To conduct a large single-institution comparison of transarterial chemoembolization (TACE) and stereotactic body radiation therapy (SBRT) outcomes in similar groups of patients with hepatocellular ...carcinoma (HCC).
From 2006 to 2014, 209 patients with 1 to 2 tumors underwent TACE (n=84) to 114 tumors or image guided SBRT (n=125) to 173 tumors. Propensity score analysis with inverse probability of treatment weighting was used to compare outcomes between treatments while adjusting for imbalances in treatment assignment. Local control (LC), toxicity, and overall survival (OS) were retrospectively analyzed.
The TACE and SBRT groups were similar with respect to the number of tumors treated per patient, underlying liver disease, and baseline liver function. Patients treated with SBRT were older (65 vs 61 years, P=.01), had smaller tumors (2.3 vs 2.9 cm, P<.001), and less frequently underwent liver transplantation (8% vs 18%, P=.01). The 1- and 2-year LC favored SBRT: 97% and 91%, respectively, for SBRT and 47% and 23% for TACE (hazard ratio 66.5, P<.001). For patients treated with TACE, higher alpha-fetoprotein (hazard ratio 1.11 per doubling, P=.008) and segmental portal vein thrombosis (hazard ratio 9.9, P<.001) were associated with worse LC. Predictors associated with LC after SBRT were not identified. Grade 3+ toxicity occurred after 13% and 8% of TACE and SBRT treatments, respectively (P=.05). There was no difference in OS between patients treated with TACE or SBRT.
Stereotactic body radiation therapy is a safe alternative to TACE for 1 to 2 tumors and provides better LC, with no observed difference in OS. Prospective comparative trials of TACE and SBRT are warranted.
Treatment of hypovascular tumors, such as pancreatic adenocarcinoma, is challenging owing to inefficient drug delivery. This report examines the potential mechanism of localized drug delivery via ...transarterial microperfusion (TAMP) using a proprietary adjustable double-balloon occlusion catheter in a porcine model.
Adult Yorkshire swine (N = 21) were used in the Institutional Animal Care & Use Committee–approved protocols. The RC-120 catheter (RenovoRx, Los Altos, California) was positioned into visceral, femoral, and pulmonary arteries with infusion of methylene blue dye, gemcitabine, or gold nanoparticles. Transmural delivery was compared under double-balloon occlusion with and without side-branch exclusion, single-balloon occlusion, and intravenous delivery. Intra-arterial pressure and vascular histologic changes were assessed.
Infusion with double-balloon occlusion and side-branch exclusion provided increased intra-arterial pressure in the isolated segment and enhanced perivascular infusate penetration with minimal vascular injury. Infusates were predominantly found in the vasa vasorum by electron microscopy.
TAMP enhanced transmural passage mediated by localized increase in arterial pressure via vasa vasorum.
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Each year approximately 8500 patients undergo liver transplantation in the USA for acute and chronic liver failure. Over the years, the success of liver transplantation has led to more clinical ...indications for liver transplantation. These expanded indications, without a proportionate increase in donors, result in increased competition for the limited pool of transplantable whole or partial grafts. The likelihood of receiving a deceased donor graft depends on many clinical variables, including the acute and chronic fitness of the candidate aligning with the timing of donor organ availability. Several types of patients are candidates for transplant: patients with acute fulminant hepatic failure who will die without a transplant, patients with decompensated cirrhosis, and patients with HCC and compensated cirrhosis. Interventional radiology can preserve equity between these subgroups and reduce patient dropout by increasing the physiologic and anatomic fitness of the candidate before and after formal listing. The primary determinants of candidacy fitness and dropout are the severity of clinical symptoms related to portal hypertension and the presence of hepatocellular cancer. There is a subgroup of patients whose disease severity is not accurately reflected by the Model for End-stage Liver Disease (MELD), such as patients with chronic cholestasis that also may benefit from IR management.
Abstract
Patients with acquired coagulopathy often require percutaneous image-guided invasive procedures for urgent control of hemorrhage or for elective procedures. Routine preprocedural evaluation ...of coagulopathy previously focused on absolute prothrombin time, partial thromboplastin time, international normalized ratio, and platelet count values. Now viscoelastic testing and greater understanding of patient- and drug-specific changes in coagulation profiles can yield better coagulation profile data. More specific reversal agents and profiles combine for less generalized and more titrated transfusion or correction algorithms. This article reviews procedural and patient-specific factors for defining both hemorrhagic risk and correction strategies.
To determine the feasibility of spleen stiffness measurement in the evaluation of portal hemodynamics in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) placement.
