Marys Medicine



Cardiovasc Intervent Radiol (2008) 31:735–744 Transcatheter Arterial Chemoembolization for AdvancedHepatocellular Carcinoma with Inferior Vena Cava and RightAtrial Tumors M. C. Chern Æ V. P. Chuang Æ T. Cheng ÆZ. H. Lin Æ Y. M. Lin Received: 24 September 2007 / Accepted: 17 March 2008 / Published online: 22 April 2008Ó Springer Science+Business Media, LLC 2008 Advanced hepatocelluar carcinoma (HCC) with (p 0.02). No serious complication was observed post- invasion of venous systems usually indicates not only a chemoembolization. In conclusion, TACE is a safe and poor prognosis but also a contraindication for transcatheter effective treatment for advanced HCC with IVC and RA arterial chemoembolization (TACE). This study evaluated tumors, and small Ivalon particles (47–180 lm) are supe- the feasibility of TACE for advanced HCC with inferior rior to large ones ([180 lm).
vena cava (IVC) and right atrium (RA) tumors and, also, tosearch for the ideal embolization particle size. Twenty-six Transcatheter arterial chemoembolization  patients who had HCC invasion into the IVC included five Hepatocellular carcinoma  Inferior vena cava  patients with coexistent RA tumors that were treated with TACE. The chemoembolization method was cisplatin,doxorubicin, and mitomycin C mixed with Lipiodol andIvalon. The selection of Ivalon particles was divided into two groups based on their size: (A) [180 lm, N = 9; and(B) 47–180 lm, N = 17. The overall response rate was Advanced hepatocellular carcinoma (HCC) with tumor 53.8% (14/26). Based on the response to TACE, the thrombi in portal veins (PVs), the inferior vena cava (IVC), or median survival period of the entire group was 4.2 months the right atrium (RA) has an extremely poor prognosis.
(range, 1.5 to 76.7 months). The median survival period of Without treatment, the survival duration is 3 months the 14 responders was 13.5 months (1.5–76.7 months), HCC invasion of PV results in liver failure or esophageal and that of the 12 nonresponders, 3.3 months (2.1 to varices bleeding and has been considered to be the terminal 24.3 months) (p 0.002). Comparing the two Ivalon par- stage. HCC invasion into the IVC and RA may be compli- ticle sizes, the response rate was 12.5% (1/9 patients) for cated by lung metastasis, pulmonary infarction, secondary group A and 76.5% for group B (13/17 patients) Budd-Chiari syndrome, ball-valve thrombus syndrome, andintractable heart failure and carries the threat of sudden death.
Several methods are available to treat HCC invasion to M. C. Chern  V. P. Chuang (&)  T. Cheng  IVC and RA, including surgery, radiotherapy, systemic Z. H. Lin  Y. M. Lin chemotherapy, and TACE Surgical resection combined Department of Radiology, Koo Foundation Sun Yat-Sen CancerCenter, 125 Lih-der Road, Pei-tou District, Taipei, Taiwan with chemotherapy is efficacious but is still limited by the patient's hepatic reserve []. Conventional radiotherapiesfor advanced HCC have shown disappointing results accompanied by severe complications []. The response rates of systemic chemotherapy for HCC are only 20% TACE for HCC is considered to be an effective and safe therapy in many serial reports []. Until now, TACEfor advanced HCC with invasion of PV, IVC, and RA is Z. H. Line-mail: [email protected] still considered a contraindication at many institutions.
M. C. Chern et al.: Transcatheter Arterial Chemoembolization for Advanced Hepatocellular Carcinoma Katsumori et al. reported the safety and efficacy of either fine-needle aspiration or core biopsy in all patients.
TACE for HCC with PV tumors []. However, there have Serum bilirubin level [3 mg/dl and Child C liver disease been only limited case reports of TACE for HCC with IVC are the exclusion criteria. Visceral angiograms including and RA tumors –Furthermore, there has been no celiac, superior mesenteric, and hepatic arteriograms were study concerning the sizes of embolized particles in TACE routinely performed prior to chemoembolization. All for advanced HCC.
patients had constant monitoring of blood pressure, heart Our study evaluates whether TACE can be performed rate, and blood oxygen saturation throughout the procedure.
safely and effectively in advanced HCC patients with IVCand RA tumors and searches for the ideal particle size to Definitions of Venous Tumor Response target the venous tumors.
