Jpn J Intervent Radiol Vol.24 No.3 2009

State of the Art
The Collaboration of Recent Oncology IVR,
Radiotherapy and Systemic Chemotherapy for Advanced Cancer

An Introduction Kazuhisa Fujiwara

1. Combined Therapy Using Arterial Infusion for Unresectable Pancreatic Cancer

Department of Radiology and Surgery1), Nara Medical University
Toshihiro Tanaka, Hideyuki Nishiofuku, Hiroshi Anai, Satoru Sueyoshi, Takeshi Sato
Aya Hashimoto, Masayuki Sho1), Yoshiyuki Nakajima1), Kimihiko Kichikawa
Department of Radiology, Nara Prefectural Mimuro Hospital
Hiroshi Sakaguchi
Department of Radiology, Saiseikai Chuwa Hospital
Kiyosei Yamamoto
Department of Radiology, Saiseikai Gose Hospital
Kengo Morimoto
Department of Radiology, Nara Prefectural Nara Hospital
Masayoshi Inoue

 In recent years, gemcitabine has been widely used as a standard systemic chemotherapy for unresectable pancreatic cancer. However, the response rate has been around 10% and the median survival time around 6 months. Thus, the efficacy of systemic gemcitabine is limited and the patient prognosis remains poor. To improve patient survival, it is required to develop novel therapeutic strategies.
 Recently, there have been reports on arterial infusion chemotherapy for unresectable pancreatic cancer, and hopes have been raised regarding the efficacy of this modality. Here, we report our experience including the results of clinical trial in which an arterial infusion of 5-FU combined with radiotherapy and systemic gemcitabine, our technique to unify the pancreatic blood supply, and the results pharmacological evaluation of experimental study.

Key words

  • Pancreatic cancer
  • Arterial infusion chemotherapy
  • Chemoradiotherapy


2. Concurrent Chemoradiotherapy with Bronchial Arterial Infusion of CDDP for the Treatment of Locally-advanced Non-small Cell Lung Cancer

Division of Radiation Oncology, Diagnostic Radiology1)
Department of Radiology Tokyo Metropolitan Cancer and Infectious diseases Center Komagome Hospital
Katsuyuki Karasawa, Noriko Kamata1)

 The standard treatment for locally advanced (stage III) non-small cell lung cancer (NSCLC) is concurrent use of chemoradiotherapy containing cisplatinum (CDDP). To enhance the local control and reduce the systemic adverse effects, we have been performing intraarterial infusion of CDDP from the bronchial arteries (BAI of CDDP) instead of intravenous administration. In principle, we administered 80㎎/㎡ of CDDP intra- arterially twice during the conventionally fractionated radiation therapy of 60 to 70Gy. The dose of CDDP was changed according to the patient’s renal function. Between 1996 and 2001 40 cases with stage III NSCLC were treated definitively. Median age was 75 years. There were 28 Sqcca and 9 adenoca. There were 7 stage III A and 33 stage III B cases. Average total RT dose was 63.4Gy and median total CDDP dose was 220㎎. Median follow-up period was 63 months. Median survival time was 27 months. Five-year overall, relapse-free and cause-specific survival rates were 41%, 33% and 56%, respectively. Five-year local relapse-free rate was 57%. As for acute complications, we had only six (15%) grade 3 hematological and 2 (5%) grade 3 pulmonary complications, and we had no severe esophageal complications, which is often a dose-limiting factor. Our survival results of concurrent radiotherapy and BAI of CDDP for the treatment of stage III NSCLC have been promising with a low rate of severe adverse effects. Judging from the high rate of long-term disease-free survivors, disease clearance by chemoradiotherapy might be quite essential to improve the treatment results.

