Computed tomography and histopathological findings after embolization with inherently radiopaque 40μm-microspheres, standard 40μm-microspheres and iodized oil in a porcine liver model

Purpose

The present study compared standard computed tomography (CT) and histopathological findings after endovascular embolization using a prototype of inherently radiopaque 40μm-microspheres with both standard 40μm-microspheres and iodized oil in a porcine liver model.

Materials and methods

Twelve pigs were divided into six study groups, of two pigs each. Four pigs were embolized with iodized oil alone and four with radiopaque microspheres; two animals in each group were sacrificed at 2 hours and two at 7 days. Two pigs were embolized with radiopaque microspheres and heparin and sacrificed at 7 days. Two pigs were embolized with standard microspheres and sacrificed at 2 hours. CT was performed before and after segmental embolization and before sacrifice at 7 days. The distribution of embolic agent, inflammatory response and tissue necrosis were assessed histopathologically.

Results

Radiopaque microspheres and iodized oil were visible on standard CT 2 hours and 7 days after embolization, showing qualitatively comparable arterial and parenchymal enhancement. Quantitatively, the enhancement was more intense for iodized oil. Standard microspheres, delivered without contrast, were not visible by imaging. Radiopaque and standard microspheres similarly occluded subsegmental and interlobular arteries and, to a lesser extent, sinusoids. Iodized oil resulted in the deepest penetration into sinusoids. Necrosis was always observed after embolization with microspheres, but never after embolization with iodized oil. The inflammatory response was mild to moderate for microspheres and moderate to severe for iodized oil.

Conclusion

Radiopaque 40μm-microspheres are visible on standard CT with qualitatively similar but quantitatively less intense enhancement compared to iodized oil, and with a tendency towards less of an inflammatory reaction than iodized oil. These microspheres also result in tissue necrosis, which was not observed after embolization with iodized oil. Both radiopaque and standard 40μm-microspheres are found within subsegmental and interlobar arteries, as well as in hepatic sinusoids.

Sclerosing cholangitis secondary to bleomycin-iodinated embolization for liver hemangioma

Sclerosing cholangitis (SC) is a rarely reported morbidity secondary to transcatheter arterial chemoembolization (TACE) with bleomycin-iodinated oil (BIO) for liver cavernous hemangioma (LCH). This report retrospectively evaluated the diagnostic and therapeutic course of a patient with LDH who presented obstructive jaundice 6 years after TACE with BIO. Preoperative imaging identified a suspected malignant biliary stricture located at the convergence of the left and right hepatic ducts. Operative exploration demonstrated a full-thickness sclerosis of the hilar bile duct with right hepatic duct stricture and right lobe atrophy. Radical hepatic hilar resection with right-side hemihepatectomy and Roux-en-Y hepaticojejunostomy was performed because hilar cancer could not be excluded on frozen biopsy. Pathological results showed chronic pyogenic inflammation of the common and right hepatic ducts with SC in the portal area. Secondary SC is a long-term complication that may occur in LCH patients after TACE with BIO and must be differentiated from hilar malignancy. Hepatic duct plasty is a definitive but technically challenging treatment modality for secondary SC.

Hypersensitivity reactions to transcatheter chemoembolization with cisplatin and Lipiodol suspension for unresectable hepatocellular carcinoma

PURPOSE

To assess the predictors of hypersensitivity reaction to chemoembolization procedures with cisplatin and Lipiodol suspension for the treatment of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Between February 2005 and December 2008, 434 patients with HCC were treated with chemoembolization with a cisplatin and Lipiodol suspension. This retrospective cohort study analyzed the incidence of hypersensitivity reactions as an adverse effect and their predictors by multivariate logistic regression analyses.

RESULTS

In total, 847 chemoembolization procedures were carried out in 434 patients. The median number of procedures per patient was 2 (range, 1-12). Mean dose of cisplatin per chemoembolization session was 27 mg (range, 15.0-80.0 mg), and the median total dose of cisplatin per patient was 55 mg (range, 5.0-560.0 mg). Hypersensitivity reactions occurred in 14 patients (1.7%). The median number of chemoembolization procedures in these patients was 7 (range, 3-10). Mean dose of cisplatin per session was 22 mg (range, 9.2-35.7 mg), and the median total dose of cisplatin was 134 mg (range, 37-286 mg). On multivariate analysis, the only parameter that showed an independent association with hypersensitivity reactions was the performance of 3 or more than three chemoembolization procedures.

CONCLUSIONS

Performance of more than three chemoembolization procedures with a cisplatin and Lipiodol suspension was found to be independently associated with hypersensitivity reactions. Patients undergoing repeated chemoembolization procedures with cisplatin and Lipiodol suspension may experience hypersensitivity reactions as an adverse effect.

[Analysis of severe complications after transcatheter arterial chemoembolization for primary hepatocellular carcinoma]

OBJECTIVE

To investigate the cause and treatment as well as prevention measures of rarely occurring severe complications after transcatheter arterial chemoembolization (TACE) for primary hepatic carcinoma.

METHODS

573 consecutive patients with primary hepatic carcinoma underwent a total of 1252 TACE procedures from January 2005 to July 2007. All the patients who developed complications after TACE received imaging and biochemical examinations. The cause, treatment and preventive measures of the complications in the 573 cases were analyzed.

RESULTS

There were upper gastrointestinal hemorrhage in 3 cases, hepatic failure in 4, pulmonary embolism in 1, cholecystitis in 4, hepatic encephalopathy in 2, gastric perforation in 1, and intrahepatic biloma in 2 cases. Two patients died of the complications: 1 of hepatic failure and 1 of gastric perforation.

CONCLUSION

The rarely occurring severe complications after transcatheter arterial chemoembolization for primary hepatic carcinoma is correlated with poor hepatic function and portal hypertension before therapy, overdose and reflux of chemotherapeutic agents or allotopic chemoembolism, etc. It can be reduced or prevented through careful selection of proper cases before the treatment, close observation, and protection of hepatic function and gastric mucosa after treatment.

Pulmonary embolism due to injection of Histoacryl and Lipiodol during endoscopic sclerotherapy of fundic varices

Pulmonary N-butyl-2-cyanoacrylate embolism is one of the potential risks associated with endoscopic obliteration of fundic gastric varices. Due to its uncommon nature, especially in children, no consensus has been proposed on its optimal management.

CASE REPORT

An 11-year-old boy with a longstanding history of lung- and liver fibrosis with portal hypertension causing haematemesis underwent endoscopic therapy for fundic varices. Shortly after injection of 0.5 ml of a N-butyl-2-cyanoacrylate (Histoacryl) and lipid soluble ethiodized oil (Lipiodol) mixture, he desaturated with secondary hypotension and bradycardia. Pulmonary embolism was confirmed on chest X-ray. The boy was successfully treated conservatively. Clinical symptoms subsided and he was discharged after three days. Pulmonary infiltrations persisted for two weeks.

