Hepatic perfusion disorders: Etiopathogenesis and related diseases

In this article, we have reviewed the hepatic perfusion disorder （HPD）, etiopathogenesis of HPD and corresponding diseases. Review of the literature was based on computer searches （PubMed, Index Medicus） and personal experiences. We considered HPD reflects perfusion differences due to redistribution of arterial blood flow among segments, subsegments and lobes of the liver. The plain CT scan findings of HPD manifests as triangular or wedge-shaped areas of low attenuation. On contrast-enhanced CT scan, HPD manifests multiple （or single） transient wedge-shaped, rotundloid or irregular appearance, homogeneous hyperattenuation （in less cases, hypoattenuation） during the hepatic arterial phase （HAP） and isoattenuated or slightly hyperattenuated areas during the portal arterial phase. Dynamic enhanced magnetic resonance （MR） features are similar to enhanced CT scan. Angiographic findings include non-opacification of portal vein on portograms or wedge-shaped segmental staining in arterial and parenchymal phases on hepatic angiograms. The causes of HPD are arterioportal shunts （APS）, intrahepatic vascular compressions and portal vein occlusion, steal phenomenon by hypervascular tumors, vascular variations and any other unknown reasons. It is very important for radiologists to be familiar with the various appearances of HPD to avoid false-positive diagnosis of pseudolesions and not to overestimate the extent of the disease.

Isolated hepatic perfusion: a regional therapy for liver cancer

BACKGROUND: Many treatments have been proposed for non-resectable primary or secondary hepatic cancer but the results have been disappointing. Isolated hepatic perfusion (IHP) was attempted five decades ago but it has been ac- cepted recently after spectacular tumour responses were ob- tained by several phase trials. DATA SOURCES: An English-language literature search using MEDLINE (2003), Index Medicus (2003) and biblio- graphic reviews of books and review articles. IHP and its history and recent clinical application. RESULTS: IHP offers unique pharmacokinetic advantages for locoregional chemotherapy and biotherapy. Surgical isolation of the liver and percutaneous techniques using bal- loon occlusion catheters are reliable and safe. They appear to have significant efficacy even in patients with advanced tumor burden or those with tumors refractory to other types of therapy. CONCLUSION: IHP which has been developed in recent years is becoming a promising strategy for the treatment of unresectable liver cancer.

Isolated hepatic perfusion for unresectable hepatic malignancies:A systematic review and meta-analysis

AIMTo investigate the effcacy and safety of isolated hepatic perfusion （IHP） in the management of unresectable liver malignancies.METHODSStudies were identified manually and on-line by using PubMed and EMBASE database. We formulate the eligibility criteria according to the PICOS elements, and accessed the quality of studies using the MINORS instrument. Data from all included studies were carefully investigated. We calculated the pooled response rate and incidences of mortality reported from all eligible studiesby using the Meta-Analyst software, and we computed a pooled relative risk （RR） and 95%CI by using the Comprehensive Meta-Analysis software. Heterogeneity was quantifed evaluated using I2 statistic.RESULTS Eight studies, including 502 patients, were selected. Of these, six studies performed IHP, while the other two studies performed percutaneous IHP. The results showed that the pooled response rate was 60.8% （95%CI： 53.1%-68%）, I2 = 37.1%. The median overall survival was 20 mo （range： 12.1 to 25 mo） following IHP or PIHP. The pooled mortality rate was 5.4% （95%CI： 2.5%-11.2%）, I2 = 37.5%. Prognostic factors predict the response to IHP or survival, and were reported in six studies. Meta-analysis demonstrated that Gender was not associated with overall survival （RR = 0.877, 95%CI： 0.564-1.365）; however, carcino-embryonic antigen ≤ 30 ng/mL was associated with a signifcant improvement in survival outcomes with colorectal cancer patients （RR = 2.082, 95%CI： 1.371-3.163）, and there was no signifcant heterogeneity.CONCLUSIONThe present systemic review and meta-analysis suggest that IHP and PIHP are potentially efficient and safe techniques for unresectable liver primary and secondarymalignancies.

