Taro Marukawa

Limitation of transcatheter arterial chemoembolization using iodized oil for small hepatocellular carcinoma. A study in resected cases

The radiologic and histologic findings are presented of the resection of 14 small hepatocellular carcinomas (HCC), less than 2 cm in maximum diameter, after transcatheter arterial chemoembolization (TCE) using iodized oil. The effect of TCE on small HCC depended on the morphologic type of the tumors. When no extracapsular invasion of tumor cells occurred, TCE was extremely effective against encapsulated tumors. However, in nine of the 14 resected specimens, viable tumor cells remained in or around the tumor. The authors suggest that small HCC are not always curable with TCE alone and that a multi‐disciplinary approach is necessary for patients with small HCC.

Effect of transcatheter arterial embolization on the boundary architecture of hepatocellular carcinoma

Daughter nodules and intrahepatic metastases are resistant to conventional transcatheter arterial embolization therapy. To clarify the mechanism of this resistance, the boundaries of hepatocellular carcinomas and their relationship to the blood supply were studied. The boundaries of the hepatocellular carcinomas studied were classified as one of five types: encapsulated, granulation, stromal, replacing, or sinusoidal. The granulation and stromal types had a capsule‐like structure, but lacked the hyalinization which is the hallmark of a true tumor capsule. The granulation and stromal types could also be differentiated from the encapsulated types because of their different blood supplies and the differing effects of transcatheter arterial embolization. When barium sulfate was infused into the portal vein, it did not enter into encapsulated tumors, but it entered granulation and stromal type tumors. Small nodules such as daughter nodules and intrahepatic metastases do not have capsules, and so have a blood supply that makes them resistant to conventional transcatheter arterial ebolization therapy.

Differentiation between hepatoma and hemangioma with inversion recovery snapshot FLASH MRI and Gd-DTPA

Thirty-eight patients with focal liver tumors (20 hepatomas, 18 hemangiomas) were studied by dynamic sequential inversion recovery (IR) snapshot fast low angle shot (FLASH) MR imaging with Gd-DTPA. Immediately after 0.05 mmol/kg Gd-DTPA was administered intravenously for 2-3 s followed by flushing with normal saline for 4-5 s, 10 images were obtained in the first 20 s (time zero is the end of flush, early phase). Then, one image every 30 s from 1 to 3 min (late phase) and images at 5 min and 7 min (delayed phase) were obtained serially. Hepatomas showed total enhancement in 18 of 20 patients in the early phase, and isointense or low intensity enhancement with respect to the surrounding liver parenchyma in 18 patients in the late to delayed phases. Hemangiomas showed peripheral enhancement in 14 patients in the early phase, but did not show total enhancement (except for two hemangiomas less than 3 cm in size) in the early phase, and showed high intensity enhancement in 15 patients in the late phase. Ninety percent of hepatomas and 82% of hemangiomas showed their characteristic enhancement patterns in the early to delayed phases. We conclude that dynamic sequential IR snapshot FLASH MR images enhanced with Gd-DTPA can facilitate differentiation between hepatomas and hemangiomas.

Determining the optimal timing for early arterial phase hepatic CT imaging by measuring abdominal aortic enhancement in variable contrast injection protocols

Objective: To find the optimal scan timing for early arterial phase hepatic CT with adequate arterial enhancement after the aortic contrast arrival. Methods: Sixty patients were divided randomly into three groups, each of which received 2.0 mL/kg of the 300 mgI/mL contrast medium with an injection duration of 30 seconds (Group A, mean rate 3.6 mL/sec); of 25 seconds (B, 4.6 mL/sec); of 30 seconds (3.6 mL/sec) followed by a saline chaser (C). Results: After the contrast arrival, aortic enhancement increased rapidly for 6-15 seconds (mean, 10 seconds) to the initial peak enhancement in all groups, and then, increased moderately to the maximum aortic enhancement over the following 19, 13, and 21 seconds, respectively. The mean maximum aortic enhancement in Group B (392 HU) and C (360 HU) were significantly higher than that in A (326 HU), respectively. The difference between the initial and maximum aortic enhancement was less than 50 HU. Conclusion: The optimal timing of the early arterial phase for hepatic CT arteriography is 10-15 seconds after the aortic arrival.

Hepatocellular carcinoma in adenomatous hyperplasia of the liver

SummaryA hepatocellular carcinoma (HCC) measuring 0.2 cm in diameter was found in the center of an adenomatous hyperplasia (AH) measuring 1.7 cm in diameter in a cirrhotic liver. The liver cells of the AH showed a marked fatty change and contained many Mallory bodies. The AH and HCC were studied in relation to liver cell dysplasia in 108 surgically resected livers. The AH was mainly associated with fully developed cirrhosis in 5 (71%) of the 7 cases. The liver cell dysplasia, however was accompanied largely by fibrosis and early-stage incomplete septal cirrhosis in 10 (67%) of the 15 cases. As far as the active inflammatory change was concerned, a fairly active inflammation was found in only 3 (20%) of the 15 livers with liver cell dysplasia, but in 4 (57%) of the 7 livers with AH.

