ORIGINAL ARTICLE
Hepatic arterial embolization for unresectable hepatocellularcarcinomas: do technical factors affect prognosis?
Koichiro Yamakado • Shiro Miyayama • Shozo Hirota • Kimiyoshi Mizunuma •
Kenji Nakamura • Yoshitaka Inaba • Akihiro Maeda • Kunihiro Matsuo • Norifumi Nishida •
Takeshi Aramaki • Hiroshi Anai • Shinichi Koura • Shigeo Oikawa • Ken Watanabe •
Taku Yasumoto • Kinya Furuichi • Masato Yamaguchi
Received: 4 April 2012 / Accepted: 10 May 2012 / Published online: 30 May 2012
� Japan Radiological Society 2012
Abstract
Purpose To evaluate retrospectively whether technical
factors of hepatic arterial embolization affect the prognosis
of patients with hepatocellular carcinoma (HCC).
Materials and methods Inclusion criteria of this study
were the following: (1) patients received embolization as
the initial treatment during 2003–2004, (2) Child A or B
liver profile, (3) five or fewer HCCs with maximum
diameter of 7 cm or smaller, and (4) no extrahepatic
metastasis. Patient data were gathered from 43 centers.
Prognostic factors were evaluated using univariate and
multivariate analyses.
Results Eight hundred fifteen patients were enrolled. The
1-, 3-, 5-, and 7-year overall survival rates were 92.0 %
(95 % CI 90.1–93.9), 62.9 % (95 % CI 59.3–66.6), 39.0 %
(95 % CI 35.1–43.0), and 26.7 % (95 % CI 22.6–30.8) in all
patients. Univariate analysis showed a Child-Pugh class-A,
alpha-fetoprotein level lower than 100 ng/ml, tumor size of
On behalf of the Clinical Research Group of the Japanese Society for
Transcatheter Hepatic Arterial Embolization and Japanese Society of
Interventional Radiology.
K. Yamakado (&)
Department of Interventional Radiology, Mie University School
of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
e-mail: [email protected]
S. Miyayama
Department of Diagnostic Radiology, Fukui-ken Saiseikai
Hospital, Fukui, Japan
S. Hirota � A. Maeda
Department of Radiology, Hyogo College of Medicine,
Nishinomiya, Japan
K. Mizunuma
Department of Radiology, Ohtawara Red Cross Hospital,
Ohtawara, Japan
K. Nakamura
Department of Radiology, Daito Central Hospital, Daito, Japan
Y. Inaba
Department of Diagnostic and Interventional Radiology,
Aichi Cancer Center Hospital, Nagoya, Japan
K. Matsuo
Department of Radiology, Narumi Hospital, Hirosaki, Japan
N. Nishida
Department of Radiology, Osaka City University, Osaka, Japan
T. Aramaki
Department of Diagnostic Radiology, Shizuoka Cancer Center,
Shizuoka, Japan
H. Anai
Department of Radiology, Nara Medical University,
Kashihara, Japan
S. Koura
Department of Radiology, Fukuoka University,
Fukuoka, Japan
S. Oikawa
Department of Radiology, Iwate Prefectural Central Hospital,
Morioka, Japan
K. Watanabe
Department of Radiology, Jikei University, Tokyo, Japan
T. Yasumoto
Department of Radiology, Toyonaka Municipal Hospital,
Toyonaka, Japan
K. Furuichi
Department of Radiology, Higashiosaka City General
Hospital, Higashiosaka, Japan
M. Yamaguchi
Department of Radiology, Kobe University, Kobe, Japan
123
Jpn J Radiol (2012) 30:560–566
DOI 10.1007/s11604-012-0088-1
3 cm or smaller, tumor number of 3 or fewer, one-lobe tumor
distribution, nodular tumor type, within the Milan criteria,
stage I or II, no portal venous invasion, use of iodized oil, and
selective embolization were significantly better prognostic
factors. In the multivariate Cox model, the benefit to survival
of selective embolization remained significant (hazard ratio
0.68; 95 % CI 0.48–0.97; p = 0.033).
