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. 2009 Sep;26(3):262–269. doi: 10.1055/s-0029-1225667

Embolization of Nonliver Visceral Tumors

Paul G Thacker 1, Jeremy L Friese 1, Matthew Loe 1, Peter Biegler III 1, Michael Larson 1, James Andrews 1
PMCID: PMC3036499  PMID: 21326571

ABSTRACT

Catheter-directed embolization of visceral tumors, with the exception of the liver, has received limited attention in the literature. The visceral arterial anatomy can be complex and its understanding is critical for procedure planning and limiting complications. Embolization of splenic neoplasms is exceedingly rare. Preoperative embolization for adrenal, renal, and gut tumors plays an important role in select patients. Embolization has been used successfully in the treatment of pancreatic insulinomas and in limited cases of unresectable pancreatic adenocarcinomas. Embolization of bleeding visceral tumors can be accomplished with a high likelihood of success.

Keywords: Tumor, embolization, visceral

Catheter-directed embolization is performed for a host of indications as varied as bleeding to palliative therapy for benign or malignant tumors. Most of the literature regarding embolization of visceral tumors is devoted to chemoembolization or radioembolization for primary and metastatic hepatic malignancies. Although much less common, embolization of nonliver visceral tumors can play an important role in appropriately selected patients. In this article, the authors provide a brief review of embolization for nonliver visceral tumors including anatomic considerations and a brief overview of indications and outcomes described in the literature.

ARTERIAL ANATOMY

A thorough understanding of the arterial anatomy and variants is critical to successfully embolize visceral tumors and limit complications. A detailed discussion is beyond the scope of this article, instead a few key points will be highlighted. This anatomy is highly variable with over 40% of patients demonstrating a variant. Eight variations of the hepatic artery have been described including a replaced common hepatic artery (10%), early bifurcation of the common hepatic artery with the gastroduodenal artery (GDA) arising from the right hepatic artery (RHA), replaced RHA (15%), replaced left hepatic artery (LHA) from the left gastric artery (23%), accessory RHA from the superior mesenteric artery (SMA) or pancreaticoduodenal trunk (31%), and accessory LHA from the left gastric (8%).1

The pancreas and duodenal anatomy is especially complex. Tumors in this region are typically supplied by several collaterals from the celiac and SMA. The posterior pancreaticoduodenal arcade typically arises from the GDA, but may receive feeding vessels from the hepatic artery and SMA. The anterior arcade often gives a pyloric branch and anastomoses with the SMA. The inferior pancreaticoduodenal artery is the first right-sided branch of the SMA. The tail of the pancreas is supplied by several branches of the splenic and gastroepiploic arteries.1,2

The stomach has a rich network of collateral arteries originating from the celiac trunk, including branches of the splenic artery and the SMA. The jejunum and ileum are fed by 12 to 15 SMA branches and the ileocolic artery. It is important to note that the left colic and middle colic arteries infrequently arise from the anterior arcade or celiac trunk, thus necessitating celiac, SMA, and inferior mesenteric artery investigation in the setting of lower gastrointestinal (GI) tumor embolization. The marginal artery of Drummond and the arc of Riolan are important collateral pathways between the mesenteric arteries.1,2

Superior, middle, and inferior adrenal arteries typically arise from the inferior phrenic artery, the aorta, and the renal arteries. However, the middle adrenal artery can be replaced from the celiac artery or SMA in 2 to 5% of patients whereas the inferior adrenal artery can have variable origins from the superior capsular renal arteries, apical segmental renal artery, or inferior phrenic artery in two-thirds of patients.2,3

The renal parenchyma is typically supplied by a main renal artery with up to two accessory renal arteries frequently found. These arteries are terminal branches. Superior, medial, and inferior capsular branches arise from an adrenal artery, the main renal artery, or a gonadal branch.1

PANCREAS

The mainstay of treatment for pancreatic neoplasia remains surgical resection. Embolization, however, has been demonstrated to be a viable option in both malignant and benign pancreatic neoplasms when surgery is not an option, or as a method to reduce ischemic complications after distal pancreatectomy. Figure 1 highlights a case of upper GI bleeding secondary to renal cell metastasis to the duodenum and pancreas, which was successfully embolized with coils and particles.

Figure 1.

