Letter: Causal relationship between aspirin and the risk of hepatocellular carcinoma remains unproven

This article is linked to Lee et al paper. To view this article, visit https://doi.org/10.1111/apt.17643

Addition of transarterial chemoembolization improves outcome of tyrosine kinase and immune checkpoint inhibitors regime in patients with unresectable hepatocellular carcinoma

Background

Transarterial chemoembolization (TACE) is the standard treatment for hepatocellular carcinoma (HCC); the value of its combination with systemic therapy is worthy of further exploration. This study aimed to investigate the efficacy and safety of TACE combined with tyrosine kinase inhibitor (TKI) and immune checkpoint inhibitor (ICI) in the treatment of unresectable HCC.

Methods

In this retrospective observational, single-center study, 147 patients with unresectable HCC were divided into a TACE group (n=98) and a non-TACE group (n=49) based on whether TACE was performed during TKI plus ICI therapy. The survival outcomes and adverse events (AEs) of the two groups were compared.

Results

Data from patients with unresectable HCC who received TKI plus ICI treatment between July 2017 and April 2020 were collected. The median intrahepatic tumor size was 8.7 cm [interquartile range (IQR), 5.9-12.4 cm]. At data cut-off, overall survival (OS) of the TACE group was significantly longer than that of the non-TACE group (19.5 and 10.8 months, respectively, P=0.005). In the high-risk cohort (with main or contralateral portal vein tumor thrombi and/or bile duct invasion and/or a tumor burden >50% of liver), the OS of the TACE group was still longer than that of the non-TACE group (14.9 and 8.7 months, respectively, P=0.031). Major AEs were tolerated in both groups, and there was no significant difference in their incidence (34.7% and 30.6%, respectively, P=0.621).

Conclusions

TACE treatment combined with TKI plus ICI regime resulted in longer OS than treatment with TKI plus ICI alone for patients with unresectable HCC.

Inflammation-related nomogram for predicting survival of patients with unresectable hepatocellular carcinoma received conversion therapy

BACKGROUND

The efficacy of conversion therapy for patients with unresectable hepatocellular carcinoma (HCC) is a common clinical concern.

AIM

To analyse the prognostic factors of overall survival (OS) in patients with unresectable HCC who received conversion therapy.

METHODS

One hundred and fifty patients who met the inclusion criteria were enrolled and divided into a training cohort (n = 120) and a validation cohort (n = 30). Using the independent risk factors in the training cohort, a nomogram model was constructed to predict OS for patients treated with transarterial chemoembolization following hepatic resection. The nomogram was internally validated with the bootstrapping method. The predictive performance of nomogram was assessed by Harrell’s concordance index (C-index), calibration plot and time-dependent receiver operating characteristic curves and compared with six other conventional HCC staging systems.

RESULTS

Multivariate Cox analysis identified that albumin, blood urea nitrogen, gamma-glutamyl transpeptidase to platelet ratio, platelet to lymphocyte ratio, macrovascular invasion and tumour number were the six independent prognostic factors correlated with OS in nomogram model. The C-index in the training cohort and validation cohort were 0.752 and 0.807 for predicting OS, which were higher than those of the six conventional HCC staging systems (0.563 to 0.715 for the training cohort and 0.458 to 0.571 for the validation cohort). The calibration plots showed good consistency between the nomogram prediction of OS and the actual observations of OS. Decision curve analyses indicated satisfactory clinical utility. With a total nomogram score of 196, patients were accurately classified into low-risk and high-risk groups. Furthermore, we have deployed the model into online calculators that can be accessed for free at https://ctmodelforunresectablehcc.shinyapps.io/DynNomapp/.

CONCLUSION

The nomogram achieved optimal individualized prognostication of OS in HCC patients who received conversion therapy, which could be a useful clinical tool to help guide postoperative personalized interventions and prognosis judgement.

Comparison of Combined Transcatheter Arterial Chemoembolization and CT-guided Radiofrequency Ablation with Surgical Resection in Patients with Hepatocellular Carcinoma within the Up-to-seven Criteria: A Multicenter Case-matched Study

Background & Aims: We compared the efficacy of transcatheter arterial chemoembolization (TACE) in combination with CT-guided radiofrequency ablation (RFA) with that of surgical resection (SR) in patients with hepatocellular carcinoma (HCC) within the up-to-seven criteria.