CONCLUSION

Patients including children undergoing obliteration of gastric varices with Histoacryl and Lipiodol should be subjected to a close follow-up. Coexisting lung conditions may enhance the risk of pulmonary embolism and can also influence the outcome.

Cerebral lipiodol embolism: a complication of transcatheter arterial chemoembolization for hepatocellular carcinoma

We report a case of cerebral lipiodol embolism following transcatheter chemoembolization (TACE) for hepatocellular carcinoma. A 70-year-old woman with a large unresectable hepatocellular carcinoma underwent TACE. Her level of consciousness deteriorated after the procedure, and magnetic resonance imaging and non-contrast computed tomography revealed a cerebral lipiodol embolism. Despite intensive care, the patient died 2 weeks later. The complication might have been due to systemic-pulmonary shunts caused by previous surgeries and/or direct invasion of the recurrent tumor.

[Incidence and risk factors of acute hepatic failure after transcatheter arterial chemoembolization for hepatocellular carcinoma]

BACKGROUND/AIMS

Although transcatheter arterial chemoembolization (TACE) is a major treatment modality for unresectable hepatocellular carcinoma (HCC), acute hepatic failure after TACE is not rare. However, reports dealing with this important complication are not good enough and results are often variable. The purpose of this study was to evaluate the incidence and associated risk factors of acute hepatic failure after TACE.

METHODS

From January 2001 to November 2004, six hundred and thirty-two TACE sessions were performed in 377 patients (294 men and 83 women). Adriamycin mixed lipiodol solution and gelfoam were used for TACE. Various clinical and radiological factors before and after the procedure were reviewed retrospectively. Univariate and multivariate analyses were performed to evaluate the risk factors associated with the development of acute hepatic failure after TACE.

RESULTS

Acute hepatic failure occurred in 76 (12.0%) of the 632 TACE sessions within 14 days. Univariate analysis revealed that Child-Pugh class, 1st TACE, total bilirubin level, number of involved segments, total size of tumor, presence of right portal vein thrombosis (PVT) or main PVT, involvement of segment 1, 5, 6, 7, modified UICC stage, and doses of chemotherapeutic agent were significantly different between the patients with or without hepatic failure after TACE. Among them, elevated total bilirubin (p=0.001, E (beta)=1.449), presence of right (p=0.035, E (beta)=2.109) or main (p=0.011, E (beta)=4.067) PVT were independently associated factors in multivariate analysis.

CONCLUSIONS

The incidence of acute hepatic failure after TACE was 12.0%. Elevated bilirubin level and portal vein thrombosis could be considered as the predictive factors for acute hepatic failure after TACE in HCC patients.

Intra-arterial rhenium-188 lipiodol in the treatment of inoperable hepatocellular carcinoma: results of an IAEA-sponsored multination study

PURPOSE

Intra-arterial injections (IAI) of 131I-lipiodol is effective in treating hepatocellular carcinoma patients, but is expensive and requires a 7-day hospitalization in a radioprotection room. 188Re is inexpensive, requires no patient isolation, and can be used with lipiodol.

METHODS AND MATERIALS

This International Atomic Energy Agency-sponsored phase II trial aimed to assess the safety and the efficacy of a radioconjugate 188Re + lipiodol (188Re-Lip) in a large cohort of hepatocellular carcinoma patients from developing countries. A scout dose is used to determine the maximal tolerated dose (lungs <12 Gy, normal liver <30 Gy, bone marrow <1.5 Gy) and then the delivery of the calculated activity. Efficacy was assessed using response evaluation criteria in solid tumor (RECIST) and alpha-feto-protein (alpha FP) levels and severe adverse events were graded using the Common Toxicity Criteria of the National Cancer Institute scale v2.0.

RESULTS

The trial included 185 patients from eight countries. The procedure was feasible in all participating centers. One treatment was given to 134 patients; 42, 8, and 1 received two, three, and four injections, respectively. The injected activity during the first treatment was 100 mCi. Tolerance was excellent. We observed three complete responses and 19 partial responses (22% of evaluable patients, 95% confidence interval 16-35%); 1- and 2-year survivals were 46% and 23%. Some factors affected survival: country of origin, existence of a cirrhosis, Cancer of the Liver Italian Program score, tumor dose, absence of progression, and posttreatment decrease in alpha FP level.

CONCLUSIONS

IAI of 188Re-Lip in developing countries is feasible, safe, cost-effective, and deserves a phase III trial.

Acute pancreatitis after embolization of liver tumors: frequency and associated risk factors

INTRODUCTION

Acute pancreatitis (AP) is a rare complication after liver embolization (LE) of primary and secondary liver tumors (approximately 1.7%), but it has a significant morbidity and mortality potential if associated with other complications. It usually develops early within 24 h after the LE procedure.

STUDY PURPOSE

To calculate the frequency of AP after LE in our institution and to analyze the factors involved in this procedure (anatomical features, embolization materials, cytostatic drugs, technical factors).

MATERIALS AND METHODS

118 LE (bland embolization and transarterial chemoembolization) were performed in our institution. The study group included 59 patients who met the following inclusion criteria: one or more LE events, with complete pre- and post-interventional laboratory studies including: serum Ca(2+), creatinine, blood urea nitrogen, glucose, lactate dehydrogenase, aminotransferases, alkaline phosphatase, amylase, lipase, C-reactive protein, hematocrit and leukocytes. The diagnosis of AP was established according to the criteria of the Atlanta system of classification. For the statistical analysis the association between two response variables (e.g. AP after embolization and risk factor during the embolization, AP after embolization and volume of embolic material) was evaluated using Pearson's chi(2) test and Fisher's exact test.

RESULTS

The calculated frequency of AP after LE in our series was 15.2%. Amylase and lipase were elevated up to 8.7 and 20.1 times, respectively, 24 h after LE. We observed a statistically significantly lower incidence of AP in those patients who received 2 ml or less of embospheres compared with those with an embolization volume of >2 ml (Pearson's chi(2) = 4.5000, Pr = 0.034, Fisher's exact test = 0.040). Although carboplatin was administered to 7 of 9 of the patients who developed AP after the embolization procedure, there was no statistical significance (Fisher's exact test = 0.197) for carboplatin as an AP risk factor when compared with all the patients who received this drug (n = 107).

CONCLUSION

Although AP after LE seems to have a multifactorial etiology, both the toxicity of the antineoplastic drugs (carboplatin-related toxicity) as well as direct ischemic mechanisms (non-target embolization, reflux mechanisms) may be the most important causes of the inflammatory pancreatic reaction after LE. We suggest that systematic measurement of serum pancreatic enzymes should be performed in cases of abdominal pain following selective LE and transarterial chemoembolization in order to confirm acute pancreatitis after embolization, which can clinically mimic a postembolization syndrome.

