Influential factors and formation of extrahepatic collateral artery in unresectable hepatocellular carcinoma

Ablative radioembolization of hepatocellular carcinoma with total arterial supply originating from the superior adrenal artery achieved complete pathologic necrosis

Exclusively extrahepatic arterial perfusion to previously untreated, early-stage, hepatocellular carcinoma (HCC) is uncommon. We present a case of right superior adrenal artery completely supplying a subcapsular HCC in a 68-year-old male. The extrahepatic arterial territory targeted excluded structures potentially vulnerable to radiation, which allowed safe ablative Y-90 radioembolization that achieved complete pathological necrosis.

Hepatocellular carcinoma with extrahepatic blood supply from right renal artery

Extrahepatic blood supply is seen in around 17–27% of hepatocellular carcinoma lesions. Evidence suggests that this extrahepatic supply most commonly originates from a right intercostal artery (70–83%) followed by left intercostal, omental and right renal arteries. Thus a comprehensive knowledge of variations in standard vascular anatomy and cognisance of factors influencing or predicting extrahepatic blood supply in HCC is instrumental in ensuring the success of surgical and interventional procedures. We present the unusual case of a 66-year-old male with HCC in Segment I of the liver with aberrant blood supply from the right renal artery in the absence of any risk factors for extrahepatic circulation. He successfully underwent transarterial chemoembolization. There was no evidence of residual disease on repeat imaging.

Right inferior phrenic artery; Don't miss on MDCT before chemoembolization of hepatic dome HCC

Background

Transarterial chemoembolization (TACE) is considered a standard local-regional treatment for intermediate-stage hepatocellular carcinoma (HCC) and the most common bridging therapy. HCC typically receives its blood supply from the hepatic artery; however, it can recruit a parasitic supply from extrahepatic collateral arteries. The right inferior phrenic artery (RIPA) is considered the most common extrahepatic collateral pathway supplying HCC and so interfere with the therapeutic efficacy of TACE resulting in treatment failure and poor outcome. Imaging by MDCT with angiography has an essential role in depicting the presence or absence of an EHC arterial supply during the pre-TACE evaluation. We analyzed MDCT studies with CT angiography of patients with hepatic dome HCC retrospectively to confirm the diagnosis of HCC and to assess its blood supply. All patients were subjected to a proper assessment by history, clinical examination, as well as routine laboratory investigations

Results

Our study includes 58 cases with hepatic dome HCC. On CT angiography, the extrahepatic collateral from the RIPA supplying hepatic dome HCC was detected in about 33 out of 58 cases (56.9%). The RIPA arose directly from the aorta in 30 cases (90.9%) with only three cases (9.1%) from the celiac trunk. All cases were managed with TACE with about 25 out of 33 cases (75.8%) with extrahepatic RIPA were undergone concomitant embolisation of both RIPA and hepatic artery during TACE procedure.

Conclusion

MDCT assesses well the HCC arterial supply which is fundamental for planning subsequent cannulation and embolization of extrahepatic RIPA supply to hepatic dome HCC.

Huge hepatocellular carcinoma with extrahepatic collateral arteries successfully treated by multidisciplinary treatment including laparoscopic devascularization: a case report

Multidisciplinary treatment is recommended for the management of patients with advanced hepatocellular carcinoma (HCC). Some operative decollateralization of extrahepatic feeding arteries with laparotomy have been introduced for HCC. We herein newly develop laparoscopic devascularization (LDEV) to continue transarterial chemoembolization (TACE) for HCC with extrahepatic collateral arteries. A 74-year-old man with multiple huge HCC (4 tumors, 18 cm in diameter) and poor liver function (non-alcoholic steatohepatitis, Child-Pugh score 7) was treated with 6 times of chemoembolization in combination with LDEV, 3 times of ablation therapies, and lenvatinib therapy. His tumor markers were triple positive (AFP, 12,906.5 ng/ml; PIVKA-II, 491,743 mAU/ml; AFP-L3, 91.8%) before treatments; however, they all returned to normal limits. Complete response was achieved according to the modified RECIST criteria. Unfortunately, he died 6 months after the final treatment with no recurrence of HCC due to the postoperative complication of primary lung cancer. LDEV is a useful tool to continue effective TACE, and multidisciplinary treatment including chemoembolization and LDEV can cure advanced HCC patients with extrahepatic collaterals and impaired liver function.