Methods: From January 2004 to December 2014, 420 multicenter consecutive patients with HCC who conformed to the up-to-seven criteria and initially received either TACE plus CT-guided RFA (TACE-RFA) or SR were enrolled. A matched cohort composed of 206 patients was selected after adjustment with propensity score matching. The overall survival (OS) of each patient was calculated with the Kaplan-Meier method and compared by the log-rank test.

Results: The median OS and 1-, 3-, and 5-year survival rates were 56.0 months, 96.1%, 76.7% and 41.3% in the TACE-RFA group and 58.0 months, 96.1%, 86.4% and 46.2% in the SR group, respectively. There was no significant difference in OS between the two groups (P = 0.138). For patients with HCC beyond the Milan criteria, TACE-RFA provided a longer median OS than SR (52.0 vs 45.0 months, P = 0.023).

Conclusions: Treatment by TACE-RFA conferred an OS rate comparable with that of SR in patients within the up-to-seven criteria. For patients with HCC between the Milan and the up-to-seven criteria, TACE-RFA might be superior to SR for survival prolongation.

Cutting balloon treatment of anastomotic biliary stenosis after liver transplantation: Report of two cases

Biliary stenosis is a common complication after liver transplantation, and has an incidence rate ranging from 4.7% to 12.5% based on our previous study. Three types of biliary stenosis (anastomotic stenosis, non-anastomotic peripheral stenosis and non-anastomotic central hilar stenosis) have been identified. We report the outcome of two patients with anastomotic stricture after liver transplantation who underwent successful cutting balloon treatment. Case 1 was a 40-year-old male transplanted due to subacute fulminant hepatitis C. Case 2 was a 57-year-old male transplanted due to hepatitis B virus-related end-stage cirrhosis associated with hepatocellular carcinoma. Both patients had similar clinical scenarios: refractory anastomotic stenosis after orthotopic liver transplantation and failure of balloon dilation of the common bile duct to alleviate biliary stricture.

Uterine artery embolization combined with methotrexate in the treatment of cesarean scar pregnancy: results of a case series and review of the literature

PURPOSE

To explore the clinical value of uterine artery embolization (UAE) combined with methotrexate in the treatment of cesarean scar pregnancy (CSP) before and after uterine curettage.

MATERIALS AND METHODS

From August 2009 to April 2012, 15 patients with CSP treated with UAE (before or after uterine curettage) were analyzed retrospectively. Eleven subjects with a definite diagnosis of CSP were offered preventive UAE combined with methotrexate before uterine curettage. The other four patients, who were misdiagnosed as having an intrauterine pregnancy, were treated with emergency UAE for uncontrollable massive hemorrhage after uterine curettage. Clinical data, treatment sequence, and outcome were analyzed, and a brief review of the published literature summarizing UAE in the treatment of CSP was performed.

RESULTS

Eleven patients with definite CSP received preventive UAE combined with methotrexate followed by uterine curettage, and CSP was resolved successfully without hysterectomy. In the four misdiagnosed patients, three were treated successfully with emergency UAE. The other patient underwent uterine curettage and emergency UAE followed by repeat curettage, but hysterectomy was performed because of continued severe hemorrhage.

CONCLUSIONS

Based on a small number of patients, it appears that UAE may be an effective means of treating CSP, including treatment in an emergency setting. Further study is required before the safety and effectiveness of UAE can be confirmed.

The role of transarterial embolization in the management of hematuria secondary to congenital renal arteriovenous malformations

OBJECTIVE

To evaluate the efficacy and safety of transarterial embolization (TAE) in the management of hematuria secondary to congenital renal arteriovenous malformations (AVM).

PATIENTS AND METHODS

Between May 2007 and February 2012, 6 patients with congenital AVM treated with TAE were analyzed retrospectively, followed by a brief review of TAE in the treatment of congenital AVM. Clinical records with respect to general conditions, location, embolic materials, complications and overall outcome were collected from the original hospital charts and outpatient medical records.

RESULTS

Three patients with AVM were confirmed by contrast-enhanced CT scans, and the other 3 patients were detected by renal angiography. TAE was performed with steel coils in 2 patients and n-butyl-2-cyanoacrylate (NBCA) in 4 patients. After a mean follow-up of 22 months, no serious adverse effects were observed in all patients. There were no complaints of hematuria at the end of the follow-up period.

