Jun Koizumi

Transcatheter arterial chemoembolization plus radiofrequency ablation therapy for early stage hepatocellular carcinoma: comparison with surgical resection.

Radiofrequency ablation (RFA) is becoming a well‐known local therapy for hepatocellular carcinoma (HCC). Transcatheter arterial chemoembolization (TACE) is expected to enhance the effects of subsequent RFA by reducing arterial blood flow. However, the long‐term efficacy of this combined therapy has not been elucidated. In this study, the survival rates of patients who received TACE combined with RFA (TACE + RFA) were compared with those of patients treated surgically.

The conventional balloon-occluded retrograde transvenous obliteration procedure: indications, contraindications, and technical applications.

Transvenous obliteration of gastric varices can be performed from the systemic venous side (draining veins or shunts) or from the portal venous side (portal afferent feeders). Balloon-occluded transvenous obliteration from the systemic veins is referred to as balloon-occluded retrograde transvenous obliteration (BRTO) and balloon-occluded transvenous obliteration from the portal veins is referred to as balloon-occluded antegrade (anterograde) transvenous obliteration (BATO). BRTO is the conventional balloon-occluded transvenous obliteration procedure and BATO is considered an alternative or adjunctive approach. This is because, from a technical standpoint, the least invasive choice of access or approach for balloon-occluded transvenous obliteration of gastric varices is the traditional or conventional transrenal route. The objective of BRTO or BATO or both is complete obliteration of the gastric varices with preservation of the anatomical hepatopetal flow of the splenoportal circulation. This article reviews the indications, contraindications, and technical considerations of the conventional BRTO procedure. The indications of concomitant portal venous modulators such as splenic embolization or the creation of a transjugular intrahepatic portosystemic shunt or both are also discussed.

Skin toxicity predicts efficacy to sorafenib in patients with advanced hepatocellular carcinoma.

AIM To study the relationship between adverse events (AEs), efficacy, and nursing intervention for sorafenib therapy in patients with hepatocellular carcinoma (HCC). METHODS We enrolled 37 consecutive patients with advanced HCC who received sorafenib therapy. Relationships among baseline characteristics as well as AE occurrence and tumor response, overall survival (OS), and treatment duration were analyzed. The nursing intervention program consisted of education regarding self-monitoring and AEs management, and telephone follow-up was provided once in 1-2 wk. RESULTS A total of 37 patients were enrolled in the study, comprising 30 males (81%) with a median age of 71 years. The disease control rate at 3 mo was 41%, and the median OS and treatment duration were 259 and 108 d, respectively. Nursing intervention was given to 24 patients (65%). Every patient exhibited some kinds of AEs, but no patients experienced G4 AEs. Frequently observed AEs > G2 included anorexia (57%), skin toxicity (57%), and fatigue (54%). Factors significantly associated with longer OS in multivariate analysis demonstrated that age ≤ 70 years, presence of > G2 skin toxicity, and absence of > G2 hypoalbuminemia. The disease control rate in patients with > G2 skin toxicity was 13/20 (65%), which was significantly higher compared with that in patients with no or G1 skin toxicity. Multivariate analysis revealed that nursing intervention and > G2 skin toxicity were independent significant predictors for longer treatment duration. CONCLUSION Skin toxicity was associated with favorable outcomes with sorafenib therapy for advanced HCC. Nursing intervention contributed to better adherence, which may improve the efficacy of sorafenib.

Deep venous thrombosis caused by congenital absence of the inferior vena cava: Report of a case

Although anomalies of the inferior vena cava (IVC) are seen frequently in a clinical setting, congenital absence of the IVC (AIVC) is rare. However, anomalies of the IVC should be considered in young patients suffering from recurrent and idiopathic DVT. We report a case of DVT possibly caused by AIVC in a 27-year-old man, and discuss the clinical features, diagnosis, and treatment of this unusual entity.

