Temporary occlusion of two hepatic veins for chemoembolization of hepatocellular carcinoma with arteriohepatic vein shunts

A review of applying transarterial chemoembolization (TACE) method for management of hepatocellular carcinoma

Liver cancer is one of the most ordinary reasons for death among cancers. Hepatocellular carcinoma (HCC) is the most common type of liver cancer. In spite of the fact that various remedial methods have been approved particularly the survival effects of the transcatheter arterial chemoembolization (TACE) method have been accomplished widely in the HCC treatment. By applying the TACE method correctly, good survival outcomes can be achieved without harmfully affecting the hepatic functions. Transarterial chemoembolization mixes the effect of avascular necrosis (AVN) with the effect of regional chemotherapy those are under the influence of arterial embolization. By knowing the fact that the metastases of liver cancer and also perfusion indices in hepatocellular carcinoma (HCC) are via hepatic arteries, doctors chose the TACE method for the treatment of liver cancer. On the other hand, in this method, the radiologists can easily convey antitumor remedies via the arteries. Anyway, medium-level HCC is a sensitive stage of the heterogeneous disease that many patients suffer from, so specialists must consider it as a hazardous syndrome. The TACE procedure could be applied just in cases that the liver function of patients is appropriate yet, the patient liver portal vein do not have any problems and the patients do not have ascites disorder. This review is aimed to figure out the evident advantages of TACE especially by a comprehensive view on the medium level HCC. Because of that this treatment method is suggested as a first-line remedy. At last, the future landscape of the initial factors of research in managing HCC disorders have been summarized.

Advanced Hepatocellular Carcinoma With Hepatic Arterioportal Shunts: Combination Treatment of Transarterial Chemoembolization With Apatinib

Object: This study aimed to compare the efficacy and safety of transarterial chemoembolization (TACE) combining with apatinib (TACE-apatinib) and TACE-alone for patients with advanced hepatocellular carcinoma (HCC) with hepatic arterioportal shunts (APS).

Materials and Methods: This retrospective study evaluated the medical records of patients with advanced HCC with APS who underwent TACE-apatinib or TACE-alone from June 2015 to January 2019. The occlusion of the shunt was performed during the TACE procedure. The time to tumor progression (TTP) and overall survival (OS) of study patients were evaluated. The modified Response Evaluation Criteria in solid tumors (mRECIST) was used to evaluate the treatment response. The apatinib-related adverse events were recorded.

Results: Fifty-eight patients were included in this study. Twenty-seven patients underwent the treatment of TACE-apatinib, and 31 received TACE-alone treatment. The median overall survival (OS) and median time of tumor progression (TTP) in the TACE-apatinib group were significantly longer than those of the TACE-alone group (OS: 12.0 vs. 9.0 months, P = 0.000; TTP: 9.0 vs. 5.0 months, P = 0.041). Multivariate analysis revealed that TACE-apatinib was a protective factor for OS, and there was no independent risk factor for TTP. In the TACE-apatinib group, the grade 3 apatinib-related adverse events occurred in four patients.

Conclusion: TACE-apatinib was an efficacious and safe treatment for patients with advanced HCC with APS, and apatinib improved the efficacy of TACE in the treatment of these patients.

Hepatopulmonary shunting on Tc99m-MAA liver mapping: correlation with dynamic cross-sectional imaging and description of different shunting patterns

PURPOSE

The purpose of the study was to correlate lung shunt fraction (LSF) calculated by intra-arterial injection of Technetium-99m (Tc-99m)-labeled macroaggregated albumin (MAA) in a hepatic artery branch with the presence of certain patterns of vascular shunts on dynamic CT or MRI of the liver.

METHODS

This retrospective study was approved by the institutional review board and informed consent was waived. We reviewed 523 MAA scans in 453 patients (301 men, 152 women) performed from July 2007 to June 2015 and their correlative cross-sectional imaging. Patterns of vascular shunts on dynamic CT or MRI performed within 3 months of the MAA study and that potentially divert hepatic arterial inflow to the systemic venous return were defined as "target shunts." Dynamic CT or MRI was classified into three groups with target shunt present, absent, or indeterminate. The mean LSF was compared across the first and second groups using paired t test.

RESULTS

342 CT and MRI studies met inclusion criteria: target shunts were present in 63 studies, absent in 271 studies, and 8 studies were indeterminate. When target shunts were visualized, the mean LSF on corresponding MAA scans was 12.9 ± 10.36% (95% CI 10.29-15.15%) compared to 4.3 ± 3.17% (95% CI 3.93-4.68%) when no target shunt was visualized. The difference was statistically significant (p value < 0.001). Identified target shunts were either direct (arteriohepatic venous shunt) or indirect (arterioportal shunt combined with a portosystemic shunt).

CONCLUSIONS

Visualizing certain patterns of vascular shunting on a dynamic CT or MRI scan is associated with high LSF.