CONCLUSION

For unexplained massive hematuria, congenital renal AVM needs to be considered as a differential diagnosis. Selective renal angiography and embolization should be recommended as the first choice to treat massive hematuria secondary to congenital renal AVM.

The inhibitory effect of MSCs expressing TRAIL as a cellular delivery vehicle in combination with cisplatin on hepatocellular carcinoma

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) has been demonstrated to induce cell apoptosis in many types of tumors, while many hepatocellular carcinoma (HCC) cells display high resistance to TRAIL. Another outstanding limitation of TRAIL is the short half-life in vivo. Stem cell-based therapies provide a promising approach for the treatment of many types of tumors because of the ability of tropism. Therefore, as a new therapeutic strategy, the combination of chemotherapeutic agents and TRAIL gene modified MSCs (TRAIL-MSCs) would improve the therapeutic efficacy of HCC in vivo. This is the first time to show the potential of combination of chemotherapeutic agents and MSCs as a gene vector in the therapy of HCC.

Cisplatin sensitizes human hepatocellular carcinoma cells, but not hepatocytes and mesenchymal stem cells, to TRAIL within a therapeutic window partially depending on the upregulation of DR5

Tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) is a member of the TNF family of cytokines and has been shown to induce cell apoptosis in many types of tumors, but not in normal cells. This tumor-selective property has made TRAIL a promising approach for the development of cancer therapy. However, hepatocellular carcinoma (HCC) cells display a striking resistance to TRAIL. Although some chemotherapeutic agents can overcome this resistance, safety issues remain a concern because the combination of these agents and TRAIL has been reported to induce toxicity in normal hepatocytes. In this study, we examined whether cisplatin could reverse TRAIL resistance in HCC cells with different p53 status and evaluated the toxicity of combination TRAIL and cisplatin to normal hepatocytes and mesenchymal stem cells (MSCs). We observed that cisplatin could efficiently sensitize HCC cells, but not hepatocytes and MSCs to TRAIL-induced apoptosis within a wide therapeutic window. The apoptosis of HCC cells only partially depended on the upregulation of DR5 and the status of p53. In addition, we provide favorable evidence supporting the feasibility of the combination of chemotherapy and MSCs transduced with TRAIL.

Chemoembolization with lobaplatin mixed with iodized oil for unresectable recurrent hepatocellular carcinoma after orthotopic liver transplantation

PURPOSE

To determine whether chemoembolization can benefit patients with unresectable recurrent hepatocellular carcinoma (HCC) after orthotopic liver transplantation (OLT).

MATERIALS AND METHODS

Twenty-eight of 71 patients (39%) with unresectable recurrent HCC following OLT and without contradictions to chemoembolization were included: 14 patients received chemoembolization after OLT (chemoembolization group) and 14 matched control subjects who did not receive chemoembolization (non-chemoembolization group). Tumor response was determined with follow-up computed tomography after each chemoembolization procedure and classified into four grades according to Response Evaluation Criteria in Solid Tumors. Overall survival was evaluated from OLT and from the diagnosis of recurrent HCC.

RESULTS

Within a median follow-up of 14.5-months, 12 of the 14 patients in the chemoembolization group (86%) and 13 of the 14 in the non-chemoembolization group (93%) developed new recurrences. Eight of the 14 patients in the chemoembolization group (57%) showed partial tumor response (>30% reduction in the size of target lesions). Moreover, patients who underwent chemoembolization had a significantly longer overall survival after OLT (P = .0133) and after the diagnosis of HCC recurrence (P = .0338) compared to those who did not. No severe complications developed in patients receiving chemoembolization during follow-up.

CONCLUSIONS

Lobaplatin-based chemoembolization may elicit effective tumor response for recurrent HCCs and improve the overall survival of patients with unresectable HCC recurrence following OLT.

MR tracking of magnetically labeled mesenchymal stem cells in rats with liver fibrosis

PURPOSE

In vivo magnetic resonance (MR) tracking of magnetically labeled bone marrow mesenchymal stem cells (BMSCs) administered via the mesenteric vein to rats with liver fibrosis.