Transarterial chemoembolisation for advanced hepatocellular carcinoma: results from a North American cancer centre

AIMS

In Asian countries, transarterial chemoembolisation (TACE) has long been used for palliation of unresectable hepatocellular carcinoma (HCC) without strong evidence of improved survival or quality of life. In 2002, a survival benefi of TACE was shown in two randomised controlled trials in Europe and Hong Kong. The effectiveness of interventions fo HCC is influenced by geographical factors related to diverse patient characteristics and protocols. Therefore, the validation of TACE as palliative modality for unresectable HCC requires confirmation in diverse patient populations. The aim of the present study was to assess the effectiveness of TACE for HCC in a North American population.

MATERIALS AND METHODS

This was a single centre prospective cohort study. Child-Pugh A cirrhosis or better patients wit unresectable HCC and without radiological evidence of metastatic disease or segmental portal vein thrombosis wer assessed between November 2001 and May 2004. Of 54 patients who satisfied the inclusion criteria, 47 underwent 80 TACE sessions. Chemoembolisation was carried out using selective hepatic artery injection of 75 mg/m(2) doxorubicin and lipiodol followed by an injection of embolic particles when necessary. Repeat treatments were carried out at 2-3 month intervals for recurrent disease. The primary outcome was overall survival; secondary outcomes were morbidity and tumour response.

RESULTS

The survival probabilities at 1, 2 and 3 years were 76.6, 55.5 and 50%, respectively. At 6 months after the first intervention, 31% of patients had a partial response and 60% had stable disease by RECIST criteria. Minor adverse events occurred after 39% of TACEs and major adverse events after 20% of sessions, including two treatment-related deaths (4% of patients). One patient had complete cancer remission after undergoing three TACE treatments. Further progression of tumour growth was prevented in 91% of tumours at the 6 month point after the first TACE. At 3 months, serum levels of the tumour marker alpha-feto protein were significantly reduced in patients with elevated levels before TACE.

CONCLUSIONS

The survival probabilities at 1 and 2 years after TACE were comparable with results in randomised studies from Europe and Asia. Most patients tolerated TACE well, but clinicians need to be aware that moderately severe sideeffects require close monitoring and prompt intervention.

Usefulness and complications of computed tomography-guided lipiodol marking for fluoroscopy-assisted thoracoscopic resection of small pulmonary nodules: Experience with 174 nodules

OBJECTIVE

Several techniques have been reported for the localization of small pulmonary nodules in thoracoscopic resection. In the present study we examined the usefulness and complications of computed tomography-guided lipiodol marking for thoracoscopic resection in our experience of 174 nodules.

METHODS

Computed tomography-guided lipiodol marking was performed on 174 nodules less than 30 mm in size. Of these nodules, 45 showed ground-glass opacity images and 129 showed solid images on computed tomography. The mean size of the nodules was 10 +/- 6 mm (range, 2-30 mm), and their mean depth from the pleural surface was 10 +/- 7 mm (range, 0-30 mm). One to 7 days before thoracoscopy, all of the nodules were marked with 0.4 to 0.5 mL of lipiodol by using computed tomography. The marked nodules were grasped with a ring-shaped forceps during fluoroscopy and resected by means of thoracoscopy.

RESULTS

All the nodules could be marked and localized by means of fluoroscopy as a clear spot during thoracoscopic surgery. Complications of the marking were chest pain requiring analgesia in 16 (11%) patients, hemosputum in 11 (6%) patients, pneumothorax in 30 (17%) patients, and hemopneumothorax in 1 (0.6%) patient. Eleven (6%) patients with pneumothorax required drainage, and the patient with hemopneumothorax required an emergency operation. No other complications were observed.

CONCLUSION

Lipiodol marking is a useful, safe, and inexpensive procedure for localizing ground-glass opacity lesions, small pulmonary nodules, or both for thoracoscopic resection.

Cyanoacrylate in the treatment of gastric varices complicated by multiple pulmonary emboli

Bleeding gastric varices are increasingly being obliterated with the aid of endoscopic injection of n-butyl-cyanoacrylate (histoacryl) diluted with lipiodol. This glue acts as a tissue adhesive that polymerizes on contact with blood in a gastric varix. Severe glue pulmonary embolism is a rare complication of injection therapy. This case involves a 52-year-old man with fundal gastric varices, who developed multiple pulmonary emboli following glue injection with profound hypoxia requiring hospital admission for 13 days, but with eventual recovery of normal lung function.

A patient with portal hypertension and blindness after transjugular intrahepatic portosystemic shunt

We report on a case of recurrent variceal bleeding from gastric varices, which was treated with transjugular intrahepatic portosystemic shunt (TIPS) and Histoacryl injection into the gastric varices. Furthermore, the patient had a small patent foramen ovale without a right-to-left shunt. After the intervention, the patient developed acute neurological disorders as a result of a cerebral paradoxical embolism. In the following, we describe the potential risk of histoacryl in paradoxical embolization when used for the injection of variceal collaterals during TIPS placement in patients with portal hypertension. The present case report shows a very rare but important complication after TIPS implantation. To avoid this complication it is recommended to perform echocardiography before all TIPS placements.

Cerebral lipiodol embolism after transcatheter arterial chemoembolization of hepatocellular carcinoma

A case of cerebral lipiodol embolism after transcatheter arterial chemoembolization (TACE) of hepatocellular carcinoma is presented. A 76-year-old man underwent TACE for advanced hepatocellular carcinoma. Immediately after chemoembolization, his level of consciousness deteriorated. Computed tomography revealed deposition of iodized oil in the cerebral cortex, basal ganglia, and thalami. Magnetic resonance imaging showed restricted diffusion within the thalami and basal ganglia. The patient's level of consciousness gradually improved, and all neurologic symptoms disappeared over 6 weeks.

188Re-HDD/lipiodol for treatment of hepatocellular carcinoma: a feasibility study in patients with advanced cirrhosis

This study aimed to investigate the feasibility of the intraarterial administration of 3.7 GBq (188)Re-4-hexadecyl-1-2,9,9-tetramethyl-4,7-diaza-1,10-decanethiol/lipiodol ((188)Re-HDD/lipiodol) for treatment of hepatocellular carcinoma (HCC) in patients with moderately advanced cirrhosis.

METHODS

Patients with HCC and underlying cirrhosis classified as Child-Pugh B in terms of severity were eligible. Whole-body scintigraphies were performed at 4 time points after injection. Absorbed doses to the various organs were calculated according to the MIRD formalism. Urine was collected for 52 h after injection. Toxicity was assessed until 6 wk after administration by means of the Common Toxicity Criteria for Adverse Events (version 3.0) scale. Responses were evaluated on MRI and by alpha-fetoprotein (AFP) monitoring.

