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Transarterial Chemoembolization for Hepatocellular Carcinoma Using a New Double-Lumen Microballoon Catheter with a Side Hole
Volume 25
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Number 9
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September
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2014
Transarterial Chemoembolization for Hepatocellular Carcinoma Using a New Double-Lumen Microballoon Catheter with a Side Hole From: Wataru Todoroki, MD Masakazu Hirakawa, MD, PhD Eiki Nagao, MD, PhD Hiroyasu Soeda, MD Satoru Tsuruta, MD Hiroshi Honda, PhD Departments of Radiology (W.T., E.N., H.S.) and Internal Medicine (S.T.) National Hospital Organization Beppu Medical Center Oita, Japan Department of Radiology (M.H.) Kyushu University Beppu Hospital 4546 Tsurumihara Beppu 874-0838, Japan Department of Clinical Radiology (H.H.) Graduate School of Medical Sciences Kyushu University Hospital Fukuoka, Japan
Editor: Intraarterial infusion chemotherapy requires superselective catheterization of a target artery (1,2), which is often difficult. We recently applied a new double-lumen microballoon catheter with a side hole in the leading end of the balloon that can be used for infusion during transarterial chemoembolization to treat hepatocellular carcinoma (HCC) without superselective catheterization of the target artery, and obtained dense lipiodol deposition. Our institutional review board approved this report of a 79-year-old woman with liver cirrhosis caused by hepatitis C virus and Child–Pugh class A disease who had previously been treated for HCC by radiofrequency ablation, percutaneous ethanol injection, and transarterial chemoembolization. Computed tomography (CT) revealed a 16-mm hepatic nodule in segments 4 and 8 with early signal enhancement that was washed out in the delayed phase. A small, solitary nodule near the left branch of the portal vein was diagnosed as recurrent HCC, and treatment with transarterial chemoembolization was selected. Angiography revealed hypervascular HCC fed by a small artery branching from the proximal right hepatic artery (RHA) at an acute angle. Selective insertion of a microcatheter (Meister Cath; Medikit, Tokyo, Japan) with 2.0-F trailing and 2.4-F leading sides over a 0.014inch guide wire (Radifocus; Terumo, Tokyo, Japan) was
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.05.019
1485
difficult. Therefore, an emulsion of 10 mg of epirubicin (Farmorubicin; Kyowa Hakko, Tokyo, Japan) and 1.5 mL of iodized oil (Lipiodol; Guerbet, Roissy, France) was infused from the proximal RHA, without Lipiodol deposition in the HCC according to CT findings. Forty days later, chemoembolization was attempted after distal occlusion with the use of a new 130-cm double-lumen microballoon catheter (Microsight; Fuji Systems, Tokyo, Japan) with 3.3-F trailing and 3.9-F leading sides. The maximum diameter of the occlusion balloon (available only in Japan) is 7.0 mm. A 4-mm side hole (Fig a) leads to the balloon end of the catheter for drug infusion by occluding the end hole with a specific guide wire (Excelmed; Fuji Systems) (3). The microballoon catheter was inserted distal to the branch point of the small target artery through a 5-F guide catheter with an inner diameter of 0.059 inches (guiding catheter; Medikit) and a 0.014-inch guide wire (Radifocus; Terumo). The balloon was inflated for distal occlusion, and the end hole was occluded by the guide wire. Right hepatic angiography then revealed a small feeding artery and tumor stain (Fig b,c). An emulsion comprising 10 mg of epirubicin, 1.5 mL of Lipiodol, and 1-mm gelatin sponge particles (Gelpart; Astellas, Tokyo, Japan) was infused from the small target artery through the side hole. Angiography showed that the tumor stain had disappeared, and CT confirmed Lipiodol deposition into the HCC (Fig d). Postoperative complications did not develop, and HCC had not recurred 4 months after treatment. The small, solitary HCC nodule in the present patient was located near the left branch of the portal vein, and therefore neither radiofrequency ablation nor percutaneous ethanol injection was attempted. Rather, we chose to perform chemoembolization with the use of a new microballoon catheter for this HCC fed by a small artery branching from the proximal RHA. Arterial flow is redistributed when selective insertion of a microcatheter is difficult. Koganemaru et al (3) recently described the new double-lumen microballoon catheter with the side hole that was used in the present patient. They noted that, when selective catheterization is difficult, the microballoon catheter enables prompt infusion of chemotherapeutic agents to a target artery via distal occlusion of the parent artery (3). Traditional microballoon catheters do not have a side hole, and therefore another catheter is needed to infuse drugs. In addition, the feeding artery branched from the proximal hepatic artery, which allowed preservation of a broad area of normal hepatocytes by distal occlusion. The side hole is a 0.3-mm 0.8mm rectangle. We passed 1-mm gelatin sponge particles (as an embolic agent) through the hole with minimal resistance. The new microballoon catheter has one major limitation: the distal portion is relatively large and stiff, so it
1486
’
Letter to the Editor
Pua and Ho
’
JVIR
Figure. Photograph of balloon microcatheter (a) and images of hepatic segments 4 and 8 in a 79-year-old woman with recurrent HCC. (b,c) A double-lumen microballoon catheter is inserted into the RHA before chemoembolization. Right hepatic angiogram after balloon inflation (black arrowhead, b) via the side hole shows a small feeding artery (white arrowhead, b) and HCC (arrow, c). (d) Unenhanced CT image 2 weeks after chemoembolization shows dense focal deposition of Lipiodol within the HCC (arrow). (Available in color online at www.jvir.org.)