MATERIALS AND METHODS

Rat BMSCs were labeled with superparamagnetic iron oxide (SPIO) and the characteristics of the BMSCs after labeling were investigated. Eighteen rats with CCL4-induced liver fibrosis were randomized to three groups to receive SPIO-labeled BMSCs (BMSC-labeled group), cell-free SPIO (SPIO group), or unlabeled BMSCs (control group). MR imaging of the liver was performed at different time points, and signal-to-noise ratio (SNR) of the liver was measured. In vivo distribution of delivered BMSCs was assessed by histological analysis.

RESULTS

Labeling of BMSCs with SPIO did not significantly alter cell viability and proliferation activity. In BMSC-labeled group, the liver SNR immediately decreased from 8.56+/-0.26 to 3.53+/-0.41 at 1 h post injection and remained at a significantly lower level till 12 days (P<.05 versus the level before). By contrast, the liver SNR of the SPIO group almost recovered to the preinjection level (P=.125) at 3 days after a transient decrease. In control group, the liver SNR demonstrated no significant difference at the tested time points. Additionally, Prussian blue-positive cells were mainly distributed in the liver parenchyma, especially in injured areas.

CONCLUSION

The magnetically labeled BMSCs infused through the mesenteric vein can be detected in the fibrotic liver of rats using in vivo MR imaging up to 12 days after injection.

[The role of early hepatic artery ischemia on biliary complications after liver transplantation and hepatic arterial interventional therapy]

OBJECTIVE

To explore the influence of early hepatic artery ischemia on the occurrence and prognosis of biliary complications after orthotopic liver transplantation (OLT), and the value of early hepatic arterial interventional therapy.

METHODS

In the 720 recipients who received OLT in our hospital from October 2003 to June 2007, 32 cases were detected hepatic artery stenosis (HAS, 30 cases) or hepatic artery thrombosis (HAT, 2 cases) by color Doppler Ultrasound from 4 to 65 days (mean, 25 +/- 15) after OLT. All of them were confirmed by DSA and/or CT angiography. Of the 32 patients, 20 were treated by hepatic arterial interventional therapy. The end-point of follow-up was the time of patient's death and retransplantation.

RESULTS

In this study, 20 cases developed biliary complications, including the common bile duct stenosis in 2 cases, intra- and extra hepatic bile duct stenosis in 13 cases and multiple intrahepatic bile duct stenosis in 5 cases. Among them, 2 patients complicated with bile leakage, 4 with biloma and 3 with liver abscess. Of the 20 patients, 8 with HAS received successful hepatic arterial interventional therapy which was performed two weeks after HAS detected; 10 with HAS didn't receive hepatic arterial interventional therapy; 1 with HAT received successful thrombolysis; 1 with HAS received failed hepatic artery stent implantation. During a median follow-up of 262 days (range, 22 -517 days), 10 patients died, 6 underwent retransplantation, and the other 4 survived; cumulated survival rates at 6, 12 and 24 months were 60.0%, 34.9% and 0, respectively. 12 cases didn't develop biliary complications. Nine of them received successful hepatic arterial interventional therapy within 2 weeks HAS detected, 2 with acute rejection received flushing anti-rejection therapy, 1 with HAT received retransplantation because of unsuccessful thrombolysis. During a median follow-up of 952 days (range, 14 - 1398 days), 3 patients died, 1 underwent retransplantation, and the other 8 survived; cumulated survival rates at 6, 12 and 24 months were 75%, 66.7% and 66.7%, respectively.

CONCLUSION

Early hepatic artery ischemia after OLT is an important agent for biliary complications. Early and successful hepatic arterial interventional therapy helped to reduce the incidence of biliary complications and improve the patients' prognosis.

[The role of multi-detector row CT in the diagnosis and hemodynamic studies of gastric varices in portal hypertension]

OBJECTIVE

To evaluate the value of multi-detector row CT (MDCT) in the diagnosis and hemodynamic studies of gastric varices (GV) in portal hypertension by comparison with endoscopy and DSA direct portography.

METHODS

Thirty-six consecutive cirrhotic patients with GV confirmed by endoscopy underwent tri-phase contrast-enhanced CT scans and CT portography (CTP) within 2 weeks after endoscopy examination. Three independent experienced radiologists, who were blinded to the patients' clinical data, analyzed the CT images, including the size and location of GV as well as afferent and efferent veins of GV, separately. Interobserver agreement among the 3 radiologists with regard to the diagnosis of submucosal and perigastric GV was determined by Kappa (k) values. The findings of endoscopy were used as standards.

