Risk of Hepatic Artery Complications After Liver Transplantation in Patients Who Received Pretransplant Transarterial Chemoembolization Therapy: A Single-Center Experience

BACKGROUND

Pretransplant transarterial chemoembolization (TACE) for patients with hepatocellular carcinoma (HCC) has been associated with an increased risk of hepatic artery thrombosis (HAT) after liver transplantation (LT). Innovative surgical LT and interventional vascular radiology TACE techniques may mitigate the risk of HAT. We sought to investigate the incidence of HAT after LT in patients who received pre-transplant TACE at our center.

METHODS

We performed a single-center retrospective review of all LT patients, >18 years of age, from October 1, 2012, to May 31, 2018. Outcomes were compared between patients who received pre-LT TACE and those who did not. Median follow-up was 26 months.

RESULTS

Among the 162 LT recipients, 110 (67%) patients did not receive pre-LT TACE (Group I), while 52 (32%) received pre-LT TACE (Group II). The <30-day incidence rates of post-LT HAT were as follows: Group I = 1.8% and Group II = 1.9% (P = .9). Most hepatic arterial complications occurred >30 days after LT. Based on competing risks regression analysis, TACE was not associated with an increased risk of HAT. Patient or graft survivals were comparable between the 2 groups (P = .1 and .2, respectively).

CONCLUSIONS

Our study shows a similar incidence of hepatic artery complications post-LT in patients who received TACE before LT compared with those who did not. In addition, we suggest that the surgical technique of early vascular control of the common hepatic artery during LT, in combination with a super-selective vascular intervention radiology approach, has clinical utility in reducing the risk of HAT in patients requiring pre-transplant TACE.

Chemical Shift MRI Monitoring of Chemoembolization Delivery for Hepatocellular Carcinoma: Multicenter Feasibility of Initial Clinical Translation

Purpose To demonstrate the feasibility of using chemical shift fat-water MRI methods to visualize and measure intrahepatic delivery of ethiodized oil to liver tumors following conventional transarterial chemoembolization (cTACE). Materials and Methods Twenty-eight participants (mean age, 66 years ± 8 [SD]; 22 men) with hepatocellular carcinoma (HCC) treated with cTACE were evaluated with follow-up chemical shift MRI in this Health Insurance Portability and Accountability Act-compliant prospective, institutional review board-approved study. Uptake of ethiodized oil was evaluated at 1-month follow-up chemical shift MRI. Measurements of tumor size (MRI and CT), attenuation and enhancement (CT), fat content percentage, and tumor:normal ratio (MRI) were compared by lesion for responders versus nonresponders, as assessed with modified Response Evaluation Criteria in Solid Tumors and European Association for the Study of the Liver (EASL) criteria. Adverse events and overall survival by the Kaplan-Meier method were secondary end points. Results Focal tumor ethiodized oil retention was 46% (12 of 26 tumors) at 24 hours and 47% (18 of 38 tumors) at 1 month after cTACE. Tumor volume at CT did not differ between EASL-defined responders and nonresponders (P = .06). Tumor ethiodized oil volume measured with chemical shift MRI was statistically significantly higher for EASL-defined nonresponders (P = .02). Doxorubicin dosing (P = .53), presence of focal fat (P = .83), and a combined end point of focal fat and low doxorubicin dosing (P = .97) did not stratify overall survival after cTACE. Conclusion Chemical shift MRI allowed for assessment of tumor delivery of ethiodized oil out to 1 month after cTACE in participants with HCC and demonstrated tumor ethiodized oil volume as a potential tool for stratification of tumor response by EASL criteria. Keywords: MRI, Chemical Shift Imaging, CT, Hepatic Chemoembolization, Ethiodized Oil Clinicaltrials.gov registration no.: NCT02173119 Supplemental material is available for this article. © RSNA, 2023.

Comprehensive genomic profiling (CGP) of fibrolamellar oncocytic hepatoma (FLO) and conventional hepatocellular carcinomas (HCC): An observational study

474

Background: FLO is a rare variant of liver cancer that disproportionately affects young adults and is frequently progressive and fatal as it is often detected in a clinically advanced stage. It is seldom associated with cirrhosis of liver, viral hepatitis or other risk factors associated with conventional HCC. Treatment options are largely limited to surgical resection, and there is dearth of effective targeted therapies for FLO. Methods: Comprehensive genomic profiling (CGP) was performed using the Foundation Medicine Inc. (FMI) data base on 63 FLO and 1,793 HCC clinically advanced cases between 6/2013-12/2020 using a hybrid capture-based assay of up to 324 genes a to detect genomic alterations (GA), tumor mutational burden (TMB) and microsatellite instability (MSI). PD-L1 expression in tumor cells (Dako 22C3) was measured by IHC and scored using the tumor proportion score (TPS) method. Results: The FLO patients (pts) were significantly younger than HCC pts (median age 20 vs. 64, respectively) and the male preponderance was similar. The HCC group featured significantly more GA/tumor than FLO group (3.74 vs 1.31 p<.0001). In the currently untargetable GA group, CTNNB1, TERT and TP53 GA were significantly more frequent in HCC than FLO. GA in potentially targetable genes were extremely uncommon in both FLO and HCC with HCC featuring slightly more MTOR pathway targets ( PTEN, TSC2, NF1). GA in DNA damage and repair (DDR) pathway including BRCA2 were infrequent in both groups. GA in targetable kinases including EGFR, ERBB2, ALK, RET and PIK3CA were extremely uncommon in both groups. GA associated with intrahepatic cholangiocarcinoma (IDH1, FGFR2) were extremely uncommon in these tumors. Although the mean TMB was significantly higher in HCC than FLO, overall TMB was low with very few cases having TMB > 10 mutations/Mb. PD-L1 expression was relatively low in both groups. GA in genes associated with immune checkpoint inhibitors (ICPI) drug response like PBRM1, CD274, MDM2, STK11 were rarely identified in both groups. Additional details are illustrated in the table. Conclusions: Comparison of CGP of FLO with HCC illustrates the multifarious nature of these cancers. In HCC, there is a high prevalence of GA in TERT, CTNNB1 and TP53. CGP identified certain targetable GA in the MTOR and DDR pathways and TMB was higher in HCC. These findings warrant further evaluation of clinically advanced FLO and HCC pts by CGP to identify possible targetable genomic pathways. [Table: see text]

Biliary-Caval Fistula following Y90 Radioembolization

The safety of radioembolization with yttrium-90 ( ⁹⁰ Y) is well documented and major complications are rare. Previous studies have demonstrated that biliary complications following ⁹⁰ Y, including bile duct injury and hepatic abscess formation, occur at an increased rate in patients who have had prior biliary surgery and interventions. This article reviews a case of a patient who developed recurrent cholangitis and sepsis as well as a biliary-caval fistula following radioembolization. Additionally, we review current data regarding biliary complications following radioembolization in patients with prior biliary intervention.

