Endovascular placement of iodine-125 seed strand and stent combined with chemoembolization for treatment of hepatocellular carcinoma with portal vein tumor thrombus

Introduction

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors worldwide. Portal venous invasion is reported in 12.5–39.7% of patients with advanced HCC (1). When the main portal vein (MPV) was involved by tumor thrombus, the patient’s prognosis was extremely poor (2). For these patients, there is no effective treatment and the optimal treatment remains controversial. Most HCCs with portal vein tumor thrombus (PVTT) are technically unresectable and they are not suitable for curative therapies. As a palliative treatment, transcatheter arterial chemoembolization (TACE) treatment for HCC with PVTT is safe and effective when there is sufficient collateral circulation. However, PVTT limits the effect of TACE on HCC and has a strong negative impact on the therapeutic effect (3). Therefore, opening the occlusion of the portal vein caused by PVTT and reperfusing the portal vein could improve the success of TACE, and this could be achieved using portal vein stenting (PVS). PVS combined with TACE has been successfully used in the treatment of HCC with PVTT. However, PVS effectively removes the portal vein obstruction but do not treat the thrombus per se, and stent restenosis may happen. Radioactive seed implantation is used in a variety of solid tumors. Iodine-125 (¹²⁵I) seed implantation was attempted to treat HCC with PVTT and achieved excellent therapeutic efficacy (4) with a good safety profile (Figure 1).

Figure 1 Endovascular placement of iodine-125 seed strand and stent combined with chemoembolization for treatment of hepatocellular carcinoma with tumor thrombus in main portal vein (5). Available online: http://www.asvide.com/article/view/26844

Operative techniques

• Perform percutaneous transhepatic portal 6F vagina vasorum implantation and CTAP by 5F pigtail catheter. It shows that the filling defect at main portal vein in the size of approximately 8 mm × 5 cm;
• Remove pigtail catheter, bring in the super smooth guide wire and small wire adopted in percutaneous transhepatic cholangiography drainage), remove vasorum and then place it by super smooth guide wire. By replacement of the vasorum, long super smooth guide wire is inside the vasorum while the short one outside;
• Preparation of seed strand: radioactivity of each ¹²⁵I seed is 25.9 MBq with a half-life of 59.4 days. The number of ¹²⁵I seeds planned to be implanted was calculated by the following formula: length of obstructed MPV (mm)/4.5+2 (Figure 2);
  

  Figure 2 ¹²⁵I seed. Radioactivity of each Iodine-125 seed is 25.9 MBq with a half-life of 59.4 days.
• Release ev3 stent with the size of 14 mm × 8 cm by smooth guide wire, guide it into the vagina vasorum of PTCD by small wires, remove small wires, and then push prepared ¹²⁵I seed strand;
• Angiography shows that portal vein is smooth with stent in the right place and ¹²⁵I seed strand is in a good condition;
• When the sheath is slowly withdrawing to liver parenchyma, use four coiling in the size of 3 mm × 3 cm to seal the puncture path;
• Perform percutaneous puncture from right femoral artery to sheath, and then guide 5F RH tube to super selective hepatic artery. Angiography shows the staining of giant tumor in right lobe of liver, which is significant in three feeding arteries. Prescribe such drugs for embolization as Pirarubicin 30 mg + Oxaliplatin 50 mg + Iodinated Oil 25 mL + PVA (500–700 µm).

Comments

• TACE cannot be directly performed on the patients with primary hepatocellular carcinoma (PHC) and PVTT. The combination of portal vein stent and endovascular implantation of ¹²⁵I seed strand can open the portal vein and conduct radiation therapy on PVTT by radioactive seeds strand;
• After opening the portal vein, TACE can be performed and the focus in portal vein or liver can be treated;
• Due to the huge tumor, complete embolization at one time may cause damage on liver function and severe postoperative reactions, so fractionated embolization should be adopted.

Acknowledgments

Funding: None.

Footnote

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/tcr.2018.07.23). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki (as revised in 2013). Written informed consent was obtained from the patient for publication of this manuscript and any accompanying images.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

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2. Zhou L, Rui JA, Wang SB, et al. Risk factors of poor prognosis and portal vein tumor thrombosis after curative resection of solitary hepatocellular carcinoma. Hepatobiliary Pancreat Dis Int 2013;12:68-73. [Crossref] [PubMed]
3. Sun JH, Zhou T, Zhu T, et al. Portal Vein Stenting Combined with Iodine-125 Seeds Endovascular Implantation Followed by Transcatheter Arterial Chemoembolization for Treatment of Hepatocellular Carcinoma Patients with Portal Vein Tumor Thrombus. Biomed Res Int 2016;2016:3048261 [Crossref] [PubMed]
4. Yang M, Fang Z, Yan Z, et al. Transarterial chemoembolization (TACE) combined with endovascular implantation of an iodine-125 seed strand for the treatment of hepatocellular carcinoma with portal vein tumour thrombosis versus TACE alone: a two-arm, randomised clinical trial. J Cancer Res Clin Oncol 2014;140:211-9. [Crossref] [PubMed]
5. Zhao S, Yang X, Gu W, et al. Endovascular placement of iodine-125 seed strand and stent combined with chemoembolization for treatment of hepatocellular carcinoma with tumor thrombus in main portal vein. Asvide 2018;5:727. Available online: http://www.asvide.com/article/view/26844