RESULTS

Sub mucosal GV was diagnosed in 34 of the 36 patients (94.4%) and perigastric GV in all 36 patients (100%) by the observation of the 3 radiologists. MDCT showed an excellent interobserver reliability with regard to the diagnosis of submucosal GV (kappa = 0.85) and perigastric GV (kappa = 1.0). Agreement between MDCT and endoscopy with regard to the opacification of variceal size and location were 86.1% and 88.9% respectively. The sensitivity, specificity, accuracy, and positive predictive value of CTP in the opacification of afferent and efferent veins of GV were all more than 80%. The frequencies of participation of posterior gastric vein and short gastric vein in blood supply to gastric fundal varices in the isolated gastric varices and gastroesophageal varices type 2 (GEV2) were 94.1% and 70.6% respectively, both significantly higher than those in the gastroesophageal varices type 1 (GEV1, 52.6% and 31.6%, respectively, both P < 0.05). The main blood drainage route of GEV1 was via azygous system into the super vena cava (100%), whereas in the gastric fundal varices the main blood drainage route was via the gastrorenal shunts into the inferior vena cava (82.4%).

CONCLUSION

MDCT can be used as an important tool for detecting submucosal and perigastric GV, and can clearly reveal the size, location, and hemodynamics of GV.

Role of interventional therapy in hepatic artery stenosis and non-anastomosis bile duct stricture after orthotopic liver transplantation

AIM: To analyze the clinical manifestations and the effectiveness of therapy in patients with orthotopic liver transplantation (OLT)-associated hepatic artery stenosis (HAS) and non-anastomosis bile duct stricture.

METHODS: Nine cases were diagnosed as HAS and non-anastomosis bile duct stricture. Percutaneous transluminal angioplasty (PTA) was performed in four HAS cases, and expectant treatment in other five HAS cases; percutaneous transhepatic bile drainage, balloon dilation, stent placement were performed in all nine cases.

RESULTS: Diffuse intra- and extra-bile duct stricture was observed in nine cases, which was associated with bile mud siltation and biliary infection. Obstruction of the bile duct was improved obviously or removed. Life span/follow-up period was 13-30 mo after PTA of four HAS cases, 6-23 mo without PTA of other five cases.

CONCLUSION: Progressive, non-anastomosis, and diffuse bile duct stricture are the characteristic manifestations of HAS and non-anastomosis bile duct stricture after OLT. These are often associated with bile mud siltation, biliary infection, and ultimate liver failure. Interventional therapy is significantly beneficial.

Portal venous stent placement for treatment of portal hypertension caused by benign main portal vein stenosis

AIM: To evaluate the value of endovascular stent in the treatment of portal hypertension caused by benign main portal vein stenosis.

METHODS: Portal vein stents were implanted in six patients with benign main portal vein stenosis (inflammatory stenosis in three cases, postprocedure of liver transplantation in another three cases). Changes in portal vein pressure, portal vein patency, relative clinical symptoms, complications, and survival were evaluated.

RESULTS: Six metallic stents were successfully placed across the portal vein stenotic or obstructive lesions in six patients. Mean portal venous pressure decreased significantly after stent implantation from (37.3±4.7) cm H₂O to (18.0±1.9) cm H₂O. The portal blood flow restored and the symptoms caused by portal hypertension were eliminated. There were no severe procedure-related complications. The patients were followed up for 1-48 mo. The portal vein remained patent during follow-up. All patients survived except for one patient who died of other complications of liver transplantation.

CONCLUSION: Percutaneous portal vein stent placement for the treatment of portal hypertension caused by benign main portal vein stenosis is safe and effective.

Capability of multidetector CT to diagnose hepatocellular carcinoma-associated arterioportal shunt

AIM: To investigate the capability of multidetector CT (MDCT) to diagnose HCC-associated arterioportal shunt (APS).

METHODS: Two hundred and eighty-two patients with HCC received both thin-slice and enhancement MDCT scanning at early hepatic arterial phase, late hepatic arterial phase and portal venous phase, and digital subtract angiography (DSA) examination. Images were analyzed jointly by two experienced radiologists blinded to the opposite examination results, including the existence or not of APS, shunt locations, types and degrees of APS, with or without thrombosis.

