Fumie Sugihara

Interventional treatment for unresectable hepatocellular carcinoma

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

Endovascular embolization strategy for renal arteriovenous malformations.

Background Renal arteriovenous malformations (AVMs) are rare vascular malformations that cause hematuria. Treatment for renal AVMs has evolved from open nephrectomy to transcatheter arterial embolization (TAE). Purpose To retrospectively evaluate efficacy and adverse events of TAE for renal AVMs. Material and Methods We examined 12 patients (three men, nine women; mean age, 56 years) with renal AVM with gross hematuria, who underwent 14 sessions of treatment, using various embolization materials (liquid embolization agents, gelatin sponge, and coils). Among the 12 patients, 10 had cirsoid AVMs, eight of which were high-flow lesions. The remaining two patients had aneurismal AVMs. We assessed technical and clinical success, and also complications. All patients were followed for 7–92 months (mean, 48 months). Results Technical success was obtained in all patients. Primary clinical success was obtained in all patients; however, recurrence was observed in two patients who were treated with coils alone. A second session of TAE led to the sustained relief of symptoms. Clinical success rate was significant better (P = 0.045) when coils combined with other agents or liquid agents were used, than when only coils were used. No major complications occurred in any of patients; post-embolization syndrome and deterioration of renal function were not observed. Conclusion TAE treatment was safe, effective, and provided a good outcome, except when only coils were used as the embolization agent.

Transcatheter arterial embolization of anomalous systemic arterial supply to the basal segment of the lung

We describe the case of a 67-year-old woman with an anomalous systemic arterial supply to the basal segment of the lung, which was managed successfully by transcatheter arterial embolization (TAE) with microcoils. Her chest computed tomography (CT) scan showed diffuse ground-glass opacity in the left lower lobe, no bronchial abnormalities, and blood supply from an anomalous artery originating from the descending thoracic aorta, with drainage to the normal pulmonary vein. We successfully performed TAE under balloon occlusion of the anomalous artery, without complications. TAE is a minimally invasive, safe, and valuable method, and could be used as first-line treatment in such cases.

Management of Gastric Varices Unsuccessfully Treated by Balloon-Occluded Retrograde Transvenous Obliteration: Long-Term Follow-Up and Outcomes

Our aim was to evaluate the long-term efficacy and safety of percutaneous transhepatic obliteration (PTO) alone and combined with balloon-occluded retrograde transvenous obliteration (BRTO) for gastroesophageal varices refractory to BRTO alone. Between July 1999 and December 2010, 13 patients with gastroesophageal varices refractory to BRTO were treated with PTO (n = 6) or a combination of PTO and BRTO (n = 7). We retrospectively investigated the rates of survival, recurrence, or worsening of the varices; hepatic function before and after the procedure; and complications. The procedure achieved complete obliteration or significant reduction of the varices in all 13 patients without major complications. During follow-up, the varices had recurred in 2 patients, of which one had hepatocellular carcinoma, and the other died suddenly from variceal rebleeding 7 years after PTO. The remaining 11 patients did not experience worsening of the varices and showed significant improvements in the serum ammonia levels and prothrombin time. The mean follow-up period was 90 months, and the cumulative survival rate at 1, 3, and 5 years was 92.9%, 85.7%, and 85.7%, respectively. Both PTO and combined PTO and BRTO seem as safe and effective procedures for the treatment of gastroesophageal varices refractory to BRTO alone.

Amplatzer Vascular Plug Anchoring Technique to Stabilize the Delivery System for Microcoil Embolization

PurposeTo evaluate the feasibility of a novel embolization technique, the Amplatzer vascular plug (AVP) anchoring technique, to stabilize the delivery system for microcoil embolization.Materials and methodsThree patients were enrolled in this study, including two cases of internal iliac artery aneurysms and one case of internal iliac arterial occlusion prior to endovascular aortic repair. An AVP was used in each case for embolization of one target artery, and the AVP was left in place. The AVP detachment wire was then used as an anchor to stabilize the delivery system for microcoil embolization to embolize the second target artery adjacent to the first target artery. The microcatheter for the microcoils was inserted parallel to the AVP detachment wire in the guiding sheath or catheter used for the AVP.ResultsThe AVP anchoring technique was achieved and the microcatheter was easily advanced to the second target artery in all three cases.ConclusionThe AVP anchoring technique was found to be feasible to advance the microcatheter into the neighboring artery of an AVP-embolized artery.

Minimizing Systemic Leakage of Cisplatin during Percutaneous Isolated Pancreas Perfusion Chemotherapy: A Pilot Study

PURPOSE To evaluate the feasibility of percutaneous isolated pancreas perfusion (PIPP) by using a pig model. MATERIALS AND METHODS All experiments were approved by the institutional Animal Experiment Ethics Committee. Fifteen pigs were assigned to five groups, and PIPP was performed. Angiographic and dye injection studies were performed to confirm the patency of the PIPP system (group 1). Blood that contained cisplatin (1.5 mg per kilogram of body weight) in an extracorporeal circuit was circulated through the pancreas at three infusion rates (40, 60, and 80 mL/min) to determine the optimal infusion rate in terms of safety and pharmacologic effectiveness (groups 2, 3, and 4, respectively). Chronological laboratory data and histologic findings were assessed in group 5, which received the optimal infusion rate. Maximum platinum concentration (Cmax) and area under the platinum concentration-time curve were compared by using the Kruskal-Wallis and Mann-Whitney U tests. RESULTS Angiography and dye injection confirmed the patency of the PIPP system. Histopathologic examinations showed no abnormalities in the pancreas or other organs at a 40 mL/min infusion rate of cisplatin. However, edematous changes in the pancreas were observed at higher infusion rates. The pharmacologic effectiveness did not differ significantly among groups; therefore, the optimal infusion rate of 40 mL/min was selected. The median pancreatic-to-systemic exposure ratios were 71.8 for Cmax and 54.8 for the area under the curve. All laboratory data remained normal or returned to pretreatment levels within 1 week. CONCLUSION PIPP at a 40 mL/min infusion rate appears to be safe and feasible for perfusion of the pancreas.