Conclusion Selective embolization contributes to sur-
vival in patients with HCCs.
Keywords Hepatocellular carcinoma � Arterial
embolization � Prognosis
Introduction
The incidence of hepatocellular carcinoma (HCC), the fifth
most common cancer in the world, is increasing worldwide
[1]. Curative therapies including resection, liver transplan-
tation, and percutaneous ablation such as percutaneous eth-
anol injection (PEI) and radiofrequency (RF) ablation are
applicable in only 30–40 % of patients with HCC [1]. Other
HCC patients are still not eligible for curative treatment
because of an advanced tumor stage or poor hepatic func-
tional reserve. Therefore, a continuing need persists for
effective palliative treatments. Recently, the benefit to sur-
vival of undergoing chemoembolization has been shown
compared with the best supportive care in meta-analyses of
randomized trials and in two individual trials [2–5].
It is important to achieve complete tumor necrosis to
prolong patient survival [6, 7]. Therefore, some techniques
have been developed in an attempt to reinforce anticancer
effects on HCC. These techniques include the use of che-
motherapeutic agents and iodized oil, and the introduction
of selective embolization [8–20]. Although some reports
have described a benefit to survival of using iodized oil and
anticancer drugs [11, 12], others have not [8–10]. Despite
the accumulation of evidence indicating that selective
embolization achieves better anticancer effects than non-
selective embolization, data demonstrating a benefit to
survival of this technique are lacking [13–20].
Therefore, we conducted this retrospective study to eval-
uate whether technical factors of transarterial embolization
have impacts on survival in patients with unresectable HCCs.
Materials and methods
Study design
The Clinical Research Group of the Japanese Society of
Transcatheter Hepatic Arterial Embolization asked 255
training centers accredited by the Japanese Society of
Interventional Radiology to take part in this study. Ques-
tionnaire sheets were sent to them. Patient data were gathered
from the 43 institutions (16.9 %, 43/255) that agreed to
participate. At each institution, IRB approval was obtained
for this study. Because of the retrospective nature of this
study, the requirement of obtaining informed consent to take
part in this study was waived at all but two institutions, where
informed consent was obtained from living patients.
Inclusion criteria of this study were the following: (1)
patients received embolization as the initial treatment
during 2003–2004 and followed at least 3 months, (2)
Child A or B liver profile, (3) five or fewer HCCs with a
maximum diameter of 7 cm or smaller, and (4) no extra-
hepatic metastasis.
Patients
In 2003 and 2004, 1290 patients received transarterial
embolization as the initial treatment of unresectable HCCs at
the 43 institutions. Of them, 815 patients (63.2 %, 815/1290)
met the inclusion criteria and were enrolled in this study.
The diagnosis of HCC was made mainly based on
imaging modalities using ultrasonography, contrast-
enhanced computed tomography (CT), magnetic resonance
(MR) imaging, and angiography, in addition to elevation of
tumor markers such as a-fetoprotein and des-c-carboxyl
prothrombin. The typical HCC was depicted as an
enhanced tumor in the arterial phase and washout in the
delayed phase in contrast-enhanced CT and MRI, and as a
hypervascular tumor in digital subtraction angiography
[21]. Alpha-fetoprotein was positive ([20 ng/ml) in 460
patients (60.6 %, 460/759), as was des-c-carboxyl pro-
thrombin ([40 mAU/ml) in 371 patients (48.8 %). Biopsy
was done in seven patients (0.9 %).
The decision for unresectable tumor was made by sur-
geons in each institution taking into account liver function,
tumor number and location, and patients’ status, such as
their age and performance status.
Patient and tumor characteristics are presented in
Table 1. The 535 men (65.6 %, 535/815) and 280 women
(34.4%, 280/815) had a mean age of 69.0 ± 8.4 years
(standard deviation) (range 40–91 years).
The mean maximum tumor diameter was 3.1 ± 1.5 cm
(range 0.5–7.0 cm) and the mean tumor number 1.8 ± 1.1
(range 1–5). Based on the Liver Cancer Study Group of Japan
(LCSGJ) tumor-node-metastasis (TNM) staging system,
65.6 % (535/815) of patients had stage I or II disease, and
34.4 % (280/815) of patients had stage III or IVA [22].