Visualization of the azygos arch valves on multidetector-row computed tomography

To evaluate the frequency and appearance of the azygos arch valves on chest examinations using multidetector-row computed tomography (MDCT), we retrospectively reviewed findings from 194 contrast-enhanced MDCT examinations of the chest. Rate of injection of 300 mgI/ml contrast materials was low (2.0 ml/s) and high (3.0 ml/s). Scanning delay was 80 s on examination on low-rate injection of contrast material and 20 s on high-rate injection of contrast material. The presence of residual contrast material in the azygos arch valves and reflux of contrast material into the azygos arch were recorded. The Cochran-Armitage trend test was used to compare the frequency of residual contrast material in the azygos arch valves and reflux of contrast material into the azygos arch in both groups. Of 92 examinations of high-rate injection of contrast material, 63 (68.5%) demonstrated residual contrast material in the azygos arch valves and 71 (77.2%) demonstrated reflux of contrast material into the azygos arch. A significantly higher frequency of reflux of contrast material into the azygos arch and residual contrast material in the azygos arch valves was seen in the high-rate injection group than in the low-rate injection group (P < 0.05). Residual contrast material in the azygos arch valves was demonstrated more frequently when contrast material was administered in the right side of the arm than in the left side of the arm (P < 0.05). Reflux of contrast material into the azygos arch was common in the high-injection-rate group and residual contrast material in the azygos arch valves was far more frequently seen in the high-injection-rate group than in the low-injection-rate group on MDCT.

Balloon-Occluded Antegrade Transvenous Obliteration With or Without Balloon-Occluded Retrograde Transvenous Obliteration for the Management of Gastric Varices: Concept and Technical Applications

Alternative routes for transvenous obliteration are sometimes resorted in the management of gastric varices. These alternative routes can be classified into A, portal venous access routes and B, systemic venous access routes. The portal venous approach to transvenous obliteration is called balloon-occluded antegrade transvenous obliteration (BATO) and is a collective definition, including 1-percutaneous transhepatic obliteration (PTO), 2-through an existing transjugular intrahepatic portosystemic shunt [(Trans-TIPS), and 3-trans-iliocolic vein obliteration (TIO)]. PTO is usually out of necessity; however, trans-TIPS approach is usually used out of serendipity (because the low-risk access route is there). The TIPS for the trans-TIPS BATO is not formed for mere access, but is done to create a TIPS or is done when there is a preexisting TIPS. The trans-TIPS approach can be resorted to in the United States in up to 19% of balloon-occluded retrograde transvenous obliteration (BRTO) cases. PTO is resorted to, out of necessity, in the United States and Japan in 10% of BRTO cases (2%-19% of BRTO cases) and can increase the technical and obliterative success rate of the transvenous obliteration procedure from 84%-98% to 98%-100%. The advantage of BATO as an adjunct to BRTO (combining a BRTO and BATO approach to obliterate the gastric varices) is not only limited to increasing the technical success rate of the obliterative procedure. BATO reduces the risk of overspill of the sclerosant from the gastric variceal system into the portal vein. Moreover, if the BATO is performed from a trans-TIPS approach, any overspill of the sclerosant mixture will partly (if not mostly) go through the patent TIPS to the systemic circulation (lung) rather than the intrahepatic portal vein branches (prevent portal vein embolization). This article discusses the clinical and technical applications, technical considerations, and the outcomes of BATO.