Postoperative recurrent factors and therapeutic and preventive strategies for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in China. The recurrence rate is about 50% at 3 years and over 70% at 5 years after hepatectomy for HCC. The high recurrence rate seriously affects the curative effect and long-term survival of patients with HCC, and is the primary cause of death after operation. Postoperative recurrence of HCC is a complex multi-step, multi-factorial process involving three factors: the body, microenvironment, and tumor tissue, which include body immunity, local pH value, interstitial pressure, vascular osmotic pressure, inflammatory reaction, tumor cell adhesion, extracellular matrix degradation, cell migration, cell proliferation, and tumor angiogenesis. HCC recurrence is closely related to abnormal gene expression and related molecular function changes, but the molecular mechanism has not been fully elucidated. How to treat the recurrence of HCC after operation directly affects the prognosis of patients with HCC, and treatments include reoperation, liver transplantation, local minimally invasive treatment, radiotherapy, molecular targeted drugs, immunotherapy, and traditional Chinese medicine treatment. It is difficult to cure or control tumor progression by a single therapy. Two or more therapeutic methods need to be combined organically to achieve a synergistic therapeutic effect. According to the specific situation of patients with HCC, it is key to analyze the individual characteristics of patients, to combine the clinical experience of clinicians and the best evidence, to adopt the individualized treatment plan, and to choose the appropriate treatment methods. For HCC patients with high-risk factors for recurrence, selecting the appropriate treatment is important to reduce the recurrence of HCC after operation and prolong the survival of patients.

Predictive factors for the benefit of triple-drug transarterial chemoembolization for patients with unresectable hepatocellular carcinoma

Background

Compared with single‐drug TACE, our previous phase III study demonstrated that triple‐drug transarterial chemoembolization (TACE) prolonged overall survival (OS) in patients with unresectable hepatocellular carcinoma (HCC). The aim of this study was to find which patients can benefit from the triple drugs TACE compared with single‐drug TACE.

Methods

Patients in the triple‐drug TACE arm received sponge embolization and emulsions composed of 50 mg epirubicin, 50 mg lobaplatin, 6 mg mitomycin C, and lipiodol, while patients in the single‐drug TACE arm received sponge embolization and emulsions composed of 50 mg epirubicin and lipiodol. From July 2007 to November 2009, 244 patients (224 men and 20 women; age ranged from 21 to 75 years) from our phase III study formed the initial cohort. From January 2010 to June 2015, external validation cohort was composed of 449 patients (411 men and 38 women; age ranged from 18 to 75 years) from another institution. The validation cohort after propensity score matching (PSM) (n = 374) was analyzed. Cox proportional hazard model was used to evaluate the interaction term between treatments for each subgroup. This retrospective study was approved by the institutional review board at each center.

Results

No difference was observed in the baseline characteristic of three cohorts. This exploratory analysis showed that triple‐drug TACE brought a survival benefit in the initial cohort, validation cohort (before PSM), and validation cohort (after PSM) compared with single‐drug TACE. The outcomes of three cohorts all showed that a significantly greater OS triple‐drug chemotherapy benefit versus single‐drug chemotherapy was seen in patients with large tumors (larger than 10 cm) while no survival difference was seen in patients with small tumors (10 cm or smaller).

Conclusions

Triple‐drug TACE seems to benefit patients with HCC larger than 10 cm in particular compared with single‐drug TACE.

