Hidenori Yamaguchi

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.

Evaluation of right adrenal vein cannulation by computed tomography angiography in 140 consecutive patients undergoing adrenal venous sampling

OBJECTIVE As it is now known that primary aldosteronism (PA) is more prevalent than was previously recognized, and is a potentially curable cause of hypertension and related cardiovascular diseases, the search for a safe and effective means of its diagnosis has reemerged as a topic of interest. Adrenal venous sampling is the gold standard for diagnosis of PA, but the technique is challenging and the small right adrenal vein can be particularly difficult to cannulate. Our objective was to evaluate the usefulness of computed tomography during angiography (angio-CT) in increasing the success of adrenal venous sampling and to identify factors associated with cannulation failure. DESIGN Retrospective review. METHODS A total of 140 consecutive patients with suspected PA except Cushings syndrome treated at a single hospital from June 2008 to May 2013 were included. Catheter misplacement and correct cannulation rates before angio-CT and success rate of sampling after angio-CT were calculated. Univariate analysis for factors related to incorrect cannulation included gender, age, height, weight, BMI, and adrenal nodules. Successful sampling was biochemically defined according to cortisol concentrations in the venous blood samples. RESULTS Angio-CT detected misplaced catheters in 13 patients (9.3%). The calculated correct cannulation rate of adrenal vein sampling increased from 86.4% before angio-CT to 95.7% after CT (P<0.001, McNemars test). Univariate analysis showed a tendency for a higher rate of failure of right adrenal venous sampling in taller patients (P=0.052, Mann-Whitneys U test). CONCLUSION Angio-CT improved success of adrenal venous sampling.

Beam-hardening artifacts on computed tomography images caused by lanthanum carbonate hydrate in a patient on dialysis

Lanthanum carbonate hydrate is a nonaluminum, noncalcium phosphate binder containing lanthanum (La). It is effective in decreasing the serum phosphate level in patients on dialysis. Because the atomic number of the La contained in lanthanum carbonate hydrate is relatively high, at 57, this agent may cause strong artifacts on computed tomography (CT) images, which may be mistakenly interpreted as foreign bodies. We recently performed CT examination of a patient on Fosrenol chewable tablets (i.e., lanthanum carbonate hydrate). The CT images were difficult to evaluate because of strong beam hardening artifacts, and differentiation from foreign body aspiration was required. We report here our experience and a discussion of the characteristics of this artifact.

Contribution of extrahepatic collaterals to liver parenchymal circulation after proper hepatic artery embolization.

To retrospectively evaluate proper hepatic artery embolization, with respect to the development of extrahepatic collaterals.

Anatomical relationship between the common carotid artery and the internal jugular vein during head rotation

This study investigated the anatomical relationship between the common carotid artery and internal jugular vein during head rotation for the effective performance of percutaneous transjugular procedures. The subjects included 30 volunteers who had never undergone internal jugular vein cannulation. In the supine position, two-dimensional ultrasonographic images of the right internal jugular vein and common carotid artery were obtained, 2 and 4 cm above the clavicle, along the lateral border of the sternal head of the sternocleidomastoid muscle. Ultrasonographic images were examined for head rotation at 0°, 15°, 30°, 45°, 60°, and 75° from the midline to the left. The percentage of overlap of the common carotid artery by the internal jugular vein and the flattening of the internal jugular vein at each head rotation position were measured and evaluated. The overlap of the common carotid artery by the internal jugular vein significantly increased at ≥45° of head rotation 2 cm above the clavicle (P < 0.01) and at ≥30° of head rotation 4 cm above the clavicle (P < 0.01), compared with that observed in the neutral position. The flattening of the internal jugular vein significantly decreased at ≥45° of head rotation 2 cm above the clavicle (P < 0.01) and at ≥30° of head rotation 4 cm above the clavicle (P < 0.01). Head rotation should be kept to <45° at 2 cm above the clavicle and <30° at 4 cm above the clavicle to decrease the risk of accidental puncture of the common carotid artery during internal jugular vein puncture. Moreover, flattening of the internal jugular vein gradually decreases during head rotation to the side.

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.

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.

Haemodynamic changes in hepatocellular carcinoma and liver parenchyma under balloon occlusion of the hepatic artery

AbstractObjectivesTo investigate haemodynamic changes in hepatocellular carcinoma (HCC) and liver under hepatic artery occlusion.MethodsThirty-eight HCC nodules in 25 patients were included. Computed tomography (CT) during hepatic arteriography (CTHA) with and without balloon occlusion of the hepatic artery was performed. CT attenuation and enhancement volume of HCC and liver with and without balloon occlusion were measured on CTHA. Influence of balloon position (segmental or subsegmental branch) was evaluated based on differences in HCC-to-liver attenuation ratio (H/L ratio) and enhancement volume of HCC and liver.ResultsIn the segmental group (n = 20), H/L ratio and enhancement volume of HCC and liver were significantly lower with balloon occlusion than without balloon occlusion. However, in the subsegmental group (n = 18), H/L ratio was significantly higher and liver enhancement volume was significantly lower with balloon occlusion; HCC enhancement volume was similar with and without balloon occlusion. Rate of change in H/L ratio and enhancement volume of HCC and liver were lower in the segmental group than in the subsegmental group. There were significantly more perfusion defects in HCC in the segmental group.ConclusionsHepatic artery occlusion causes haemodynamic changes in HCC and liver, especially with segmental occlusion.Key Points• Hepatic artery occlusion causes haemodynamic changes in hepatocellular carcinoma and liver. • Segmental occlusion decreased rate of change in hepatocellular carcinoma-to-liver attenuation ratio. • Subsegmental occlusion increased rate of change in hepatocellular carcinoma-to-liver attenuation ratio. • Hepatic artery occlusion decreased enhancement volume of hepatocellular carcinoma and liver. • Hepatic artery occlusion causes perfusion defects in hepatocellular carcinoma.