Quality of Life and Cost Considerations: Y-90 Radioembolization

Objective  Transarterial radioembolization (TARE) offers a minimally invasive and safe treatment option for primary and metastatic hepatic malignancies. The benefits of TARE are manifold including prolonged overall survival, low associated morbidities, and improved time to progression allowing prolonged treatment-free intervals. The rapid development of new systemic therapies including immunotherapy has radically changed the treatment landscape for primary and metastatic liver cancer. Given the current climate, it is critical for interventional oncologists to understand the benefits of TARE relative to these other therapies. Therefore, this report aims to review quality-of-life outcomes and the cost comparisons of TARE as compared with systemic therapies.

Costs of care with liver directed therapy (LDT) and sorafenib (S) in patients (pts) with hepatocellular carcinoma (HCC)

383

Background: 80% of HCC pts present with advanced disease, treatment for such pts is palliative in nature. It is important to ascertain cost associated with such palliative therapy, considering modest survival benefit afforded by these treatments. Methods: Utilizing a non-Medicare national claims database (MarketScan), we analyzed a cohort of pts with HCC diagnosis (Dx). Consistent with literature, pts selected had at least two claims with HCC code (155.0) between 1/1/2010 and 12/31/2013, at least 2 claims with chronic liver condition within 1 year of the HCC Dx, no claims for other malignancies for 1 year before HCC Dx, and excluded hepatectomy or transplant. Follow up was from date of first HCC claim to end of continuous insurance coverage (EOC) with prescription drug claim tracking, or 12/31/2015. Pts were divided into 4 groups based on receipt of S, LDT, combined therapy (LDT+S), or best supportive care (BSC) after HCC Dx. Costs obtained by adding payment (Pmt) amounts for all inpatient, outpatient, and drug claims over follow-up period. Demographics and costs were summarized using means for continuous and frequencies for categorical variables. No adjustment for censoring was done, as no reason available for EOC. Average monthly cost was computed for each pt, and then averaged over pts. Results: Data were available for 6,987 patients over specified period, 67% were males, mean age was 60.2 years. Cost data by therapy received are summarized in the table below. Conclusions: Majority of HCC pts in this database were treated with BSC. Time to EOC tracked was significantly shorter for pts treated with S, compared to other 3 groups. Monthly cost associated with LDT, LDT+S, and S were not substantially different, but higher than cost associated with BSC. Prospectively collected survival, quality of life and cost data are important to ascertain true impact of palliative therapy in pts with advanced HCC. [Table: see text]

Arterioureteral Fistula

Arterioureteral fistula is a rare clinical entity that has been reported more frequently over the past decade. The risk factors for arterioureteral fistula include previous pelvic or urologic surgery, ureteral stenting, pelvic irradiation, and previous vascular pathology. All patients who present with this clinical entity have at least one of these risk factors, and the majority of patients have more than one risk factor. Radiographic demonstration of an arterioureteral fistula may be difficult and often requires more than one diagnostic modality. Angiography and retrograde ureterography appear to be the most helpful in establishing a diagnosis. The literature suggests that patients with a diagnosis of arterioureteral fistula before surgery have an increased incidence of renal salvage and decreased mortality. Methods of repair have been varied, but in the past several years, endovascular approaches to this problem have become more common. The authors report two cases of arterioureteral fistulae, one managed operatively, and one managed by endovascular placement of a covered stent. The literature is reviewed, and etiology, diagnosis, surgical therapy, and endovascular therapy are discussed.

Lipiodol transarterial chemoembolization for hepatocellular carcinoma: A systematic review of efficacy and safety data

Transarterial chemoembolization (TACE) using lipiodol-based regimens, including the administration of an anticancer-in-oil emulsion followed by embolic agents, is widely used in the treatment of hepatocellular carcinoma (HCC). This approach has been supported by meta-analyses of randomized, controlled trials (RCTs) performed more than a decade ago. We performed a systematic review to understand current efficacy and safety data of lipiodol TACE in treatment of HCC. A search of the literature published between January 1, 1980 and June 30, 2013 was performed using MEDLINE and EMBASE databases. All potentially relevant publications were reviewed and articles were selected based on predefined inclusion and exclusion criteria. Of a total of 1,564 articles reviewed, 101 articles, including a total of 10,108 patients treated with lipiodol TACE, were selected for the efficacy analysis. Objective response rate was 52.5% (95% confidence interval [CI]: 43.6-61.5). Overall survival (OS) was 70.3% at 1 year, 51.8% at 2 years, 40.4% at 3 years, and 32.4% at 5 years. Median OS was 19.4 months (95% CI: 16.2-22.6). A total of 217 articles presenting precise description on numbers of adverse events (AEs) were selected for the safety review: In these studies, a total of 21,461 AEs were reported in 15,351 patients. Liver enzyme abnormalities were the most commonly observed AE, followed by the symptoms associated with postembolization syndrome. Overall mortality rate was 0.6% and the most common cause of death was related to acute liver insufficiency.

CONCLUSIONS

In a systematic literature review, survival figures of HCC patients undergoing lipiodol TACE appear to be in line with those reported in previous RCTs, and no new or unexpected safety concerns were identified. (Hepatology 2016;64:106-116).