Chemoembolization of Hepatocellular Carcinoma with Extrahepatic Collateral Blood Supply: Anatomic and Technical Considerations

Transarterial chemoembolization (TACE) is considered a standard local-regional treatment for intermediate-stage hepatocellular carcinoma (HCC) and the most common bridging therapy. This treatment is offered to more than 70% of patients who are on the waiting list for liver transplantation in the United States. HCC typically receives its blood supply from the hepatic artery; however, it can recruit a parasitic supply from extrahepatic collateral (EHC) arteries. The development of an EHC arterial blood supply can interfere with the therapeutic efficacy of TACE and result in treatment failure and poor outcome. Cross-sectional imaging-specifically computed tomography and magnetic resonance imaging-has some limitations in depicting the presence or absence of an EHC arterial supply during the pre-TACE evaluation. Catheterization and angiography of every possible EHC artery during a routine TACE procedure would be time consuming and technically challenging and would not always be feasible. Therefore, the prediction of a potential EHC arterial supply on the basis of tumor location before, during, and after TACE is fundamental to achieving optimal therapeutic efficacy. To perform TACE through EHC arteries, special considerations are necessary to avoid potentially serious complications. The authors review the factors influencing the development of an EHC arterial blood supply to HCC and describe a systematic approach to enhance the ability to predict the presence of EHC arteries. They also describe the proper technique for TACE of each EHC artery and how to avoid potential technique-related complications. ^©RSNA, 2017.

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.

Angiographic evaluation of hepatic arterial injury after cisplatin and Gelfoam-based transcatheter arterial chemoembolization for hepatocellular carcinoma in a 205 patient cohort during a 6-year follow-up

OBJECTIVE

To evaluate the overall and cumulative incidence, degree, interval change and predictors of hepatic arterial injury (HAI) after cisplatin and Gelfoam® (Upjohn, Kalamazoo, MI)-based transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC).

METHODS

A total of 205 patients with HCC who underwent three or more sessions of TACE without additional surgical or local treatment were included. HAI was evaluated at each segment of the hepatic artery using a three-grade scale: 1 (slight wall irregularity), 2 (overt stenosis) and 3 (occlusion). HAI interval change was categorized into three groups: progression, stable state and improvement. Cumulative incidence of HAI was analysed using Kaplan- Meier method, and predictors of HAI (patient age, sex, portal vein thrombosis and Child-Pugh classification) were analysed by univariate logistic regression.

RESULTS

HAI occurred in 50 of the 205 study patients (24.4%). The cumulative incidence of HAI was 16.0% [95% confidence interval (CI), 10.21-21.77] during 5 sessions of TACE, 52.1% (95% CI, 37.83-66.29) during 10 sessions and 68.0% (95% CI, 67.62-88.46) during 15 sessions. Initial HAI was interpreted as grades 1, 2 and 3 in 11 (22.0%), 17 (34.0%) and 22 (44.0%) patients, respectively. When the interval change was assessed in 48 patients with available follow-up TACE, 40 (83.3%) were included in the progression, 2 (4.2%) in the stable state and 6 (12.5%) in the improvement groups. The univariate analysis used to determine the predictors of HAI revealed no significant predictors.

CONCLUSION

In three or more sessions of TACE, the incidence of HAI was 24%. Increasing TACE causes increased incidence of HAI. The initial presentation was most commonly grade 3, and 12.5% of the patients with HAI showed improvement of the HAI grade during follow-up TACE.

ADVANCES IN KNOWLEDGE

In patients who underwent three or more sessions of cisplatin and Gelfoam-based TACE, the overall incidence of HAI was 24.4%, and increasing TACE causes increased incidence of HAI.

Hepatocellular carcinoma with blood supply from parasitized omental artery: angiographic appearance and chemoembolization

OBJECTIVE

To analyze angiographic appearance of hepatocellular carcinoma (HCC) with blood supply from parasitized omental artery (POA), and evaluate the technical feasibility, safety and therapeutic efficacy of chemo-embolization via the POAs.

METHODS

A total of 1,221 HCC patients who had undergone chemoembolization procedures were evaluated retrospectively. The evaluated indexes included the incidence rate of POAs, success rate of superselective catheterization, post-reaction after chemoembolization, and the cumulative survival rates.