We ...prospectively correlated the spleen stiffness as measured by the shear wave velocity with the portal pressure and portosystemic gradient in patients undergoing TIPS procedures. Twenty-three consecutive patients referred for placement of a TIPS were enrolled. Included in our study were 19 patients in whom a spleen stiffness measurement was obtained before, immediately after, and 1 to 3 days after placement. Spleen stiffness was measured by calculating the Young modulus estimated from the shear wave velocity. A 2-tailed nonparametric Mann-Whitney U test was used to assess statistically significant differences in spleen stiffness measurement after TIPS placement, and regression analysis was used to correlate spleen stiffness measurement with portal pressure.
After TIPS placement, the spleen stiffness measurement increased, with a mean increase in the Young modulus ± SD of 6.54 ± 6.29 kPa in 42% of patients (8 of 19). In the remaining 58% (11 of 19), the spleens became softer after TIPS placement (Young modulus decreased by 9.57 ± 8.82 kPa). Eight patients, including 5 with concurrent embolization or thrombosis of competitive shunts, had increased spleen stiffness. The mean change in the median spleen stiffness before and after TIPS placement between the patients with and without competitive shunts was statistically significantly different (P < .04, nonparametric Mann-Whitney U test). There was no measurable correlation between spleen stiffness measurement and portal pressure before and after TIPS placement.
This study demonstrates the feasibility of a noninvasive spleen stiffness measurement, which could complement conventional sonography with additional functional information in patients undergoing TIPS procedures.
To evaluate the safety and efficacy of percutaneous nephrostomy (PCN) in pregnancy.
PCN tubes were placed during 52 pregnancies in 49 patients from 2008 to 2018. The medical records during ...pregnancies were retrospectively reviewed for imaging findings, procedural parameters, outcomes of delivery, and complications.
The mean gestational age on percutaneous nephrostomy placement was 27 weeks (range, 8–36 weeks). PCN catheters were placed for the following indications: 1) flank or lower abdominal pain (42%), 2) obstructing calculi (37%), 3) pyelonephritis (20%), and 4) obstructing endometrioma (2%). Prior to PCN, retrograde ureteric stenting was performed in 17 of 49 patients (34%) and attempted but failed in 4 patients (8%). Nephrostomy drainage relieved pain completely or significantly in all 12 patients without prior ureteral stenting, but in only 4 of 10 with retrograde ureteric stents. In one patient in whom the ureteral stent had been removed, PCN relieved her flank pain. The mean number of PCN catheter exchanges was 1.6, ranging from 0 to 9, with a mean time interval of 21.3 days between exchanges. There were 29 difficult exchanges due to encrustation in 15 patients with a mean of 20.5 days between exchanges.
PCN drainage is a safe and effective treatment for managing symptomatic hydronephrosis in pregnant patients but is less effective in treating pain when retrograde ureteral stents are in place. Rapid encrustation, seen more commonly in pregnancy, tends to recur in the same patients and requires more frequent exchanges than the general population.
•In pregnant patients, unique challenges during nephrostomy placement, include anesthesia, radiation dose, and catheter encrustation.•Nephrostomy drainage is safe and effective in pregnancy; however, it is unclear if pain management alone is effective.•Nephrostomy is less effective in treating hydronephrosis-related pain in patients with pre-existing ureteral stents.
Injury to the thoracic duct with resultant chylothorax can cause significant patient morbidity and mortality. Conservative treatment strategies often fail to address the problem. Open surgical and ...percutaneous approaches are often required to manage patients with refractory chylothorax. This review describes in detail the major role of minimally invasive interventional therapies for thoracic duct (TD) injury. The review emphasizes strategies for identifying the TD on preprocedural imaging and describes various techniques for percutaneous access to the TD. The advantages and disadvantages of several approaches for accessing the duct are discussed. The technique of duct embolization is highlighted. The role of the minimally invasive percutaneous approach over open surgical approaches is discussed with a review of clinical outcomes, as reported in the literature. This review will also briefly discuss the surgical approach to TD ligation.
Objectives
Three‐dimensional (3D)/4‐dimensional (4D) sonographic measurement of blood volume flow in transjugular intrahepatic porto systemic shunt revision with the intention of objective assessment ...of shunt patency.
Methods
A total of 17 patients were recruited (12 male and 5 female; mean age, 55 years; range, 30–69 years). An ultrasound system equipped with a 2.0–5.0‐MHz probe was used to acquire multivolume 3D/4D color Doppler data sets to assess prerevision and postrevision shunt volume flow. Volume flow was computed offline based on the principle of surface integration of Doppler‐measured velocity vectors in a lateral‐elevational c‐surface positioned at the color flow focal depth (range, 8.0–11.5 cm). Volume flow was compared to routine measurements of the prerevision and postrevision portosystemic pressure gradient. Prerevision volume flow was compared with the outcome to determine whether a flow threshold for revision could be defined.