90Y Radioembolization of Colorectal Hepatic Metastases Using Glass Microspheres: Safety and Survival Outcomes from a 531-Patient Multicenter Study

Hepatic metastases of colorectal carcinoma are a leading cause of cancer-related mortality. Most colorectal liver metastases become refractory to chemotherapy and biologic agents, at which point the median overall survival declines to 4-5 mo. Radioembolization with (90)Y has been used in the salvage setting with favorable outcomes. This study reports the survival and safety outcomes of 531 patients treated with glass-based (90)Y microspheres at 8 institutions, making it the largest (90)Y study for patients with colorectal liver metastases.

METHODS

Data were retrospectively compiled from 8 institutions for all (90)Y glass microsphere treatments for colorectal liver metastases. Exposure to chemotherapeutic or biologic agents, prior liver therapies, biochemical parameters before and after treatment, radiation dosimetry, and complications were recorded. Uni- and multivariate analyses for predictors of survival were performed. Survival outcomes and clinical or biochemical adverse events were recorded.

RESULTS

In total, 531 patients received (90)Y radioembolization for colorectal liver metastases. The most common clinical adverse events were fatigue (55%), abdominal pain (34%), and nausea (19%). Grade 3 or 4 hyperbilirubinemia occurred in 13% of patients at any time. The median overall survival from the first (90)Y treatment was 10.6 mo (95% confidence interval, 8.8-12.4). Performance status, no more than 25% tumor burden, no extrahepatic metastases, albumin greater than 3 g/dL, and receipt of no more than 2 chemotherapeutic agents independently predicted better survival outcomes.

CONCLUSION

This multiinstitutional review of a large cohort of patients with colorectal liver metastases treated with (90)Y radioembolization using glass microspheres has demonstrated promising survival outcomes with low toxicity and low side effects. The outcomes were reproducible and consistent with prior reports of radioembolization.

Comparative Effectiveness of Hepatic Artery Based Therapies for Unresectable Colorectal Liver Metastases: A Meta-Analysis

Background

Patients with unresectable Colorectal Liver Metastases (CRLM) are increasingly being managed using Hepatic Artery Based Therapies (HAT), including Hepatic Arterial Infusion (HAI), Radioembolization (RE), and Transcatheter Arterial Chemoembolization (TACE). Limited data is available on the comparative effectiveness of these options. We hypothesized that outcomes in terms of survival and toxicity were equivalent across the three strategies.

Methods

A meta-analysis was performed using a prospectively registered search strategy at PROSPERO (CRD42013003861) that utilized studies from PubMed (2003–2013). Primary outcome was median overall survival (OS). Secondary outcomes were treatment toxicity, tumor response, and conversion of the tumor to resectable. Additional covariates included prior or concurrent systemic therapy.

Results

Of 491 studies screened, 90 were selected for analyses—52 (n = 3,000 patients) HAI, 24 (n = 1,268) RE, 14 (n = 1,038) TACE. The median OS (95% CI) for patients receiving HAT in the first-line were RE 29.4 vs. HAI 21.4 vs. TACE 15.2 months (p = 0.97, 0.69 respectively). For patients failing at least one line of prior systemic therapy, the survival outcomes were TACE 21.3 (20.6–22.4) months vs. HAI 13.2 (12.2–14.2) months vs. RE 10.7 (9.5–12.0). Grade 3–4 toxicity for HAT alone was 40% in the HAI group, 19% in the RE group, and 18% in the TACE groups, which was increased with the addition of systemic chemotherapy. Level 1 evidence was available in 5 studies for HAI, 2 studies for RE and 1 for TACE.

Conclusion

HAI, RE, and TACE are equally effective in patients with unresectable CRLM with marginal differences in survival.

Safety and efficacy of transarterial chemoembolization in patients with transjugular intrahepatic portosystemic shunts

BACKGROUND

Transarterial chemoembolization (TACE) for the treatment of hepatocellular carcinoma (HCC) is an important option as the majority of patients present with advanced disease. Data regarding treatment outcomes in patients who have undergone transjugular intrahepatic portosystemic shunts (TIPS) are limited. The present study seeks to evaluate the safety and efficacy of TACE in HCC patients with a TIPS.

METHODS

A retrospective review identifying patients with HCC and concomitant TIPS who were treated with TACE was performed.

RESULTS

From 1999 to 2014, 16 patients with HCC underwent a total of 27 TACE procedures; eight patients required multiple treatments. The median patient age at the time of the initial TACE was 60.5 years [interquartile range (IQR) : 52.5-67.5] with the majority being male (n = 12, 75%) and Childs-Pugh Class B (n = 12, 75%). At 6 weeks after TACE, 56.3% of patients achieved an objective response rate (complete and partial response) by mRECIST criteria. Clavien Grade 3 or higher complications occurred in 11.1% of TACE procedures. There were no peri-procedural deaths. The median progression-free (PFS) and overall survival (OS) were 9 and 22 months, respectively, when censored for liver transplantation (median follow-up: 11.5 months).

CONCLUSION

TACE is an effective treatment strategy for HCC in TIPS patients; albeit may be associated with higher complication rates.

Randomized controlled trial of irinotecan drug-eluting beads with simultaneous FOLFOX and bevacizumab for patients with unresectable colorectal liver-limited metastasis

BACKGROUND

Reports have demonstrated the superior activity of combining both irinotecan and oxaliplatin (FOLFOXIRI) therapy. An option for gaining similar benefits with less toxicity would be the administration of irinotecan through a hepatic artery approach. The aim of this study was to assess the response and adverse event rates for irinotecan drug-eluting beads (DEBIRI) with folinic acid, 5-fluorouracil, and oxaliplatin (FOLFOX) and bevacizumab as a first-line treatment for unresectable colorectal liver metastasis.

METHODS

Patients with colorectal liver metastases were randomly assigned to modified FOLFOX (mFOLFOX) and bevacizumab or mFOLFOX6, bevacizumab, and DEBIRI (FOLFOX-DEBIRI). The primary endpoint was the response rate. The secondary endpoints were adverse events, the rate of conversion to resection, and progression-free survival.

