British Journal of Radiology (2004) 77, 516-518
© 2004 British Institute of Radiology
doi: 10.1259/bjr/63282776
Adenosquamous carcinoma of the liver successfully treated with repeated transcatheter arterial infusion chemotherapy (TACE) with degradable starch microspheres
T Nakai, MD1,2,
K Ono, MD, PhD1,
K Terayama, MD1,
T Yamagami, MD, PhD2 and
T Nishimura, MD, PhD2
1 Department of Radiology, Osaka Tetsudou Hospital and 2 Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiichyou Kawaramachi-Hirokouji Kamigyou Kyoto 602-8566 Japan
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Abstract
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This report describes a 58-year-old female with adenosquamous carcinoma (ASC) of the liver presenting with right lower abdominal pain. In most ASC of the liver, surgery is the first choice of treatment. However, surgery often seems to be ineffective because of the aggressive behaviour of this disease. At surgical laparotomy in the present case, there was a large tumour occupying the entire right lobe of the liver and invading the diaphragm. Thus, partial hepatectomy was performed. For the residual tumour, we performed repeated transcatheter arterial infusion chemotherapy with degradable starch microspheres (DSM). After four sessions of transcatheter arterial infusion chemotherapy, tumour size decreased remarkably and tumour markers had also decreased. Despite the poor prognosis, the patient remains alive and well 12 months after laparotomy. It is suggested that minimally invasive transcatheter infusion chemotherapy with DSM can be an effective treatment preserving a high quality of life.
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Introduction
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Primary adenosquamous carcinoma (ASC) of the liver is a relatively rare disease, and the prognosis of patients is very poor [1–9]. Although the most widely accepted first choice of treatment for this tumour is surgical resection, about half of such patients do not undergo surgery because of difficulty in making the diagnosis in the early stage, the aggressive behaviour of the tumour, and its poor prognosis [2]. Even when surgery is performed, most patients die within 1 year [3].
In this paper, a case of ASC of the liver, showing marked improvement after transcatheter hepatic arterial infusion chemotherapy using degradable starch microspheres (DSM) is reported.
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Case report
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A 58-year-old female who felt pain in the right lower abdomen was admitted to our hospital. CT images showed multiple cystic lesions with enhanced areas in the peripheral zone in the right and left lobes of the liver and a solid areas extending irregularly under the diaphragm (Figure 1a
). Arteriography of the right inferior phrenic artery and right hepatic artery showed the blood supply of the lesion (Figure 1b). Laboratory findings showed elevated level of serum squamous cell carcinoma-related antigen (SCC-Ag), 42.5 ng ml–1 (normal range <1.5 ng ml–1). Before surgery, needle biopsy was performed. Microscopic analysis showed ASC containing both malignant squamous and glandular elements. At surgery, the main tumour had invaded the inferior vena cava and the diaphragm, thus complete resection of the tumour was considered difficult, and partial hepatectomy (resection of small part of S4 and S8) with partial resection of the diaphragm was performed. The level of SCC-Ag after surgery but before chemoembolisation is 35.8 ng ml–1. Although additional therapy for the residual tumour was necessary, the patient rejected systemic intravenous chemotherapy. Repeated transcatheter hepatic arterial infusion chemotherapy was undertaken, after informed consent was obtained from the patient.
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Figure 1. A 58-year-old female with adenosquamous carcinoma of liver. (a) Intravenous contrast-enhanced CT scan of the upper abdomen demonstrating cystic lesions and heterogeneously enhanced areas in the right lobe of the liver. In other areas of the right lobe, there were multiple lesions with both cystic and solid areas similar to this lesion. (b) Arteriogram from the right hepatic artery (left) and right inferior phrenic artery (right) showed a tumour lesion with enhancement in the right lobe.
