There have been major advances in the armamentarium for hepatocellular carcinoma (HCC) since the last official update of the Barcelona Clinic Liver Cancer prognosis and treatment strategy published ...in 2018. Whilst there have been advances in all areas, we will focus on those that have led to a change in strategy and we will discuss why, despite being encouraging, data for select interventions are still too immature for them to be incorporated into an evidence-based model for clinicians and researchers. Finally, we describe the critical insight and expert knowledge that are required to make clinical decisions for individual patients, considering all of the parameters that must be considered to deliver personalised clinical management.
Purpose
To study the correlation between absorbed perfused liver dose using Y90 radioembolization and degree of hepatocellular carcinoma (HCC) necrosis in liver explants in a multicenter cohort ...analysis
Methods
A retrospective analysis of 45 HCC patients treated between 2014 and 2017 is presented. Inclusion criteria were treatment-naïve solitary HCC ≤ 8 cm and Child-Pugh A liver status using the radiation segmentectomy approach. All patients underwent liver resection or transplantation (LT). Liver explants were examined per institutional routine protocols to assess histopathological viability of HCC. Tumor pathological necrosis was classified into complete (100% necrosis), extensive (> 50% and ≤ 99%) necrosis, and partial (< 50%) necrosis. Absorbed perfused liver doses were estimated using MIRD calculations. Associations between dose and degree of necrosis were studied.
Results
Thirty-four (76%) patients underwent LT, and 11 (24%) patients underwent hepatic resection. Median radiation dose was 240 (IQR: 136–387) Gy. Thirty (67%) patients had complete pathologic necrosis (CPN) at explant, while 10 (22%) and 5 (11%) had extensive and partial necrosis, respectively. There were significant differences among perfused liver doses that exhibited partial, extensive, and complete necrosis (
p
= 0.001). Twenty-four out of twenty-eight (86%) patients who had dose > 190 Gy achieved CPN, while 11/17 (65%) who had < 190 Gy did not (Fisher’s exact test;
p
= 0.001). Using binary logistic regression, only absorbed radiation dose was significantly associated with CPN (
p
= 0.01), while tumor size was not (
p
= 0.35). All patients receiving > 400 Gy exhibited CPN.
Conclusion
Radiation segmentectomy for early HCC with ablative dosing > 400 Gy results in CPN. This represents the new standard target dose for radiation segmentectomy.
Purpose
To report a comparative systematic review and meta-analysis of prostatic artery embolization (PAE) and transurethral resection of the prostate (TURP) for the management of benign prostatic ...hyperplasia (BPH).
Materials and Methods
A multi-database search for relevant literature was conducted on 15 July 2020 to include studies published on or before that date. Search terms used were: (prostate embolization OR prostatic embolization OR prostate embolization OR prostatic embolization) AND (prostatic hyperplasia OR prostatic obstruction). Risk of bias was assessed using Cochrane Collaboration and ROBINS-I criteria. Random-effects meta-analysis was performed using RevMan 5.3.
Results
Six studies with 598 patients were included. TURP was associated with significantly more improvement in maximum urinary flow rate (
Q
max
) (mean difference = 5.02 mL/s; 95% CI 2.66,7.38;
p
< 0.0001;
I
2
= 89%), prostate volume (mean difference = 15.59 mL; 95% CI 7.93,23.25;
p
< 0.00001;
I
2
= 88%), and prostate-specific antigen (PSA) (mean difference = 1.02 ng/mL; 95% CI 0.14,1.89;
p
= 0.02;
I
2
= 71%) compared to PAE. No significant difference between PAE and TURP was observed for changes in International Prostate Symptoms Score (IPSS), IPSS quality of life (IPSS-QoL), International Index of Erectile Function (IIEF-5), and post-void residual (PVR). PAE was associated with fewer adverse events (AEs) (39.0% vs. 77.7%;
p
< 0.00001) and shorter hospitalization times (mean difference = −1.94 days;
p
< 0.00001), but longer procedural times (mean difference = 51.43 min;
p
= 0.004).
Conclusion
Subjective symptom improvement was equivalent between TURP and PAE. While TURP demonstrated larger improvements for some objective parameters, PAE was associated with fewer AEs and shorter hospitalization times.
Level of Evidence II
Level 2a, Systematic Review
Objective
To describe the technique and outcomes of mesenteric access under ultrasound guidance to perform portal vein recanalization–transjugular intrahepatic portosystemic shunt (PVR-TIPS).