RESULTS

The intention-to-treat population comprised 70 patients: 10 patients in the pilot and then 30 patients randomly assigned to the FOLFOX-DEBIRI arm and 30 patients randomly assigned to the FOLFOX/bevacizumab arm. The 2 groups were similar with respect to the extent of liver involvement (30% vs 30%), but a greater percentage of patients in the FOLFOX-DEBIRI arm had an Eastern Cooperative Oncology Group performance status of 1 or 2 (57% vs 31%) and extrahepatic disease (56% vs 32%, P = .02). The median numbers of chemotherapy cycles were similar (10 vs 9), and there were similar rates of grade 3/4 adverse events (54% for the FOLFOX-DEBIRI group vs 46% for the FOLFOX/bevacizumab group). The overall response rate was significantly greater in the FOLFOX-DEBIRI arm versus the FOLFOX/bevacizumab arm at 2 (78% vs 54%, P = .02), 4 (95% vs 70%, P = .03), and 6 months (76% vs 60%, P = .05). There was significantly more downsizing to resection in the FOLFOX-DEBIRI arm versus the FOLFOX/bevacizumab arm (35% vs 16%, P = .05), and there was improved median progression-free survival (15.3 vs 7.6 months).

CONCLUSIONS

The simultaneous administration of mFOLFOX6 (with or without bevacizumab) and DEBIRI through the hepatic artery (FOLFOX-DEBIRI) is safe and does not cause treatment delays or increase the systemic toxicity of chemotherapy. This strategy leads to improved overall response rates, improved hepatic progression-free survival, and more durable overall progression-free survival in patients downsized to resection.

Radiofrequency ablation of stage IA non-small cell lung cancer in medically inoperable patients: Results from the American College of Surgeons Oncology Group Z4033 (Alliance) trial

BACKGROUND

This study evaluated the 2-year overall survival rate, adverse event rate, local control rate, and impact on pulmonary function tests for medically inoperable patients with stage IA non-small cell lung cancer (NSCLC) undergoing computed tomography (CT)-guided radiofrequency ablation (RFA) in a prospective, multicenter trial.

METHODS

Fifty-four patients (25 men and 29 women) with a median age of 76 years (range, 60-89 years) were enrolled from 16 US centers; 51 patients were eligible for evaluation (they had biopsy-proven stage IA NSCLC and were deemed medically inoperable by a board-certified thoracic surgeon). Pulmonary function tests were performed within the 60 days before RFA and 3 and 24 months after RFA. Adverse events were recorded and categorized. Patients were followed with CT and fludeoxyglucose positron emission tomography. Local control rate and recurrence patterns were analyzed.

RESULTS

The overall survival rate was 86.3% at 1 year and 69.8% at 2 years. The local tumor recurrence-free rate was 68.9% at 1 year and 59.8% at 2 years and was worse for tumors > 2 cm. In the 19 patients with local recurrence, 11 were re-treated with RFA, 9 underwent radiation, and 3 underwent chemotherapy. There were 21 grade 3 adverse events, 2 grade 4 adverse events, and 1 grade 5 adverse event in 12 patients within the first 90 days after RFA. None of the grade 4 or 5 adverse events were attributable to RFA. There was no significant change in the forced expiratory volume in the first second of expiration or the diffusing capacity of lung for carbon monoxide after RFA. A tumor size less than 2.0 cm and a performance status of 0 or 1 were associated with statistically significant improved survival of 83% and 78%, respectively, at 2 years.

CONCLUSIONS

RFA is a single, minimally invasive procedure that is well tolerated in medically inoperable patients, does not adversely affect pulmonary function tests, and provides a 2-year overall survival rate that is comparable to the rate reported after stereotactic body radiotherapy in similar patients.

Transarterial therapies for the treatment of intrahepatic cholangiocarcinoma

Cholangiocarcinoma, whether arising from the intrahepatic or extrahepatic biliary system, is a rare but devastating malignancy. Prognosis is poor, with 5-year overall survival <5% including patients undergoing surgery. Resection is the only curative treatment; however, only ∼30% of patients present at a resectable stage, and intrahepatic recurrence is common even after complete resection. This article discusses the current role of transarterial therapies in the treatment of intrahepatic cholangiocarcinoma.

Microwave ablation for hepatic malignancies: a call for standard reporting and outcomes

BACKGROUND

Clinical standards of reporting microwave ablation outcomes have not been defined with regard to ablation success, 90-day morbidity, local recurrence after ablation, and nonablation hepatic recurrence. We propose recommendations for microwave ablation reporting and quality standards.

METHODS

Literature review of clinical studies focusing on microwave ablation of primary and metastatic hepatic tumors was reported.

RESULTS

Ablation success remains the highest quality reporting standard with variations in nomenclature, but with a universal agreement of complete destruction of the target lesion within 1 month after initial microwave ablation. Local recurrence after ablation remains highly variable, with reports as low as 2.2% to as high as 22%; standards lack a common, clearly defined distance from the initial target ablated lesion and the requirement that the target lesion be defined as an ablation success before it can be called a recurrence. Nonablation hepatic recurrence, nonhepatic recurrence, and 90-day morbidity and mortality remain limited in the current literature.

CONCLUSIONS

Standardization of hepatic microwave ablation reporting standards are proposed. Current reporting standards in microwave ablation of hepatic malignancies are suboptimal and lack standardization for comparison across institutions.

Percutaneous in utero thoracoamniotic shunt creation for fetal thoracic abnormalities leading to nonimmune hydrops

PURPOSE

To describe a transabdominal, transuterine Seldinger-based percutaneous approach to create a shunt for treatment of fetal thoracic abnormalities.

MATERIALS AND METHODS

Five fetuses presented with nonimmune fetal hydrops secondary to fetal thoracic abnormalities causing severe mass effect. Under direct ultrasound guidance, an 18-gauge needle was used to access the malformation. Through a peel-away sheath, a customized pediatric transplant 4.5-F double J ureteral stent was advanced; the leading loop was placed in the fetal thorax, and the trailing end was left outside the fetal thorax within the amniotic cavity.