Balloon-Occluded Retrograde Transvenous Obliteration of Gastric Varices: Use of CT-Guided Foam Sclerotherapy to Optimize Technique

OBJECTIVE Balloon-occluded retrograde transvenous obliteration has been traditionally based on liquid sclerotherapy. However, overdose and systemic spillage of liquid sclerosant can cause severe complications, such as hemolysis, which lead to hemoglobinuria, allergy, acute respiratory distress syndrome, and other disorders. The purpose of this study was to evaluate the performance of foam sclerotherapy with C-arm CT guidance to reduce the amount of sclerosant and to optimize the safety of balloon-occluded retrograde transvenous obliteration while preserving its efficacy. MATERIALS AND METHODS Twenty consecutively registered patients with gastric varices underwent balloon-occluded retrograde transvenous obliteration with polidocanol foam. C-arm CT guidance was used to confirm gas filling of the target vessels. In this retrospective analysis of a prospectively encoded database, total net doses of polidocanol used for transvenous obliteration and of contrast medium used for venography before transvenous obliteration were compared, and subsequent complications, including hemoglobinuria, were documented. RESULTS In all patients, foam was observed in the target vessels at C-arm CT. The mean dose of polidocanol used for balloon-occluded retrograde transvenous obliteration (3.9 ± 1.5 mL) was significantly smaller (p < 0.001) than the dose of contrast medium used for venography (16.4 ± 7.9 mL). Hemoglobinuria was found in only one patient. Except in one instance of recanalization, full variceal thrombosis was confirmed at contrast-enhanced CT 1 week after transvenous obliteration (success rate, 95%). In one patient, air migrated into the liver during transvenous obliteration but was spontaneously absorbed. No serious complication occurred. CONCLUSION Balloon-occluded retrograde transvenous obliteration with polidocanol foam under C-arm CT guidance allowed significant reduction of sclerosant dose and resulted in a low complication rate while a high technical success rate and efficacy were maintained.

C-arm CT-guided Foam Sclerotherapy for the Treatment of Gastric Varices

The authors describe here the use of foam sclerotherapy under C-arm computed tomography (CT) guidance for the treatment of gastric varices via balloon-occluded retrograde transvenous obliteration in seven patients and percutaneous transhepatic obliteration in one patient. All gastric varices were occluded successfully after replacement of blood by foam, which was trapped in the gastric varices as shown by C-arm CT. It also helped reduce the amount of sclerosant, an issue that is associated with severe complications, such as hemolysis, allergy, acute respiratory distress syndrome, and others. Foam sclerotherapy under C-arm CT guidance is a promising tool in the therapeutic armamentarium against gastric varices.

Successful Endovascular Stent-Graft Treatment for an Aortoesophageal Fistula Caused by a Descending Thoracic Aortic Aneurysm : Report of a Case

Conventional surgery for aortoesophageal fistula (AEF) is technically difficult, and is associated with high morbidity and mortality. We report a case of primary AEF caused by a descending thoracic aortic aneurysm, which was successfully treated with an endovascular stent-graft technique. The patient has been followed up for 3 years with no signs of infection.

Complete Response after Short-Term Sorafenib Treatment in a Patient with Lymph Node Metastasis of Hepatocellular Carcinoma

A 60-year-old man received interferon/ribavirin combination therapy for chronic hepatitis C in 2002 and achieved sustained virological response. In 2008, a hepatocellular carcinoma (HCC) with a diameter of 60 mm appeared and surgical resection was performed. In March 2011, the patient was referred to our hospital because of portal lymph node swelling. Abdominal ultrasonography, dynamic CT and dynamic MRI did not show any tumors in the liver, but revealed portal lymph node swelling (18 × 11 mm). Taking the elevation of serum des-γ-carboxy prothrombin and alpha-fetoprotein levels, including the lectin-bound type, into consideration, we made the diagnosis of HCC metastasis to the portal lymph node. We started sorafenib therapy at a dose of 800 mg/day, but discontinued it after 11 days due to grade 3 hand-foot skin reaction and rash. In spite of treatment termination, portal lymph node swelling disappeared and the serum des-γ-carboxy prothrombin and alpha-fetoprotein levels normalized. We considered that our patient achieved complete response to sorafenib according to the Response Evaluation Criteria in Solid Tumors (RECIST). The patient maintains remission up to June 2012, more than 1 year after the discontinuation of sorafenib therapy. Sorafenib could be a good option for unresectable or recurrent HCC.