Hepatic Perfusion Alterations in Septic Shock Patients： Impact of Early Goal-directed Therapy

Background： Early goal-directed therapy （EGDT） has become an important therapeutic management in early salvage stage of septic shock. However, splenic organs possibly remained hypoperfused and hypoxic despite fluid resuscitation. This study aimed to evaluate the effect of EGDT on hepatic perfusion in septic shock patients. Methods： A prospective observational study was carried out in early septic shock patients who were admitted to Intensive Care Unit within 24 h after onset and who met all four elements of the EGDT criteria after treatment with the standard EGDT procedure within 6 h between December 1, 2012 and November 30, 2013. The hemodynamic data were recorded, and oxygen metabolism and hepatic functions were monitored. An indocyanine green clearance test was applied to detect the hepatic perfusion. The patients＇ characteristics were compared before treatment （TO）, immediately after EGDT （T 1 ）, and 24 h after EGDT （T2）. This study is registered at ClinicalTrials.org, NCT02060773. Results： Twenty-one patients were included in the study; however, the hepatic perfusion data were not included in the analysis for two patients： therefore, 19 patients were eligible for the study. Hemodynamics data, as monitored by pulse-indicator continuous cardiac output, were obtained from 16 patients. There were no significant differences in indocyanine green plasma disappearance rate （ICG-PDR） and 15-min retention rate （Rl 5） at TO （ 11.9 ±5.0%/min and 20.0 ±13.2%）, T1 （ 11.4 ± 5.1%/min and 23.6 ± 14.9%）, and T2 （ 11.0 ±4.5%/rain and 23.7 ± 15.3%） （all P 〉 0.05）. Both of the alterations of ICG-PDR and R l 5 showed no differences at TO, T1, and T2 in the patients of different subgroups that achieved different resuscitation goal numbers when elected （P 〉 0.05）.

Progression of hepatic hyperperfusion disorders revealed during follow-up CT scan of digestive system neoplasm

Objective： The aim of this study was to investigate progression of hepatic hyperperfusion disorders revealed during follow-up contrast material-enhanced multi-slice spiral computed tomography （MSCT） scan of digestive system neoplasm. Methods： Three-phase contrast material-enhanced MSCT were performed during the follow-up in patients with digestive system malignant tumor confirmed histologically. The progression of hepatic hyperperfusion disorders revealed on contrast material-enhanced CT image were investigated at the 2 years follow-up with approximately 6 months interval. Results： The hepatic hyperperfusion disorders were showed in 39 patients on follow-up contrast material-enhanced MSCT scans. Among the 39 patients, initial hyperperfusion disorders were revealed in 6 （15.38%）, 26 （66.67%）, and 7 （17.95%） patients in 6, 12, and 18 months during follow-up respectively. The initial hyperperfusion disorders revealed in 12 months were more frequent than those revealed in 6 months （X2 = 14.82, P 〈 0.05） and 18 months （X2 = 15.02, P 〈 0.05）. Among the 39 patients, the hyperperfusion disorders progressed into liver metastasis based on typical CT findings in 37 （94.87%） patients, and were not obvious changes in 2 （5.13%） patients. Among the 37 patients, the hyperperfusion disorders progressed into metastasis in 10 （25.64%） patients in 6 months after the hyperperfusion disorders were revealed, and in 27（69.23%） patients in 12 months. The hyperperfusion disorders developing into metastasis were more in 12 months than those in 6 months （X2= 14.98, P 〈 0.05）. Conclusion： Most hepatic hyperperfusion disorders revealed at the follow-up of digestive system neoplasm may be early manifestations of liver metastasis. The careful follow-up of hepatic hyperperfusion disorders is necessary.

Percutaneous hepatic perfusion with melphalan for unresectable liver metastasis

Percutaneous hepatic perfusion(PHP)is an investigative technique for treating patients with diffuse unresectable metastatic liver disease.The technique has been clinically evaluated and shows great treatment potential for regional therapy to the liver.The advantage of PHP lies in its minimally invasive approach and ability to be repeated when compared to isolated hepatic perfusion.In a literature search,135 publications were screened and 16 of these publications,including clinical trials and reviews,contributed to this review of PHP with melphalan.Melphalan is an alkylating agent that,when used as the chemotherapeutic agent in PHP,has shown potential for significant control of tumor burden in the liver,especially in metastatic ocular melanoma.In the current landscape of liver directed therapy,PHP is a viable option for those with unresectable metastatic disease to the liver.This article will focus on the technical aspects of PHP and describe the current data available from clinical trials,including outcomes of patients treated with this minimally invasive approach.