RESULTS

A mean activity +/- SD of 3.7 +/- 0.2 GBq (188)Re-HDD/lipiodol was administered in the hepatic artery to 12 patients; 36.2% +/- 5.7% of the activity was excreted in the urine 52 h after injection. The absorbed dose to the liver, lungs, kidney, and thyroid was 7.6 +/- 2.9, 4.8 +/- 2.6, 0.8 +/- 0.7, and 0.2 +/- 0.1 Gy (mean +/- SD), respectively. Two weeks after administration, 6 of 12 patients had adverse events consisting of aggravations of preexisting laboratory changes (3 patients), fatigue (2 patients), vomiting (1 patient), fever (1 patient), encephalopathy (1 patient), and ascites (1 patient). Toxicity assessment at week 6 revealed single cases of the worsening of hyperbilirubinemia, pleural effusion, thrombocytopenia, and dyspnea. Three patients dropped out of the study because of deterioration of their general condition. The response was assessable by MRI in 8 patients: 1 patient with a partial response and 7 patients with stable disease were reported. Nine patients with an initially elevated AFP were evaluated. Stable AFP was recorded in 1 patient and 3 showed a reduction, whereas a considerable increase was observed in 5 patients.

CONCLUSION

After the administration of 3.7 GBq (188)Re-HDD/lipiodol, half of the Child-Pugh B patients in the present study had a worsening of their general condition or aggravation of preexisting symptoms. This was associated with a rise in AFP in a considerable number of patients. In the future, administration of the radiopharmaceutical as close to the tumor feeding arteries as possible might avoid further deterioration of the liver function and show enhanced antitumoral activity.

A comparison of chemoembolization combination with and without radiotherapy for unresectable hepatocellular carcinoma

PURPOSE

This study evaluated the effect of transcatheter arterial chem-oembolization combined with external beam radiotherapy on the response rates and sur vival of patients with unresectable hepato-cellular carcinoma. Transcatheter arterial chemoembolization is frequently used for the treatment of this cancer, but complete or massive necrosis is seldom observed. Historically, radiotherapy for hepatocellular carcinoma has yielded poor long-term survival. Multimodality therapy has been initiated in an effort to improve survival statistics.

PATIENTS AND METHODS

We retrospectively studied 203 patients with unresectable hepa-tocellular carcinoma, who were free of tumor thrombus, lymph node involvement, or extrahepatic metastasis based on computed tomography scans of the chest and abdomen. Among the 203 patients who received transcatheter ar terial chemoembolization as initial therapy, 54 also received combination therapy with external beam radiotherapy. Tumor response rate, survival, and failure patterns were analyzed and compared between the two groups.

RESULTS

Objective responses (complete and partial responses) on computed tomography study were obser ved in 31% and 76% of patients in the non-radiotherapy and radiotherapy groups, respectively. Overall survival rates in the patients in the radiotherapy group were 71.5%, 42.3%, and 24.0% at 1, 2, and 3 years, respectively, improved over the non-radiotherapy group rates of 59.6%, 26.5%, and 11.1% at 1, 2, and 3 years, respectively. Intrahepatic failure was lower in the radiotherapy group than in the non-radiotherapy group, but the difference was not significant. Side effects from radiotherapy were common, but rarely severe.

CONCLUSIONS

This retrospective study suggests that the outcome of unresectable hepatocellular carcinoma can be influenced by radiation therapy, but a prospective randomized trial would be necessary to draw definitive conclusions.

Cerebral lipiodol embolism during transcatheter arterial chemoembolization

Cerebral lipiodol embolism (CLE) is a rare complication that may occur during chemoembolization. The authors present three cases of CLE during transcatheter arterial chemoembolization for hepatocellular carcinoma. Multiple small nonconfluent hyperintense intracerebral lesions were found on the diffusion-weighted and fluid-attenuated inversion recovery MRI. Clinical signs completely resolved and MRI lesions markedly improved on follow-up evaluation within a 3-week period.

Granulomatous meningitis as a late complication of iodized oil myelography

The present report is an autopsy case of an 83 year old man with severe kyphoscoliosis and granulomatous meningitis as a late complication of iodized oil myelography. He suffered from mild cognitive impairment and died of pneumonia. At autopsy, the brain showed yellow-brown granular material on its surface, mainly in the Sylvian fissure. Microscopically, granulation tissue was seen around areas of ossification encasing the foreign material. Iodized oil apparently changed into two types of foreign bodies: eosinophilic membranous lipodystrophy-like features and homogenous yellow crystals of various sizes. The pathology was identical to foreign-body granulomatous meningitis, caused by iodized oil myelography, and caused cognitive impairment in this patient.

Biologic dosimetry of 188Re-HDD/lipiodol versus 131I-lipiodol therapy in patients with hepatocellular carcinoma

One approach to treatment of primary hepatocellular carcinoma (HCC) is intraarterial injection of (131)I-lipiodol. Although clinical results have been positive, the therapy can be improved by using (188)Re instead of (131)I as the radionuclide. (188)Re is a high-energy beta-emitter, has a shorter half-life than (131)I, and has only low-intensity gamma-rays in its decay. The present study compared the cytotoxic effect of the radionuclide therapy in HCC patients treated with (131)I-lipiodol and (188)Re-4-hexadecyl 2,2,9,9-tetramethyl-4,7-diaza-1,10-decanethiol (HDD)/lipiodol. To this end, dicentric chromosomes (DCs) were scored in metaphase spreads of peripheral blood cultures. The equivalent total-body dose was deduced from the DC yields using an in vitro dose-response curve.

METHODS

Twenty (131)I-lipiodol treatments and 11 (188)Re-HDD/lipiodol treatments were performed on, respectively, 16 and 7 patients with inoperable HCC. Patients received a mean activity of 1.89 GBq of (131)I-lipiodol or 3.56 GBq of (188)Re-HDD/lipiodol into the liver artery by catheterization. For each patient, a blood sample was taken during the week before therapy. A blood sample was also taken 7 and 14 d after administration for the patients treated with (131)I-lipiodol and 1 or 2 d after administration for the patients treated with (188)Re-HDD/lipiodol.

RESULTS

The mean DC yield of (188)Re-HDD/lipiodol therapy (0.087 DCs per cell) was significantly lower than that of (131)I-lipiodol therapy (0.144 DCs per cell) for the administered activities. Corresponding equivalent total-body doses were 1.04 Gy for (188)Re-HDD/lipiodol and 1.46 Gy for (131)I-lipiodol. Data analysis showed that, in comparison with (131)I-lipidol, (188)Re-HDD/lipiodol yielded a smaller cytotoxic effect and a lower radiation exposure for an expected higher tumor-killing effect.

CONCLUSION

(188)Re is a valuable alternative for (131)I in the treatment of HCC with radiolabeled lipiodol, and a dose escalation study for (188)Re-HDD/lipiodol therapy is warranted.

Pulmonary and cerebral oil embolism after hysterosalpingography with oil soluble contrast medium

Pulmonary oil embolism (POE) is an extremely rare complication of hysterosalpingography (HSG). A case report of a 29-year-old woman who developed confusion and respiratory distress 12 h after HSG is presented. Intravasation of the contrast material was obvious on the HSG. High-resolution CT revealed ground-glass pattern predominantly in the lower lobes. The clinical picture and radiological findings improved on the tenth hospital day. It is believed that this is the first report of high-resolution CT findings in a case complicating HSG.