Key words

  • Non-small cell lung cancer
  • Concurrent chemoradiotherapy
  • Bronchial arterial infusion


3. Intra-arterial Infusion Chemoradiotherapy for Advanced Carcinoma of the Uterine Cervix

Department of Radiation Oncology, Radiology1), Obstetrics and Gynecology2), Hiroshima University
Yuko Kaneyasu, Yasushi Nagata, Naoyuki Toyota1), Hideaki Kakizawa1), Ikuno Nishibuchi
Tomoki Kimura, Yuji Murakami, Masahiro Kenjo, Hisaya Fujiwara2), Yoshiki Kudo2)
Department of Obstetrics and Gynecology, Asa Citizen Hospital
Nobutaka Nagai

 Prognosis for patients with advanced uterine cervical cancer is still poor. In order to improve the prognosis for such patients, further effort is required. Intra-arterial infusion chemotherapy (IAIC) is considered to be useful for improvement of local control and survival. Many investigations have shown encouraging results for local control, but many reports have shown no definite effect on survival time. We analyzed 29 cases of Stage III squamous cell carcinoma of the uterine cervix treated with radiotherapy and IAIC of CDDP from 1991 to 2006. Five-year overall survival (OAS) rate for StageIII patients was 62%, cause specific survival (CSS) rate was 70% and local relapse-free survival rate was 89%. Severe late complication rates (Grade 3≦) of the bladder, rectum and intestine were 3%, 3% and 10%, respectively. Our study showed good local control, although numerous extra-pelvic distant metastases, especially PAN metastases were noted. Therefore, in order to decrease distant metastases, it is thought that some whole body chemotherapies are necessary. We should evaluate the position of the catheter and the drug distribution from the effectiveness and safety points of view. We confirmed excellent drug distribution directly by using angio-CT. To improve the survival rate for advanced cervical cancer, it is advocated that to improve local control IAIC be considered, and to reduce potential systemic disease, systemic chemotherapy be considered. In order to improve the prognosis of these patients, we should furthermore consider a combination of IAIC and systemic chemotherapy.

Key words

  • Cervical carcinoma
  • Intra-arterial infusion chemotherapy
  • Radiotherapy
  • High-dose rate brachytherapy


4. Radiofrequency Ablation Therapy after Primary Systemic Therapy for Breast Cancer

Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University
Shoji Oura

 In the past three decades, local management of breast cancer has dramatically changed from mastectomy and axillary dissection to breast-conserving therapy and sentinel node biopsy. In addition, breast-conserving therapy has become to be often applied to breast cancers responding to primary systemic therapy (PST). Radiofrequency ablation therapy (RFA) has attracted attention in the treatment of localized early breast cancer, and is expected to be a useful approach in the PST setting, too. In our department, 63 breast cancer patients were treated with primary systemic therapy followed by RFA, the mean follow-up period of which was 41 months (11~69 months). Three of the 63 patients developed in-breast recurrence. Of the three patients, one was alive without further recurrence after salvage surgery, and another was successfully treated with surgery and trastuzumab-containing chemotherapy. Cosmesis of the patients treated with PST followed by RFA was equally excellent to those with primary RFA. In conclusion, PST followed by RFA may be a feasible therapeutic option for breast cancer.

Key words

  • Breast cancer
  • Primary systemic therapy
  • Radiofrequency ablation


5. Percutaneous Radiofrequency Ablation Plus Systemic Chemotherapy of Lung Tumors

Department of Radiology, Chemotherapy Center and Respiratory Medicine1),
Osaka City University Graduate School of Medicine
Toshiyuki Matsuoka, Shinzo Kudo1)

 Recently, percutaneous radiofrequency ablation (RF ablation) has been increasingly attracting attention as a new modality of local treatment of malignant tumors in various organs. Especially for liver tumors, good results of the procedure are reported, and RF ablation is widely performed. Since the first clinical cases of RF ablation of lung tumors were reported in 2000, many reports have been published. The puncture is carried out under CT guidance. The heat generated by radiofrequency coagulates the tissues surrounding the electrode. However, at present this procedure is still limited to only a few institutions. In the first part of this report, we describe the flow of enforcement, indications, and the details of the technical procedure conducted in our institution. Local control rate was about 80%, and the most frequent complication was pneumothorax, which was observed in about 30%. Good results can be expected for tumors with a diameter of 3cm or less. The initial results were promising, and further development is expected in combination with other therapies. In the latter part of this report, general ideas about the systematic chemotherapy of primary and secondary lung tumors is described by an expert. Although the interventional radiologist is not familiar with chemotherapy, it could be useful in the expansion of indications and improvement of prognosis to be familiar with the latest knowledge of chemotherapy.