Diagnosis of hepatic inflammatory pseudotumor by fine-needle biopsy

Hepatic inflammatory pseudotumor(IPT)is a benign lesion characterized by chronic infiltration of inflammatory cells and fibrosis that clinically,radiologically,and pathologically mimics malignancy.However,the epidemiology of IPTs remains unclear.IPTs are often misdiagnosed as malignant lesions because of the lack of characteristic features.We present the case of a 32-year-old man that was misdiagnosed as intrahepatic cholangiocarcinoma by CECT,CEMRI,and CEUS,which was finally confirmed as IPT by fine-needle liver biopsy.In this report,the key factor in the diagnosis of liver inflammatory masses was the presence of hepatic perfusion disorder.

Study on Treatment of Primary Hepatic Carcinoma by Arterial Perfusion Embolization with Zedoary Turmeric Oil

To evaluate the effect, side-effect and prospect of hepatic arterial perfusion embolization (HAPE) with Zedoary turmeric oil (ZTO) in treating primary hepatic carcinoma (PHC).Methods: Clinical study was carried out by administration of 1-3 ml ZTO through arterial catheter to induce embolism in 32 patients of PHC, and compared with 32 patients treated by hepatic arterial perfusion embolization with chemical agents (HAPE-C) in the control group. The Chinese herbal medicine was given orally to both groups according to Syndrome Differentiation of TCM. In the experimental study, transplantation hepatic carcinoma model was established in 40 rats. They were randomly divided into the treated group and the control group, 20 in each group, and were perfused with 10 mg/kg ZTO and 0.2-0.3 ml normal saline respectively to observe the effect of treatment.Results: The effect of treatment in the ZTO group was CR in 1 case and PR in 13 cases, the total effective rate being 43.75%, with AFP negative reversed in 7 cases, titer decreased in 7; while in the control group it was PR in 10 cases, the total effective rate being 31.25%, AFP negative reversed in 5, titer decreased in 2, and the difference of therapeutic effect between the two groups was insignificant (P>0.05). The post-perfusion thrombotic syndrome occurrence, with the symptoms of fever, abdominal pain, vomiting, etc. in the two groups was similar, but no bone marrow inhibition occurred in the ZTO group, which was different from the control group (P<0.01, P<0.05). The mean survival time, median survival time, 1-, 2-, 3- and 4-year survival rate in the ZTO group was 13.84 months, 10 months, 37.5%, 18.87%, 9.70% and 6.4% respectively, and in the control group, 8.03 months, 6 months, 15.6%, 6.27%, 0% and 0% respectively, the mean survival time, median survival time and 1-year survival rate in the ZTO group were significantly superior to those in the control group (P<0.05). Experimental study showed that the effect in the treated group was better than that in the control group in tumor growth inhibition with the tumor growth rate as 10.8±4.5%% vs 20.6±12.7%, P<0.05, tumor necrosis degree (P<0.01) and survival time prolonged (14.8±3.4 days vs 11.7±1.9 days, P<0.05).Conclusion: HAPE-ZTO in treating PHC showed the therapeutic effect similar to that of HAPE-C, but superior to the latter in survival time prolongation and bone marrow inhibition.

Therapeutic Effects of Pefusing Compound Salvia Miltiorrhiza Injection Through the Hepatic Artery in the Late Stage of Hepatocarcinoma

In the treatment of 20 patients with advanced hepatocarcinoma, whose conditions wors-ened affer chemotherapy, with hepatic artery intubation, by injection of Compound Salvia Miltiorrhizathrough the hepatic artery, it can be seen that their signs were relaxed and tumor masses were diminishedand biochemical indices were improved. The test group had a 65% rate of general efficiency, while thecontrol group had only 25%. There is a significant difference (P<0. 01) between the two groups. There-fore the method of treatment for such patients is thought to be worthy of being further studied.