Chemoembolization for Malignant Hepatic Tumors Supplied by Extrahepatic Feeders: Single-Center Experience of 126 Interventions

Purpose: To present the experience of chemoembolizations of extrahepatic feeders to malignant hepatic tumors performed in a single oncological center.
Materials and methods: One hundred and twenty six transarterial chemoembolizations(TACE) were performed in 69 patients with hepatocellular carcinoma (HCC) and other malignant hepatic tumors. Chemoembolization with drug-eluting microspheres (DEMTACE) was performed in 77 (61.9 %) cases, conventional chemoembolization with lipiodol/chemotherapeutic drug emulsion (cTACE) in 45(35.7 %) and bland embolization in 4(3.2 %). TACE of extrahepatic feeders (TACE EHF) was carried out with TACE of hepatic artery branches at the same session in 78(61.9 %) cases. TACE of single EHF was performed in 100 (79.4 %) cases, two feeders in 24(19 %) and three in 2(1.6 %). The branches of following arteries were EHF to the tumors: inferior phrenic artery 71(56.3 %), cystic artery — 23(18.3 %), omental branch from the gastroepiploic artery –18(14.3 %), inferior right intercostal arteries — 10(7.9 %), left inferior phrenic artery — 7(5.6 %), right and left internal thoracic arteries — 4(3.2 %), gastroduodenal artery — 4(3.2 %), left gastric artery — 3(2.4 %), superior mesenteric artery — 3(2.4 %), right renal capsular artery — 3(2.4 %), right inferior adrenal artery — 3(2.4 %), right middle adrenal artery — 1(1.6 %) and right first lumbar artery — 1(1.6 %) case.
Results and discussion: After TACE EHF to hepatic tumors 14(11.1 %) complications occurred. Severe pain with irradiation to the right shoulder was observed in 10 procedures after TACE of the inferior phrenic artery (Grade 3 a — 6, Grade 2 — 4 cases according to CIRSE Classification System for Complications). Permanent skin erythema in the area supplying by an artery (grade 4) took place in 4 cases after TACE of the right intercostal arteries, right internal thoracic artery and left gastric artery branches. In the group of 36 patients with HCC treated only by TACE median overall survival from the time of first TACE EHF was 13.7 months, overall cumulative survival rates were 72.2±7.5 % (at 6 months), 55.6±8.3 % (at 1 year), 26.7±7.5 % (at 2 years), 17.8±6.5 % (at 3 years), 11.9±5.5 % (at 5 years). Median overall survival from the time of first TACE was 20.9 months, overall cumulative survival rates were 77.8±6.9 % (at 6 months), 72.2±7.5 % (at 1 year), 38.9±8.1 % (at 2 years), 30.6±7.7 % (at 3 years), 18.5±6.6 % (at 5 years). Based on own experience and literature data a review of all possible complications and techniques to avoid its was performed. Causes and imaging of extrahepatic blood supply were observed. The possibility to perform not only cTACE but DEM-TACE too was emphasized. The feature of our group was the presence of a relatively large number of patients with hepatic metastases in contrast to literature data based on analysis of treatment outcomes only of HCC.
Conclusion: Extrahepatic blood supply to hepatic tumors is frequently encountered in large tumors, peripherally located tumors and after repeated TACE. It can be observed not only in HCC but in other hepatic tumors even hypovascular ones. TACE EHF allows to continue endovascular management of hepatic tumors and to improve treatment outcomes.

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