Hypervascular hepatocellular carcinoma : Combined dynamic MDCT and SPIO-enhanced MRI versus combined CTHA and CTAP

Aim:  Recently, many diagnostic modalities have been developed for the detection of hepatocellular carcinoma (HCC). Of these, a less invasive and more accurate diagnostic procedure is desirable. This study was undertaken to compare combined dynamic multidetector row helical computerized tomography (MDCT) and superparamagnetic iron oxide (SPIO)‐enhanced magnetic resonance imaging (MRI) with combined CT hepatic arteriography (CTHA) and CT during arterial portography (CTAP) for the detection of hypervascular HCC.

Retroperitoneal schwannomas simulating adrenal tumors

Tumors in the area of the adrenal were detected by chance in two patients who underwent a regular physical check-up. On arteriography the tumors were found to be fed by the adrenal artery. The diagnosis was retroperitoneal schwannoma, but in both patients it was difficult to differentiate the schwannoma from an adrenal tumor preoperatively.

Adrenal venous sampling analysis of primary aldosteronism: value of ACTH stimulation in the differentiation of adenoma and hyperplasia

Adrenal venous blood samples drawn before and after stimulation with adrenocorticotropic hormone (ACTH) were analysed in 32 consecutive patients with primary aldosteronism. Twenty-six patients had aldosterone-producing adenomas and six patients had bilateral hyperplasia.The ratio of higher to lower levels of aldosterone in the right and left adrenals (aldosterone ratio), aldosterone to cortisol ratio (A/C ratio), and the ratio of higher to lower levels of A/C ratio in the right and left adrenals (ratio of A/C ratios) were calculated. We used both aldosterone ratio and ratio of A/C ratios as a means of diagnosis, a ratio of 3.0 or more for unilateral adenoma, and less than 3.0 for bilateral hyperplasia. With ACTH stimulation, correct characterization of lesions increased from 91% (29 of 32) to 97% (31 of 32) by aldosterone ratio and from 84% (27 of 32) to 97% (30 of 31) by ratio of A/C ratios. Correct diagnosis of bilateral hyperplasia increased markedly from 67% (4 of 6) to 100% and 50% (3 of 6) to 83% (5 of 6) with use of each criterion.In patients with adenoma, aldosterone ratio rose in 54% (14 of 26) from the pre-stimulation levels. Before stimulation, it ranged from 1.5 to 115.9 (mean 34.8), and afterwards, from 2.1 to 1097.9 (mean 95.5). In contrast, in all patients with bilateral hyperplasia aldosterone ratio fell to less than 3.0 following stimulation with ACTH. With ACTH stimulation, aldosterone ratio increased in patients with adenoma and decreased in patients with hyperplasia.Measurement of A/C ratio is used to ensure correct access to the adrenal veins, but it was useful in only one case and aldosterone ration was a more reliable diagnostic parameter than ratio of A/C ratios in both pre-and post-ACTH stimulations.Assay of aldosterone levels and calculation of aldosterone ratios before and after ACTH stimulation were valuable in locating small adenomas in the right and left adrenal and especially in differentiating bilateral hyperplasia from adenoma.

Siderotic nodules in hepatic cirrhosis disappearing after biliary hemorrhage : MR imaging

Magnetic resonance demonstrated siderotic regenerating nodules in a patient with hepatocellular carcinoma with accompanying liver cirrhosis. The siderosis disappeared when iron deficiency anemia developed in association with biliary hemorrhage. Magnetic resonance was sensitive enough to follow changes in the siderosis. The mechanism of iron deposition in regenerating nodules that accompanied liver cirrhosis did not seem to be related to the severity of the liver damage.

NECROSIS OF PORTAL TUMOR EMBOLUS OF HEPATOCELLULAR CARCINOMA BY LIPIODOL TRANSCATHETER CHEMO-EMBOLIZATION. A Case Report

We describe a case of hepatocellular carcinoma in which a tumor embolus in the portal vein and 3 of 4 intrahepatic metastases were necrosed completely by Lipiodol transcatheter chemo‐embolization (Lipiodol‐TCE). Tumor emboli in the portal vein and intrahepatic metastases usually cannot be necrosed by conventional transcatheter chemo‐embolization alone, because small nodules such as intrahepatic metastases and tumor emboli in the portal vein are supplied blood from the portal vein. However, in this case, Lipiodol‐TCE was effective against tumor emboli in the portal vein and intrahepatic metastases. ACTA PATHOL JPN 38: 1363‐1367, 1988.