Improved efficacy of transcatheter arterial chemoembolization using warmed miriplatin for hepatocellular carcinoma.

The aim of this study was to evaluate the efficacy and safety of transcatheter arterial chemoembolization (TACE) using warmed and nonwarmed miriplatin for hepatocellular carcinoma. Eighty patients (117 nodules), treated between January 2010 and June 2013, were evaluated. Thirty-two and 85 nodules were treated with nonwarmed and warmed miriplatin, respectively. The efficacy of TACE was evaluated on a per nodule basis according to treatment effect (TE). Adverse events were evaluated according to the Common Terminology Criteria for Adverse Events (CTCAE) v4.0. TE grades were significantly improved in the warmed group compared to the nonwarmed group (nonwarmed: TE 4, 12.5%; TE 3, 0%; TE 2, 15.6%; TE 1, 71.9%; warmed: TE 4, 34.1%; TE 3, 5.9%; TE 2, 9.4%; TE 1, 50.6%; P = 0.017) . Multivariate analysis revealed significant impact of warming miriplatin on objective response rate (odds ratio, 12.35; 95% confidence interval, 2.90–90.0; P = 0.0028). CTCAE grades of elevated aspartate and alanine transaminase after TACE were significantly higher in the warmed group (P = 0.0083 and 0.0068, resp.); however, all adverse events were only transient. The use of warmed miriplatin in TACE significantly improved TE without causing serious complications.

Coil embolization using microballoon assistance combined with the double-catheter technique for a large superior mesenteric arterial pseudoaneurysm and fistula secondary to acute pancreatitis

Pseudoaneurysm of the superior mesenteric artery (SMA) is rare and associated with the risk of massive fatal hemorrhage and acute mesenteric ischemia. We describe a 43-year-old man with acute pancreatitis who presented with an SMA pseudoaneurysm measuring 13 × 12 cm in diameter. The pseudoaneurysm originated between the first and second jejunal arteries and drained into the mesenteric vein. The SMA trunk between the first and second jejunal arteries was embolized with detachable coils using microballoon assistance. After coil placement, arteriography showed the collateral circulation and no perfusion delay of the distal SMA. This technique was useful for isolation of the SMA pseudoaneurysm.

Novel treatment strategy for advanced hepatocellular carcinoma: combination of conventional transcatheter arterial chemoembolization and modified method with portal vein occlusion for cases with arterioportal shunt: a preliminary study

Background A novel strategy to combine conventional transcatheter arterial chemoembolization (TACE) and TACE during portal vein occlusion (TACE-PVO) in the presence of high-flow arterioportal shunt (APS) has been developed to treat hepatocellular carcinoma (HCC) with portal invasion. Purpose To evaluate the efficacy of this strategy. Material and Methods Twenty-five cases of HCC with portal invasion, treated between April 2006 and December 2015, were evaluated. Balloon occlusion of the portal venous outlet was performed in eight cases of high-flow APS when performing TACE. Conventional TACE was performed in the other 17 cases. The primary endpoint was overall survival. Adverse events and deterioration of liver function were also evaluated. Results The median survival time (MST) was 12 months. One-, two-, and three-year survival rates were 48.0%, 39.3%, and 26.2%, respectively. Subgroup analysis and multivariate analysis revealed the CLIP score as prognostic factor. MST was 2.5 months in the subgroup with CLIP score ≥4 and 26.0 months in the subgroup with CLIP score ≤3 (hazard ratio = 7.7, 95% confidence interval = 2.3–25.8). Transient elevations of the levels of transaminase and bilirubin were observed; however, deterioration of liver function was infrequent; upgrading of Child-Pugh class in 9.1% of cases. Conclusion A novel strategy, combining conventional TACE and TACE-PVO, is effective for HCC with portal invasion. The CLIP score may be useful for considering treatment indication.

Evaluation of the relationship between hepatocellular carcinoma location and transarterial chemoembolization efficacy

AIM To evaluate the relationship between the location of hepatocellular carcinoma (HCC) and the efficacy of transarterial chemoembolization (TACE). METHODS We evaluated 115 patients (127 nodules), excluding recurrent nodules, treated with TACE between January 2011 and June 2014. TACE efficacy was evaluated according to mRECIST. The HCC location coefficient was calculated as the distance from the central portal portion to the HCC center (mm)/liver diameter (mm) on multiplanar reconstruction images rendered (MPR) to visualize bifurcation of the right and left branches of the portal vein and HCC center. The HCC location coefficient was compared between complete response (CR) and non-CR groups in Child-Pugh grade A and B patients. RESULTS The median location coefficient of HCC among all nodules, the right lobe, and the medial segment was significantly higher in the CR group than in the non-CR group in the Child-Pugh grade A patients (0.82 vs 0.62, P < 0.001; 0.71 vs 0.59, P < 0.01; 0.81 vs 0.49, P < 0.05, respectively). However, there was no significant difference in the median location coefficient of the HCC in the lateral segment between in the CR and in the non-CR groups (0.67 vs 0.65, P > 0.05). On the other hand, in the Child-Pugh grade B patients, the HCC median location coefficient in each lobe and segment was not significantly different between in the CR and in the non-CR groups. CONCLUSION Improved TACE efficacy may be obtained for HCC in the peripheral zone of the right lobe and the medial segment in Child-Pugh grade A patients.