Two parameters on CT images were used to evaluate theresponse of IVC and RA tumors: the diameter and the Materials and Methods length of the tumor. Partial response was defined as areduction in tumor diameter of [20% or in tumor length of From August 1997 to December 2005, 26 patients under- more than one CT slice ([7 mm). Complete response was went TACE for advanced HCC with IVC tumors and 5 of defined as total clearance of tumors in the IVC or RA.
them had coexisting RA tumors at our institution. Thirteen Others including stable condition were considered to be patients had PV tumors simultaneously. The age range was from 34 to 74 years. The sex distribution was 20 males and6 females. The other baseline characteristics of patients are summarized in Table . All patients had three-phase spiralcomputed tomography (CT) of the abdomen in axial images Preprocedure, patients were hydrated with 1000 ml normal at 7-mm slice thickness to demonstrate the extent of liver saline solution and medicated with 5 mg tropisetron, 5 mg tumors into the IVC and/or RA. Additionally, 13 of 26 dexamethasone, and 10 mg metoclopramide.
patients had PV thrombosis. Eleven patients had thrombosis Celiac and superior mesentery arteriograms were rou- of the right PV and two had thrombosis of the left PV. Two tinely performed to show hepatic arterial anatomy and patients had concomitant main PV thrombosis. The histo- portal venous system and to ensure either patent portal veins logical or cytological diagnosis of HCC was confirmed by or periportal collaterals with hepatopedal flow. Selective Table 1 Baseline characteristics of the patients Responders (N = 14) Nonresponders (N = 12) Hepatitis B virus Hepatitis C virus Hepatitis B & C virus Serum total bilirubin, lmol/L (range) Serum albumin, g/L (range) Prothrombin time, s (range) 13.9 (10.9–16.1) 13.8 (11.9–15.3) 13.9 (10.9–16.1) Serum a-fetoprotein, ng/ml ( 20/20–400/ [ 400) Diameter of the largest tumor, cm Tumor volume C50% of liver volume, no.
Right atrium tumor Hepatic vein invasion Portal vein obstruction Okuda stage (I/II/III) M. C. Chern et al.: Transcatheter Arterial Chemoembolization for Advanced Hepatocellular Carcinoma hepatic and/or extrahepatic arteriogram, especially inferior Statistical Analysis phrenic arteries, were performed to demonstrate tumorvascularity, blood supplies, and arteriovenous shuntings.
Statistical analyses were performed with chi-square anal- The standard dosage of our chemoembolization protocol ysis and Fisher's exact test where appropriate, with consists of three drugs, 100 mg cisplatin, 50 mg doxoru- statistical significance achieved at a p value 0.05. Sur- bicin, and 10 mg mitomycin C, dissolved in 10 ml normal vival rates were analyzed by the Kaplan-Meier actuarial saline, then mixed with Lipiodol (Lipiodol Ultrafluide; method, with statistical significance determined by the log- Laboratoire Guerbet, Aul-nay-sous-Bois, France) at a 1:1.1 rank statistic with SAS 8.02 statistical software (SAS volume ratio. Lipiodol volume is 10% larger than the drug Institute Inc., Cary, NC, USA). Univariate and multivariate mixture and rinsing continuously between two syringes to survival analyses were performed on selected variables, assure emulsion formation.
including AFP, albumin, total bilirubin, Child-Pugh score, Particulate materials are added to the above drug- Okuda stage, PV thrombosis, tumor type, tumor volume Lipiodol emulsion to improve drug retention inside the ([50%), and age (Table ). A value of p 0.05 was tumor. Polyvinyl alcohol (PVA or Ivalon; Cook Inc., considered statistically significant.