Transarterial embolization
Transarterial embolization was done using a gelatin sponge
in all patients (Table 1). Iodized oil was used in 98 % of
Jpn J Radiol (2012) 30:560–566 561
123
patients (799/815) and anticancer drugs in 98.2 % of patients
(800/815). The iodized oil dose was 1–15 ml, with a mean
dose of 3.9 ± 2.1 ml. Anticancer drugs were epirubicin,
used in 76.9 % of patients (615/800), epirubicin and mito-
mycin in 17.8 % of patients (142/800), and others in 5.4 % of
patients (43/800). The epirubicin dose was 5–90 mg with a
mean dose of 32.5 ± 14.2 mg. That of mitomycin was
2–12 mg with a mean dose of 6.2 ± 2.3 mg.
The definition of selective embolization was the fol-
lowing: transarterial embolization performed in the seg-
mental artery or more peripherally. Even when selective
embolization was performed at two or more different sites,
the technique was defined as selective embolization. When
selective embolization was combined with lobar or whole
liver embolization, the procedure was not regarded as
selective embolization. Selective embolization was done in
86.6 % of patients (706/815). Subsegmental embolization
consisted of 28.3 % in selective embolization (200/706),
segmental embolization of 30.3 % (214/706), and multiple
sessions of both of 41.4 % (292/706).
Assessments
Overall and recurrence-free survival was evaluated. Overall
and recurrence-free survival was defined as the time from the
initial transarterial embolization to death or last patient
contact, and recurrence-free survival to death, last patient
contact, or detection of disease progression. Disease pro-
gression was divided into three categories: local tumor pro-
gression in the treated HCC lesion, a new HCC lesion that
appeared in the untreated liver, and extrahepatic metastasis.
Complications related to transarterial embolization were
evaluated using clinical records.
Statistical analysis
The 16 variables presented in Table 1 were analyzed via
univariate analysis to identify factors affecting overall and
recurrence-free survival. The multivariate analysis was
performed using the Cox proportional hazard model. The
overall and recurrence-free survival rates were obtained
using the Kaplan-Meier method and compared using the log-
rank test. All variables with a p value of\0.05 by univariate
analysis and sex and age were subjected to multivariate
analysis. All significance tests were two-tailed, and a p value
\0.05 was regarded as statistically significant. All statistical
analyses were performed using the Statistical Analysis
System (SAS version 8.02; SAS Inc., Cary, NC, USA).
Results
Overall survival
The 1-, 3-, 5-, and 7-year overall survival rates were 92.0 %
(95 % CI 90.1–93.9), 62.9 % (95 % CI 59.3–66.6), 39.0 %
(95 % CI 35.1–43.0), and 26.7 % (95 % CI 22.6–30.8) in all
patients (Fig. 1). The univariate analysis showed that a
Child-Pugh class-A, alpha-fetoprotein level lower than
100 ng/ml, tumor size of 3 cm or less, tumor number of three
or fewer, one-lobe tumor distribution, nodular tumor type,
within the Milan criteria, stage I or II, no portal venous
invasion, use of iodized oil, and selective embolization are
significantly better prognostic factors (Fig. 2; Table 2). In
the multivariate Cox model, the benefit to survival of
selective embolization remained significant (hazard ratio
0.68; 95 % CI 0.48–0.97, p = 0.033) (Table 3).