Interventional treatment for unresectable hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the sixth most common cancer and third leading cause of cancer-related death in the world. The Barcelona clinic liver cancer classification is the current standard classification system for the clinical management of patients with HCC and suggests that patients with intermediate-stage HCC benefit from transcatheter arterial chemoembolization (TACE). Interventional treatments such as TACE, balloon-occluded TACE, drug-eluting bead embolization, radioembolization, and combined therapies including TACE and radiofrequency ablation, continue to evolve, resulting in improved patient prognosis. However, patients with advanced-stage HCC typically receive only chemotherapy with sorafenib, a multi-kinase inhibitor, or palliative and conservative therapy. Most patients receive palliative or conservative therapy only, and approximately 50% of patients with HCC are candidates for systemic therapy. However, these patients require therapy that is more effective than sorafenib or conservative treatment. Several researchers try to perform more effective therapies, such as combined therapies (TACE with radiotherapy and sorafenib with TACE), modified TACE for HCC with arterioportal or arteriohepatic vein shunts, TACE based on hepatic hemodynamics, and isolated hepatic perfusion. This review summarizes the published data and data on important ongoing studies concerning interventional treatments for unresectable HCC and discusses the technical improvements in these interventions, particularly for advanced-stage HCC.

Transcatheter arterial chemoembolization based on hepatic hemodynamics for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the sixth most common cancer and the third leading cause of cancer-related deaths in the world. The Barcelona Clinic Liver Cancer (BCLC) classification has recently emerged as the standard classification system for clinical management of patients with HCC. According to the BCLC staging system, curative therapies (resection, transplantation, and percutaneous ablation) can improve survival in HCC patients diagnosed at an early stage and offer potential long-term curative effects. Patients with intermediate-stage HCC benefit from transcatheter arterial chemoembolization (TACE), and those diagnosed at an advanced stage receive sorafenib, a multikinase inhibitor, or conservative therapy. Most patients receive palliative or conservative therapy only, and approximately 50% of patients with HCC are candidates for systemic therapy. TACE is often recommended for advanced-stage HCC patients all over the world because these patients desire therapy that is more effective than systemic chemotherapy or conservative treatment. This paper aims to summarize both the published data and important ongoing studies for TACE and to discuss technical improvements in TACE for advanced-stage HCC.

Yttrium-90 radioembolization of renal cell carcinoma metastatic to the liver

PURPOSE

To investigate the safety and efficacy of yttrium-90 ((90)Y) hepatic radioembolization treatment of patients with liver-dominant metastatic renal cell carcinoma (RCC) refractory to immunotherapy and targeted therapies.

MATERIALS AND METHODS

Between March 2006 and December 2010, six patients with metastatic RCC underwent eight radioembolization treatments with (90)Y-labeled resin microspheres for unresectable liver-dominant metastases. All six patients had previous hepatic tumor progression despite targeted therapies or immunotherapies. All had bilobar disease and required whole-liver treatment. Clinical and biochemical toxicities were recorded, and tumor response was assessed every 2-3 months after treatment by cross-sectional imaging.

RESULTS

The median dose delivered was 1.89 Gbq (range 0.41-2.03 Gbq). Grade 1 and 2 toxicities were noted in all patients, primarily fatigue. Follow-up imaging was available for five patients. In follow-up periods from 2-64 months (mean 25 months), three patients showed complete responses, and 1 patient showed a partial response by standard imaging criteria, and these patients are alive at 64 months, 55 months, 17 months, and 7 months after treatment. Two patients with rapid progression of disease died within 2 months of treatment, although hepatic malignancy or failure was not the cause of death in either patient.

CONCLUSIONS

(90)Y radioembolization is a promising option for liver-dominant metastatic RCC with potential for providing long-term survival in patients refractory to or intolerant of targeted therapies.

Initial experience of transcatheter arterial chemoembolization during portal vein occlusion for unresectable hepatocellular carcinoma with marked arterioportal shunts

The purpose of this study was to assess the clinical effects of transcatheter arterial chemoembolization (TACE) during the corresponding portal vein occlusion (TACE-PVO) in patients with hepatocellular carcinoma (HCC) and marked arterioportal (AP) shunts. This was a prospective, nonrandomized study of TACE-PVO in patients with HCC who had marked AP shunts. The subjects were 21 patients with unresectable HCC and marked AP shunts who underwent shunt embolization with the use of coils and/or gelatin-sponge particles (group A: n = 7) or by TACE-PVO (group B: n = 14). Clinical parameters and data on embolization of AP shunts and on tumor response were assessed prospectively. No major procedure-related complication occurred in either group. Effectiveness of AP-shunt treatment was significantly better in group B than in group A in terms of both immediate results (P = 0.009) and subsequent results (P = 0.028). Tumor response in the therapeutic target area was significantly (P = 0.002) better in group B than in group A. Survival was significantly better in group B than in group A (P = 0.008). TACE-PVO may be a safe and useful therapy for selected patients with unresectable HCC and marked AP shunts.

