Hepatocellular Carcinoma: Targeted Therapy and Multidisciplinary P19

11 Portal Vein Embolization Prior to Resection 165 a b c Fig. 11.4 Schematic representation shows modification of the ipsilateral technique for RPVE extended to segment 4. (a) Placement of a 6-French vascular sheath into the right portal branch. An angled 5-French catheter is placed into the left portal system with coaxial placement of a micro-catheter into a segment 4 branch. Particulate embolization is performed followed by placement of coils until all the branches are occluded. (b) After segment 4 embolization is completely occluded, a 5-French reverse-curve catheter is used for RPVE. (c) After embolization of the right and seg-ment 4 portal veins are complete, the access tract is embolized with coils to prevent subcapsular hemorrhage angled 5-French catheter into the portal vein branches supplying segment 4 so that particulate embolics and coils can then be delivered. Once complete occlusion of the segment 4 embolization is achieved, a 5-French reverse-curve catheter may be needed to embolize the portal veins supplying segments 5 through 8 (i.e., right liver). After complete occlusion of the right portal venous system, the access tract is embolized with coils and/or gelfoam to diminish the risk of perihepatic bleeding at the access site. A distinct advantage of the ipsilateral approach is that the FLR is not instru-mented. However, while disadvantages do exist, they are minor. Catheterization and embolization of the right portal vein branches may be slightly more difficult due to the severe angulations between right portal branches; however, this is rarely a prob-lem when reverse-curve catheters are used. Another potential disadvantage is that some embolic material could be displaced upon catheter removal, leading to non-target embolization, although this has not occurred in our experience with more than 200 RPVEs, most of which included extension to segment 4 branches. Similarly, in our experience, ipsilateral access has not been an issue in patients with large liver tumors. 166 D.C. Madoff and R. Avritscher a b c d e f Fig. 11.5 A 72-year-old man with history of hepatitis B, cirrhosis, and hepatocellular carcinoma HCC, who had transhepatic ipsilateral RPVE with particles and coils prior to right hepatectomy. (a) Contrast-enhanced CT scan of the liver shows a hypervascular mass in the right hepatic lobe consistent with HCC (arrow). (b) Contrast-enhanced CT scan of the liver shows small left liver (FLR/TELV of 35%) with underlying cirrhosis (FLR isshaded area). (c) Anteroposterior flush por-togram shows a 6-French vascular sheath (arrowheads) in a right portal vein branch and a 5-French flush catheter (arrow) in the main portal vein. (d) Postprocedure anteroposterior flush portogram shows occlusionof theportal veinbranches tosegments 5–8 (black arrows)withcontinuedpatency of the vein supplying the left lobe (segments 2–4) (white arrows). (e) Contrast-enhanced CT scan of the liver performed 1 month after RPVE shows hypertrophy of the left liver (FLR/TELV of 45%) (FLR is shaded area). (f) Contrast-enhanced CT scan of the liver performed after successful right hepatectomy shows hypertrophy of the liver remnant 11 Portal Vein Embolization Prior to Resection 167 a b c d e f Fig. 11.6 A 45-year-old man with history of non-alcoholic steatohepatitis and HCC who had transhepatic ipsilateral RPVE extended to segment 4 with particles and coils prior to extended right hepatectomy. (a) Contrast-enhanced CT scan of the liver shows a heterogeneous mass in the right hepatic lobe consistent with HCC (black arrow) and small left lateral liver (shaded area) with FLR/TELV of 27%. (b) Anterior-posterior flush portogram from the ipsilateral approach shows a 6-French vascular sheath in a right portal vein branch and a 5-French flush catheter (arrow) in the mainportal vein.(c)Selectiveleftportogram witha5-French catheterintheleftportalvein(arrow) shows the veins that supply segments 2 (s2), 3 (s3), and 4 (s4). (d) Postprocedure portogram shows complete occlusion (with particles and coils) of the portal vein branches to segments 4–8 (arrows) withcontinuedpatencyoftheveinssupplyingtheleftlaterallobe(segments2and3)(shadedarea). (e) Contrast-enhanced CT scan performed 4 weeks after PVE shows hypertrophy of the left lateral liver (FLR/TELV now 39%, a degree of hypertrophy of 12%) with rounded margins (shaded area). Coil within segment 4 (arrowhead) is seen. (f) Contrast-enhanced CT scan of the liver performed after successful extended right hepatectomy shows hypertrophy of the