RESULTS

Seven thoracoamniotic shunts were successfully placed in five fetuses; one shunt was immediately replaced because of displacement during the procedure, and another shunt was not functioning at follow-up requiring insertion of a second shunt. All fetuses had successful decompression of the thoracic malformation, allowing lung reexpansion and resolution of hydrops. Three of five mothers had meaningful (> 7 d) prolongation of their pregnancies. All pregnancies were maintained to > 30 weeks (range, 30 weeks 1 d-37 weeks 2 d). There were no maternal complications.

CONCLUSIONS

A Seldinger-based percutaneous approach to draining fetal thoracic abnormalities is feasible and can allow for prolongation of pregnancy and antenatal lung development and ultimately result in fetal survival.

Randomized controlled trial of irinotecan drug-eluting beads with simultaneous FOLFOX and bevacizamab for patients with unresectable colorectal liver-limited metastasis

174

Background: Reports have demonstrated the activity of combining both Irinotecan and Oxaliplatin into a FOLFOXIRI therapy. An option to gain similar benefits and less toxicity to FOLFOXIRI would be to administer the irinotecan through an hepatic arterial apporach. The aim of this study was to assess the maximal response and adverse event rates of Irinotecan Drug Eluting Beads (DEBIRI) with FOLFOX and Bevacizumab (Bev) as a first line treatment for unresectable colorectal liver metastasis (CLMs). Methods: Metachronous and Synchronous CLMs were randomly assigned to mFOLFOX6/Bev or mFOLFOX6, Bev and DEBIRI (FOLFOXDEBIRI). Primary end point was optimal response rates and adverse events. Secondary endpoints were patients (pts) converted to resection and survival. Results: The intention-to-treat population comprised 70 pts, 40 pts randomly assigned to the FOLFOXDEBIRI arm and 30 pts to FOLFOX/Bev arm. Both were similar with synchronous disease (50% vs. 36%), extent liver involvement (35% vs. 31%), but greater percentage in the FOLFOXDEBIRI arm of ECOG 1/2 (57% vs. 31%), p=0.04) and extra-hepatic disease (51% vs. 36%, p=0.02). Median number of chemotherapy cycles was similar in both arms of 8, with a similar Grade 3/4 adverse event rate of 54% FOLFOXDEBIRI and 46% FOLFOX/Bev arm. The overall response rate was significantly greater in the FOLFOXDEBIRI arm vs. FOLFOX/BEV at 2 mons (78% vs. 54%), 4 mons (95% vs. 70%) and 6 mons (76% vs. 60%, p=0.03). Significantly greater downsizing to resection in the FOLFOXDEBIRI arm vs. FOLFOX/Bev (35% vs. 16%, p=0.05), with an improved median progression free survival (15.3 mons vs. 7.6 mons). Overall improvement in hepatic specific progression free survival was seen in the treatment arm (12.8 mons vs. 10.5 mons). Conclusions: Simultaneous mFOLFOX6 with bevacizumab and hepatic arterial irinotecan drug eluting beads is safe, without causing chemotherapy delivery delays and without increasing chemotherapy toxicity. Simultaneous FOLFOXDEBIRI leads to improved overall response rates, improved hepatic progression free survival, and more durable overall progression free survival in patients downsized to resection. Clinical trial information: NCT00932438.

Neutrophil-to-lymphocyte ratio as a predictor of outcomes for patients with hepatocellular carcinoma: a Western perspective

BACKGROUND AND OBJECTIVES

Neutrophil-to-lymphocyte ratio (NLR) is simple, inexpensive, and has been proposed to be predictive in hepatocellular carcinoma (HCC) in Europe and Asia. We aimed to evaluate whether NLR at presentation in a Western center provides any prognostic value compared to other common prognostic scores.

METHODS

NLR was calculated for 75 consecutive patients at presentation with HCC and regression models were used to analyze its value for predicting treatment strategy and short-term survival with Child-Pugh and Model for End Stage Liver Disease (MELD).

RESULTS

NLR was not predictive of future treatment regimens with hepatectomy, liver transplant, or transarterial chemoembolization (TACE; odds ratio [OR]: 0.85, 95% confidence interval [CI]: 0.71-1.02, P = 0.079) as compared the predictive value of MELD (OR: 0.81, CI: 0.72-0.93, P = 0.002) or Child-Pugh (OR: 0.48, CI: 0.34-0.69, P < 0.001). Adding additional adjustment for treatment, NLR did not correlate with short-term overall survival (hazard ratio [HR]: 1.09, CI: 0.95-1.24, P = 0.227). MELD also did not correlate with overall survival (HR: 1.04, CI: 0.96-1.13, P = 0.357) whereas Child-Pugh (HR: 1.56, CI: 1.10-2.19, P = 0.011) was predictive.

CONCLUSIONS

This study does not support the prognostic value of NLR to guide therapy for HCC in a Western center, whereas MELD and Child-Pugh score were more predictive.

Incidence of venous thromboembolism in patients with hematologic malignancies related to upper extremity peripherally inserted central venous catheters