Results
Linear regression of data from revised transjugular intrahepatic portosystemic shunt cases showed an inverse correlation between the mean‐normalized change in prerevision and postrevision shunt volume flow and the mean‐normalized change in the prerevision and postrevision portosystemic pressure gradient (r2 = 0.51; P = .020). Increased shunt blood flow corresponded to a decreased pressure gradient. Comparison of prerevision flows showed preliminary threshold development at 1534 mL/min, below which a shunt revision may be recommended (P = .21; area under the receiver operating characteristic curve = 0.78).
Conclusions
Shunt volume flow measurement with 3D/4D Doppler sonography provides a potential alternative to standard pulsed wave Doppler metrics as an indicator of shunt function and predictor of revision.
Objectives
To determine the feasibility of spleen stiffness measurement in the evaluation of portal hemodynamics in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) placement.
...Methods
We prospectively correlated the spleen stiffness as measured by the shear wave velocity with the portal pressure and portosystemic gradient in patients undergoing TIPS procedures. Twenty‐three consecutive patients referred for placement of a TIPS were enrolled. Included in our study were 19 patients in whom a spleen stiffness measurement was obtained before, immediately after, and 1 to 3 days after placement. Spleen stiffness was measured by calculating the Young modulus estimated from the shear wave velocity. A 2‐tailed nonparametric Mann‐Whitney U test was used to assess statistically significant differences in spleen stiffness measurement after TIPS placement, and regression analysis was used to correlate spleen stiffness measurement with portal pressure.
Results
After TIPS placement, the spleen stiffness measurement increased, with a mean increase in the Young modulus ± SD of 6.54 ± 6.29 kPa in 42% of patients (8 of 19). In the remaining 58% (11 of 19), the spleens became softer after TIPS placement (Young modulus decreased by 9.57 ± 8.82 kPa). Eight patients, including 5 with concurrent embolization or thrombosis of competitive shunts, had increased spleen stiffness. The mean change in the median spleen stiffness before and after TIPS placement between the patients with and without competitive shunts was statistically significantly different (P < .04, nonparametric Mann‐Whitney U test). There was no measurable correlation between spleen stiffness measurement and portal pressure before and after TIPS placement.
Conclusions
This study demonstrates the feasibility of a noninvasive spleen stiffness measurement, which could complement conventional sonography with additional functional information in patients undergoing TIPS procedures.
Purpose
In 90Y microsphere radioembolization (RE), accurate post‐therapy imaging‐based dosimetry is important for establishing absorbed dose versus outcome relationships for developing future ...treatment planning strategies. Additionally, accurately assessing microsphere distributions is important because of concerns for unexpected activity deposition outside the liver. Quantitative 90Y imaging by either SPECT or PET is challenging. In 90Y SPECT model based methods are necessary for scatter correction because energy window‐based methods are not feasible with the continuous bremsstrahlung energy spectrum. The objective of this work was to implement and evaluate a scatter estimation method for accurate 90Y bremsstrahlung SPECT/CT imaging.
Methods
Since a fully Monte Carlo (MC) approach to 90Y SPECT reconstruction is computationally very demanding, in the present study the scatter estimate generated by a MC simulator was combined with an analytical projector in the 3D OS‐EM reconstruction model. A single window (105 to 195‐keV) was used for both the acquisition and the projector modeling. A liver/lung torso phantom with intrahepatic lesions and low‐uptake extrahepatic objects was imaged to evaluate SPECT/CT reconstruction without and with scatter correction. Clinical application was demonstrated by applying the reconstruction approach to five patients treated with RE to determine lesion and normal liver activity concentrations using a (liver) relative calibration.
Results
There was convergence of the scatter estimate after just two updates, greatly reducing computational requirements. In the phantom study, compared with reconstruction without scatter correction, with MC scatter modeling there was substantial improvement in activity recovery in intrahepatic lesions (from > 55% to > 86%), normal liver (from 113% to 104%), and lungs (from 227% to 104%) with only a small degradation in noise (13% vs. 17%). Similarly, with scatter modeling contrast improved substantially both visually and in terms of a detectability index, which was especially relevant for the low uptake extrahepatic objects. The trends observed for the phantom were also seen in the patient studies where lesion activity concentrations and lesion‐to‐liver concentration ratios were lower for SPECT without scatter correction compared with reconstruction with just two MC scatter updates: in eleven lesions the mean uptake was 4.9 vs. 7.1 MBq/mL (P = 0.0547), the mean normal liver uptake was 1.6 vs. 1.5 MBq/mL (P = 0.056) and the mean lesion‐to‐liver uptake ratio was 2.7 vs. 4.3 (P = 0.0402) for reconstruction without and with scatter correction respectively.
Conclusions
Quantitative accuracy of 90Y bremsstrahlung imaging can be substantially improved with MC scatter modeling without significant degradation in image noise or intensive computational requirements.
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