Bloomington, IN, USA) particles [180 lm were used asembolization agents until 1999, then smaller PVA particles(two sizes, 47–90 and 90–180 lm). There is no difference in the embolization technique before versus after 1999, exceptPVA size. Based on PVA size, the patients were divided into Survival and Response two groups. In group A (N = 9), the PVA particles were[180 lm. In group B (N = 17), they were 47–180 lm.
All 26 patients tolerated sequential TACE over the course The catheter was placed as close as to the tumor as of the study without treatment-related major complications.
possible. The PVA particles were mixed with the drug- Twenty-two patients expired during the course of the study.
Lipiodol emulsion. Embolization proceeded with slow The survival period of the entire group was from 1.5 to injection of the above mixture till the tumor was well 76.7 months (median, 4.2 months) (Fig. ). The 12-, 24-, opacified by the Lipiodol. When arterial flow started to and 36-month survival rates were 41%, 25%, and 7%, slow down, we stopped the procedure. This was to avoid reflux of drugs and also to prevent excessive embolization Based on tumor response to TACE by image study, the of the peribiliary plexus and the segmental hepatic artery 26 patients were divided into two groups, 14 responders itself. Attention was paid not to reach total stasis of arterial (53.8%) and 12 nonresponders (46.2%). The two groups flow, especially in patients with PV thrombosis.
were balanced in their main characteristics, especially in If arteriovenous or arterioportal shuntings were present, the size and distribution of tumors and PV invasion a small bolus of 1–2 ml drug-Lipiodol emulsion was (Table The median survival of responders was injected first to observe the flow pattern and the tumor 13.5 months (range, 1.5 to 76.7 months), while that of uptakes. If shunting was prominent, larger PVA particles nonresponders was 3.3 months (2.1 to 24.3 months). The were used. When shunting was decreased, smaller PVA difference in the survival period of the two groups was particles were added for the remaining tumor.
statistically significant (p 0.002; Fig. The total amount of chemotherapeutic agents adminis- When the coexisting PV tumor was added to the survival trated was dependent on the total vascular spaces of the analysis, the survival of 13 patients without PV tumor was tumor, but not the size of the tumor itself. Nineteen patients 10.9 months and that of the other 13 patients with PV received the full dosage of drugs, and the others received tumor was 14.3 months. The survival rate by coexisting PV [60% of the standard dosage.
tumor was not statistically significant (p = 0.98) (Fig. Additionally, comparison of patients with coexisting PV tumor in responders (8/14 patients) versus nonresponders(5/12 patients) also showed no statistically significant dif- Immediate nonenhanced CT was obtained within 30 min ference (p = 0.43). Of five patients who had RA tumors, after TACE to assess the completeness of tumor emboli- three showed complete response (60%) and one partial zation, especially the venous component of the tumor. One response (20%). The last patient showed tumor progres- month after TACE, all patients underwent triphasic CT sion. Tumor response by particle size showed only 1 of 8 studies. Patients with residual tumors received repeat patients (12.5%) in group A and 13 of 18 patients (72.2%) TACE 6 to 8 weeks after the previous TACE. Patients were in group B. The difference in response rate was statistically followed up until death or to the end of the study period significant (p 0.01). Four of five patients (80%) with (January 31, 2006).
regression of RA tumors were all in group B.

M. C. Chern et al.: Transcatheter Arterial Chemoembolization for Advanced Hepatocellular Carcinoma Table 2 Univariate and multivariate analysis in patients with advanced HCC with IVC/RA tumors Univariate analysis Multivariate analysis Tumor volume ([50%) Note: RR, relative risk; CI, confidence interval; AFP, a-fetoprotein; PV, portal vein * Statistically significant correlation Fig. 1 Overall survival rate of the entire group Fig. 2 Survival rate by response after TACE Prognostic Factors Immediate CT after TACE showed only a trace of Lipiodolretention in both lower lungs of all patients, but without Prognostic factors included in univariate and multivariate symptoms of dyspnea, chest pain, or a decline in blood survival analysis were AFP, albumin, total bilirubin, Child- oxygen saturation. There was no TACE-related liver fail- Pugh score, Okuda stage, PV thrombosis, tumor type, ure, 30-day mortality, or encephalopathy. Especially, tumor volume ([50%), and age. Both univariate and pulmonary embolism was not observed after embolization multivariate survival analysis showed statistically signifi- in the entire group. Other minor complications were fever cant correlation with Child-Pugh score and tumor volume (80.7%), abdominal pain (70.9%), vomiting (61.5%), and transient deterioration of liver function (100%).

