Korean J Radiol.  2006 Dec;7(4):257-266. 10.3348/kjr.2006.7.4.257.

Transcatheter Arterial Chemoembolization of Hepatocellular Carcinoma: Prevalence and Causative Factors of Extrahepatic Collateral Arteries in 479 Patients

• Chung JW
• Kim HC
• Yoon JH
• Lee HS
• Jae HJ
• Lee W
• Park JH

• KMID: 1092549
• DOI: http://doi.org/10.3348/kjr.2006.7.4.257

Abstract

OBJECTIVE
We wanted to investigate the prevalence and causative factors of extrahepatic arterial blood supply to hepatocellular carcinoma (HCC) at its initial presentation and during chemoembolization. MATERIALS AND METHODS: Between February 1998 and April 2000, consecutive 479 patients with newly diagnosed HCC were prospectively enrolled into this study. A total of 1629 sessions of transcatheter arterial chemoembolization (TACE) were performed in these patients (range: 1-15 sessions; mean: 3.4 sessions) until April 2004. For each TACE procedure, we determined the potential extrahepatic collateral arteries (ExCAs) depending on the location of the tumor, and we performed selective angiography of all suspected collaterals that could supply the tumor. The prevalence of ExCAs and the causative factors were analyzed. RESULTS: At initial presentation, 82 (17%) of these 479 patients showed 108 ExCAs supplying tumors. Univariate analysis showed that tumor size (p < 0.01), patient age (p = 0.02), a surface location (p < 0.01), and a bare area location (p < 0.01) were significantly associated with the presence of ExCAs. Multiple logistic regression analysis showed that only tumor size was predictive of ExCA formation (p < 0.01, odds ratio = 1.737, confidence interval: 1.533 to 1.969). During repeated TACE sessions, 97 additional ExCAs were detected in 70 (14%) patients. The cumulative probability of ExCAs in patients with a large tumor (> or = 5 cm) was significantly higher than that for those patients with a small tumor (< 5 cm) (p < 0.01). CONCLUSION: The presence of ExCAs supplying HCC is rather common, and the tumor size is a significant causative factor for the development of these collateral arteries.

Keyword

Liver neoplasms, chemotherapeutic embolization; Liver neoplasms, angiography; Liver neoplasms, blood supply

MeSH Terms

Neovascularization, Pathologic/*etiology/physiopathology/radiography
Middle Aged
Male
Logistic Models
Liver Neoplasms/physiopathology/*therapy
Humans
Female
Collateral Circulation/drug effects/physiology
Chemoembolization, Therapeutic/*methods
Carcinoma, Hepatocellular/physiopathology/*therapy
Angiography
Aged, 80 and over
Aged
Adult

Figure

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  Fig. 1 A 51-year-old man with hepatocellular carcinoma. A. Enhanced CT scan shows enhancing nodular lesion (arrowhead) 2 cm in size in the liver segment 7. B. Right hepatic angiogram shows staining of a small nodular tumor (arrow). C. Right inferior phrenic angiogram shows staining of small nodular tumor (arrowheads) that are supplied by the right inferior phrenic artery. Note the staining of the adrenal gland (arrow) that's supplied by the superior adrenal artery (open arrow) from the right inferior phrenic artery.

• 

  Fig. 2 A 39-year-old man with hepatocellular carcinoma. A. Enhanced CT scan shows a large exophytic mass (arrowheads) in the right liver lobe with prominent vessels (arrows) around the tumor. B. Celiac angiogram shows a large stained tumor (arrowheads) that's supplied by the right hepatic artery and omental branches (arrow) from the gastroepiploic artery. Note the defect (dotted circle) of tumor staining. C. Right inferior phrenic angiogram shows tumor staining (arrowheads) corresponding to the defect on the celiac angiogram. D. The superior mesenteric angiogram shows that hypertrophied colic branch (arrow) supply the tumor. Omental branches (arrowheads) supplying the tumor are also opacified via the pancreaticoduodenal arcade. E. Gastroepiploic angiogram shows multiple hypertrophied omental branches (arrowheads) supplying the tumor. Note the tip of the microcatheter (arrow).

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  Fig. 3 A 60-year-old man with hepatocellular carcinoma. A. Enhanced CT scan after six sessions of chemoembolization shows small enhancing tumor (arrowheads) in the liver segment 6. Note the nodule that has taken up iodized oil (arrow) without viable tumor. B. Celiac angiogram at the seventh session of chemoembolization shows a small stained tumor (arrow) that's supplied by an omental branch (arrowhead) from the gastroduodenal artery. Note attenuation of the hepatic artery (curved arrow) caused by repeated chemoembolization.

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  Fig. 4 The relationship of the tumor size and the presence of extrahepatic collateral arteries supplying hepatocellular carcinoma at the initial transcatheter arterial chemoembolization.

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  Fig. 5 Cumulative probability curve of the extrahepatic collateral supply. A. Kaplan-Meier plot shows the cumulative probability curve of extrahepatic collateral arteries supplying all tumors (A) and the primary tumor only (B).The gap between the two curves means the probability of extrahepatic collateral arteries for recurrent tumors during repeated TACE sessions. B. The Kaplan-Meier plot shows the cumulative probability curve of the extrahepatic collateral arteries in patients who all had large tumors (≥ 5 cm) (A), primary large tumors (B), all small tumors (< 5 cm) (C), and primary small tumors (D). The cumulative probability of ExCAs was statistically different between large tumor (≥ 5 cm, A) and small tumor (< 5 cm, C) (log-rank test, p < 0.01). The gap between curves A and B stands for the probability of extrahepatic collateral arteries for recurrent tumors in patients with large tumors (≥ 5 cm). The gap between curves C and D represents the probability of extrahepatic collateral arteries for recurrent tumors in patients with small tumors (< 5 cm).

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