RESULTS

Totally 1,221 HCC patients had undergone 3,639 chemoembolization procedures, and 32 patients with POAs were enrolled, with 97 POAs found in 76 angiography procedures, giving an incidence rate of 2.09%. POA was observed mostly at the right lobe and left medial lobe except the segment II, and 62 POAs underwent superselective catheterization with microcatheter, giving a success rate of 63.9%. The angiographic appearance was: (1) hypertrophic POAs participating in tumor staining (n=28); (2) stiff and distorted POA (n=11), displaced due to tumor's oppression (n=8); and (3) defective tumor staining close to either gastrocolic omentum distribution or liver capsule (n=7). In 19 patients, chemoembolization via POAs was performed successfully (A group), while the remaining 13 patients failed (B group). Except 1 acute edema pancreatitis case, no serious complication was recorded. The cumulative survival rates of 6-, 12-, 18- and 24-month were 78.9%, 47.4%, 31.6% and 21.1% respectively for A group; correspondingly, 61.5%, 30.8%, 15.4% and 7.7%% for B group, in which 2 patients died of ruptured HCC.

CONCLUSION

Chemoembolization with microcatheter via POAs is a relatively safe, feasible and valuable method.

Ectopic blood supply of hepatocellular carcinoma as depicted by angiography with computed tomography: associations with morphological features and therapeutic history

OBJECTIVE

To investigate the associations of ectopic blood supply of hepatocellular carcinoma (HCC) with its morphological features and therapeutic history.

METHODS

Three hundred and six patients with 373 HCC lesions were enrolled in this study, and underwent biphasic contrast-enhanced scans on a 64-section MDCT. The anatomy of ectopic blood supply, morphological characteristics of HCC including the size, location and pseudocapsule, and history of transcatheter arterial chemoembolization (TACE) therapy were quantitively assessed and statistically analyzed.

RESULTS

Ectopic blood supply was found in 30.8% (115/373) lesions. The ectopic arteries were predominantly composed of inferior phrenic artery (86/115) followed by left and right gastric artery (25/115). Tumor size, location, status of pseudocapsule, and history of TACE therapy could impact the origination of ectopic arteries (all p<0.05).

CONCLUSION

The ectopic feeding arteries of HCC predominantly composed of the perihepatic arteries are associated with the morphological features of the tumor and therapeutic history.

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.

Vascular complications of hepatic artery after transcatheter arterial chemoembolization in patients with hepatocellular carcinoma

OBJECTIVE

The purpose of this article is to review the angiographic changes, development of collaterals, and possible complications after transcatheter arterial chemoembolization (TACE) in hepatocellular carcinoma (HCC).

CONCLUSION

Extrahepatic collateral arteries can supply the tumor after repeated TACE. Knowledge of hepatic artery changes can help in repeated TACE procedures and reduce TACE time. Appreciation of the complications and collaterals may improve the outcome of patients with HCC.

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.

Superior phrenic artery: an anatomic study

The majority of anatomical textbooks offer very little information concerning the anatomy and distribution of the superior phrenic artery (SPA). However, in the last decade, a number of reports have appeared with reference to the transcatheter arterial chemoembolization of the collateral arterial supply of hepatic carcinoma (HC). Considering the potential role of the SPA as a source of collateral blood supply to HC, the aim of this study was to identify the origin and distribution of the SPA. One hundred formalin-fixed adult cadavers with no evidence of significant gross diaphragmatic pathology were examined. The right SPA originated from the aorta (R1) in 42%, as a branch of the proximal segment of the 10th intercostal artery (R2) in 33%, and as a branch of the distal segment of the 10th intercostal artery (R3) in 25%, of the specimens. The left SPA originated from the aorta (L1) in 51%, from proximal segment of the left 10th intercostal artery (L2) in 40%, and from the distal segment of the left 10th intercostal artery (L3) in 9%, of the specimens. In types R1, R2, L1 and L2 the SPA terminated, after a short course, within the medial and posterosuperior surfaces of the thoracic diaphragm and diaphragmatic crura. Conversely, in types R3 and L3 the lateral origin of the SPAs confined the ultimate distribution of the vessels to the posterior surface of the diaphragm. These findings could provide a better understanding of the anatomy and distribution of the arterial supply of the diaphragm and the potential involvement of the right SPA as an extrahepatic collateral artery developed in HC.