IVR 会誌 Jpn J Intervent Radiol Vol.20 No.3 2005

State of the Art
IVR for Breast Lesions

1. Arterial Supply of the Breast
Professor Emeritus, Clinical Anatomy, Tokyo Medical and Dental University
Tatsuo Sato

The major sources of mammary blood supply are internal thoracic and axillary arteries. The medial mammary branches arise from one or two of the upper four perforating branches of the internal thoracic artery. The lateral mammary branches originate from the lateral thoracic
rtery of the axillary artery.
The lateral thoracic descends just anterior to the intercostobrachial nerves and curves round the lateral border of the pectoralis major to approach the mammary gland. This artery sometimes originates from the thoracoacromial or from the subscapular arteries.
Additional minor sources of mammary blood supplyare posterior intercostal arteries and pectoral branches of the thoracoacromial artery.
Branching patterns of axillary artery are discussed in view of their relationship with the brachial plexus.

Key words
● Arteries of the breast
● Topographic anatomy of the breast
● Axillary artery

2. Vascular IVR for Advanced Breast Cancer with Special Reference to Arterial Embolization and Arterial Infusion Chemotherapy
Department of Diagnostic Imagings and IVR1), Department of surgery2), Tenshi Hospital Carese Aliance Medical Corporation
Yutaka Morita1), Kenju Kusumoto2)

Vascular IVR for advanced breast cancer with special reference to transcatheter arterial embolization (TAE) and arterial infusion chemotherapy is described.The vasculo-anatomical characteristics of the breast consist of complicated arterial blood supply and anastomoses. Therefore, many technical ideas on IVR are needed. For the control of massive hemorrhage from locally advanced or recurrent breast cancer, the suitable procedure for TAE is embolization from the distal and proximal ends of the bleeding artery using a coaxial microcatheter system and micro-coils. Arterial redistribution should be done as a preconditioning of the arterial infusion chemotherapy. The basic procedures of arterial redistribution are coil embolization for the origin of the lateral thoracic artery and the distal end of the internal thoracic artery.

Key words
● Advanced breast cancer
● Trancatheter arterial embolization
● Arterial infusion chemotherapy

3. High Intensity Focused Ultrasound for the Treatment of Breast Cancer
Clinica E.T.
Fumikiyo Ganaha, Tetsuji Okuno

High intensity focused ultrasound (HIFU) offers a truly noninvasive tumor ablative treatment without any skin incision but with precise focusing of the target. Breast tumors appear to be good candidates for HIFU treatment because of the in superficial location. This article describes the rationale, therapeutic system and techniques of HIFU for treating breast cancer. Our initial experience of HIFU in 20 patients with breast cancer is also presented. In addition, other clinical and experimental applications of therapeutic ultrasound are discussed briefly.

Key words
● Focused ultrasound
● Therapeutic ultrasound
● Tumor ablation
● Breast neoplasms

4. Image- guided Vacuum-assisted Breast Biopsy
-Stereo-guided Biopsy-
Department of Radiology and Breast Surgical Oncology1), St. Luke’s International Hospital
Hiroko Tsunoda-Shimizu, Mari Kikuchi, Hiroshi Yagata1), Seigo Nakamura1)

Stereotaxic vacuum-assisted breast biopsy has become a common method to diagnose suspicious calcifications. By insertion of the probe under the precise procedure, pathological diagnosis is proven without major complications. Many papers have already reported the efficacy of stereotaxic vacuum-assisted breast biopsy. On the other hand, breast cancer screening using mammography (MMG) is already being applied for women in their forties in Japan. Many cases with suspicious calcifications will be detected by screening MMG from now. Japanese mammography guidelines decided the category of calcifications. We have to divide the cases with calcifications into the follow-up groups and mammotome indications correctly using this category. Stereotaxic vacuum-assisted breast biopsy will contribute to the diagnosis of early breast cancer by appropriate use in the present situation in Japan.

Key words
● Stereotaxic vacuum-assisted breast biopsy (mammotome biopsy)
● Calcifications
● Mammography

5. Imaging-guided Vacuum-assisted Breast Biopsy(2)
- Ultrasound-guided Biopsy-
Department of Breast Surgical Oncology and Radiology1), St. Luke’s International Hospital
Hiroshi Yagata, Seigo Nakamura, Hiroko Tsunoda1), Mari Kikuchi1)

Ultrasound-guided vacuum-assisted breast biopsy (Mammotome R, Ethicon Endo-Surgery of Johnson & Johnson) is a fast and minimally invasive as well as fine needle aspiration cytology (FNAC) and core needle biopsy (CNB). It can acquire large numbers of specimens consecutively with a single needle insertion and provide highly accurate diagnosis. The indication of ultrasound-guided Mammotome biopsy is as follow : 1) Suspicious malignancy by FNAC or CNB, 2) Insufficient material by FNAC or CNB, 3) Excision of benign lesion, 4) Sampling of cancer tissue before neoadjuvant chemotherapy. Insertion of the Mammotome needle is performed under local anesthesia and specimen is usually removed just below the lesion. The complications include bleeding, hematoma, pneumothorax, and skin defect, but the in incidence is very low. We performed Mammotome biopsy to 429 breast lesions between April 1999 and December 2004. Definitive diagnosis was obtained from most of the lesions which were suspicious of malignancy by FNAC or CNB. We experienced only two minor complications (bleeding from the part of needle insertion, and hematoma). Ultrasound-guided Mammotome biopsy is a safe method for breast lesions and compensates for shortcomings of FNAC and CNB.