Figure 1

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A 51-year-old woman with metastatic renal cell carcinoma to the duodenum and pancreas resulting in endoscopically confirmed upper gastrointestinal bleeding. (A) Gastroduodenal artery (GDA) injection shows tumor blush (arrow) from branches of the anterior pancreaticoduodenal arcade arising from the right gastroepiploic (RGE) and terminal GDA. The RGE was coil embolized to prevent recanalization and the anterior arcade was particle embolized, followed by coil embolization of the proximal GDA. (B) Superior mesenteric angiography (SMA) angiography shows dominant flow to the tumor (arrows). (C) Inferior pancreaticoduodenal arcade injection shows prominent tumor blush (arrows), which was successfully embolized with particles and coils. (D) Completion SMA angiography shows no residual tumor blush (arrow). This was also confirmed with celiac angiography.

Rott et al reported the successful treatment of a single patient with a symptomatic insulinoma who refused surgical resection.4 Here, the authors super-selectively embolized the dorsal pancreatic artery with trisacryl gelatin microspheres. A computed tomography (CT) scan 3 days after the procedure demonstrated complete devascularization of the tumor, and the patient was without clinical or laboratory signs of recurrence one year after the procedure. Although there remains a paucity of articles dedicated to the use of embolization in insulinomas, similar findings were demonstrated by Urflacker and Moore.5,6

Embolization has also been reported as an option in advanced-stage pancreatic adenocarcinoma. The largest case series reported the use of chemoembolization in 31 patients with advanced pancreatic carcinoma. Embolization with arterial infusion achieved a response rate of 74% (9% complete response rate and a partial response rate of 65%). Overall median survival time was 22.86 months. The authors concluded that chemoembolization should be attempted as a last ditch effort in patients with advanced pancreatic carcinoma.7

Lastly, embolization has been demonstrated to be useful in the preoperative period in preparation for pancreatectomy. Kondo et al reported its use in four patients who underwent coil embolization of the common hepatic artery 1 to 7 days before distal pancreatectomy. Here the authors demonstrated that extensive collateralization immediately after embolization had a protective mechanism against ischemic damage from en bloc resection of the celiac artery during distal pancreatectomy.8

Nontarget embolization and incomplete treatment can be avoided with a thorough understanding of the complex vascular anatomy and the rich collateral networks about the pancreas.

SPLEEN

Metastatic and primary neoplasms of the spleen, with the exception of lymphoma and melanoma, are rare entities. Primary splenic neoplasms include sarcoma and melanoma. The mainstay of treatment for primary neoplasms is splenectomy with little attention given to the role of embolization. In fact, despite more than 1000 articles published on splenic angiography and embolization, no articles were found describing embolization of splenic tumors. The majority of the literature on splenic embolization is related to trauma and vascular abnormalities such as an aneurysm. Embolization is also a well-established technique to treat hypersplenism.9,10,11,12,13,14,15,16 Although splenectomy is the gold-standard treatment for splenic tumors, embolization may play a select role in the preoperative setting.

STOMACH, SMALL AND LARGE BOWEL

Embolization involving stomach, small and large bowel tumors is largely reserved for preoperative management and tumors associated with GI bleeding. Due to the vascular nature of many GI neoplasms, preoperative embolization can reduce tumor size and subsequently reduce the extent of tumor resection.17 This has been demonstrated most commonly with GI stromal tumors (GIST).18,19 Kurihara et al reported a 60% reduction in tumor size following preoperative embolization of a duodenal GIST. Furthermore, preoperative embolization can decrease intraoperative blood loss. Joyce et al reported a case of VIPoma with colonic and duodenal invasion in which widespread resection was done following splenic artery embolization with a minimal operative estimated blood loss of ~500 mL.20

Embolization has utility in the case of GI bleeding secondary to tumor invasion/ulceration. Intestinal neoplasms are an uncommon cause of upper GI bleeding, but are responsible for 8 to 26% of cases of lower GI bleeding.21 GI bleeding has been associated with several tumors including gastric and small bowel lymphoma, gastric carcinoma, intestinal adenocarcinoma, GISTs, metastatic disease, as well as benign lesions such as colonic adenomatous polyps (Fig. 2). Tumor-associated bleeding is often difficult to control with conservative measures.22 The technical success rate of embolization of lower GI bleeding has been reported as high as 93 to 96% for bleeding from any cause, with a prolonged clinical success rate as high as 81%.23 Embolization has also been shown to be effective in the management of acute and recurrent GI bleeding associated with tumors.22,24,25 However, an increased rate of rebleeding is expected and is most commonly attributed to tumor progression. Kikuth et al describes rebleeding in a patient secondary to progression of his widely metastatic pancreatic cancer with right colonic invasion.23

Figure 2.