6586

Background: Central venous catheters (CVCs) are an integral part of management in patients with hematological malignancies (HMs). CVCs are not without risk however, including DVT which adds significant morbidity. Peripherally inserted central venous catheters (PICCs) via the brachiocephalic veins were the most common CVCs utilized at the Medical College of Wisconsin for patients with HMs. Recent evidence has indicated an increased risk of DVT in patients with PICCs. Methods: We retrospectively reviewed patients admitted to our institution from 2009-2011 with a HM and a CVC placed based upon CPT codes. A chart review was performed and those with a radiologic-confirmed DVT were identified. Results: From 2009-2011, 487 patients with HMs had 1091 CVCs placed. Diagnoses included lymphoproliferative disorders (35.8%), acute leukemia excluding APL (23.8%), APL (1.6%), plasma cell dyscrasias (34.6%), MDS (1.7%), CML (1.6%), and other diagnoses (0.7%). Of the CVCs placed 51% were in patients undergoing stem cell transplantation (HCT) and 49% were placed in non-HCT patients. A total of 91 DVTs were documented and confirmed. DVTs occurred in 85 of 728 PICCs (11.7%), 3 of 104 implanted ports (2.9%), 3 of 249 tunneled CVCs (1.2%), and 0 of 10 other CVCs. DVT rates were similar between HCT (47 of 556, 8.4%) and non-HCT (44 of 535, 8.2%) patients. The highest number of DVTs were associated with plasma cell dyscrasias (29 of 378, 7.7%) followed by lymphoproliferative disorders (28 of 391, 7.2%), acute leukemia (26 of 260, 10%), APL (3 of 18, 16.6%), MDS (3 of 19, 15.8%), and CML (2 of 17, 11.7%). Two DVTs occurred in the setting of warfarin therapy, 5 while on prophylactic and 9 while on therapeutic LMWH. The mean duration from line placement to DVT was 21 days (range 1-169). Using standard chi-squared evaluation, PICC lines were significantly more likely to be associated with DVTs than tunneled or implanted CVCs (p<0.0001). Conclusions: Brachiocephalic PICC-lines are associated with a high incidence of DVT in patients with HMs compared to other CVCs. We have currently changed our practice to utilizing a tunneled internal jugular PICCs for central venous access.

Recurrence after microwave ablation of liver malignancies: a single institution experience

BACKGROUND

Microwave ablation (MWA) is increasingly used to achieve local control for liver tumours. This study sought to examine a monocentric experience with MWA, with a primary hypothesis that primary tumour histology was a significant predictor of early recurrence.

METHODS

Retrospective single-institution review identified consecutive patients with liver tumours treated by MWA. Cox proportional hazards models assessed significance of prognostic variables.

RESULTS

Seventy-two patients (43 female, 60%) underwent 83 MWA procedures for 157 tumours. Tumour histologies included hepatocellular cancer (10 operations), colorectal metastases (39), metastatic carcinoid (20) and other (14). The median tumour size was 2.0 cm. A concomitant liver resection was performed in 50 cases (60%). Crude peri-operative morbidity and mortality rates were 16% and 1%, respectively. The median follow-up was 16 months. Ablations were complete for 149 out of 157 tumours (95%). The median overall and recurrence-free survivals were 36 and 18 months, respectively. There was no difference in time to recurrence between the primary tumour types. In multivariable models, recurrence-free survival was independently associated with the use of neoadjuvant [hazard ratio (HR): 2.90, 95% confidence interval (CI): 1.09-7.76, P = 0.034] and adjuvant chemotherapy (HR: 0.36, 95% CI: 0.15-0.82, P = 0.016).

CONCLUSIONS

MWA is a safe and feasible approach for local control of liver tumours. While chemotherapy administration was associated with time to recurrence after MWA, larger studies are needed to corroborate these findings.

Microwave ablation for hepatic malignancies: A multi-institutional analysis

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Background: Although many hepatobiliary centers have moved from radiofrequency ablation to microwave ablation (MWA), the factors that influence local control with MWA are not well described. We hypothesized that tumor size, number of tumors, and tumor histology significantly affected MWA success and recurrence-free survival (RFS). Methods: Consecutive patients with hepatic malignancy treated by MWA were included from 4 high-volume institutions (2003-2011), and grouped by histology: hepatocellular cancer (HCC), colorectal metastases (CM), neuroendocrine metastases (NM), and other cancers. Independent significance of variables was established with logistic regression and Cox proportional hazards models. Results: Four-hundred seventy three ablation procedures were performed (139 HCC, 198 CM, 61 NM, and 75 other) for a total of 875 tumors. Median follow-up was 18 months. Complete ablation was confirmed for 839 of 865 tumors (97.0%) on follow-up cross-sectional imaging (Table). NM had greater odds of an incomplete ablation compared to other histologies (odds ratio: 3.07, 95% confidence interval [CI]: 1.08-8.67, p=0.035), however this was not significant in adjusted models. The local recurrence rate was 6.1% overall, and was highest for HCC tumors (10.3%, p=0.051). RFS did not vary significantly between histologies. In adjusted models, tumor size ≥3cm was the only variable predicting poorer RFS (hazard ratio: 1.60, 95% CI: 1.02-2.50, p=0.039). Independent predictors of poorer OS included age, number of tumors ablated, and tumor size ≥3cm. Conclusions: In this large dataset, patients with ≥3cm tumors showed a propensity for early recurrence, regardless of histology. Higher rates of local recurrence were noted in HCC patients, which may reflect underlying liver disease. Accounting for recurrence at any site, however, there were no significant differences in RFS between tumor histologies. [Table: see text]

Longitudinal quality of life assessment of patients with hepatocellular carcinoma after primary transarterial chemoembolization

PURPOSE

To determine the effects of primary chemoembolization on the health-related quality of life (HRQOL) of patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Single-center prospective data collection with longitudinal analysis of HRQOL scores obtained via the Short Form-36 (SF-36) assessment tool was performed before and during serial chemoembolization procedures in 73 patients with HCC. Baseline HRQOL scores were evaluated for significant (P < .05) change within the total patient population during 4, 8, and 12 months of treatment, and separately within a subset of 23 patients who underwent three or more chemoembolization procedures.

RESULTS

Patients had decreased pretreatment baseline scores within all eight scales of the SF-36 compared with healthy age-adjusted norms. Within the total population, mental health scores improved after 4 months of chemoembolization (rate of change, 5.6; P = .05; n = 48), but no significant change was present at 8 or 12 months. Subset patients experienced improvements of mental health scores after the first (score change, 13; P = .008; n = 21) and second procedures (score change, 12.2; P = .002; n = 23) and improvements of bodily pain scores (score change, 9.9; P = .047; n = 21) after the initial procedure. Vitality scores worsened (score change, -7.8; P = .044; n = 21) in the subset after the first chemoembolization.