M. C. Chern et al.: Transcatheter Arterial Chemoembolization for Advanced Hepatocellular Carcinoma bilirubin, 1.2 mg/dl; HBsAg, negative; HCV antibody,positive; and AFP, 6.2 ng/ml.
CT scan of the abdomen showed a 12-cm tumor in the left lobe of the liver, with invasion of the IVC and RA(Fig. A) and tumor thrombus in the left PV (Fig. Common hepatic arteriogram showed a huge hypervas-cular left hepatic tumor extending via the IVC into theRA (thread and streaks sign) (Fig. C) accompaniedby (Fig. D). TACE was performed at the left hepatic arterywith the standard dosage and 75 mg PVA (47–180 lm).
CT scan 1 month post TACE showed shrinkage of the RAand hepatic tumors with excellent Lipiodol retention intumors (Fig. and F) and an opacified left PV (Fig. F).
CT after 2 months showed clearance of the RA tumorand marked reduction of the left hepatic tumors (Fig. and H).
Fig. 3 Survival rate by coexisting PV tumor Until July 2004, the paient's hepatic tumors were con- trolled well by three courses of TACE. However, tumor Illustrative Cases recurrence in the right lobe with invasion into the main PVresulted in progressive hepatic failure. She expired in Case 1. Complete response of IVC/RA tumor, with 6 year September 2004, for a total survival of 2 years 7 months.
Case 3. HCC with HV, IVC/RA, and PV tumor, and lung A 70-year-old man had a history of hepatitis B and C. He was metastasis, with 2 year 9 month survival referred to our hospital after CT scan diagnosis of hepatictumors with IVC and RA invasion. Pertinent laboratory tests A 55-year-old man had been suffering from persistent dry were as follows: AST (GOT), 91 U/L; ALT (GPT), 94 U/L; cough for 2 to 3 months. Chest x-ray showed multiple lung total bilirubin, 0.7 mg/day; albumin, 3.8 g/dl; HBsAg, nodules with elevation of the right hemidiaphragm. He was positive; HCV antibody, positive; and AFP, 30 ng/ml.
referred to our hospital under the diagnosis of liver tumors CT scan of the abdomen showed hepatic tumors with with lung metastasis.
IVC and RA tumors (Fig. A). Proper hepatic arteriogram Pertinent laboratory tests were as follows: AST (GOT), showed a prominent hypervascular tumor extending into 53 U/L; ALT(GPT), 43 U/L; albumin, 3.9 g/dl; total the IVC an RA with delineation of multiple fine vessels bilirubin, 1.0 mg/dl; HBsAg, positive; HCV antibody, (thread and streaks sign) (Fig. B). TACE was performed negative; and AFP, 47,978 ng/ml.
at the right and middle hepatic arteries with 50% standard CT scan showed multiple liver tumors with IVC, drug dosage and 100 mg PVA (47–180 lm). CT scan RA, and right PV tumor invasion (Fig. and B). Right 1 month after TACE showed shrinkage and necrosis of hepatic arteriogram showed hypervascular hepatic tumors IVC and RA tumors (Fig. and excellent Lipiodol and IVC (Fig. C) and PV tumors (thread and streaks retention in these tumors (Fig. CT scan 2 months after sign) (Fig. C). TACE of the right hepatic artery with TACE showed clearance of IVC and RA tumors (Fig. 50% of the standard drug dosage and 75 mg PVA and F). The patient had been treated with six courses of (47–180 lm). The immediate CT scan showed Lipiodol TACE and was still alive after 6 years 4 months.