RESULTS: There were 56 APS associated with HCC, including 48 central, seven peripheral and one mixed, or 42 severe, seven moderate, seven mild APS. Forty-one severe, seven moderate and central APS were all revealed with MDCT and DSA. Seven mild and peripheral APS were all displayed with MDCT; only five of them displayed DSA, two faint shunt APS associated with massive HCC were missed. One mixed APS was demonstrated as severe combined with mild shunt with both MDCT and DSA.

CONCLUSION: MDCT could diagnose not only DSA revealed APS, but also missed mild and peripheral APS with DSA due to faint shunt associated with massive HCC, is a simple, effective and noninvasive new technique for diagnosis of HCC-associated APS.

[Multidetector spiral CT findings of arteriovenous fistula associated with hepatocellular carcinoma]

BACKGROUND & OBJECTIVE

In clinical practice, a large number of patients might not undergo transcatheter hepatic angiography as a routine examination, which resulted in missed diagnosis of arteriovenous fistula (AVF) associated with hepatocellular carcinoma (HCC) and loss of embolism opportunity. The study was designed to investigate multidetector spiral CT (MDSCT) findings of AVF associated with HCC, so as to improve its diagnosis and differential diagnosis.

METHODS

Thin-slice and dynamic enhancement MDSCT findings of AVF proved by digital subtraction angiography of 56 patients with HCC were analyzed.

RESULTS

MDSCT demonstrated earlier enhancement of main portal trunks and/or the first order branches than superior mesenteric veins or spleen veins (n=31), 1 patient had early enhancement and strong enhancement of left hepatic vein with thromboses in it and upper part of inferior vena cava, 1 patient had transient patchy enhancement peripheral to HCC focus in late hepatic arterial phase and became isoattenuation at portal vein phase among them; stronger opacification of main portal trunks and/or the first order branches than superior mesenteric veins or spleen veins (n=18); earlier enhancement of the second order branches and smaller of portal veins than main portal trunks (n=4), stronger opacification of the second order branches and smaller of portal veins than main portal trunks (n=3), accompanying with transient patchy enhancement (n=3) or wedge-shaped enhancement (n=4) peripheral to HCC foci at late hepatic arterial phase and became isoattenuation at portal vein phase. Enhancement degrees of HCC foci and spleens were all decreased, and enhancement degrees of liver parenchyma without HCC foci were increased and heterogeneous in 49 patients with severe or moderate and central AVF.

CONCLUSION

There are complex MDSCT findings of AVF associated with HCC, and its main manifestations are earlier enhancement and stronger opacification of portal veins and/or hepatic veins.

Transjugular intrahepatic portosystemic shunt for palliative treatment of portal hypertension secondary to portal vein tumor thrombosis

AIM: To evaluate the palliative therapeutic effects of transjugular intrahepatic portosystemic shunt (TIPS) in portal vein tumor thrombosis (PVTT) complicated by portal hypertension.

METHODS: We performed TIPS for 14 patients with PVTT due to hepatocellular carcinoma (HCC). Of the 14 patients, 8 patients had complete occlusion of the main portal vein, 6 patients had incomplete thrombosis, and 5 patients had portal vein cavernous transformation. Clinical characteristics and average survial time of 14 patients were analysed. Portal vein pressure, ascites, diarrohea, and variceal bleeding and circumference of abdomen were assessed before and after TIPS.

RESULTS: TIPS was successful in 10 cases, and the successful rate was about 71%. The mean portal vein pressure was reduced from 37.2 mmHg to 18.2 mmHg. After TIPS, the ascites decreased, hemorrhage stopped and the clinical symptoms disappeared in the 10 cases. The average survial time was 132.3 d. The procedure failed in 4 cases because of cavernous transformation in portal vein and severe cirrhosis.

CONCLUSION: TIPS is an effective palliative treatment to control hemorrhage and ascites due to HCC complicated by PVTT.

Multislice spiral CT displaying extrahepatic feeding arteries of hepatocellular carcinoma for interventional treatment

AIM: To diagnose extrahepatic feeding arteries of hepatocellular carcinoma (HCC) in hepatic arterial phase multislice computerized tomography (MSCT) for interventional treatment.

METHODS: Biphasic MSCT and transcatheter arterial chemoembolization (TACE) were performed in 52 patients with HCC, who were confirmed with 60 branches extrahepatic feeding arteries by arteriography, in which 34 were intial patients, 18 with multi-TACEs. According to the arteriography, the MSCT signs of feeding arteries and tumors were studied retrospectively.