Preliminary results of transarterial rhenium-188 HDD lipiodol in the treatment of inoperable primary hepatocellular carcinoma

A multicentre study was sponsored by the International Atomic Energy Agency (Vienna) to assess the safety and efficacy of trans-arterial rhenium-188 HDD conjugated lipiodol (radioconjugate) in the treatment of patients with inoperable hepatocellular carcinoma (HCC). The radioconjugate was prepared by using an HDD (4-hexadecyl 1-2,9,9-tetramethyl-4,7-diaza-1,10-decanethiol) kit developed in Korea, and lipiodol. Over a period of 18 months, 70 patients received at least one treatment of radioconjugate. Some patients were re-treated if there was no evidence of disease progression. The level of radioconjugate administered was based on radiation-absorbed dose to critical normal organs, calculated following a "scout" dose of radioconjugate. The organs at greatest risk for radiation toxicity are the normal liver, the lung and the bone marrow. An Excel spreadsheet was used to determine maximum tolerated activity (MTA), defined as the amount of radioactivity calculated to deliver no more than 12 Gy to lungs, or 30 Gy to liver, or 1.5 Gy to bone marrow. These doses have been found to be safe in multiple trials using external beam therapy, but this has not been confirmed for systemically administered radiopharmaceuticals. Patients were followed for at least 12 weeks after therapy, until recovery from all toxicity. The clinical parameters evaluated included toxicity, response as determined by contrast-enhanced computed tomography, palliation of symptoms, overall survival, performance status (Karnofsky) and hepatic function (Child's classification). Liver function tests, serum alpha-fetoprotein (AFP) levels and complete blood counts were done at each follow-up visit. In the majority of patients, the scout dose studies indicated the radiation absorbed dose to normal liver to be the limiting factor to the treatment dose, while in a few patients dose to lung was the limiting factor. Radiation dose to bone marrow was negligible and was thus not a factor for the MTA calculations. Side-effects were minimal and usually presented as loss of appetite, right hypochondrial discomfort and low-grade fever, even at high levels of administered radioactivity. The symptoms resolved with simple supportive therapy within 3 days of onset. Liver function tests at 24 and 72 h showed no significant changes and complete blood counts at 1 week, 4 weeks and 12 weeks showed no changes (no bone marrow suppression). Sixteen patients were treated in the dose escalation phase of the study, when the activities administered started at 1.8 GBq (50 mCi) and rose to 7.7 GBq (206 mCi). In the efficacy phase of the study a further 54 patients were treated. Both groups of patients are included in this paper. The treatment activity of 188Re-lipiodol administered transarterially ranged from 1.8 to 9.8 GBq (50-265 mCi), with a mean activity of 4.6 GBq (124 mCi). Survival at 3 months was 90%, and at 6 months, 60%; 19% survived for 1 year. Mean survival after treatment in the total treated group of 70 patients was 9.5 months, with a range of 1-18 months. The results of this multicentre study show that 188Re-lipiodol is a safe and cost-effective method to treat primary HCC via the transarterial route. In terms of efficacy, it is potentially a new therapeutic approach for further evaluation by treatment of larger numbers of patients.

Rare pulmonary complications after transarterial chemoembolisation for hepatocellular carcinoma: two case reports

We report two rare cases of acute pulmonary complication after transarterial chemoembolisation for inoperable hepatocellular carcinoma. Both cases involved a large tumour and hepatic vein invasion. The first patient, a 27-year-old man, died of pulmonary tumour embolism 4 days after transarterial chemoembolisation. Acute dyspnoea developed in the second patient, a 63-year-old man, following the procedure due to pulmonary oil embolisation and chemical pneumonitis. The chest condition of this patient improved, but he subsequently died of liver failure 3 weeks later. Our cases illustrate the point that if locoregional treatment is offered as a palliative treatment, patients with hepatic vein invasion should be warned of the possible complications of massive tumour embolism, pulmonary oil embolisation, and subsequent death.

Safe radiation exposure of medical personnel by using simple methods of radioprotection while administering 131I-lipiodol therapy for hepatocellular carcinoma

The intra-arterial administration of 131I-lipiodol is a therapeutic approach increasingly used for the treatment of inoperable hepatocellular carcinomas. This technique has even become the reference treatment for hepatocellular carcinomas with portal thrombosis and is the only effective treatment to reduce the risk of recurrence among patients who could benefit from surgical operation. Currently, few data have been published concerning the levels of exposure for personnel carrying out this type of treatment. We undertook a dosimetric study targeted mainly on the exposure of the person performing the injection of 131I-lipiodol to show that this treatment can be carried out with an exposure at the extremities distinctly lower than the regulatory annual threshold by using simple means of radioprotection. The point of puncture was carried out at the level of left femoral artery, the preparation and injection of the therapeutic dose was carried out extemporaneously by the nuclear medicine specialist using a 10 ml syringe (for an injected volume of 4 ml) fitted with an adapted syringe protector. The injection was carried out as rapidly as possible under scopic control while avoiding reflux, with compression carried out by the radiologist. This study comprises 52 intra-arterial injections of 131I-lipiodol (2016+/-92 MBq). For the nuclear medicine specialists, 52 measurements were carried out at the level of the thorax and 41 on the fingers. For the radiologists, 22 measurements were carried out at the level of the thorax and six on their index fingers; nine measurements were carried out at the level of the thorax for the technologist and four at the level of the thorax for the stretcher bearer. For the nuclear medicine specialists, the average dose received at the level of the fingers varies between 140 and 443 microSv (according to the fingers) and the average dose at the thorax is 17 microSv. For the radiologists, the average dose received is 215 microSv at the level of the fingers and 15 microSv at the thorax. These results show that the administration of high therapeutic activities of 131I-lipiodol can be carried out for the exposed personnel with a dose at the level of the fingers much lower than the European regulatory limit of 500 mSv.

Iodized oil as a complement to iodized salt in schoolchildren in endemic goiter in Romania

OBJECTIVE

To evaluate the long-term efficacy and possible side effects of low doses of iodized oil on iodine nutrition and thyroid function in endemic goiter in Romania.

METHODS

Random selection of 214 schoolchildren aged 6-14 years. Serial measurements of urinary iodine, thyroid volume with ultrasound, serum concentrations of thyrotropin, free thyroxine, thyroglobulin and thyroid autoantibodies before and up to 2 years after the oral administration of 200 mg iodine in iodized oil.

RESULTS

Urinary iodine concentrations indicated a moderate iodine deficiency before therapy, sharply increased soon after therapy and slowly decreased thereafter but remained within the normal range up to more than 1 year after therapy. The prevalence of goiter was 29% before the administration of iodized oil and 9% 1 year later. Thyroid function tests and autoantibodies were normal before and up to 2 years after therapy.

CONCLUSION

A single dose of 200 mg iodine from oral Lipiodol appears adequate and safe for correcting moderate iodine deficiency in children.