retention in the RA (Fig. and PV (Fig. tumors,but a Lipiodol pooling defect in the main tumor near the Case 2. Complete response of IVC/RA and PV tumor with dome (Fig. D). CT scan after two sessions of TACE 2 year 7 month survival including extrahepatic arterial embolization (right inferiorphrenic artery) showed shrinkage and necrosis of RA/IVC In February 2002, a 69-year-old woman was referred to our tumors (Fig. and G) and reopening of the right PV hospital because of upper abdominal pain and a palpable hepatic mass. She was diagnosed as having cirrhosis of the The patient received four courses of TACE and liver and HCC.
expired 2 years 9 months later due to progressive recur- Pertinent laboratory tests were as follows: AST (GOT), rent tumors in the liver parenchyma, but none in the 90 U/L; ALT (GPT), 42 U/L; albumin, 3.0 g/dl; total venous systems.

M. C. Chern et al.: Transcatheter Arterial Chemoembolization for Advanced Hepatocellular Carcinoma Fig. 4 HCC with invasion intoIVC/ RA. (A) CT scan showshepatic tumors with IVC andRA tumors (arrow). (B) Properhepatic arteriogram shows an 8-to 10-cm hypervascular tumorextending into IVC an RA(thread and streaks sign)(arrows). (C, D) CT scan1 month after TACE showsshrinkage and necrosis of IVCand RA tumors (arrowhead)with excellent Lipiodolretention in right lobe and righthepatic vein tumors (arrows).
(E, F) CT scan 2 months afterTACE shows clearance of IVCand RA tumors (arrows) confirmed a distinct survival advantage for TACE in patientswith unresectable HCC –]. Greatly advanced HCC The natural course of HCC with tumor thrombus in the PV, including PV or IVC thrombosis is still considered an IVC, or RA is dismal. Until now, greatly advanced HCC absolute contraindication for TACE at most institutions with tumor extension into the IVC and RA has had an because of the potentially increased risk of liver failure after extremely poor prognosis. The median survival of patients the procedure. However, recent articles have demonstrated with IVC tumor thrombus was only 2–3 months without the safety and efficacy of TACE in those patients with effective treatment [For HCC with a tumor thrombus advanced HCC. Georgiades et al. showed that TACE was not extending into the IVC, no effective treatment has yet been a contraindication in patients with PV thrombosis and had a reported. Previous studies on conventional radiotherapies survival benefit ]. Additionally, Kiely et al. suggested that for HCC have shown disappointing results accompanied TACE can be performed safely in patients with advanced by severe complications [–]. The outcome of surgery for disease and decreased hepatic reserve [However, there is HCC with IVC tumor thrombi has also been disappointing, still a lack of large series in the literature showing the efficacy with a mean postoperative survival time ranging from 7.3 and safety in patients with advanced HCC with IVC and RA tumors treated by TACE. A search of the literature revealed TACE has become an acceptable treatment for most only some case report studies about TACE in treatment of unresectable HCCs. Recent randomized controlled trials HCC with IVC and RA tumors [].

M. C. Chern et al.: Transcatheter Arterial Chemoembolization for Advanced Hepatocellular Carcinoma Fig. 5 HCC of left hepatic lobewith invasion into IVC/RA andleft portal vein. (A) CT showshepatic tumor invasion of theIVC and RA (arrows). (B) A 12-cm tumor in the left hepatic lobe(arrow) and nonopacified leftportal vein (arrowhead). (C)Common hepatic arteriogram,early phase, shows a hugehypervascular left hepatic tumorextending via the IVC into theRA (arrows). (D) Late phase,marked arterioportal(arrowhead) and arteriovenousshuntings (arrows). (E, F) CTscan 1 month after TACEshows shrinkage RA andhepatic tumors with excellentLipiodol retention in tumor(arrows) and opacified leftportal vein (arrowhead). (G, H)CT after 2 months showsclearance of the RA tumor andmarked left lobe tumorreduction Our study indicates that TACE not only is not contra- median survival of 3.3 months, a significant difference indicated in patients with advanced HCC with invasion into (p = 0.002).
