PMC4241331_01
CT images. (a) and (b) refer to images at the initial presentation. (a) Shows a hypoattenuating mass with areas of heterogeneous enhancement in the left hepatic lobe. Visible right branch of portal vein was present in arterial phase axial CT image ((a), arrow), whereas main portal vein showed little contrast enhancement on arterial phase imaging ((b), arrow). (c) and (d) demonstrate the decreases of tumor diameter after the treatment at 59 and 152 days after the diagnosis, respectively.
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CT scan demonstrated a low-attenuation mass about 12.5 cm in diameter in the left hepatic lobe. Contrast-enhanced CT images confirmed a hypoattenuating mass with areas of heterogeneous enhancement (Figure 1(a)). CT images, whereas main portal vein showed little contrast enhancement on arterial phase imaging (Figures 1(a) and 1(b)).
Hepatic arteriography images. Figures 1(a), 1(b), and 1(c) refer to 5, 5, and 151 days after the diagnosis of the tumor, respectively. Figure 1(a) shows early visualization of the right branch of portal vein which implies a prominent APS.  Figure 1(b) demonstrates the tumor staining and the occlusion of the APS due to the embolization with gelfoam through the left hepatic artery.  Figure 1(c) reveals reestablishment of the APS and tumor shrink after the treatment by TACE and TAC plus sorafenib.
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Five days after the diagnosis, angiography in the first session of TACE showed that the mass was supplied by the right and the left hepatic arteries (Figure 2(a)). An APS communication between the left hepatic artery and the right branch of portal vein was demonstrated by early visualization of the right branch of portal vein in hepatic arteriography (Figure 2(a)). APS was successfully occluded by delivering gelfoam through the left hepatic artery (Figure 2(b)). An emulsion of 5 mL iodized oil and 40 mg doxorubicin, 1000 mg floxuridine, and 20 mg hydroxycamptothecin was then infused via the right hepatic artery. Tumor shrinks were revealed by hepatic arteriography at 27 days, 84 days, and 151 days after the diagnosis of the tumor (Figure 2(c)).