Bioavailability of oral vs intramuscular iodinated oil (Lipiodol UF) in healthy subjects

BACKGROUND

In order to fight against iodine deficiency, the essential cause of endemic goiter and cretinism, several health organizations promoted campaigns of iodinated oil (Lipiodol UF) administration using iodinated oil administered intramuscularly. However, it seems preferable to administer iodinated oil orally, as this is more appropriate and since the efficacy of this route has been demonstrated as well as for intramuscular route by controlled clinical trials.

OBJECTIVE

To assess the bioavailability of iodinated oil (Lipiodol UF) administered via two different administration routes and the safety profile of this agent.

DESIGN

A randomized bioavailability study was performed comparing a single oral dose of 3 capsules (570 mg of iodine) vs a single intramuscular injection of 1 ml of Lipiodol UF (480 mg of iodine) in 36 healthy subjects followed for 9 months.

RESULTS

The results show that, at these dosages, the 24 h urinary iodine values are above baseline for both oral and intramuscular administrations (im: >12 months/oral: 6 months) for prolonged period of time. In terms of safety, Lipiodol, administered by im injection or orally, did not induce any undesirable effects or any alteration of thyroid function tests in this study.

CONCLUSIONS

In conclusion, this study shows that im or oral administration of a single dose of Lipiodol provides a significant and prolonged iodine supplement. The results obtained confirm the possibility of protection of exposed populations after annual administration of an appropriate single oral dose, without inducing any clinical or laboratory adverse effects. The product, by either route of administration, has a prolonged efficacy in iodine-deficient subjects (im: 2-3 years/oral: 1 year).

Thyroid uptake and radiation dose after 131I-lipiodol treatment: is thyroid blocking by potassium iodide necessary?

In radionuclide therapy with iodine-131 labelled pharmaceuticals, free (131)I may be released and trapped by the thyroid, causing an undesirable radiation burden. To prevent this, stable iodide such as potassium iodide (KI) can be given to saturate the thyroid before (131)I is administered. The guidelines of the European Association of Nuclear Medicine do not, however, recommend special precautions when administering (131)I-lipiodol therapy for hepatocellular carcinoma. Nevertheless, some authors have reported (131)I uptake in the thyroid as a consequence of such therapy. In this study, the influence of prophylactic KI on the thyroid uptake and dose (MIRD dosimetry) was prospectively investigated. (131)I-lipiodol was given as a slow bolus selectively in the proper hepatic artery or hyperselectively in the right and/or left hepatic artery. Patients were prospectively randomised into two groups. One group received KI in a dose of 100 mg per day starting 2 days before (131)I-lipiodol administration and continuing until 2 weeks after therapy (KI group; n=31), while the other group received no KI (non-KI group; n=37). Thyroid uptake was measured scintigraphically as a percentage of administered activity 7 days after (131)I-lipiodol ( n=68 treatments). The absorbed radiation dose to the thyroid was assessed by scintigraphy after 7 and 14 days using a mono-exponential fitting model and MIRD dosimetry ( n=40 treatments). The mean activity of (131)I-lipiodol administered was 1,835 MBq in a volume of 2 ( n=17) or 4 ( n=51) ml. Thyroid uptake was lower in the KI group, being 0.23%+/-0.06% of injected activity ( n=31) compared with 0.42%+/-0.20% in the non-KI group ( n=37); the mean thyroid dose was 5.5+/-1.6 Gy in the KI group ( n=19) versus 11.9+/-5.9 Gy in the non-KI group ( n=21). These differences were statistically significant ( P<0.001). No effect of the amount of added cold lipiodol (4 vs 2 ml total volume) or selectivity of (131)I-lipiodol administration was evident ( P>0.1). (131)I-lipiodol is associated with a generally low thyroid uptake and dose that may be significantly decreased by KI premedication. Given the low cost and the very good tolerance of the KI treatment, we believe the use of KI should be recommended in the majority of the patients.

Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma

This randomized, controlled trial assessed the efficacy of transarterial Lipiodol (Lipiodol Ultrafluide, Laboratoire Guerbet, Aulnay-Sous-Bois, France) chemoembolization in patients with unresectable hepatocellular carcinoma. From March 1996 to October 1997, 80 out of 279 Asian patients with newly diagnosed unresectable hepatocellular carcinoma fulfilled the entry criteria and randomly were assigned to treatment with chemoembolization using a variable dose of an emulsion of cisplatin in Lipiodol and gelatin-sponge particles injected through the hepatic artery (chemoembolization group, 40 patients) or symptomatic treatment (control group, 40 patients). One patient assigned to the control group secondarily was excluded because of unrecognized systemic metastasis. Chemoembolization was repeated every 2 to 3 months unless there was evidence of contraindications or progressive disease. Survival was the main end point. The chemoembolization group received a total of 192 courses of chemoembolization with a median of 4.5 (range, 1-15) courses per patient. Chemoembolization resulted in a marked tumor response, and the actuarial survival was significantly better in the chemoembolization group (1 year, 57%; 2 years, 31%; 3 years, 26%) than in the control group (1 year, 32%; 2 years, 11%; 3 years, 3%; P =.002). When adjustments for baseline variables that were prognostic on univariate analysis were made with a multivariate Cox model, the survival benefit of chemoembolization remained significant (relative risk of death, 0.49; 95% CI, 0.29-0.81; P =.006). Although death from liver failure was more frequent in patients who received chemoembolization, the liver functions of the survivors were not significantly different. In conclusion, in Asian patients with unresectable hepatocellular carcinoma, transarterial Lipiodol chemoembolization significantly improves survival and is an effective form of treatment.

High-dose iodized oil transcatheter arterial chemoembolization for patients with large hepatocellular carcinoma

AIM: To conduct a randomized trial to evaluate the role of using high-dose iodized oil transcatheter arterial chemoembolization(TACE) in the treatment of large hepatocellular carcinoma (HCC).

METHODS: From January 1993 to June 1998, 473 patients with unresectable hepatocellular carcinoma were divided into two groups: 216 patients in group A received more than 20mL iodized oil during the first TACE treatment; 257 patients in group B received 5-15 mL iodized oil in the same way. The Child’s classification and ICG-R15 for evaluating the liver function of the patients were done before the treatment. During the TACE procedure the catheters was inserted into the target artery selectively and the tumor vessels were demonstrated with contrast medium in the hepatic angiography. The anticancer drug mixed with iodized oil (Lipiodol) were Epirubicin and Mitomycin. In group A, 112 cases received 20-29 mL Lipiodol in the first procedure, 85 cases 30-39 mL, 19 cases more than 40 mL. The largest dose was 53 mL and the average dose was 28.3 mL. In group B, 119 cases received 5-10 mL Lipiodol, 138 cases received 11-15 mL, and the average dose was 11.8 mL.