Transcatheter arterial chemoembolization of hepatocellular carcinoma with hepatic arteriovenous shunt after temporary balloon occlusion of hepatic vein

PURPOSE

Hepatocellular carcinoma with hepatic artery to hepatic vein (AV) shunt has increased risk of pulmonary complications during transcatheter arterial chemoembolization (TACE). The purpose of this study is to assess temporary balloon occlusion as a means of preventing pulmonary complications during TACE of hepatocellular carcinoma with AV shunt.

MATERIALS AND METHODS

Eleven hepatocellular carcinoma patients (M: F = 9:2; mean age, 48 years) with angiographically evident AV shunt underwent TACE with occlusion of the shunt-draining hepatic veins using temporary occlusion balloon catheters. All tumors were in the right lobe, and all AV shunts were between the right hepatic artery and right hepatic vein. The occlusion balloon was inserted via femoral (n = 6) or jugular (n = 5) venous access. The balloon diameter ranged from 8.5 to 11.5 mm and time of ballooning was 3 to 15 minutes (mean, 9.5 minutes). TACE was performed using emulsion of iodized oil and doxorubicin, followed by Gelfoam embolization. The balloon was deflated immediately after chemoembolization, and physical examination and chest radiography were performed. Follow-up computed tomography was performed within 2 weeks after TACE to evaluate the result and pulmonary complications.

RESULTS

The technical success rate was 100%. There was no symptom, sign, or radiographic evidence of pulmonary complication. Follow-up computed tomography revealed complete iodized oil uptake by the tumor in eight patients and incomplete uptake by the tumor in three patients. There was no iodized oil uptake in the lungs.

CONCLUSIONS

Temporary balloon occlusion of the hepatic vein in hepatocellular carcinoma with AV shunt allowed completion of TACE using conventional method while preventing pulmonary complications.

Reduction of Arteriohepatovenous Shunting by Temporary Balloon Occlusion in Patients Undergoing Radioembolization

Radioembolization with yttrium-90 resin microspheres is a treatment option that selectively targets hepatic tumors. One of the primary limiting factors for this therapy is the degree of arteriohepatovenous shunting, as excessive radiation to the lungs may cause radiation pneumonitis. To safeguard patients against this, a technetium Tc 99m macroaggregated albumin scan is performed before treatment to assess the degree of arteriohepatovenous shunting. As lung shunt fraction increases, activity reductions are mandated, with a 20% shunt sufficient to prohibit treatment. Temporary occlusion of shunts may be achieved by placement of balloon catheters in the hepatic veins. This endovascular technique used to reduce arteriohepatovenous shunting allows otherwise untreatable patients to undergo radioembolization.

Haemodynamic changes in the liver under balloon occlusion of a portal vein branch: evaluation with single-level dynamic computed tomography during hepatic arteriography

AIM

To assess haemodynamic changes in the liver under temporary occlusion of an intrahepatic portal vein.

MATERIALS AND METHODS

Between February 2000 and October 2004, 16 patients with hepatobiliary disease underwent single-level dynamic computed tomography during hepatic arteriography (SLD-CTHA) under temporary balloon occlusion of an intrahepatic portal vein. All patients needed percutaneous transhepatic portography for therapy of their disease. SLD-CTHA was undertaken to clarify the time-attenuation curve influenced by portal vein occlusion, and it was performed continuously over a period of 30s. The difference in absolute attenuation of the liver parenchyma in segments with occluded and non-occluded portal vein branches was determined by means of the CT number, and the difference in absolute attenuation of the occluded and non-occluded portal veins themselves was also evaluated.

RESULTS

SLD-CTHA demonstrated a demarcated hyperattenuation area in the corresponding distribution of the occluded portal vein branch. The attenuation of the liver parenchyma supplied by the occluded portal vein was significantly higher than that in the non-occluded area (p<0.01). The balloon-occluded portal branch enhancement in 15 of 16 cases (94%) appears due to arterio-portal communications. Failure to evaluate a remaining case for portal branch enhancement was due to absence of a visualized portal branch in the section.

CONCLUSION

Under temporary occlusion of an intrahepatic portal vein, hepatic angiography produced enhancement of the occluded portal branches and their corresponding parenchymal distribution; this finding is considered consistent with the presence of arterio-portal communications.

Radioembolization with 90Yttrium Microspheres: A State-of-the-Art Brachytherapy Treatment for Primary and Secondary Liver Malignancies

Yttrium-90 microspheres are increasingly being used as a treatment modality for primary and secondary liver tumors. As these therapies continue to be accepted, it is natural that their application in more complex clinical scenarios will become more common. This article is meant to introduce these controversies and to generate interest and dialogue by the interventional oncology community. This discussion is based on more than 900 (90)Y radioembolization procedures performed over a 5-year period.