During the mean follow-up of 39.6 ± 25.8 months
(range 3.0–98.0 months), 447 patients (54.8 %, 447/815)
died. At the end of the follow-up, 124 patients were still
Table 1 Patient and tumor backgrounds
Patient
Number 815
Male/female 535 (65.6)/280 (34.4)
Age (years) (range) 69.0 ± 8.4 (40–91)
B70/[70
Hepatitis B/C/others/unknown 71 (8.7)/619 (76.0)/85
(10.4)/40 (4.9)
Child-Pugh class A/B 585 (71.8)/230 (28.2)
Tumor
Maximum diameter
(cm) (range)
3.1 ± 1.5 (0.5–7.0)
B3/3.1–7 499 (61.2)/316 (38.8)
Number (range) 1.8 ± 1.1 (1–5)
1–3/4–5 731 (89.7)/84 (10.3)
Type, nodular/infiltrating 773 (94.85)/33 (4.05)/9 (1.10)
Distribution, hemilobe/bilateral
lobes/unknown
585 (71.78)/170 (20.86)/60 (7.36)
Portal venous invasion,
no/yes/unknown
778 (95.5)/37 (4.5)
Alpha-fetoprotein
(ng/ml) (range)
1263.3 ± 12412.5 (1.0–302200.0)
B100/[100/unknown 530 (65.0)/230 (28.2)/55 (6.8)
Milan criteria, within/
beyond/unknown
543 (66.6)/263 (32.3)/9 (1.1)
Stage I or II/III or IVA 535 (65.6)/280 (34.4)
Hepatic arterial embolization
Anticancer drug, used/not used 800 (98.2)/15 (1.8)
Epi/Epi ? MMC/others 615 (76.875)/142 (17.75)/43
(5.375)
Iodized oil, used/not used 799 (98.0)/16 (2.0)
Selective embolization, yes/no 706 (86.6)/109 (13.4)
Parentheses, percentage
Epi epirubicin, MMC mitomycin C
562 Jpn J Radiol (2012) 30:560–566
123
alive (15.2 %). Cancer progression was the most frequent
cause of death, followed by liver failure, other disease,
gastrointestinal hemorrhage, unknown cause, and tumor
rupture (Table 4).
Fig. 1 Overall survival curve. The 1-, 3-, 5-, and 7-year overall
survival rates were 92.0 % (95 % CI 90.1–93.9), 62.9 % (95 % CI
59.3–66.6), 39.0 % (95 % CI 35.1–43.0), and 26.7 % (95 % CI
22.6–30.8) in all 815 patients
Fig. 2 Overall survival curves based on a selective embolization
technique. A significant difference was found in survival rates
between patients who underwent selective embolization and those
who underwent non-selective embolization (p = 0.0034). The respec-
tive 1-, 3-, 5-, and 7-year survival rates were 92.7 % (95 % CI,
90.8–94.7), 64.5 % (95 % CI 60.9–68.6), 40.8 % (95 % CI
36.6–45.1), and 28.4 % (95 % CI 24.0–32.7) in the patient group
that received selective embolization, and 87.0 % (95 % CI
80.4–93.6), 51.3 % (95 % CI 40.4–62.2), 25.7 % (14.9–36.5 %),
and 12.9 % (95 % CI 2.0–23.7) in the group that received non-
selective embolization
Table 2 Results of univariate analysis
Variable Survival (%) p value
1 year 3 year 5 year 7 year
Gender
Male 92.8 63.9 39.1 25.5 0.89
Female 90.4 61.1 38.9 29
Age
B70 91.4 61.2 40.1 27.3 0.42
[70 92.3 61.1 34.7 24.1
Hepatitis
C 91.5 62.6 37.3 24.3 0.11
Others 93.5 64 45.2 34.6
Child-Pugh
Class A 94.7 68 44.1 31.3 \0.0001
Class B 85.1 48.8 24.5 12.7
Maximum tumor size (cm)
B3 94.9 67.8 43.6 29.1 0.0001
\3 87.3 54.6 30.8 22.9
Tumor number
One to three 92.4 64.4 40.2 27.8 0.011
Four or five 88.7 49.9 29 17.4
Tumor type
Nodular 92.9 64.3 39.5 26.7 0.0049
Infiltrating 74.7 36 28 23.3
Tumor distribution
One lobe 92.8 64.9 41.8 30.2 \0.0001
Both lobes 89.4 50.9 27.1 8.3
Portal venous invasion
No 93.4 63.9 40 27.9 \0.0001
Yes 58.3 40.6 17.7 0.4
Alpha-fetoprotein (ng/ml)
B100 94 67.5 42.6 30.1 \0.0001
[100 87.4 47.6 27.8 16.9
Milan Criteria
Within 94.1 66.8 42.7 29.3 0.0006
Beyond 87.9 55.2 31 21
Tumor stage
I or II 94.2 67 44 31.2 \0.0001
III or IVA 87.5 54.5 28.2 16.8
Anticancer drug
Used 92.2 63.3 39.2 26.6 0.33
Not used 79.4 43.3 32.5 32.5
Anticancer drug
Epi 91.9 63.2 39.6 26.9 0.18
Epi ? MMC 94.2 64.8 42.7 30