RESULTS: High-dose Lipiodol chemoembolization caused tolerable side effects and a little hurt to the liver function in the patients with Child grade A or ICG-R15 < 20. But the patients with child grade B or ICG-R15 > 20 had higher risk of liver failure after high-dose TACE. More type I and type II lipiodol accumulations in CT scan after 4 weeks of TACE were seen in the group A patients than those in the group B patients (P < 0.01). The resection rate and complete tumor necrosis rate in group A were higher than those of group B (P < 0.05). The 1-,2-,3-year survival rates of group A patients with Child grade A were 79.2%, 51.8% and 34.9%, respectively, better than those of group B (P < 0.001).

CONCLUSION: High-dose Lipiodol can result in more complete tumor necrosis by blocking both arteries and small portal vein of the tumor. High-dose TACE for treatment of large and hypervascular hepatocellular carcinoma is practically acceptable with the better effect than the routine dose. For the patients with large and hypervascular tumor of Child grade A liver function or ICG-R15 less than 20%, oily chemoembolization with 20-40 mL Lipiodol is recommended.

Long-term prognosis of patients undergoing transcatheter arterial chemoembolization for unresectable hepatocellular carcinoma: comparison of cisplatin lipiodol suspension and doxorubicin hydrochloride emulsion

PURPOSE

To evaluate long-term prognosis of transcatheter arterial chemoembolization (TACE) with use of cisplatin (CDDP) lipiodol (LPD) suspension (CDDP/LPD) compared with that with use of doxorubicin hydrochloride (ADM) LPD emulsion (ADM/LPD) in patients with unresectable hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

One hundred eight patients were treated with use of CDDP/LPD and 26 were treated with use of ADM/LPD. Survival rates and frequency of side effects and complications in the CDDP/LPD group were compared with those in the ADM/LPD group.

RESULTS

CDDP/LPD was given at a dose of 15-70 mg (mean dose, 41 mg), whereas ADM/LPD was given at a dose of 20-100 mg (mean dose, 57 mg) throughout the study period. The survival rates in the CDDP/LPD group were 81% at 1 year, 41% at 3 years, 19% at 5 years, and 13% at 7 years, whereas those in the ADM/LPD group were 67% at 1 year, 18% at 3 years, and 0% at 5 years. The CDDP/LPD group showed significantly better survival than the ADM/LPD group (P <.05). In the CDDP/LPD group, there was a significant prolongation of survival in patients with monofocal HCC (P <.05) and patients with HCC assessed as an almost complete LPD accumulation (P <.05). There were no significant differences in survival rates in the ADM/LPD group according to tumor size and number of tumors. Hepatic failure was observed in 8% of all procedures and was not different between the two therapeutic groups. Renal dysfunction was observed in 2% of all treatments involving CDDP/LPD, and it resolved spontaneously with appropriate medications.

CONCLUSIONS

TACE with use of low-dose CDDP was efficacious for unresectable HCC and had few complications. TACE with use of CDDP may contribute to prolongation of the life span of patients with HCC versus TACE with use of ADM.

[Transarterial chemoembolization with high dose iodized oil for the treatment of large hepatocellular carcinoma]

OBJECTIVE

To report the method and result of high dose iodized oil chemoembolization for the treatment of large hepatocellular carcinoma.

METHODS

From 1993 to 1998, 163 patients with unresectable hepatocellular carcinoma were treated by transarterial chemoembolization (TACE) with more than 20 ml lipiodol.

RESULTS

TACE with high dose lipiodol was well tolerated by the treated patients. In patients whose liver function was of Child A stage, or in patients whose residual indocyanine green level 15 min after injection was less than 20%, the frequency of post-treatment hepatic insufficiency was not significantly different from that of patients treated with routine dose of lipiodol. On CT scan at 4 wk after TACE, more lipiodol was located in the liver. The 1-, 2-,3-year survival rate of patients in Child A stage was 79.8%, 50.3%, and 38.5%, respectively, as compared to 57.5%, 24.8% and 8.37%, respectively in patients treated with routine dose of lipiodol (P = 0.0136).

CONCLUSION

High dose lipiodol TACE for the treatment of large hepatocellular carcinoma is practically acceptable with better therapeutic effect but its use should be limited to those patients with compensated liver function.

Side-effects of iodized oil administration in patients with simple goiter

The objective of this study was to determine side-effects associated with iodized oil injection in patients with simple goiter. In an iodine-deficient population, 3420 patients with simple goiter, who were not taking supplemental iodine, were chosen for this study. They received a single intramuscular injection of 1 ml iodized oil, containing 480 mg iodide. Clinical and laboratory evaluations were performed every 3 months for one year and every 6 months for the next 4 years. The incidence of hypo- and hyperthyroidism was 0.6% each, with equal prevalence in both sexes. Most cases of hypo- and hyperthyroidism were observed during the first 5 months after the injection. Eight cases of hyperthyroidism were asymptomatic. A further 8 patients had overt thyrotoxicosis and required treatment with methimazole for 18 months. Recurrence of hyperthyroidism was observed in one patient. Five hypothyroid patients were diagnosed only by abnormal thyroid function tests, and 4 cases needed no treatment. Others received T4 treatment for a mean of 14.5 months. Among 14 T4-treated patients, recurrence of hypothyroidism occurred in 7 patients after treatment was discontinued. Twenty-nine patients (0.8%) were afflicted with dermatologic complications. The most common dermatologic side-effect was urticarial reaction. In 15 subjects, skin lesions appeared 8 to 14 days after injection. It is concluded that side-effects of iodized oil injection are rare, and in most cases the complications are transient and self-limited. The occurrence of iodine induced hyperthyroidism following iodized oil administration is close to the ratio observed in spontaneous thyrotoxicosis.

Physiology and pharmacology of iodized oil in goiter prophylaxis

Thyroid complications resulting from excess iodide such as thyrotoxicosis, thyroiditis, sialadenitis, or hypothyroidism are much rarer after iodine supplementation with Lipiodol than with KI. They do not militate against its widespread use in endemic goiter populations, especially in pregnant women. However, patients with multinodular goiter should not be treated or should be treated only under careful observation. When Lipiodol-induced thyrotoxicosis occurs it tends to be mild or even subclinical and self-limited. If treatment is required, potassium perchlorate with or without thionamides is recommended. Iodide goiter has not been seen after Lipiodol supplementation, nor has thyroiditis. Sialadenitis occurs rarely. Iodide derived from Lipiodol readily enters the fetus, possibly by active transport, and theoretically endangers the fetus because autoregulation of the fetal thyroid occurs late during gestation. Despite the difficulty in distinguishing iodide goiter from iodide deficiency goiter of the newborn, no cases of neonatal iodide goiter have been reported. Possible mechanisms of thyroid inhibition by excess iodide are briefly discussed. The use of locally produced iodized plant oils is recommended for financial reasons as well as for the benefits derived from local participation.