can be inserted into only relatively large vessels (3). Therefore, the new microballoon catheter can be used for transarterial chemoembolization only when tumors are fed by a diminutive artery branching from a relatively large, proximal artery. As with all balloon catheters, complications such as spasm, vessel injury, and dissection can result from inflation.
Size of Microspheres after Drug Loading: Perhaps It Is Time to Take a Closer Look From: Uei Pua, MBBS, MMed, FRCR, FAMS Bernard Chi Shern Ho, MBBS, MIAC, FRCPath, FAMS Department of Diagnostic Radiology (U.P.) and Pathology (B.C.S.H.) Tan Tock Seng Hospital 11 Jalan Tan Tock Seng Singapore 308433
Neither of the authors has identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.06.001
REFERENCES 1. Lewandowski RJ, Geschwind JF, Liapi E, Salem R. Transcatheter intraarterial therapies: rationale and overview. Radiology 2011; 259:641–657. 2. Bertino G, Occhini A, Falco CE, et al. Concurrent intra-arterial carboplatin administration and radiation therapy for the treatment of advanced head and neck squamous cell carcinoma: short term results. BMC Cancer 2009; 9:313. 3. Koganemaru M, Abe T, Anai H, et al. A newly developed double lumen microballoon catheter with a side hole: initial experience of intraarterial infusion chemotherapy and/or embolization. Jpn J Radiol 2012; 30:870–874.
Editor: Several embolic platforms capable of drug loading and elution are now commercially available, including DC Bead (Biocompatibles UK Ltd, Farnham, United Kingdom), HepaSpheres (QuadraSpheres in United States) (Merit Medical Systems, Inc, South Jordan, Utah), and ONCOZENE (Embozene TANDEM outside of United States) (CeloNova BioSciences, Inc, San Antonio, Texas), all with unique physical and pharmacokinetics profiles. Although pharmacokinetics properties, such as efficacy and speed of drug absorption, elution curve, duration of elution, and peak drug levels, are areas of interest (1–4), an important characteristic of these platforms that is of particular relevance is the concept of “effective size” of
’
Number 9
’
September
’
2014
Transarterial Chemoembolization for Hepatocellular Carcinoma Using a New Double-Lumen Microballoon Catheter with a Side Hole From: Wataru Todoroki, MD Masakazu Hirakawa, MD, PhD Eiki Nagao, MD, PhD Hiroyasu Soeda, MD Satoru Tsuruta, MD Hiroshi Honda, PhD Departments of Radiology (W.T., E.N., H.S.) and Internal Medicine (S.T.) National Hospital Organization Beppu Medical Center Oita, Japan Department of Radiology (M.H.) Kyushu University Beppu Hospital 4546 Tsurumihara Beppu 874-0838, Japan Department of Clinical Radiology (H.H.) Graduate School of Medical Sciences Kyushu University Hospital Fukuoka, Japan
Editor: Intraarterial infusion chemotherapy requires superselective catheterization of a target artery (1,2), which is often difficult. We recently applied a new double-lumen microballoon catheter with a side hole in the leading end of the balloon that can be used for infusion during transarterial chemoembolization to treat hepatocellular carcinoma (HCC) without superselective catheterization of the target artery, and obtained dense lipiodol deposition. Our institutional review board approved this report of a 79-year-old woman with liver cirrhosis caused by hepatitis C virus and Child–Pugh class A disease who had previously been treated for HCC by radiofrequency ablation, percutaneous ethanol injection, and transarterial chemoembolization. Computed tomography (CT) revealed a 16-mm hepatic nodule in segments 4 and 8 with early signal enhancement that was washed out in the delayed phase. A small, solitary nodule near the left branch of the portal vein was diagnosed as recurrent HCC, and treatment with transarterial chemoembolization was selected. Angiography revealed hypervascular HCC fed by a small artery branching from the proximal right hepatic artery (RHA) at an acute angle. Selective insertion of a microcatheter (Meister Cath; Medikit, Tokyo, Japan) with 2.0-F trailing and 2.4-F leading sides over a 0.014inch guide wire (Radifocus; Terumo, Tokyo, Japan) was
None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.05.019
1485