Key words
● Vacuum-assisted breast biopsy
● Mammotome, ultrasound

Original Article
Arterial Infusion Therapy for Severe Acute Pancreatitis: Correlation between Drug Distribution and Change of Necrotizing Area
Department of Radiology, Emergency and Critical care Medicine1),Nara Medical University
Hideyuki Nishiofuku, Hiroshi Sakaguchi, Toshihiro Tanaka, Hiroshi Anai
Kiyosei Yamamoto, Kengo Morimoto, Kimihiko Kichikawa
Yoshinori Murao1), Kazuo Okuchi1)

 Purpose : To evaluate the relationship between drug distribution of arterial infusion and change of the necrotizing area in patients with severe acute pancreatitis (SAP)
Materials and Methods : Thirty-nine patients with SAP (necrotizing SAP : 23, edematous SAP : 16) were treated by arterial infusion therapy. One or 2 catheters were placed into the celiac and/or superior mesenteric artery. A protease inhibitor (Nafamostate mesilate : 240m/day) and antibiotics (Imipenem : 1n/day) were infused via the catheters. The drug distribution was evaluated by CT during arterial injection of contrast material on day 1, 3 and 7 in this therapy. The necrotizing area was evaluated by CT under intravenous bolus injection of contrast material. The relationship between drug distribution and change of the necrotizing area was studied.
 Results : Twenty-seven patients showed the distribution of contrast material to cover the entire area of the pancreas (good distribution). The remaining 12 showed that the distribution of contrast material did not cover the entire area of the pancreas (poor distribution). Two of 27 (11%) with good distribution showed enlargement of the necrotizing area in contrast to 8 of 12 (67%) with poor distribution. Enlargement of the necrotizing area was significantly more frequent (P=0.00037) in poor distribution as compared to that in good distribution. The overall mortality rate associated with this treatment was 12.8%.
 Conclusion : It is suggested that obtaining good distribution is important to prevent enlargement of the necrotizing area in SAP.

Key words
●Acute pancreatitis
●Arterial infusion
●Protease inhibitor

Case Report
A case of Successful Transcatheter Arterial Embolization for Intraabdominal Hemorrhage due to Suspected Segmental Mediolytic Arteriopathy
Department of Radiology, Kurume University School of Medicine
Department of Emergency and Critical Care Medicine, Kurume University School of Medicine1)
Daiji Uchiyama, Masamichi Koganemaru, Toshi Abe, Naofumi Tomita
Masaaki Nonoshita, Kensaku Higaki1), Teruo sakamoto1), Naofumi Hayabuchi

Segmental mediolytic arteriopathy (SMA) is a rare, nonatherosclerotic and noninflammatory arterial disease, and can be a cause of intraabdominal hemorrhage. We experienced a 65 -year - old woman who was admitted to our hospital with subarachnoid hemorrhage and was performed coil embolization of a basilar tip aneurysm. Six days later, she developed anemia and was revealed to have an intraabdominal hemorrhage by abdominal CT. An emergent angiography was performed. Not only a ruptured pseudoaneurysm of anterior inferior pancreaticoduodenal artery (AIPDA), but also“string of beads”of another pancreaticoduodenal artery and left gastric artery were shown. A ruptured pseudoaneurysm of AIPDA was successfully treated by transcatheter arterial embolization (TAE) with microcoils. These findings were suspected SMA.

Key words
●Segmental mediolytic arteriopathy (Segmental arterial mediolysis)
●Transcatheter arterial embolization
●Intraabdominal hemorrhage

Case Report
Iatrogenic Injury of the Internal Iliac Artery Branch ; Successful Coil Embolization in One Case
Department of Radiology, Saiseikai Fukuoka General Hospital
Koji Yamashita, Shunichi Matsumoto, Kenji Shinozaki, Makiko Koike, Naonobu Kunitake

Pseudoaneurysm following diagnostic or interventional procedures is a well-recognized complication. We report a case of iatrogenic injury of branch of the internal iliac artery.
A 78-year-old female developed lower abdominal distension during cardiac catheterization. Diagnosis was confirmed by a right internal iliac arteriography. This pseudoaneurysm was successfully treated by embolization with coils. No additional complications occurred. We consider that transcatheter arterial embolization (TAE) for injury of a branch of the internal iliac artery is effective and safe.

Key words
●Internal iliac artery
●Transcatheter arterial embolization

Technical Note
Initial Experience with Use of Micronester Coil for Embolotherapy
Department of Diagnostic and Interventional Radiology, Osaka University Graduate School of Medicine
Keigo Osuga, Azzam A. Khankan, Saki Nakata, Koji Mikami, Hiroki Higashihara
Takahiro Tsuboyama, Tonsok Kim, Masatoshi Hori, Kaname Tomoda
Takamichi Murakami, Hironobu Nakamura
Department of Diagnostic Radiology, Yale University School of Medicine
Robert I. White, Jr.

We report the first experience with use of a new 0.018inch pushable fibered microcoil (MicronesterR) for transarterial embolization in Japan. It is a long helical platinum microcoil with an extended length of 14b and a variety of diameters ranging from 3 to 10a. The coils were successfully deployed via a 0.021-inch endhole microcatheter by either wire-push or saline-flush technique. A tightly packed coil mass resulted in immediate cross-sectional occlusion of the targeted vessels. Clinical cases with renal arteriovenous malformation and gastroduodenal artery occlusion for the implantation of a port-catheter system were presented.

Key words