RESULTS: Before initial TACE, 34 branches extrahepatic feeding arteries (56.7%, 34/60) were displayed in 33 patients in arterial phase MSCT. Follow-up data showed that another 13 branches were displayed (78.3%, 47/60), and 13 branches were not displayed. All the tumors fed by extrahepatic arteries located in the margin of liver and its longitude was average 6.9±2.2 cm. The tumors conglutinated with the nearby organs and tissues in 36 cases. The displaying rate was higher in longitudinal position arteries (for example, inferior phrenic arteries, internal thoracic artery.), showed a "dot" high density. In 33 branches feeding inferior phranic arteries, 21 branches were displayed as the source arteries. The displaying rate was lower in axial position arteries.

CONCLUSION: Arterial phase MSCT can display extrahepatic feeding arteries of HCC easily. While TACE, extrahepatic arteries are firstly identified and TACE later, followed by transhepatic artery TACE, which can improve the efficacy of interventional treatment.

Comparison of long-term effects between intra-arterially delivered ethanol and Gelfoam for the treatment of severe arterioportal shunt in patients with hepatocellular carcinoma

AIM: To evaluate long-term effect of ethanol embolization for the treatment of hepatocellular carcinoma (HCC) with severe hepatic arterioportal shunt (APS), compared with Gelfoam embolization.

METHODS: Sixty-four patients (ethanol group) and 33 patients (Gelfoam group) with HCC and APS were respectively treated with ethanol and Gelfoam for APS before the routine interventional treatment for the tumor. Frequency of recanalization of shunt, complete occlusion of the shunt, side effects, complications, and survival rates were analyzed between the two groups.

RESULTS: The occlusion rate of APS after initial treatment in ethanol group was 70.3%(45/64), and recanalization rate of 1 month after embolization was 17.8%(8/45), and complete occlusion rate was 82.8%(53/64). Those in Gelfoam group were 63.6%(21/33), 85.7%(18/21), and 18.2%(6/33). There were significant differences in recanalization rate and complete occlusion rate between the two groups (P < 0.05). The survival rates in ethanol group were 78% at 6 months, 49% at 12 months, 25% at 24 months, whereas those in Gelfoam group were 58% at 6 months, 23% at 12 months, 15% at 24 months. The ethanol group showed significantly better survival than Gelfoam group (P < 0.05). In the ethanol group, there was a significant prolongation of survival in patients with monofocal HCC (P < 0.05) and Child class A (P < 0.05). There were no significant differences in survival rate in the Gelfoam group with regard to the number of tumor and Child class (P > 0.05). The incidence rate of abdominal pain during procedure in ethanol group was 82.8%. There was no significant difference in postembolization syndromes between two groups. Procedure-related hepatic failure did not occur in ethanol group.

CONCLUSION: Ethanol embolization for patients with HCC and severe APS is efficacious and safe, and may contribute to prolongation of the life span versus Gelfoam embolization.

Study on hepatocelluar carcinoma-associated hepatic arteriovenous shunt using multidetector CT

AIM: To investigate multidetector CT (MDCT) findings of hepatocelluar carcinoma (HCC)- associated hepatic arteriovenous shunt (HAVS) and to evaluate their clinical significance.

METHODS: Thin-slice and dynamic enhancement MDCT of HAVS was performed on 56 patients with HCC. MDCT findings, including those of portal veins, hepatic veins, superior mesenteric veins, splenic veins, HCC foci, liver parenchyma without HCC foci, spleens, and thromboses in portal veins and hepatic veins, were all confirmed by digital subtract angiography and analyzed.

RESULTS: MDCT demonstrated earlier enhancement of main portal trunks and/or the first order branches than that of superior mesenteric veins or splenic veins (n = 31). One patient had strong early enhancement of left hepatic vein with thromboses in left hepatic vein and upper part of inferior vena cava and 1 patient had transient patchy enhancement peripheral to HCC foci in late hepatic arterial phase among them. It demonstrated stronger opacification of main portal trunks and/or the first order branches than that of superior mesenteric veins or splenic veins (n = 18), and earlier enhancement of the second order and smaller branches of portal veins than that of main portal trunks (n = 4), stronger opacification of the second order and smaller branches of portal veins than that of main portal trunks (n = 3), with transient patchy enhancement (n = 3) or wedge-shaped enhancement (n = 4) peripheral to HCC foci in late hepatic arterial phase. Enhancement degree of HCC foci was all decreased. As for 49 patients with severe or moderate shunts, enhancement degree of liver parenchyma without HCC foci was increased with heterogeneous density, but enhancement degree of spleens was decreased. There were thromboses in main portal trunks and/or the first order branches in 32 patients.