Key words

  • Radiofrequency ablation
  • Lung cancer
  • Chemotherapy

Original Article

Transcatheter Arterial Chemoembolization with Cisplatin-Lipiodol Emulsion for Epirubicin-Lipiodol TACE Resistant Unresectable Hepatocellular Carcinoma : Initial Evaluation of Efficacy and Toxicity

Department of Radiology, Fujieda Municipal General Hospital
Akihiko Seki, Tatsuya Igarashi
Department of Radiology, Internal Medicine1), GateTower Institute for Image Guided Therapy
Akihiko Seki, Toshio Kawauchi, Shinich Hori, Seiji Narumiya1)

In this study, we evaluated the efficacy and toxicity of transcatheter arterial chemoembolization (TACE) with Cisplatin-Lipiodol emulsion in 14 patients with unresectable hepatocellular carcinoma (HCC). The eligibility criteria were history of undergoing at least two sessions of TACE with Epirubicin-Lipiodol emulsion and relapse within three months ; performance status (PS) 0-2 ; Child-Pugh A or B ; adequate cardiac and renal function. For TACE, the catheter was placed selectively in the tumor feeding arteries, and Cisplatin-Lipiodol emulsion, followed by gelatin sponge particles, was injected. Therapeutic effect and overall response on the tumors were evaluated at 3 and 6 months after TACE. Therapeutic effect : The complete and partial response rates were 35.7% and 42.9%. Overall response : The complete and partial response rates were 28.6% and 35.7%. Grade 3/4 toxicities were : leukopenia (7.1%), thrombocytopenia (7.1%), AST elevation (50%), ALT elevation (35.7%), and hyperbilirubinemia (7.1%). These severe side effects disappeared within two weeks after TACE. No renal and/or hepatic dysfunction was encountered. These data suggest that TACE with Cisplatin-Lipiodol emulsion may be a useful therapeutic option with relatively tolerable toxicities for patients with unresectable HCC.

Key words

  • Hepatocellular carcinoma
  • Transcatheter arterial chemoembolization
  • Cisplatin
  • Epirubicin
  • Liver function

Original Article

Selective Transcatheter Embolization for Patients with High Flow Priapism

Department of Radiology, Okinawa Prefectural Nanbu Medical Center
Kimei Azama, Fumikiyo Ganaha, Shirou Iraha, Kiyoshi Oshiro
Department of Radiology, The Jikei University School of Medicine
Shinjiro Tojo, Ken Koyama, Shunichi Sadaoka

We present 4 patients with high flow priapism who underwent transcatheter embolization. Three patients presented priapism following penile trauma. In one patient, there was no history of causative trauma and the etiology was unknown. The intracavernosal arteriovenous fistula was detected by color duplex ultrasound, and transcatheter embolization was performed subsequently. The arteriovenous fistula was embolized superselectively using gelatin sponge particles via a microcatheter. In all, an immediate pain relief was obtained and the penis returned to a normal size within a week. On follow-up, the erectile function was maintained in 3 patients and one patient was lost. Endovascular treatment with superselective embolization is a safe and effective method to treat this pathological condition.

Key words

  • Priapism
  • High flow
  • Embolization
  • Erectile dysfunction
  • Gelatin sponge

Case Report

Deep Renal Injury at the Isthmus of Horseshoe Kidney Successfully Treated by TAE Using N-butyl Cyanoacrylate and Metallic Coils : A Case Report

Department of Radiology, Suita Municipal Hospital
Koji Mikami
Department of Diagnostic and Interventional Radiology, Osaka University Graduate School of Medicine
Keigo Osuga

We report a case of deep renal injury at the isthmus of a horseshoe kidney treated by transcatheter arterial embolization (TAE). A 9-year-old boy suffered abdominal blunt trauma by steering wheel injury from a cycling accident. Contrast-enhanced computed tomography (CT) revealed deep injury at the left-side isthmus of a horseshoe kidney with perirenal hematoma and urinoma. Digital subtraction angiography showed extravasation from the aberrant artery to the isthmus originating from the aorta. TAE with N-butyl cyanoacrylate and metallic coils was successfully performed. One week later, hematuria disappeared and perirenal urinoma decreased, but the urine leak persisted. Therefore, ureteral catheterization into the left ureter was subsequently performed. Four months after TAE, the perirenal urinoma regressed, and the ureter catheter was removed.