CONCLUSIONS

Patients with HCC are likely to perceive improved mental health during the first 4 months of primary treatment with chemoembolization. In addition, if patients ultimately undergo more than two procedures, they are likely to perceive improved mental health during the first two sessions, with decreased bodily pain during the initial session. Patient-perceived vitality will likely worsen after the initial procedure.

Transcatheter therapy for hepatic malignancy: standardization of terminology and reporting criteria

The field of interventional oncology includes tumor ablation as well as the use of transcatheter therapies such as embolization, chemoembolization, and radioembolization. Terminology and reporting standards for tumor ablation have been developed. The development of standardization of terminology and reporting criteria for transcatheter therapies should provide a similar framework to facilitate the clearest communication among investigators and provide the greatest flexibility in comparing established and emerging technologies. An appropriate vehicle for reporting the various aspects of catheter directed therapy is outlined, including classification of therapies and procedure terms, appropriate descriptors of imaging guidance, and terminology to define imaging and pathologic findings. Methods for standardizing the reporting of outcomes toxicities, complications, and other important aspects that require attention when reporting clinical results are addressed. It is the intention of the group that adherence to the recommendations will facilitate achievement of the group's main objective: improved precision and communication for reporting the various aspects of transcatheter management of hepatic malignancy that will translate to more accurate comparison of technologies and results and, ultimately, to improved patient outcomes.

Hepatic neuroendocrine metastases: chemo- or bland embolization?

INTRODUCTION

Aggressive management of hepatic neuroendocrine (NE) metastases improves symptoms and prolongs survival. Because of the rarity of these tumors, however, the best method for hepatic artery embolization has not been established. We hypothesized that in patients with hepatic NE metastases, hepatic artery chemoembolization (HACE) would result in better symptom improvement and survival compared to bland embolization (HAE).

METHODS

Retrospective review identified all patients with NE hepatic metastases managed by HACE or HAE at three institutions from January 1996 through December 2007.

RESULTS

We identified 100 patients managed by HACE (n = 49) or HAE (n = 51) that were similar with respect to age, gender, and primary tumor type. The percentage of patients experiencing morbidity, 30-day mortality, and symptom improvement were similar between the two groups (HACE vs. HAE: 2.4% vs. 6.6%; 0.8% vs. 1.8%; and 88% vs. 83%, respectively.) No differences in the median overall survival were observed between HACE and HAE from the time of the first embolization procedure (25.5 vs. 25.7 months, p = 0.79). Multivariate analysis revealed that resection of the primary tumor predicted survival (73.8 vs. 19.4 months, p < 0.04).

CONCLUSIONS

These data suggest that morbidity, mortality, symptom improvement, and overall survival are similar in patients with hepatic neuroendocrine metastases managed by chemo- or bland hepatic artery embolization.

Safety and effectiveness of repeat arterial closure using the AngioSeal device in patients with hepatic malignancy

PURPOSE

To retrospectively evaluate the safety and effectiveness of the use of the AngioSeal device for repeat arterial closure in patients with hepatic malignancy.

MATERIALS AND METHODS

A retrospective analysis of patients with hepatic malignancy who had undergone repeated arterial closure with the AngioSeal device was performed. All charts for patients undergoing transarterial chemoembolization or TheraSphere radioembolization were reviewed for the method of hemostasis and the number of arterial closures. A total of 53 patients (58.5% men, 41.5% women; mean age, 58.7 years) had repeat AngioSeal arterial puncture closure after chemoembolization or TheraSphere treatment. Percutaneous closure of the common femoral artery with the AngioSeal device was performed in accordance with the manufacturer's recommendations. The patients were examined for complications on follow-up. Effectiveness was defined by the ability to obtain satisfactory hemostasis. Safety was assessed by the absence of groin complications and by vessel patency on follow-up angiograms of the puncture site obtained at subsequent liver-directed therapy sessions.

RESULTS

Fifty-three patients in this study group had a total of 203 common femoral artery punctures. There were a total of 161 closures with the AngioSeal device (79.3%): 58 (36%) single closures and 103 (64.0%) repeat closures. Of the 161 attempts at AngioSeal closure, there was one closure failure in the single-puncture group, yielding a success rate of 98.3%; and one closure failure in the repeat-puncture group, yielding a success rate of 99%. In these two patients, hemostasis was achieved with traditional manual compression without the need for any other device, and no complications were noted. The overall success rate of AngioSeal device closure was 98.7%.

CONCLUSIONS

The repeat use of the AngioSeal closure device is safe and effective in patients with hepatic malignancy undergoing regional oncologic interventional procedures.

Treatment of diffuse large B-cell lymphoma of the liver with yttrium-90 microsphere embolization

BACKGROUND

A 41-year-old male with a 4-year history of chronic hepatitis C presented with a 1-month history of abdominal pain, fatigue, weight loss, and night sweats.

INVESTIGATIONS

Laboratory examinations, chest, abdomen, and pelvic CT scans, PET-CT scans, ultrasound-guided needle biopsies of liver lesions, bone-marrow biopsy, flow cytometry, and immunohistochemical staining for B-cell markers including CD20.

DIAGNOSIS

Chemoresistant diffuse large B-cell lymphoma, with gradual loss of CD20 antigen expression.

MANAGEMENT

Embolization of hepatic tumors using yttrium-90 microspheres (Therasphere, Theragenics Corporation, Buford, GA).

Transcatheter therapy for hepatic malignancy: standardization of terminology and reporting criteria

The field of interventional oncology includes tumor ablation as well as the use of transcatheter therapies such as embolization, chemoembolization, and radioembolization. Terminology and reporting standards for tumor ablation have been developed. The development of standardization of terminology and reporting criteria for transcatheter therapies should provide a similar framework to facilitate the clearest communication among investigators and provide the greatest flexibility in comparing established and emerging technologies. An appropriate vehicle for reporting the various aspects of catheter directed therapy is outlined, including classification of therapies and procedure terms, appropriate descriptors of imaging guidance, and terminology to define imaging and pathologic findings. Methods for standardizing the reporting of outcomes toxicities, complications, and other important aspects that require attention when reporting clinical results are addressed. It is the intention of the group that adherence to the recommendations will facilitate achievement of the group's main objective: improved precision and communication for reporting the various aspects of transcatheter management of hepatic malignancy that will translate to more accurate comparison of technologies and results and, ultimately, to improved patient outcomes.

