0±14.1 per group. The number of EHAs increased proportionally with the number of TACE sessions. The number of EHAs was positively associated with tumor size, peripheral location of the tumor and number of TACE sessions.

Hepatocellular carcinomas smaller than 4 cm supplied by the intercostal artery: can we predict which intercostal artery supplies the tumor?

OBJECTIVE

To predict which intercostal artery supplies a tumor by examining the spatial relationship between hepatocellular carcinoma (HCC) and the intercostal artery feeding the tumor on transverse computed tomography (CT) images.

MATERIALS AND METHODS

Between January 2000 and September 2009, 46 intercostal arteries supplying HCCs smaller than 4 cm were noted in 44 patients, and CT scans and angiograms of these patients were retrospectively reviewed. The intercostal artery feeding the tumor was marked on the CT scan showing the center of the tumor. In addition, its spatial relationship with the tumor center was examined. The angle of the tumor location was measured on the transverse CT scan in the clockwise direction from the sagittal line on the virtual circle centered in the right hemithorax. Correlations between the angle of the tumor location and the level of the tumor-feeding intercostal artery were assessed with the Spearman rank coefficient.

RESULTS

Of 46 intercostal arteries feeding HCC, 39 (85%) were the first ones observed from the tumor center in a counterclockwise direction on the transverse CT image containing the tumor center. The level of the tumor-feeding intercostal artery was significantly correlated with the angle of the tumor, as the posteriorly located tumor tends to be supplied by lower intercostal arteries, while the laterally located tumor by upper intercostal arteries (Spearman coefficient = -0.537; p < 0.001).

CONCLUSION

We can predict the tumor feeder with an accuracy of 85% as the first intercostal artery encountered from the tumor center in a counterclockwise direction on a transverse CT image.

Hepatocellular carcinoma: prediction of blood supply from an intercostal artery with multidetector row computed tomography

PURPOSE

To evaluate the ability of multidetector row computed tomography (CT) to detect blood supply from the intercostal artery in patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Between January 2003 and December 2007, angiography of the intercostal artery was performed in 93 patients (76 men and 17 women, mean age 58 years) with HCC who had also undergone multidetector row CT. CT scans and digital subtraction angiograms of these patients were retrospectively reviewed by two investigators in consensus to evaluate tumor feeding vessels. Multiple logistic regression analysis was used to identify factors that predict the presence of an HCC blood supply from an intercostal artery.

RESULTS

Tumor staining fed by an intercostal artery was noted in 65 patients (70%; 112 tumor feeding vessels) by intercostal angiography. Readers interpreted that tumor feeding vessels were evident by CT in 35 (54%) of these 65 patients with tumor staining supplied by an intercostal artery by angiography. Multiple logistic regression analysis showed that a visible tumor feeding vessel by CT (P = .003) and hepatic artery attenuation by angiography (P = .014) were significantly related to the presence of a blood supply from an intercostal artery.

CONCLUSIONS

Visualization of a tumor feeding vessel from the intercostal artery by multidetector row CT is an important sign of parasitic supply to an HCC.

The march of extrahepatic collaterals: analysis of blood supply to hepatocellular carcinoma located in the bare area of the liver after chemoembolization

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

Hepatocellular Carcinoma with Internal Mammary Artery Supply: Feasibility and Efficacy of Transarterial Chemoembolization and Factors Affecting Patient Prognosis

PURPOSE

To determine technical feasibility, therapeutic efficacies, and identify prognostic factors in patients with hepatocellular carcinoma (HCC) treated by transarterial chemoembolization via the internal mammary artery.

MATERIALS AND METHODS

From August 1996 to July 2005, the authors identified the internal mammary arteries supplying HCCs in 97 (2.2%) of 4,438 HCC patients. Computed tomography scans and digital subtraction angiography images of these 97 patients were retrospectively reviewed by consensus between two of the authors regarding technical success and clinical outcome. The technical success of internal mammary artery chemoembolization was defined as achievement of catheterization into feeding vessels, delivery of drugs via those vessels, and no residual tumor staining fed by the internal mammary artery. Multivariate Cox proportional hazard regression analysis was performed to enable evaluation of prognostic factors for survival.

RESULTS

Technical success by selective chemoembolization via internal mammary artery was achieved in 53 (55%) of the 97 patients. The clinical responses of the 97 patients were complete remission (n=3), partial remission (n=19), no response (n=65), and no available follow-up image (n=10). Overall cumulative survival rates, calculated from times of internal mammary artery chemoembolization, were 55.9% (at 6 months), 32.5% (at 1 year), 15.4% (at 2 years), and 8.2% (at 3 years). Multivariate analysis showed that tumor multiplicity (single vs multiple nodular or diffuse; P=.013), portal vein thrombosis (P=.004), and the technical success of internal mammary artery chemoembolization (P=.02) each significantly affected survival.

CONCLUSIONS

Although patients with HCC supplied by the internal mammary artery had poor prognosis because of their advanced stage of disease, chemoembolization via the internal mammary artery is possible and worth performing in selective situations.

Internal Mammary Arteries Supplying Hepatocellular Carcinoma: Vascular Anatomy at Digital Subtraction Angiography in 97 Patients

PURPOSE

To retrospectively evaluate the vascular anatomy of the internal mammary arteries that supply hepatocellular carcinomas (HCCs), with an emphasis on number of tumor feeders.

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board; informed consent was waived. Between August 1996 and July 2005, internal mammary arteries that supply HCCs were found in 97 (2.2%) of 4438 patients (76 men, 21 women; mean age, 55 years +/- 10.5 [standard deviation]; range, 19-79 years). Computed tomographic scans and digital subtraction angiograms in these 97 patients were retrospectively reviewed in consensus by two interventional radiologists. Tumor size, number of tumor feeders, and tumor location were recorded. The t test and analysis of variance were used to correlate tumor size with number of tumor feeders, tumor feeder laterality, and transcatheter arterial chemoembolization (TACE) time.

RESULTS

The following 125 tumor feeders were identified in 97 patients: phrenic branch (n = 59), musculophrenic artery (n = 40), superior epigastric artery (n = 15), anterior intercostal artery (n = 6), ensiform artery (n = 4), and pericardiacophrenic artery (n = 1). In two patients, tumors were in dorsal hepatic areas directly beneath the diaphragm. Half of the tumors located in liver segments II or III were supplied by the right internal mammary artery. In three patients, the tumor feeders from the left internal mammary artery crossed the midline. Tumor size was not statistically associated with number of tumor feeders (P = .076), tumor feeder laterality (P = .141), and TACE time (P = .729).

CONCLUSION

The common tumor feeders of the internal mammary artery are the phrenic branch and the musculophrenic artery. Moreover, the internal mammary artery can supply a tumor even in the dorsal hepatic area.