liver remnant 168 D.C. Madoff and R. Avritscher Additional PVE Approaches PVE Followed by Bland Transarterial Embolization Other approaches have been used for PVE. The thought of combining PVE and TAE for complete portal venous and hepatic arterial occlusion has been reported in patients with biliary tract cancer and colorectal metastases who had inadequate hypertrophy after PVE alone [91, 92]. Nagino and colleagues [91] described a patient that required an extended left hepatectomy but the FLR volume (i.e., right posterior liver) did not increase 51 days after PVE. After TAE, the FLR volume increased from 485 cm3 before PVE to 685 cm3 after PVE, an addition of 215 cm3. Another patient required a right hepatectomy, but no significant volume change was seen after PVE (pre-PVE: 643 cm3 and post-PVE: 649 cm3). After TAE, the left liver volume enlarged to 789 cm3, an increase of 140 cm3. Both patients underwent successful and uneventful resection after the staged procedures. However, there are potential drawbacks. As both arterial and portal systems are deprived of blood, the potential for hepatic infarction exists such that only half the target segments were treated with TAE, superselectively. While this approach was effective, the disad-vantage is that two separate procedures are needed, performed at different times, leading to considerably longer waiting periods. During these waiting periods, tumor progression could occur to the degree that the tumors become unresectable. Sequential Arterial Embolization and PVE In 2004, Aoki and colleagues [72] described their experience with the use of sequen-tial transcatheter arterial chemoembolization followed within 2 weeks by PVE in 17 patients with HCC (Fig. 11.7). Their justification for this approach was as fol-lows: (1) The livers of most patients with HCC are compromised by underlying liver disease such that the liver’s regenerative capability after hepatic resection is weakened, making it hard to predict if adequate FLR hypertrophy can be achieved after PVE. (2) Since most HCCs are hypervascular and supplied largely by arte-rial blood flow, termination of portal flow induces compensatory augmentation in arterial blood flow (i.e., “arterialization of the liver”) in the embolized segments that may lead to rapid tumor progression after PVE. (3) Arterioportal shunts often found in cirrhotic livers and HCC may limit the effects of PVE. To this end, sequen-tial chemoembolization and PVE were used to prevent tumor progression during the time between the PVE and planned hepatectomy and to strengthen the effect of PVE by embolizing arterioportal shunts with chemoembolization. As a result, the researchers found that the combined procedures were safe, induced sufficient FLR hypertrophy within 2 weeks, and caused no worsening of the basal hepatic func-tional reserve or increase in tumor progression. Importantly, when the explanted livers were evaluated, tumor necrosis was profound but without substantial injury to the non-cancerous liver, and they therefore encourage the aggressive application of this treatment strategy in patients with large HCC and chronically injured livers. 11 Portal Vein Embolization Prior to Resection 169 a b c d e f Fig. 11.7 A 71-year-old man with history of liver steatosis, fibrosis, and HCC, who underwent sequential transcatheter arterial chemoembolization followed 1 month later by RPVE prior to a right hepatectomy. (a) A single image from pre-PVE contrast-enhanced CT scan shows a large hypervascular mass in the right hepatic lobe (arrow) and a small left liver (shaded area) with a FLR/TELV of 27%. (b) Celiac arteriogram performed during chemoembolization shows a hyper-vascular mass with iodized oil uptake in the right hepatic lobe (arrows). (c) Contrast-enhanced CT shows iodized oil uptake in the HCC (arrow). (d) Anterior-posterior flush portogram from the ipsilateral approach shows a 6-French vascular sheath in a right portal vein branch and a 5-French flush catheter (white arrows) in the main portal vein. Persistent iodized oil uptake in the right hep-atic mass is seen (black arrows). (e) Postembolization portogram shows complete occlusion of all branches to right portal vein (black arrows). The left portal vein remains patent (white arrow). (f) Contrast-enhanced CT scan of the liver after RPVE shows complete necrosis of the right liver mass (black arrow), hypertrophy of the left liver (shaded area), and massive atrophy of the right liver (arrowheads). The FLR/TELV increased to 56%. The patient underwent uncomplicated right hepatectomy ... - tailieumienphi.vn