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ORIGINAL ARTICLE
Year : 2014  |  Volume : 51  |  Issue : 6  |  Page : 49-51
 

Arterial embolization of massive hepatocellular carcinoma with lipiodol and gelatin sponge


Department of Interventional Radiology, Affiliated Hospital of Qingdao University, Qingdao, 266003, China

Date of Web Publication24-Feb-2015

Correspondence Address:
Dr. C J Sun
Department of Interventional Radiology, Affiliated Hospital of Qingdao University, Qingdao, 266003
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.151990

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 » Abstract 

Background: Transarterial chemoembolization (TACE) has been used to treat unresectable massive hepatocellular carcinoma (HCC). Lots of embolic agents have been applied in embolization because of it can decrease patient discomfort and side-effects. Aim: The aim was to evaluate the clinical efficacy and safety of TACE with lipiodol and gelatin sponge. Materials and Methods: A total of 109 patients with massive HCC (the size of tumor >10 cm and unresectable) from January 2011 to August 2014 in our institution was divided into group A and group B based on the different embolitic agents. Before and about 1-month after each case of TACE, clinical and biological data such as tumor size, child-pugh stage, serum Alpha-fetoprotein (AFP), complications, were recorded at the same time. Results: In group A, the diameter of the tumor reduced from 12.57 ± 1.26 cm to 9.04 ± 0.89 cm. No patient was complete response (CR), partial response (PR) 36, stable disease (SD) 7 and PD 6; in group B, the diameter of tumor decreased from 12.08 ± 1.42 cm to 8.43 ± 1.05 cm, CR 0, but PR 27, SD 18 and PD 15. RR in group A was significantly higher than in group B (P < 0.05).The change of child-pugh stage and AFP pre- and post-operative in group A can be found significantly better than in group B. Conclusions: TACE with lipiodol and gelatin sponge is a highly effective for massive HCC.


Keywords: Gelatin sponge, hepatocellular carcinoma, lipiodol, transarterial chemoembolization


How to cite this article:
Xie L L, Sun C J, Li X D, Wang Y H, Wang C E. Arterial embolization of massive hepatocellular carcinoma with lipiodol and gelatin sponge. Indian J Cancer 2014;51, Suppl S2:49-51

How to cite this URL:
Xie L L, Sun C J, Li X D, Wang Y H, Wang C E. Arterial embolization of massive hepatocellular carcinoma with lipiodol and gelatin sponge. Indian J Cancer [serial online] 2014 [cited 2021 Dec 1];51, Suppl S2:49-51. Available from: https://www.indianjcancer.com/text.asp?2014/51/6/49/151990



 » Introduction Top


Hepatocellular carcinoma (HCC) is the most common cancer, and major healthcare threaten in our country, the incidence is also increasing. The massive HCC, which is a common type, large volume, adjacent to the oppression and intrahepatic important structures, often with liver cirrhosis and portal venous tumor emboli, satellite nodules and intrahepatic metastases, mostly lose the opportunity of surgical resection. [1] Recently years, transarterial chemoembolization (TACE) is concerned to be standard therapy for terminal-stage liver cancer (specially for massive HCC) in many centers. Various combinations of embolic agents have been used in attempts to control the development of tumor and to extend the lifetime of patients. [2] Lipiodol is an iodized oil that selectively remains in tumor tissue for a long time, this treatment was considered as effective, and reduced tumor growth has often been observed. [3] Gelatin sponge was also proved as an effective embolic agent in another trial. The purpose of this study was to evaluate the efficiency and safety of TACE using lipiodol combined with gelatin sponge for massive HCC.


 » Materials and Methods Top


General data

Totally, 109 patients with massive HCC (the size of tumor >10 cm and unresectable) from January 2011 to August 2014 were treated at our institution by TACE.49 patients were treated by lipiodol combined with gelatin sponge, defined as group A, 43 cases of male, 6 cases of female, age 42-75, the average age of 51.60 patients were treated by exclusive lipiodol, defined as group B, 45 cases of male, 5 cases of female, age 39-72, the average age of 50. All patients were diagnosed by clinical, imaging, laboratory and pathological examination for primary massive HCC.