Figure 2

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A 63-year-old man with metastatic hemangiopericytoma and lower gastrointestinal bleed. (A) A red blood cell (RBC) scan shows pooling in the right lower quadrant (arrow). (B) Selective angiography of an ileal branch shows tumor vascularity (arrows). This was embolized with polyvinyl alcohol (PVA) 500–700 μm particles with clinical success.

Acute ischemic complications following embolizations of GI bleeding from all causes is estimated as high as 22%. Recent data on super-selective coil embolization suggests a 6 to 7% incidence.26 Selection of an embolization agent is somewhat controversial. Given the increased risk of rebleeding, we prefer long-term control with particles thus allowing for repeat treatment as necessary.

ADRENAL

Adenoma is the most common adrenal mass. Although most are clinically silent, adenomas may present as hyperfunctioning neoplasms. Commonly accepted treatment in these cases include open or laparoscopic-assisted adrenalectomy.27 However, limited reports of embolization with alcohol have demonstrated success when treating patients with secondary hypertension.28,29,30 Hokotate et al published a retrospective study of 33 patients with unilateral aldosteronomas who underwent embolization with ethanol or iohexol-ethanol.28 In 27 of 33 patients (82%), embolization was successfully performed with 70% of patients experiencing good therapeutic result without long-term complications.31 However, it should also be noted that several patients required multiple treatments for success and adrenalectomy.

Beginning in the 1980s, scattered case studies described successful embolization of pheochromocytoma to treat spontaneous hemorrhage or hypertension.32,33,34,35,36,37 Successful use of Gelfoam® (Pfizer Pharmaceuticals, New York, NY), particles. and coils were all reported.

Case reports suggest that embolization may be useful in Cushing's syndrome secondary to hyperfunctioning adenoma, carcinoma, or adrenal hyperplasia.38,39 O'Keefe et al reported a successful therapeutic response for hyperfunctioning adrenocortical carcinoma in 2 of 3 patients.40 Blunt et al demonstrated the use of bilateral embolization with alcohol and coils to treat Cushing's syndrome from metastatic medullary thyroid carcinoma.41 This resulted in adequate control of cortisol levels with additional medications to allow for bilateral adrenalectomy. A similar case was reported by Bourlet et al with successful treatment using particles.42

The adrenal gland is the fourth most common site of metastasis with almost 25% of cancer patients having adrenal involvement on autopsy. Consequently, embolization may play a role in the presurgical treatment plan.43 Reported case studies described successful embolization prior to pheochromocytoma resection.33,34,37 Furthermore, a recent case study reported embolization for tumor bed recurrence from metastatic adrenocortical carcinoma for palliation of pain.44 Although embolization may provide pain relief, reduction in tumor size should not be expected.40 Recent retrospective studies have shown that management of adrenal metastasis from hepatocellular carcinoma with nonsurgical treatment provides short-term survival benefit similar to surgical resection but inadequate long-term survival. Current management strategies recommend surgical resection for adrenal metastasis as long as there is some residual hepatic function. When surgery is not indicated, transarterial catheterization or percutaneous chemoablation may be indicated to control the progression of the adrenal metastasis.45,46

Last, adrenal neoplasms have the propensity for spontaneous hemorrhage. Pheochromocytoma is the most common underlying tumor causing hemorrhage. Similarly, case studies have reported successful bleeding control in adrenocortical carcinoma, adrenal myelolipoma, and metastasis (Fig. 3).47,48,49 Tumor embolization offers an alternative to emergent surgery for successful hemostasis in unstable patients.48

Figure 3.

Figure 3

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An 83-year-old man with known right adrenal adenoma. (A) A noncontrast computed tomography (CT) scan shows hyperdense hemorrhage (arrows) in the right adrenal, which resulted in pain and a decrease in hematocrit. (B) Superior adrenal artery angiography shows a pseudoaneurysm (arrow). This artery was embolized with polyvinyl alcohol (PVA) 250–350 μm particles. (C) The middle adrenal artery was selected and prophylactically embolized.