Others 93 62.2 24.3 15.7
Iodized oil
Used 91.9 62.1 38.8 26.6 0.018
Not used 80.2 33.3 16.7 16.7
How to embolize
Selective 92.7 64.5 40.8 28.4 0.0034
Non-selective 87 51.3 25.7 12.9
Total 92 62.9 39 26.7
Epi epirubicin, MMC mitomycin C
Jpn J Radiol (2012) 30:560–566 563
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Recurrence-free survival
Recurrence following transarterial embolization was found
in 651 patients (79.9 %, 651/815) with a mean recurrence
time of 17.0 ± 19.8 months (range 0.4–96.0 months). The
initial recurrence site was local recurrence in the treated
liver in 275 patients (42.2 %, 275/651), new liver tumor in
the untreated liver in 373 patients (57.3 %, 373/651), and
both in 3 patients (0.5 %). No patient experienced extra-
hepatic disease at the initial recurrence site. The 1-, 3-, 5-,
and 7-year recurrence-free survival rates were, respec-
tively, 46.8 % (95 % CI 42.9–50.2), 17.1 % (95 % CI
14.2–20.0), 10.1 % (95 % CI 7.7–12.6), and 7.2 % (95 %
CI 4.7–9.6).
Ten prognostic factors identified in the univariate anal-
ysis were again detected as significant factors affecting
recurrence-free survival. However, the multivariate Cox
model showed no significant influence of selective embo-
lization on recurrence-free survival. Tumor size of 3 cm or
less (hazard ratio 0.59; 95 % CI 0.45–0.76, p \ 0.0001)
and an alpha-fetoprotein level of 100 ng/ml or less (hazard
ratio 0.75; 95 % CI 0.60–0.93, p \ 0.01) were found to be
significant factors affecting recurrence-free survival in the
multivariate analysis.
Transarterial embolization alone was again performed
for initial recurrent tumors in 510 of 651 patients (78.3 %),
combined transarterial embolization and infusion chemo-
therapy in 5 patients (0.8 %), and combined with RF
ablation in 4 patients (0.6 %). PEI or RF ablation was done
in 51 patients (7.8 %), arterial infusion chemotherapy in 18
patients (2.8 %), hepatectomy in 8 patients (1.2 %),
radiotherapy in 3 patients (0.5 %), chemotherapy in 2
patients (0.3 %), and no treatment in the other 50 patients
(7.7 %). Treatments for recurrent tumors were performed
on demand when recurrence was found.
Complications
Fourteen complications (1.7 %, 14/815) were recorded:
liver infarction in 8 patients (57.14 %, 8/14), cholangitis in
3 patients (21.43 %, 3/14), and biloma in 3 patients (21.43,
3/14). No death related to transarterial embolization
occurred.
Discussion
Our survey has shown that the transarterial embolization
techniques used in training centers accredited by the Jap-
anese Society of Interventional Radiology were homoge-
neous. Iodized oil and anticancer drugs were used in most
procedures, and hepatic arteries were embolized using a
gelatin sponge in all procedures. Selective embolization
was conducted in more than 85 % of procedures.
This study was conducted to assess whether technical
factors affect patient survival in a large patient series.
Despite a persistent lack of evidence, a tendency to better
survival has been shown following selective embolization
than that following non-selective embolization. The 5-year
survival rates have been reported, respectively, as
30.2–53 % after selective embolization and 16–20 % after
non-selective embolization [13, 14, 20, 23, 24]. The report of
the present study has described similar results (40.8 % in
selective embolization vs. 25.7 % in non-selective emboli-
zation, p = 0.0034) to those previously reported, and
selective embolization was proved to be a prognostic factor.