the IVC and RA, but also is beneficial to their survival. The In the literature, HCC patients with invasion into the effectiveness of TACE in our study is clear when survival IVC and RA without treatment have an extremely poor durations of responder versus nonresponder patients are prognosis, i.e., 3 months, similar to that of patients with compared (Fig. In our study, the median survival of PV tumor thrombi. Zeng et al. ] also showed the same responders was 13.5 months, whereas nonresponders had a results. In the study published by Georgiades [the 1-,

M. C. Chern et al.: Transcatheter Arterial Chemoembolization for Advanced Hepatocellular Carcinoma Fig. 6 HCC with invasion intothe IVC/RA and right portalveins. (A, B) CT scan showsmultiple liver tumors and IVC,RA, and right portal vein tumorinvasion. (C) Right hepaticarteriogram showshypervascular hepatic tumorsand IVC (arrow) and portal veintumors (arrow head): ‘‘threadand streaks sign.'' (D)Immediate CT scan after TACEshows Lipiodol retention inliver and IVC-RA tumors(arrowhead) but a poolingdefect around the liver dome(*). (E) Immediate CT alsoshows Lipiodol retention in onebranch of right portal vein. (F,G, H) CT scan after twosessions of TACE includingright inferior phrenic arterialembolization shows shrinkageand necrosis of RA/IVC tumors(arrow) and reopening of rightportal vein (arrowhead) 2-, and 3-year survival rates of patients with HCC and PV We observed that TACE using different particle sizes thrombosis have been reported to be 17%, 8%, and 0%, showed different response rates. The response rate (72.2%) respectively. Nevertheless, the 1-, 2-, and 3-year survival of group B (PVA 180 lm) was significantly higher than rates of patients with HCC and IVC/RA thrombosis in our that of group A (PVA [ 180 lm) (p 0.01). It is sug- study were 41%, 25%, and 7%. According to our results gested that smaller embolized particles more effectively treatment with TACE effected a survival benefit in some blocked the arterial flow not only closer to but also directly into the tumors and, thus, prolonged the retention time of

M. C. Chern et al.: Transcatheter Arterial Chemoembolization for Advanced Hepatocellular Carcinoma chemotherapeutic agents in tumors. This can also explain support the concept of aggressive primary tumor treatment why the patients showed a higher response rate (80%) of in the presence of distant metastasis.
RA tumors treated with smaller PVA particles. The reso- PV tumor thrombus seems not to be a major factor in lution of RA tumors should decrease the risk of sudden influencing the response to TACE in these patients with death and intractable heart failure in these patients.
IVC/RA tumor because its presence showed no difference Our past experience using Gelfoam pledgets (1 to in responders versus nonresponders (Fig. Accordingly, 2 mm) and larger Ivalon particles (250 to 420 lm) fre- it should not be a contraindication to TACE in patients who quently resulted in a reduction of parenchymal tumors but have IVC/RA tumors, even coexistent with PV tumors, if seldom showed improvement of tumors within the PV, the hepatic reserve is adequate. Although the survival rate IVC, and RA. We believe that these agents blocked tumor also showed no difference in the presence of PV tumors, vessels well proximal to the tumor mass. We systematically the survival of nonresponders with coexisting PV tumors studied and downsized the particles so they would reach was still the worst (Fig. ). According to the univariate and and stay within the tumors to provide the maximal effect. It multivariate survival analyses of our series, tumor volume is widely believed that tumor vessels are larger than arte- [50% and Child-Pugh score were the only two main rioles supplying the normal sinusoids. Thus, it is possible prognostic factors with statistic significance in these to find a proper particle size which targets the tumor but spares the normal parenchyma. Our study suggested that a The theoretical concern of complications from TACE size of 47–180 lm meets this goal. Our future study will for IVC /RA tumors is pulmonary embolism induced by further compare two subgroups of particles, 47–90 and 90– embolized particles because the angiography of IVC and RA tumors demonstrate the ‘‘thread and streaks'' sign of Immediate nonenhanced CT after TACE was used to the tumors accompanying with marked arteriovenous evaluate the distribution of Lipiodol within the tumors and shuntings into the heart ]. Besides, the mechanism of to predict the effectiveness of the treatment in our patients diminution of IVC and RA tumors is thought to be tumor (Fig. We observed in two nonresponding patients that necrosis followed by breaking-down to form emboli.
