nterventional Radiology Rounds Transcatheter Arterial Embolization of the Internal Mammary Artery in Hepatocellular Carcinoma1 Ji Hye Kim, MD Jin Wook Chung, MD Joon Koo Han, MD Jae Hyung Park, MD Byung Ihn Choi, MD Man Chung Han, MD Index terms: Arteries, internal mam- mary, 949.1264 Arteries, therapeutic blockade, 949,1264,952,1264 Embo- lism, oil, 952.1264 Hepatic arteries, therapeutic blockade, 952.1264 Liver neoplasms, chemotherapeutic infusion, 76.1264,76.1266,76.323 Liver neo- plasms, therapy, 76.1264 JVIR 1995; 6:71-77 From the Department of Radiology, Seoul National University, College of Medicine, 28, Yongon-Dong, Chongno-Gu, Seoul 110- 744, Korea. Received April 8,1994; revi- sion requested June 1; revision received July 21; accepted August 1. Address re- print requests to J.H.P. O SCVIR, 1995 CASE REPORTS Case 1.-A 41-year-old woman with hepatitis B surface antigen was admitted with aching pain in the epigastric area. Two hepatic masses were detected at ultrasonography, and serum a-fetoprotein level was more than 70,000 ngImL. Liver func- tion was class A according to the cri- teria of Pugh-modified Child classifi- cation. Hepatic arteriography through the replaced right hepatic artery from the superior mesenteric artery showed multiple nodular hypervascular masses in the right hepatic lobe (Fig la). No tumor ves- sel or stain from the left hepatic ar- tery was demonstrated at celiac ar- teriography. The tumor was not resectable, and tissue for histologic examination was not obtained. How- ever, a final diagnosis of multinodu- lar hepatocellular carcinoma (HCC) could be made from the radiologic findings and elevated serum a-feto- protein level. An emulsion of 15 mL of iodized oil (Lipiodol [iodized ethyl esters of the fatty acids of poppyseed oil, 38% weight-to-weight ratio]; Andre Guer- bet, Aulnay-sous-Bois, France) and 50 mg of doxorubicin hydrochloride (ADM; Dong-A, Seoul, Korea) was infused into the right hepatic artery, which was then embolized with gels- " tin sponge particles (Gelfoam; Spon- gostan Standard. Ferrosan. Den- &ark). ~ostembolization radio- graphs showed a defect of iodized oil retention in the upper portion of the mass that suggested a parasitic blood supply (Fig lb). Right inferior phrenic arteriography revealed only a small amount of tumor stain at the medial aspect of the mass, and selec- tive arteriography of intercostal ar- teries did not show any tumor stain or neovascularization. Transcath- eter arterial embolization (TAE) was performed through the right hepatic artery, but iodized oil had not yet ac- cumulated in the upper portion of the mass. At 5-months follow-up, radiogra- phy showed that the size of the tu- mor had increased in the area where the iodized oil had not accumulated. Extrahepatic collateral blood supply was suspected, and subsequent se- lective arteriography of the right in- ternal mammary artery demon- strated neovascularization in the upper half of the mass (Fig lc). Us- ing a coaxial technique with a 3-F tracker-18 catheter (Target Thera- peutics, Los Angeles, Calif), we per- formed TAE through the internal mammary artery with an emulsion of 3 mL of iodized oil and 20 mL of doxorubicin hydrochloride. After TAE, the level of serum a- fetoprotein was 26,400 ngImL. The patient complained of severe pain in the right upper chest for 2 days in addition to the usual postemboliza- tion symptoms of nausea, vomiting, and abdominal pain. Two months later, TAE via the internal mam- mary artery and the hepatic artery was repeated. Four months later, a radiograph showed that the size of the mass had decreased and that a dense, homogeneous iodized oil accu- mulation was present (Fig Id). The level of serum a-fetoprotein, which was monitored for 16 months after the initial TAE procedure performed via the internal mammary artery, continuously decreased and re- mained below 5,000 ng/mL. Case 2.-A 39-year-old woman with hepatitis B surface antigen,