Aside from selective embolization, liver function, tumor
background, and a tumor marker were found to be prog-
nostic factors, as described in previous studies [23–25].
Regarding the cause of death (Table 4), the fact that more
than three-fourths of patients died of tumor progression or
liver failure underscores the importance of these factors.
Table 3 Prognostic factors identified in multivariate analysis
Variable Hazard ratio (95 %
CI)
p value
Age \70 0.96 (0.75–1.18) 0.57
Male 0.92 (0.72–1.17) 0.50
Other than hepatitis C 0.79 (0.59–1.05) 0.11
Child A 0.58 (0.45–0.75) \0.0001
Maximum tumor diameter B3 cm 0.76 (0.58–1.06) 0.11
Tumor number of 1–3 0.95 (0.61–1.49) 0.95
Nodular tumor type 0.50 (0.31–0.81) 0.0047
Hemilobe tumor distribution 0.89 (0.65–1.20) 0.44
Lack of portal venous invasion 0.41 (0.23–0.70) 0.0013
Alpha-fetoprotein of 100 ng/ml or
less
0.58 (0.45–0.75) \0.0001
Within the Milan Criteria 0.89 (0.59–1.35) 0.89
Stage I or II 0.69 (0.50–0.96) 0.026
Use of iodized oil 0.63 (0.084–4.44) 0.63
Selective embolization 0.68 (0.48–0.97) 0.033
CI confidence interval
Table 4 Cause of death
Cause of death Patient no. (%)
Cancer progression 197 (44.07)
Liver failure 146 (32.66)
Other disease 68 (15.21)
Gastrointestinal bleeding 21 (4.70)
Unknown 8 (1.79)
Tumor rupture 7 (1.57)
Total 447
564 Jpn J Radiol (2012) 30:560–566
123
Advantages of selective embolization over non-selective
embolization are less damage to the liver parenchyma and
a stronger anticancer effect than those of non-selective
embolization [16, 19]. Both the advantages of selective
embolization seem to contribute to prolonging patients’
survival.
Given that selective embolization is the sole prognostic
factor influenced by interventional radiologists, we must
try to perform selective embolization to the greatest degree
possible.
The use of anticancer drugs and iodized oil showed no
significance in multivariate analysis, although the latter
variable was identified as a prognostic factor in univariate
analysis. A recent prospective randomized study demon-
strated that chemoembolization using doxorubicin-eluting
beads presents a better local response, fewer recurrences,
and a longer time to progression than bland embolization
[10]. However, no significant benefit to survival of doxo-
rubicin-eluting bead chemoembolization was found.
Moreover, the benefits to survival of using cisplatin and
doxorubicin have not been proven [8, 9]. Results show no
superiority of one chemotherapeutic regimen over others in
our study, although a recent retrospective report has
described a benefit to survival of using cisplatin rather than
using epirubicin [11].
A benefit to survival of using iodized oil was demon-
strated in a previous study [12]. However, no description of
the embolization technique used in that study indicates
whether embolization was performed selectively or not.
Further studies are still required about the advantage of
using anticancer drugs and iodized oil.
Selective embolization had no significant impact on
recurrence-free survival in our study, although one recent
report described a significant benefit of selective emboliza-
tion on disease-free survival [18]. In our study, the most
frequent recurrence pattern was a new tumor in the untreated
liver parenchyma attributable to multicentric occurrence and
intrahepatic metastasis [26]. Factors affecting recurrence-
free survival were tumor size and alpha-fetoprotein, as pre-
vious studies have demonstrated [14, 17, 18].
The complication rate following transarterial emboliza-
tion was as low as 1.7 %. No procedure-related death
occurred after transarterial embolization in our study. A
higher severe adverse event rate (29.6 %) has been reported
after conventional transarterial embolization in a recent
prospective randomized study [27]. This difference in the
severe complication rate might be attributed to the dose of
anticancer drugs. A higher dose of anticancer drugs, usually
of 100–150 mg of doxorubicin, was used in that prospective
randomized study, although the most frequently used drug in
our study was epirubicin, with a mean dose of 32.5 mg.
