Epirubicin

To determine all the feeding arteries of the tumor, angiography of the abdominal trunk and superior mesenteric artery is performed with a 5F RH catheter (Terumo, Tokyo, Japan). Angiography of the left gastric artery, bilateral phrenic artery, right renal artery, and bilateral internal thoracic artery were also performed if necessary. Then, 5-8 mL of lipiodol, 1 mL of polyvinyl alcohol (PVA) foam embolization particles (COOK), 30 mg of epirubicin (Pfizer, New York, USA), and 22–25 mL of ioversol were mixed and emulsified. The target artery was catheterized with a 2.7F microcatheter (Terumo). Under the guidance of digital subtraction angiography (DSA), the target artery was embolized by the mixture. This process is shown in Fig. 2.

The treatment protocol was performed as previously described [21 (link), 23 (link)]. First, using the Seldinger technique to puncture the femoral artery, a 5 Fr catheter was introduced to the celiac trunk and superior mesenteric artery, and angiography was performed to evaluate the tumor blood supply and to assess the flow of the portal vein. Then, superselective catheterization was performed using a microcatheter to the tumor feeding artery. Next, an emulsion was created using 10–20 mL of Lipiodol (Guerbet, Paris, France) mixed with 20–40 mg of epirubicin (Pfizer, New York, USA). Based on the tumor load, the emulsion was injected into the tumor feeding artery via microcatheter. When the emulsion slowed or backflowed, the injection was stopped, with a maximum volume of no more than 20 mL. Finally, embolization was performed using gelfoam particles (350–560 μm).
Sorafenib was administered on days 1–3 after the TACE procedure. The initial dose was 400 mg twice daily. Based on the grade of toxicity, the dosages were modified. If the patients experienced intolerable toxicities, a standard dosage management process was performed: from 600 mg/d, to 400 mg/d, and then to 400 mg every other day (q.o.d). Patients were encouraged to continue sorafenib treatment until untreatable progression or intolerable toxicities occurred.

A 5F catheter was introduced through the femoral artery, to assess liver vascular anatomy and to confirm the patency of the portal vein by visceral angiography. Then, a selected micro-catheter (Terumo, Tokyo, Japan) was then super-selectively inserted into the hepatic lobe or hepatic segmental artery branch. A 1:1 mixed suspension of iodized oil (1–10 mL; Andre´ Guerbet Laboratories,) and epirubicin (20–40 mg; Pharmorubicin; Pfizer, Wuxi, China) were infused into the artery through the catheter, depending on the size and number of the tumor. Finally, the embolization was performed using a gelatin sponge until the blood supply of the tumor significantly decreased.

All the animal studies were conducted in accordance with the protocol approved by the Institutional Animal Care and Use Committee (IACUC) of Sun Yat-sen University.
The cultured SK3R and SK3G cells were trypsinized, counted and mixed in equal numbers. The cell mixture (2 × 10⁶) was diluted in 70 μl of PBS mixed with 70 μl of Matrigel™ (BD) and injected into the mammary fat pads (MFP) of eight 4-week-old Balb/c-nude mice. The tumour xenografts were observable in the MFP 4 days after injection. When the diameter of the xenograft tumour reached ∼10 mm, we separated the mice into the chemotherapy treatment group (three mice) and the null control group (three mice).
The mice in the chemotherapy group were treated with 8 g/kg epirubicin (Pfizer, China) by tail vein injection [23 (link)]. The null control group received an injection of an equal volume of saline.

Angiographies of celiac, hepatic, superior mesenteric, left gastric, and inferior phrenic arteries were performed to identify all of the feeding arteries of the tumor. The chemotherapeutic drug and lipiodol (Lipiodol UltraFluide; Guerbet Laboratories) were mixed into a suspension and injected through the segmental or subsegmental target artery. The chemotherapeutic drugs used generally comprised of at least one of the following four types: platinum (25‐50 mg lobaplatin [Hainan Changan International Pharmaceutical Co. Ltd.], 100‐300 mg carboplatin [Bristol‐Myers Squibb], 50‐150 mg oxaliplatin [Sanof Synthelabo France]), anthracycline (30‐60 mg pirarubicin [Wan Le Pharmaceutical; Shen Zhen Co. Ltd.]), antibiotics (30‐60 mg epirubicin [Pfizer], 4‐10 mg mitomycin C [Zhejiang Hisun Pharmaceutical Co. Ltd.]), or fluorouracil (30‐60 mg Floxuridine [Nantong Jinghua Pharmaceutical Co. Ltd.], 100‐500 mg 5‐fluorouracil [Shanghai Xudong Haipu Pharmaceutical Co. Ltd.]). Similar drugs were not repetitively applied. Absorbable gelatin sponge (AGS) (H32024096; Gelfoam; Hanzhou alc Ltd) 350‐560 µm in diameter or polyvinyl alcohol (PVA) (Cook) 300 µm in diameter was injected in place of lipiodol if necessary. The mixture was infused at a rate of 0.5‐1 mL/min until flow stasis was achieved in the tumor vasculature.