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Initially, a 5-French catheter (Clinical Supply, Gifu, Japan) was inserted via the right femoral artery and advanced to the common hepatic artery via the coeliac artery. A microcatheter (On the Road, Solution Corporation, Yokohama, Japan) was inserted co-axially, and anti-cancer drugs (i.e. cisplatin 50 mg and 5-fluorouracil 250 mg) mixed with 4 ml of lipiodol (Laboratoire Guerbet, Roissy, France) were infused followed by injection of 300 mg of DSM via the microcatheter with its tip located in the anterior superior branch of the right hepatic artery and right inferior phrenic artery, using a further technique. 1 month later, anti-cancer drugs utilizing DSM containing the same dose of the drugs and lipiodol was used; hepatic arterial infusion chemotherapy was injected into the anterior superior branch of the right hepatic artery and the right inferior phrenic artery. 1 month after hepatic arterial chemotherapy, the right inferior phrenic arteriogram showed disappearance of tumour blush. However, the tumour blood supply from the hepatic arterial branches (caudate branch, and anterior superior and posterior branches of the right hepatic artery) was confirmed on hepatic arteriography. Following this an identical dose of drugs including lipiodol as previously used was injected via these arterial branches on two occasions. After the hepatic arterial infusion chemotherapy described above was repeated four times at intervals of 1 month, the tumour size and vascularity decreased significantly (Figure 2) and SCC-Ag level decreased to 3.9 ng ml–1 (<1.5 ng ml–1) at 2 weeks after the fourth chemoembolisation. The only complication noted was transient mild pain in the right abdomen occurring only after the first chemoembolisation.
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Figure 2. Photographs after four sessions of transcatheter hepatic arterial infusion chemotherapy with degradable starch microspheres. (a) Intravenous contrast-enhanced CT scan showing lipiodol accumulation in the tumour and a decrease in tumour size after 1 week of the fourth chemoembolisation. (b) Arteriogram at the time of the fourth chemoembolisation showing decrease in tumorous enhancement.
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Currently, 12 months after surgical laparotomy and 8 months after the last hepatic arterial infusion chemotherapy, the patient remains well off medication.
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Discussion
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Since the first report by Barr and Hancock in 1975 [1], about 50 cases of ASC have been published. Histologically, the tumour is characterized by co-existence of two distinct histological patterns, being malignant squamous and glandular components. There exists a transitional zone between the two areas in which the two histological types exclusively exist [3–5]. Reports describing radiological images of ASC have been few. According to some reports, ASC is shown as a low density mass with irregular rim enhancement on CT images, resembling the findings of cholangiocarcinoma, liver abscess, or metastatic liver disease. Arteriography shows a hypervascular area in the peripheral zone and a hypovascular region at the centre. The level of serum SCC-Ag, carcionoembryonic antigen, and carbohydrate antigen 19-9 are elevated in some cases. However, alpha-fetoprotein has not been reported as being elevated. The elevation of serum SCC-Ag is considered to be a useful marker for pre-operative diagnosis and may indicate recurrence ASC [4, 6].
Surgery is the treatment of choice. There have been some reports of the effectiveness of combining surgical resection and radiation therapy [7]. However, in many cases, ASC shows more aggressive clinical and pathological features than cholangiocarcinoma [8]. According to previous reports, ASC invades vessels, lymph nodes, and diaphragm at an early stage often preventing complete resection. It has been reported that majority of patients died within 1 year despite intensive therapy.
In the present case, transcatheter arterial infusion chemotherapy using DSM reduced tumour volume, that was too advanced to be completely resected at laparotomy. Infusion of anti-cancer drugs via the main arterial supply to the tumour, in combination with DSM causing transient reduction in blood flow, results in the prolonged retention of anti-cancer drugs in the tumour. As a result, the local anti-tumour effect on malignant lesions may be reinforced. Clinically, DSM is mainly used at the time of transcatheter hepatic arterial infusion chemotherapy for non-resectable metastatic liver disease, and some investigators have reported that this therapy is effective [10]. On intravenous contrast-enhanced CT image, the present case had multi-cystic areas with partial enhancement in the peripheral zone, which is similar to findings of metastatic liver disease. Because we expected the combined use of DSM and anti-cancer drugs to act on the ASC lesion in a manner similar to that on metastatic liver cancer lesions, we attempted the additional use of DSM in transcatheter hepatic arterial infusion chemotherapy in this case.
In conclusion, success in decreasing the size of ASC of the liver in the present case suggests that minimally invasive transcatheter hepatic arterial infusion chemotherapy with DSM might be an effective treatment, while maintaining a high quality of life for patients. To our knowledge, this is the first report of ASC of the liver successfully treated by repeated hepatic arterial infusion chemotherapy with DSM.
Received for publication October 9, 2002.
Revision received August 13, 2003.
Accepted for publication September 22, 2003.
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References
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Abstract
Introduction