Pulmonary lipiodol embolism during transcatheter arterial chemoembolization for hepatoblastoma under general anaesthesia

We present a case of pulmonary embolism that occurred during the injection of lipiodol during transcatheter arterial chemoembolization under general anaesthesia. A 7-year-old child suffering from a large hepatoblastoma was admitted for arterial chemoembolization and carcinostatic administration. Pulmonary embolism due to lipiodol during arterial chemoembolization was evident by a sudden fall in oxyhaemoglobin saturation from 100 to 90%. This was associated with a spread of lipiodol into both lungs, particularly the middle lung zones and detected by chest fluoroscopy. Arterial blood gases returned to normal values 1 day later but pulmonary infiltration persisted for 7 days before final clearance. Pulmonary embolism caused by lipiodol during arterial chemoembolization is infrequent, but such a complication could prove fatal. Understanding the risk of pulmonary embolism in patients receiving lipiodol, during and after arterial chemoembolization, and late onset pulmonary injury is important and a close follow-up for several days after arterial chemoembolization is advisable.

Tumor-targeted chemotherapy with SMANCS in lipiodol for renal cell carcinoma: longer survival with larger size tumors

OBJECTIVES

To evaluate the anticancer effects of a lipophilic macromolecular anticancer agent, poly(styrene-co-maleic acid)-conjugated neocarzinostatin (SMANCS), dissolved in a lipid contrast medium (Lipiodol) given via the renal artery to patients with renal cell carcinoma.

METHODS

Among 467 patients with renal cell carcinoma treated between April 1984 and March 1993, 191 were treated with SMANCS dissolved in a lipid contrast medium (a 3:2 mixture of Lipiodol F and Lipiodol Ultrafluid; Lpd). Selective arterial infusion of SMANCS/Lpd was performed at a dose of 1.0 or 1. 5 mg/mL. The infusion was repeated at intervals of about 2 weeks or longer, but the doses and the total number of infusions varied among patients, according to results of computed tomography analysis.

RESULTS

Statistical analysis was performed for 415 patients who met the criteria of this study. Twenty-six surgical patients with metastases who underwent infusion therapy of SMANCS/Lpd for primary lesions showed 3 and 5-year survival rates of 23.0% and 12.8%, respectively; the rates were 19.3% and 9.7% in 31 patients who did not receive SMANCS infusion therapy. In 125 surgical patients without metastases who underwent SMANCS/Lpd infusion, the 5 and 10-year survival rates were 83.0% and 75.2%, respectively, whereas rates of 84.6% and 78.9% were observed in 199 surgical patients whose median tumor size was significantly smaller, however, than the SMANCS/Lpd infusion group. The maximal tumor diameter at the beginning of treatment was significantly larger (mean diameter 70.8 mm) in the SMANCS/Lpd infusion group than in the noninfusion group (59.1 mm). The survival rate was statistically better for patients with tumors of 100 mm diameter or larger in the SMANCS/Lpd infusion group (P <0.05): 5 and 10-year survival rates were 70.4% and 61.6%, respectively, for the infusion group and 64.6% and 50.9% for the group receiving no drug. In patients with larger tumor (greater than 110 mm), the survival rate at 13 years was 75% in the SMANCS/Lpd infusion group and 0% in the surgery group.

CONCLUSIONS

Arterial infusion therapy with SMANCS/Lpd appears to be effective for large renal cell carcinoma without metastases in conjunction with surgery.

Thrombotic risk associated with the use of iodinated contrast media in interventional cardiology: pathophysiology and clinical aspects

A review of the current knowledge of the anti-thrombotic properties of iodinated contrast media (CM) has been conducted. CM are classified according to their chemical structure, either ionic or non-ionic (monomeric or dimeric). Numerous in vitro and in vivo data show that, although all CM have anti-coagulant properties, ionic molecules are more potent than non-ionic and, furthermore, do not activate resting platelets, unlike non-ionic agents. These properties may lead to a decrease in thrombus formation during interventional procedures. Several clinical trials have shown that CM may play a role in the occurrence of acute thrombotic complications but also in delayed ischaemic events during interventional procedures. A recent meta-analysis showed that, compared to non-ionic monomers, ionic low-osmolar CM reduce the rate of coronary artery abrupt closure, but no significant difference was found with respect to ischaemic complications. Ionic CM lead to a lower deposit of thrombotic materials on catheters and guide-wires. To date, clinical data comparing ionic CM and non-ionic dimers are scarce, significantly heterogeneous and, unlike experimental data, they do not show differences between both classes of CM. Further studies are required to better understand the precise mechanisms of such interactions and to analyse the effect of CM when new antiplatelet agents or new procedures (stenting) are used, to comply with new clinical strategies.

Adjuvant hepatic arterial infusion chemotherapy after radical hepatectomy for hepatocellular carcinoma--results of long-term follow-up

BACKGROUND/AIMS

This clinical study aimed to clarify the effectiveness and indication of adjuvant hepatic arterial infusion chemotherapy (HAIC) that is performed to prevent recurrence after radical hepatectomy for hepatocellular carcinoma (HCC).

METHODOLOGY

From January 1986 to December 1992, 135 HCC patients, who tolerated curative hepatic resection in which all of the macroscopic HCC was removed, were included in this study. They were divided into two groups. One group was comprised of 68 patients who received HAIC after radical hepatectomy (HAIC (+) group), and the other group was comprised of 67 patients who received radical hepatectomy alone (HAIC (-) group). In the HAIC (+) group, an emulsion of doxorubicin (30-50 mg) and lipiodol (3-5 ml) was injected from a reservoir every 2 or 3 months for 1 year.

RESULTS

The cumulative survival rates in the HAIC (+) group (79.1%, 54.5% and 39.9% at 3, 5, and 7 years after hepatectomy, respectively) were better than those in the HAIC (-) group (69.2%, 38.1% and 26.8%, respectively) (p = 0.086). The disease-free survival rates in the HAIC (+) group (50.8%, 31.7% and 25.6% at 3, 5, and 7 years after hepatectomy, respectively) were significantly better than those in the HAIC (-) group (25.7%, 20.6% and 6.4%, respectively) (p = 0.006). This improvement was evident for 3 years after hepatectomy. The adjuvant HAIC was effective especially in patients with good liver function, whose tumor size ranged between 2.1 cm and 5 cm in diameter, and who received a minor hepatic resection.

CONCLUSIONS

Adjuvant HAIC was effective in preventing recurrence after radical hepatectomy for HCC. This treatment is especially indicated for patients with good liver function, whose tumor size ranges between 2.1 cm and 5 cm in diameter, and who have received a minor hepatic resection.

Cerebral and renal embolization after lymphography in a patient with non-Hodgkin lymphoma: case report

An unusual case of lipid embolization to brain and kidney after lymphography in a patient with non-Hodgkin lymphoma of the upper anterior mediastinum is reported. Contrast material-enhanced echocardiography demonstrated a right-to-left shunt to the left atrium without evidence of a patent foramen ovale. Echo contrast particles were transiently present within the tumor surrounding the great vessels.