Key words

  • Horseshoe kidney
  • Deep renal injury
  • Transcatheter arterial embolization

Case Report

Stent-grafting for Pseudoaneurysm of Superior Mesenteric Artery : A Case Report

Department of Radiology, Aichi Medical University
Akira Kitagawa, Seiji Kamei, Yuichiro Izumi, Yukihiko Oshima, Eisuke Katsuda
Makiyo Hagihara, Joe Matsuda, Junko Kimura, Toshiki Kawamura, Tsuneo Ishiguchi

We report a case of postsurgical pseudoaneurysm of the superior mesenteric artery that was successfully treated by endovascular stent-graft placement. A woman in her 70’s was admitted with gastrointestinal bleeding. She had a history of pancreatoduodenectomy for pancreatic head carcinoma two months before. Contrast-enhanced CT and angiography demonstrated a pseudoaneurysm with a diameter of 2㎝ at the proximal trunk of the superior mesenteric artery. A 5㎝ long self-expandable PTFE-covered stent-graft was percutaneously placed through a 9-French sheath via the right femoral artery. The length of the stent-graft was selected so as not to occlude the jejunal arteries. GI bleeding stopped immediately and did not recur until the patient died of recurrent cancer. Stent-grafting is considered as a safe and effective treatment for pseudoaneurysm of the superior mesenteric artery. Precise measurement of the lesion is important for preservation of arterial flow of the intestinal branches.

Key words

  • Pseudoaneurysm
  • Gastrointestinal bleeding
  • Stent-graft

Technical Note

Case of Hepatocellular Carcinoma Treated by Selective Hepatic Arterial Chemoembolization on Sonazoid US Angiography

Department of Radiology and Hepatology1), St. Marianna University School of Medicine
Atsuko Fujikawa, Kenji Takizawa, Hiroshi Shimamoto, Iwao Uejima,Yukihisa Ogawa, Kunihiro Yagihashi, Misako Yoshimatsu, Shingo Hamaguchi, Yasuo Nakajima
Kotaro Matsunaga1), Hiroki Ikeda1), Masaru Okamoto1), Ryujiro Negishi1)

We herein report a case of hepatocellular carcinoma (HCC) treated with transcatheter arterial chemoembolization (TACE) on Sonazoid US angiography. A women in her 70s female with liver cirrhosis had HCC in the medial segment of the left lobe of the liver. As she had an allergy to iodine contrast material, TACE on Sonazoid US angiography was attempted. Following CO2-DSA, the feeding artery for HCC was clearly identified on Sonazoid US angiography with 1% diluted Sonazoid manually injected into the medial branch of the left hepatic artery. TACE using an emulsion consisting of Sonazoid, IA-call and Spherex was achieved under ultrasonography. The tumor showed decreased size on MRI 2.5 months later. Thus, selective TACE for HCC was successfully achieved through a combination of CO2-DSA and Sonazoid US angiography without iodine contrast material.

Key words

  • US angiography
  • Transarterial embolization
  • Sonazoid
  • CO2 angiography

Technical Note

A Novel Technique of Ipsilateral Portal Vein Embolization with Absolute Ethanol Injection via Sheath under Balloon Occlusion : Report of Two Case

Department of Radiology and Surgery1), Saga Medical School
Junichi Nojiri, Yoshiaki Egashira, Hiroyuki Irie, Tomokazu Tanaka1), Naohiko Kohya1)
Takateru Otsuka, Noriyuki Kamachi, Kohji Miyazaki1), Sho Kudo

We report a novel technique of ipsilateral portal vein embolization. The procedure was performed prior to operation in 2 patients with hilar bile duct cancer. The usual double lumen balloon catheter and sheath were used, and absolute ethanol was injected via the sheath under the balloon occlusion of the right portal vein. Right portal vein embolization was thus achieved without severe complications.

Key words

  • Portal vein
  • Balloon occlusion
  • Ethanol