Adrenal tumor embolization carries significant risk because of the variable anatomy and risk of malignant hypertension. Close monitoring of vitals signs via an arterial line throughout the procedure is mandatory and anesthesia personnel should be involved in these cases. It has been suggested that slower injection rates (~1 mL/min) may help reduce the incidence of hypertension and tachycardia. Additionally, use of particles over alcohol may reduce this risk.50 Alpha- and β-adrenergic blocker medications should be readily available to control any acute hypertensive crisis.50 Other complications include postembolization syndrome, renal insufficiency, abscess formation, infarction of normal tissue, and sepsis.

RENAL

Embolization of renal neoplasms is controversial and is utilized primarily in two clinical scenarios: preoperative treatment to reduce hemorrhage risk and palliation. Preoperative embolization aims to decrease intraoperative blood loss and operative time. The procedure is typically performed 24 to 48 hours before the surgery, but can be completed up to several weeks prior to resection. In addition to decreasing arterial flow, embolization is theorized to result in vein collapse, facilitating safe resection of tumor thrombus and decreased blood loss.51 In addition to decreased bleeding risk, preoperative embolization may impart a survival benefit. A recent retrospective cohort analysis of 118 preoperative embolization patients and 116 surgery-alone patients showed 5- and 10-year survival rates of 62% and 47% in the embolization cohort compared with 35% and 23% in nonembolization cohort (p = 0.01), respectively. Interestingly, survival benefit was observed in patients with stage II and III disease, as well as those with lymphatic metastases at surgery.52

Embolization of renal neoplasms may provide benefit in the patient with unresectable renal neoplasms including renal cell carcinoma and angiomyelolipoma (Fig. 4).52,53 Nevertheless, palliative embolization of renal neoplasms has been decreasing in frequency over the past decade. This decline is theorized to be related to the better quality of diagnostic cross-sectional imaging with the resultant detection of neoplasms at an earlier stage. Regardless, embolization has been shown to be an effective treatment option for patients with unresectable stage IV neoplasm, widely disseminated disease, or those who are unable to tolerate surgery. Published results note improvement in hematuria and lumbar pain ranging between 75 to 100% and 50 to 75%, respectively.54

Figure 4.

Figure 4

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A 49-year-old woman with right angiomyolipoma (AML) causing flank pain. (A) Enhanced computed tomography (CT) scan shows a fatty mass arising from the right kidney (arrow) with a prominent feeding artery (arrowhead). (B) Right renal angiogram shows tumor vascularity (arrows). (C) Selective angiogram shows pseudoaneurysm (arrow) and tumor vascularity (arrowheads). Stasis was achieved with 45–150 μm polyvinyl alcohol (PVA) particles and ethanol mixture.

Published complication rates for renal tumor embolization are as high as 20% with prolonged hematuria being most common. The mortality rate reported is 3.3%.55,56 Postinfarction syndrome, consisting of fever, groin pain, and nausea, is common and occurs in nearly all patients. These symptoms typically resolve by 36 hours and are managed medically.54,57

DISCUSSION

Catheter-directed embolization of visceral tumors, with the exception of the liver, is an entity that has received little attention in the literature. In the above review, we discussed the various mesenteric organs and tumor types that may be amenable to embolization and the indications for its usage. Embolization for splenic tumors is an unexplored area with no articles to date discussing its efficacy. Small and large bowel tumors are rarely treated with embolization, but if so, embolization is primarily used prior to operative resection or in cases of tumor-induced GI hemorrhage. Embolization of pancreatic insulinoma and carcinoma has been described. In the adrenals, embolization is primarily used for preoperative debulking or for symptomatic relief from hyperfunctioning tumors. Embolization for renal cell carcinoma and angiomyelolipoma is mainly used in the preoperative setting to reduce blood flow prior to surgical resection. The embolization agents utilized were predominantly permanent including alcohol, particles, and coils.

In conclusion, catheter-directed embolization is an important technique in the treatment of nonliver mesenteric tumors, primarily in the setting of nonoperable neoplasms, preoperative tumor control, or tumor hemorrhage.

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