Lipiodol only pooled in some parts of the IVC and RA However, no pulmonary embolic event was detected clin- tumors on CT scan after TACE. That is because their tumor ically throughout the courses of our patients. This study blood supplies were from more than one artery including suggests that PVA particles (47–180 lm) were trapped by both hepatic and extrahepatic sources. In this series, the tumors and not passed through into the lungs. Another right inferior phrenic artery was the most common extra- reason for the safety of TACE of IVC/RA tumors might be hepatic feeder of IVC/RA tumors. We suggest that all because the surfaces of IVC and RA tumors were smooth feeding arteries of IVC/RA tumors be completely embol- and mostly covered with endothelia as demonstrated in ized in the first session of TACE, if technically feasible, to autopsy cases by Kojiro et al. ]. This endothelial barrier achieve a good response.
might prevent the necrotic tumor from disrupting into the The presence of the ‘‘thread and streaks sign'' in the IVC. After TACE, the necrotic venous tumor thrombus venous tumors in all 26 patients indicated that the enlarged might shrink and retract backward instead of fragmenting vasa vasorum of the venous wall is a vital element oftumoral growth within the vein. To treat them effectively,the embolization particles should be smaller than thesevessels. Considering the marked difference in response rate(12.5% vs 72.2%) between the large (180-lm) and thesmall (47- to 180-lm) PVA particle sizes, we postulatedthat 47–180 lm is closer to the true diameter of tumor-feeding arteries. CT scan immediately following TACEwas very useful in the demonstration of how well thevenous tumor was embolized (Figs. and E).
When a stage IV patient has a large tumor bulk, PV, IVC, and RA tumor, and lung metastasis, as in case 3,traditionally it is usually treated with only palliative che-motherapy or symptomatic treatment. Because of thereasonable hepatic function reserve (total bilirubin, 1.0 mg/dl), we decided to proceed with aggressiveTACE. The marked response of the liver tumor (Figs. and H) and survival of 2 years 9 months in this patient Fig. 7 Survival rate by response and PV tumor M. C. Chern et al.: Transcatheter Arterial Chemoembolization for Advanced Hepatocellular Carcinoma into the IVC or pulmonary artery because of the intact carcinoma: assessment of efficacy on cases of resection following embolization. Radiology 147:401–405 11. Dazai Y, Katoh T, Katoch I, Sueda S, Yoshida R (1989) Effec- In conclusion, our study suggests that TACE is an tiveness of chemoembolization therapy for metastatic right atrial effective and safe treatment method in patients with tumor thrombus associated with hepatocellular carcinoma. Chest advanced HCC invading the IVC and RA. Smaller em- bolized particles (47–180 lm) are more effective. Overall, 12. Kashima Y, Miyazaki M, Kaiho T et al (1996) A successful treatment for hepatocellular carcinoma with atrial tumor throm- these patients showed a high response rate of IVC/RA bus. Hepatogastroenterology 43:1040–1045 tumors to TACE, without major complications, and some 13. Zeng Z, Fan J, Tang Z et al (2005) A comparison of treatment of them gained survival benefit.
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W H AT W E K N O W Managing Medication for Adults with AD/HDAD/HD is recognized as a neurobiological disorder that often persists from childhood into adulthood, resulting in about 4-5% of adults having AD/HD.1-5 Medication, which is an integral part of the multimodal treatment of AD/HD in children, is the cornerstone of treatment for adults.6-8 Although there is a significant amount of research in children, there is much less controlled research data on medication therapy in adults.4,9 Regarding the use of medication in the treatment of AD/HD, it has been said that "pills do not substitute for skills."45 This means that medication alone is not sufficient to help a person improve his or her problems in areas such as organization, time management, prioritizing, and using cognitive aids. However, medication levels the neurobiologic playing field, and allows adults with AD/HD to learn and develop the skills they need to succeed.