difficult. Therefore, an emulsion of 10 mg of epirubicin (Farmorubicin; Kyowa Hakko, Tokyo, Japan) and 1.5 mL of iodized oil (Lipiodol; Guerbet, Roissy, France) was infused from the proximal RHA, without Lipiodol deposition in the HCC according to CT findings. Forty days later, chemoembolization was attempted after distal occlusion with the use of a new 130-cm double-lumen microballoon catheter (Microsight; Fuji Systems, Tokyo, Japan) with 3.3-F trailing and 3.9-F leading sides. The maximum diameter of the occlusion balloon (available only in Japan) is 7.0 mm. A 4-mm side hole (Fig a) leads to the balloon end of the catheter for drug infusion by occluding the end hole with a specific guide wire (Excelmed; Fuji Systems) (3). The microballoon catheter was inserted distal to the branch point of the small target artery through a 5-F guide catheter with an inner diameter of 0.059 inches (guiding catheter; Medikit) and a 0.014-inch guide wire (Radifocus; Terumo). The balloon was inflated for distal occlusion, and the end hole was occluded by the guide wire. Right hepatic angiography then revealed a small feeding artery and tumor stain (Fig b,c). An emulsion comprising 10 mg of epirubicin, 1.5 mL of Lipiodol, and 1-mm gelatin sponge particles (Gelpart; Astellas, Tokyo, Japan) was infused from the small target artery through the side hole. Angiography showed that the tumor stain had disappeared, and CT confirmed Lipiodol deposition into the HCC (Fig d). Postoperative complications did not develop, and HCC had not recurred 4 months after treatment. The small, solitary HCC nodule in the present patient was located near the left branch of the portal vein, and therefore neither radiofrequency ablation nor percutaneous ethanol injection was attempted. Rather, we chose to perform chemoembolization with the use of a new microballoon catheter for this HCC fed by a small artery branching from the proximal RHA. Arterial flow is redistributed when selective insertion of a microcatheter is difficult. Koganemaru et al (3) recently described the new double-lumen microballoon catheter with the side hole that was used in the present patient. They noted that, when selective catheterization is difficult, the microballoon catheter enables prompt infusion of chemotherapeutic agents to a target artery via distal occlusion of the parent artery (3). Traditional microballoon catheters do not have a side hole, and therefore another catheter is needed to infuse drugs. In addition, the feeding artery branched from the proximal hepatic artery, which allowed preservation of a broad area of normal hepatocytes by distal occlusion. The side hole is a 0.3-mm 0.8mm rectangle. We passed 1-mm gelatin sponge particles (as an embolic agent) through the hole with minimal resistance. The new microballoon catheter has one major limitation: the distal portion is relatively large and stiff, so it
1486
’
Letter to the Editor
Pua and Ho
’
JVIR
Figure. Photograph of balloon microcatheter (a) and images of hepatic segments 4 and 8 in a 79-year-old woman with recurrent HCC. (b,c) A double-lumen microballoon catheter is inserted into the RHA before chemoembolization. Right hepatic angiogram after balloon inflation (black arrowhead, b) via the side hole shows a small feeding artery (white arrowhead, b) and HCC (arrow, c). (d) Unenhanced CT image 2 weeks after chemoembolization shows dense focal deposition of Lipiodol within the HCC (arrow). (Available in color online at www.jvir.org.)
can be inserted into only relatively large vessels (3). Therefore, the new microballoon catheter can be used for transarterial chemoembolization only when tumors are fed by a diminutive artery branching from a relatively large, proximal artery. As with all balloon catheters, complications such as spasm, vessel injury, and dissection can result from inflation.
Size of Microspheres after Drug Loading: Perhaps It Is Time to Take a Closer Look From: Uei Pua, MBBS, MMed, FRCR, FAMS Bernard Chi Shern Ho, MBBS, MIAC, FRCPath, FAMS Department of Diagnostic Radiology (U.P.) and Pathology (B.C.S.H.) Tan Tock Seng Hospital 11 Jalan Tan Tock Seng Singapore 308433
Neither of the authors has identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.06.001
REFERENCES 1. Lewandowski RJ, Geschwind JF, Liapi E, Salem R. Transcatheter intraarterial therapies: rationale and overview. Radiology 2011; 259:641–657. 2. Bertino G, Occhini A, Falco CE, et al. Concurrent intra-arterial carboplatin administration and radiation therapy for the treatment of advanced head and neck squamous cell carcinoma: short term results. BMC Cancer 2009; 9:313. 3. Koganemaru M, Abe T, Anai H, et al. A newly developed double lumen microballoon catheter with a side hole: initial experience of intraarterial infusion chemotherapy and/or embolization. Jpn J Radiol 2012; 30:870–874.
Editor: Several embolic platforms capable of drug loading and elution are now commercially available, including DC Bead (Biocompatibles UK Ltd, Farnham, United Kingdom), HepaSpheres (QuadraSpheres in United States) (Merit Medical Systems, Inc, South Jordan, Utah), and ONCOZENE (Embozene TANDEM outside of United States) (CeloNova BioSciences, Inc, San Antonio, Texas), all with unique physical and pharmacokinetics profiles. Although pharmacokinetics properties, such as efficacy and speed of drug absorption, elution curve, duration of elution, and peak drug levels, are areas of interest (1–4), an important characteristic of these platforms that is of particular relevance is the concept of “effective size” of