Transarterial chemoembolization method

Under local anesthesia, 5F Cobra catheter was placed after Seldinger method was used to conduct the femoral arterial puncture intubation. After identification of the vascular anatomy, a super selective microcatheter with 2.5F outer diameter was advance into the feeding arteries. After that, the emulgator mixed with lipiodol and anticancer drugs was injected gradually until the abundant visualization of the surrounding portal vein is seen. In group A, after injection of lipiodol, gelatin sponge was injected until a complete stoppage of the arterial flow is achieved.

Treatment evaluation and follow-up

Before and about 1-month after each case of TACE, CT of liver was performed to observe changes from tumor size, lipiodol capture and renew tumor area [Figure 1] and [Figure 2] and evaluate the response of tumor to the therapy: (1) Complete response (CR): All lesions disappeared in the targeted area; (2) partial response (PR): The maximum diameter was decreased to 30-99% in the targeted area; (3) stable disease (SD): It was between PR and progressive disease (PD); (4) PD: The maximum diameter was increased over 20% in the targeted area. Clinical response rate (RR) = (CR + PR)/total number of cases × 100%. [4] Excpect CT performance, clinical and biological data, such as child-pugh stage, serum alpha-fetoprotein (AFP), were recorded at the same time.
Figure 1: Computed tomography scan of liver pre-opretive

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Figure 2: One month after the embolization with lipiodol and gelatin lipiodol capture on computed tomography scan

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Statistical analysis

Statistical Package for Social Sciences 16.0 statistical software was applied to analyze the data. P < 0.05 was considered as statistically significant.


 » Results Top


Clinical efficiency [Table 1]

Computed tomography (CT) performance of liver and the tumor response to the therapy are presented in [Table 1]. In group A, the diameter of the tumor reduced from 12.57 ± 1.26 cm to 9.04 ± 0.89 cm. No patient was CR, PR 36, SD 7 and PD 6; in group B, the diameter of tumor decreased from 12.08 ± 1.42 cm to 8.43 ± 1.05 cm, CR 0, but PR 27, SD 18 and PD 15. RR in group A was significantly higher than in group B (P < 0.05).
Table 1: Tumor size and tumor response to the therapy pre-and postoperative

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The change of child-pugh stage and alpha-fetoprotein [Table 2]

[Table 2] lists the change of the Child-Pugh stage and AFP pre- and post-operative in group A and group B. The change can be found significantly better when lipodol were combined with gelatin.
Table 2: Child-Pugh stage and serum AFP level pre-and postoperative

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Complications

After chemotherapy embolism, the incidence of side effects as follows: In group A, fever 37 cases (75.5 0%), abdominal distension 35 cases (71.4%), abdominal pain 43 cases (87.8%), nausea 23 cases (46.9%). Group B fever 29 cases (48.3%), abdominal distension 18 cases (30.0%), abdominal pain 32 cases (53.3%), nausea 19 cases (31.7%). Postoperative incidence of complications in group B was lower than that in group A. There were no recurrences of severe complications (gastrointestinal hemorrhage, liver abscess, biliary damage, liver and kidney function failure, et al.).


 » Discussion Top


Hepatocellular carcinoma remains one of the most highly malignancy in our country. Surgical resection and liver transplantation offer the only chance for a cure; however, tumors in most patients are unresectable at presentation. [5] TACE has been the most widely used to treat HCC, specially for massive HCC. The rationale of TACE: 90% of the blood supply for massive HCC is from the hepatic artery, TACE can make the lesions in the intravenous or oral chemotherapy drug concentration higher than 10 a 30 times, embolization material blocking tumor blood supply can cause ischemic necrosis of tumor and tumor cell apoptosis. And 75% of normal liver cell supply is from the portal vein, chemotherapy embolism can lose tumor blood supply, and normal liver tissue won't lose blood supply. Two recent randomized trials investigated therapeutic aspects and found benefits from chemoembolization. [6],[7] However, arterial embolitic agent is described rarely in the literature because of it can decrease patient discomfort and side effects.