The retrospective nature of this study is a limitation.
However, the prevalence of the selective embolization
technique and anticipation of achieving better results than
those of non-selective embolization might prevent the
performance of a prospective randomized control study.
The second limitation is that we did not analyze the rela-
tion between the tumor response and survival because of a
lack of items on the questionnaire sheet. The third limita-
tion is that we did not evaluate the effect of ‘‘on demand’’
transarterial embolization because transarterial emboliza-
tion was not performed periodically at the fixed interval.
Another limitation is that beads were not used as an
embolic material because they are not, even now, com-
mercially available in Japan.
In conclusion, selective embolization contributes to
survival in patients with HCCs.
Acknowledgments We thank the following institutions and doctors
for supporting this study: (1) Okitama Public General Hospital,
Department of Radiology, Hitoshi Ito, MD, (2) Toho University
Omori Hospital, Department of Department of Gastroenterology and
Hepatology, Manabu Watanabe, MD, (3) National Center for Global
Health and Medicine, Department of Radiology, Kanehiro Hasuo,
MD, (4) Tokai University, Department of Radiology, Takeshi
Hashimoto, MD, (5) Yamanashi University, Department of Radiology,
Hiroki Okada, MD, (6) Shinshu University, Department of Radiology,
Kazuhiko Ueda, MD, (7) Kouseiren Takaoka Hospital, Department of
Radiology, Koji Nobata, MD, (8) Ishikawa Prefectural Central Hos-
pital, Department of Radiology, Takeshi Kobayashi, MD, (9) Ham-
amatsu University School of Medicine, Department of Radiology,
Mika Kamiya, MD, (10) Nagoya City University, Department of
Radiology, Masashi Shimohira, MD, (11) Aichi Medical University,
Department of Radiology, Seiji Kamei, MD, (12) Shiga University of
Medical Science, Department of Radiology, Norihisa Nitta, MD, (13)
Kohka Public Hospital, Department of Radiology, Michio Yamasaki,
MD, (14) Japanese Red Cross Kobe Hospital, Department of Radi-
ology, Koji Sugimoto, MD, (15) Nishi-Kobe Medical Center,
Department of Radiology, Yoichiro Kuwata, MD, (16) Wakayama
Medical University, Department of Radiology, Nobuyuki Kawai,
MD, (17) Hiroshima University, Department of Radiology, Hideaki
Kakizawa, MD, (18) Chugoku Rosai Hospital, Department of Radi-
ology, Akira Naito, MD, (19) Tottori University, Department of
Radiology, Toshio Kamino, MD, (20) Shimane University, Depart-
ment of Radiology, Msakatsu Tsurusaki, MD, (21) Oita University,
Department of Radiology, Hiromu Mori, MD, (22) Kumamoto Uni-
versity, Department of Radiology, Osamu Ikeda, MD, (23) Kago-
shima University, Department of Radiology, Yasutaka Baba, MD,
(24) Kanazawa University, Department of Radiology, Tetsuya Mi-
nami, MD, (25) Hokkaido University, Department of Radiology,
Daisuke Abo, MD, (26) Okayama University, Department of Radi-
ology, Hideo Gobara, MD, (27) Osaka University, Department of
Radiology, Keigo Osuga, MD, (28) National Cancer Center,
Department of Radiology, Yoshito Takeuchi, (29) Teikyo University,
Department of Radiology, Hiroshi Kotake, MD, (30) Japan Red Cross
Kyoto Daiichi Hospital, Department of Radiology, Hiroyuki
Morishita, MD, (31) Kochi Health Science Center, Department of
Radiology, Yasuhiro Hata, MD, (32) Nanbu Medical Center,
Department of Radiology, Fumikiyo Ganaha, MD, and (33) Keio
University, Department of Diagnostic Radiology, Sachio Kuribayashi,
MD.
Jpn J Radiol (2012) 30:560–566 565
123
Conflict of interest The authors declare that they have no conflict
of interest.
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