CONCLUSION: The main MDCT findings of HCC-associated HAVS are earlier enhancement and stronger opacification of portal veins and/or hepatic veins. Understanding of these findings will contribute to the diagnosis and prognosis of the disease and improve therapy for the patients.

Percutaneous transhepatic metal versus plastic biliary stent in treating malignant biliary obstruction: a multiple center investigation

OBJECTIVE

To compare the efficacy of metal versus plastic biliary stent implantation in the treatment of malignant biliary obstruction.

METHODS

Percutaneous transhepatic self-expandable metal stent (MS, n=61) and 10F plastic stent (PS, n=34) were placed in 95 patients with malignant biliary obstruction in three hospitals of Guangdong province. All patients were followed up until death or at least one year after the procedure. Kaplan-Meier analysis was used to compare the survival of the patients and the rates of stent patency.

RESULTS

The 30-day mortality rate was lower in the MS group (6/61, 9.8%) than in the PS group (9/34, 26.5%, P<0.05). The 30-day reobstruction rate and the complication rate were 15.0%, 16.4% in the MS group and 32.4%, 29.4% in the PS group, respectively (P<0.01). The median patency period of stents and median survival period of the patients were 230 days, 224 days in the MS group and 90 days, 94 days in the PS group, respectively (P<0.01).

CONCLUSION

Metal stent is clinically superior to plastic stent in the treatment of malignant biliary obstruction.

The dynamic change of plasma endothelin-1 during the perioperative period in patients with rheumatic valvular disease and secondary pulmonary hypertension

The arterial plasma endothelin-1 concentration was substantially more elevated in 15 patients with rheumatic valvular disease and secondary pulmonary hypertension than in healthy volunteers (3.66 +/- 2.20 versus 1.17 +/- 0.38 pg/ml, mean +/- standard deviation; p < 0.01). The preoperative plasma endothelin-1 level was highly correlated with the pulmonary hemodynamics: pulmonary artery systolic pressure (r = 0.94, p < 0.001), pulmonary artery mean pressure (r = 0.86, p < 0.001), pulmonary capillary wedge pressure (r = 0.82, p < 0.001), and pulmonary vascular resistance (r = 0.63, p < 0.02). After valve replacement, the plasma endothelin-1 concentration declined substantially and the pulmonary hemodynamics improved markedly. Two weeks after the operation, the plasma endothelin-1 level in patients (1.26 +/- 0.45 pg/ml, mean +/- standard deviation) was not statistically different from that in the healthy volunteers. The plasma endothelin-1 concentration continuously increased during the course of cardiopulmonary bypass and peaked after cessation of bypass. The peak plasma endothelin-1 level (13.49 +/- 4.60 pg/ml, mean +/- standard deviation) positively correlated with the bypass time (r = 0.64, p < 0.02) and negatively correlated with the urine volume during bypass (r = -0.69, p < 0.01). We conclude that (1) increased plasma endothelin-1 might be implicated in the pathogenesis of secondary pulmonary hypertension caused by rheumatic valvular disease and (2) markedly elevated plasma endothelin-1 concentrations might be associated with the mechanism of cardiac or renal dysfunction after prolonged cardiopulmonary bypass.

[Surgical treatment of infective endocarditis complicated by aortic and/or mitral valvular perforation]

From February 1980 to July 1987, 27 patients with valvular bacterial endocarditis complicated by aortic and/or mitral valvular perforation and vegetation were operated upon. AVR was performed in 23 cases and double valve replacement was done in 4. There were 3 deaths after operation. Follow-up of 21 patients showed that heart function improved from class III-IV to class I-II. In discussion, the importance of echocardiography in detecting valvular perforation and vegetation and the need of early diagnosis and early surgical intervention are emphasized; especially in patients with intractable heart failure and deteriorating general condition.