With the development of new embolitic materials, TACE for HCC might also be seen in a different light. In our study, the efficacy and safety of lipiodol combined with gelatin sponge have been evaluated from several aspects (tumor size, AFP, RR, Child-Pugh stage). The reasons of this combination in our study as follows: (1) Lipiodol, a semi-fluid, can deposit in hypervascular tumors by siphonage; tumor blood vessels lack of muscular, lipiodol can attached to the wall that is not easy to be washed away; the effective lipiodol carry anticancer drugs deposit in tumor tissues and slow release, killing tumor cells and tumor blood supply, effectively inhibit the growth of tumor; [6],[8] (2) Gelatin sponge is a peripheral vascular embolizatic agent. Although in principle, can be recanalizated, the use of gelatin sponge combined with lipiodol embolization tumor blood vessels can significantly extend the time of tumor ischemia time, effectively prevent regenerate. Even in small artery gelatin sponge can thrombosis to reduce the blood supply for caner in a longer period. [9]

Our study demonstrate that the efficacy of group A, which therapy is lipiodol combined with gelatin sponge is better than group B. With CT perfusion technique found that lipiodol combined with gelatin sponge embolism can more effectively reduce arterial perfusion of cancer, and better than exclusive lipiodol embolism. [10]

The complications of two groups demonstrate that the use of lipiodol and gelatin sponge is worse. However, during the first week after operation, the treatment-related discomfort was improved. There were no severe side-effects like gastrointestinal hemorrhage, liver abscess, biliary damage, liver and kidney function failure, etc.


 » Conclusion Top


The disadvantages of this study are limited number of patients and shorter follow-up time, TACE is a feasible therapy for unresectable massive HCC. A further and more extensive evaluation of the combination lipiodol with gelatin sponge and other embolitic agents is underway.

 
 » References Top

1.
Guo Z, Xing WG, Liu F,Yu HP, Li BG, Guo XY, et al. Clinical application of Argon-helium freezing in interventional therapy for huge type liver cancer. Chin J Radiol 2005; 39:86-91.  Back to cited text no. 1
    
2.
Toyama T, Nitta N, Ohta S, Tanaka T, Nagatani Y, Takahashi M, et al. Clinical trial of cisplatin-conjugated gelatin microspheres for patients with hepatocellular carcinoma. Jpn Radiol Soc 2012;30:62-8.  Back to cited text no. 2
    
3.
Dumortier J, Chapuis F, Borson O, et al. Unresectable hepatocellular carcinoma: Survival and prognostic factors after lipiodol chemoembolisation in 89 patients. Dig Liver Dis 2006;38:125-33.  Back to cited text no. 3
    
4.
Wang N, Lv YZ, Xu AH, Huang YR, Peng L, Li JR. Application of lobaplatin in trans-catheter arterial chemoembolization for primary hepatic carcinoma. Asian Pac J Cancer Prev 2014;15:647-50.  Back to cited text no. 4
    
5.
Geschwind JF. Chemoembolization for hepatocellular carcinoma: Where does the truth lie? J Vasc Interv Radiol 2002;13:991-4.  Back to cited text no. 5
    
6.
Lo CM, Ngan H, Tso WK, Liu CL, Lam CM, Poon RT, et al. Randomized controlled trial of transarterial lipiodol chemoembolization for unresectable hepatocellular carcinoma. Hepatology 2002;35:1164-71.  Back to cited text no. 6
    
7.
Llovet JM, Real MI, Montaña X, Planas R, Coll S, Aponte J, et al. Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: A randomised controlled trial. Lancet 2002;359:1734-9.  Back to cited text no. 7
    
8.
Sergio A, Cristofori C, Cardin R, Pivetta G, Ragazzi R, Baldan A, et al. Transcatheter arterial chemoembolization (TACE) in hepatocellular carcinoma (HCC): The role of angiogenesis and invasiveness. Am J Gastroenterol 2008;103:914-21.  Back to cited text no. 8
    
9.
Xing DJ, Xu AM. Huge HCC embolized by gelatin sponge particles and iodized oil compared with by iodized oil alone. J Hepatobiliary Surg 2012;20:47-50.  Back to cited text no. 9
    
10.
Ogura T, Hara K, Hijioka S, Mizuno N, Imaoka H, Niwa Y, et al. Can endoscopic ultrasound-guided fine needle aspiration offer clinical benefit for tumors of the ampulla of vater?-an initial study. Endosc Ultrasound 2012;1:84-9.  Back to cited text no. 10
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