Psychosocial Management of Distress in Interventional Radiology Patients with Cancer

Cancer patients experience a wide variety of psychosocial stresses which greatly influence their quality of life. Consistent evaluation and management of the psychosocial wellbeing of cancer patients not only improves patient outcomes but also strengthens relationships between staff and patients and increases staff satisfaction. This article will review the use of a Distress Tool to evaluate and quantify patient psychosocial distress, describe psychosocial interventions to be made within the interventional radiology clinic setting and discuss when to refer patients to an outside psychosocial professional.

Bland embolization of telangiectatic subtype of hepatic focal nodular hyperplasia

Focal nodular hyperplasia (FNH) is a common benign liver tumor that is usually treated conservatively. This report describes a histologic subtype of FNH that is more likely to be symptomatic as a result of hemorrhage and necrosis. The patient in this case was treated initially with surgical resection for multiple focal nodular hyperplasias and subsequently with bland embolization of an unresectable, symptomatic lesion.

Combining local and regional therapeutic modalities to treat hepatic malignancies

Hepatocellular carcinoma and metastatic colon cancer have proven to be challenging problems in oncology today. Currently multiple treatment options are available for treating patients with these diseases, and for this reason, a multimodality and multidisciplinary approach is needed to optimize the effectiveness of treatment. Local ablation techniques along with intra-arterial therapy may be complementary and therefore increase survival in patients being treated for hepatocellular carcinoma and metastatic colon cancer. With proper patient selection, further improvement in treatment outcomes can be achieved when these techniques are combined with surgical resection and multidrug systemic chemotherapy. Therefore, it is imperative that interventional radiologists work closely with our colleagues in other medical and surgical specialties to provide our patients with the best possible treatment options.

Chemoembolization in Patients at High Risk: Results and Complications

PURPOSE

Transarterial chemoembolization (TACE) has become a standard treatment option for unresectable hepatocellular carcinoma (HCC) and is often used to palliate hepatic metastases. Many patients who are candidates for TACE present with poor hepatic reserve, advanced tumor stage with major portal vein (PV) invasion or thrombosis, and/or biliary dilation. These factors have been associated with a poor prognosis and increased complications after chemoembolization. Accordingly, these patients are classified as being at high risk and may not be considered for therapy. The aim of this study is to evaluate the results of TACE in these patients.

MATERIALS AND METHODS

Over a period of 5 years, 141 patients underwent 355 TACE procedures. Thirty-six patients (26%) were in the high-risk group as a result of major PV thrombosis, increased serum bilirubin level (>2 mg/dL), and/or intrahepatic biliary dilation. HCC was the underlying tumor in 60% of patients. Thirty-seven percent of patients had Child-Pugh class B/C disease. Patients in the high-risk group received more selective embolization with fewer particles and fewer procedures (2.0 vs 2.7; P < .04).

RESULTS

Patients in the high-risk group were more likely to have HCC (83% vs 51%; P < .01) and were also more likely to have advanced disease according to Child-Pugh classification versus patients in the low-risk group (49% vs 20%; P < .01). The overall complication rate was 4.3%, with no significant difference in complication rate between groups (3.2% vs 8.2%; P = .12). The overall 30-day mortality rate was 2.3%, and no significant difference in 30-day mortality rate was observed between the high- and low-risk groups (5.5% vs 1.4%; P = .11). A trend toward increased survival in the low-risk group did not reach statistical significance.

CONCLUSIONS

These data suggest that patients with advanced disease and decreased hepatic reserve who are treated with TACE exhibit no significant increase in morbidity or mortality and no significant decrease in survival. With variations in technique, TACE can be performed safely in patients with the relative risk factors that may classify them in high-risk groups.

Neuroendocrine hepatic metastases: does aggressive management improve survival?

OBJECTIVE

The aim of this study was to determine whether aggressive management of neuroendocrine hepatic metastases improves survival.

SUMMARY BACKGROUND DATA

Survival in patients with carcinoid and pancreatic neuroendocrine tumors is significantly better than adenocarcinomas arising from the same organs. However, survival and quality of life are diminished in patients with neuroendocrine hepatic metastases. In recent years, aggressive treatment of hepatic neuroendocrine tumors has been shown to relieve symptoms. Minimal data are available, however, to document improved survival with this approach.

METHODS

The records of patients with carcinoid (n = 84) and pancreatic neuroendocrine tumors (n = 69) managed at our institution from January 1990 through July 2004 were reviewed. Eighty-four patients had malignant tumors, and hepatic metastases were present in 60 of these patients. Of these 60 patients, 23 received no aggressive treatment of their liver metastases, 19 were treated with hepatic resection and/or ablation, and 18 were managed with transarterial chemoembolization (TACE) frequently (n = 11) in addition to resection and/or ablation. These groups did not differ with respect to age, gender, tumor type, or extent of liver involvement.

RESULTS

Median and 5-year survival were 20 months and 25% for the Nonaggressive group, >96 months and 72% for the Resection/Ablation group, and 50 months and 50% for the TACE group. The survival for the Resection/Ablation and the TACE groups was significantly better (P < 0.05) when compared with the Nonaggressive group. Patients with more than 50% liver involvement had a poor outcome (P < 0.001).

CONCLUSIONS

These data suggest that aggressive management of neuroendocrine hepatic metastases does improve survival, that chemoembolization increases the patient population eligible for this strategy, and that patients with more than 50% liver involvement may not benefit from an aggressive approach.

Preoperative embolization

Preoperative embolization procedures are constantly evolving and allow the performance of, or improve the outcome of, subsequent surgical interventions. Currently, some of the more frequently performed procedures in this group are portal vein embolization (PVE) in anticipation of extended liver resection, preoperative embolization of hypervascular tumors, and chemoembolization of hepatocellular carcinoma (HCC) as a bridge to liver transplantation. The indications, technique, and results of these procedures will be reviewed.