Methods
...Four patients (3 male: 1 female, mean age: 46.2 years; range 38–64 years) with portal vein thrombosis (PVT) and cavernous transformation were eligible for PVR-TIPS. Due to inaccessible splenic vein (one patient with history of splenectomy and 3 patients with unavailable splenic vein during the procedure), noninvasive direct puncture of superior (
n
= 3) and inferior (
n
= 1) mesenteric vein was conducted under ultrasound guidance to obtain access for PVR-TIPS.
Results
Trans-mesenteric access and PVR-TIPS were successful in all patients at first attempt. No immediate complication was observed following the procedures. Follow-up imaging with computed tomography (CT) scan and Doppler ultrasound revealed patent TIPS and portal venous vasculature in all patients.
Conclusion
Percutaneous noninvasive transmesenteric access is a feasible approach for PVR-TIPS in patients with inaccessible splenic veins.
Level of evidence IV
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors
www.springer.com/00266
.
Budd-Chiari syndrome and non-cirrhotic non-tumoral portal vein thrombosis are 2 rare disorders, with several similarities that are categorized under the term splanchnic vein thrombosis. Both ...disorders are frequently associated with an underlying prothrombotic disorder. They can cause severe portal hypertension and usually affect young patients, negatively influencing life expectancy when the diagnosis and treatment are not performed at an early stage. Yet, they have specific features that require individual consideration. The current review will focus on the available knowledge on pathophysiology, diagnosis and management of both entities.
Purpose
A multidisciplinary expert panel convened to formulate state-of-the-art recommendations for optimisation of selective internal radiation therapy (SIRT) with yttrium-90 (
90
Y)-resin ...microspheres.
Methods
A steering committee of 23 international experts representing all participating specialties formulated recommendations for SIRT with
90
Y-resin microspheres activity prescription and post-treatment dosimetry, based on literature searches and the responses to a 61-question survey that was completed by 43 leading experts (including the steering committee members). The survey was validated by the steering committee and completed anonymously. In a face-to-face meeting, the results of the survey were presented and discussed. Recommendations were derived and level of agreement defined (strong agreement ≥ 80%, moderate agreement 50%–79%, no agreement ≤ 49%).
Results
Forty-seven recommendations were established, including guidance such as a multidisciplinary team should define treatment strategy and therapeutic intent (strong agreement); 3D imaging with CT and an angiography with cone-beam-CT, if available, and
99m
Tc-MAA SPECT/CT are recommended for extrahepatic/intrahepatic deposition assessment, treatment field definition and calculation of the
90
Y-resin microspheres activity needed (moderate/strong agreement). A personalised approach, using dosimetry (partition model and/or voxel-based) is recommended for activity prescription, when either whole liver or selective, non-ablative or ablative SIRT is planned (strong agreement). A mean absorbed dose to non-tumoural liver of 40 Gy or less is considered safe (strong agreement). A minimum mean target-absorbed dose to tumour of 100–120 Gy is recommended for hepatocellular carcinoma, liver metastatic colorectal cancer and cholangiocarcinoma (moderate/strong agreement). Post-SIRT imaging for treatment verification with
90
Y-PET/CT is recommended (strong agreement). Post-SIRT dosimetry is also recommended (strong agreement).
Conclusion
Practitioners are encouraged to work towards adoption of these recommendations.
Transcatheter intraarterial therapies have proved valuable in the battle against primary and secondary hepatic malignancies. The unique aspects of all such therapies are their reduced toxicity ...profiles and highly effective tumor responses. These unique characteristics coupled with their minimally invasive nature provide an attractive therapeutic option in patients who may have previously had few alternatives. The concept of all catheter-based intraarterial therapies is to selectively deliver anticancer treatment to tumor(s). These therapies, which include transarterial embolization, intraarterial chemoinfusion, transarterial chemoembolization with or without drug-eluting beads, and radioembolization with use of yttrium 90, inflict lethal insult to tumors while preserving normal hepatic parenchyma. This is possible because hepatic neoplasms preferentially derive their blood supply from an arterial source while the majority of noncancerous liver is supplied by the portal vein. As part of the interventional oncology review series, in this article we describe the rationale behind each of these transcatheter therapies and provide a review of the existing medical literature.
Image-guided tumor ablation has become a well-established hallmark of local cancer therapy. The breadth of options available in this growing field increases the need for standardization of ...terminology and reporting criteria to facilitate effective communication of ideas and appropriate comparison among treatments that use different technologies, such as chemical (eg, ethanol or acetic acid) ablation, thermal therapies (eg, radiofrequency, laser, microwave, focused ultrasound, and cryoablation) and newer ablative modalities such as irreversible electroporation. This updated consensus document provides a framework that will facilitate the clearest communication among investigators regarding ablative technologies. An appropriate vehicle is proposed for reporting the various aspects of image-guided ablation therapy including classification of therapies, procedure terms, descriptors of imaging guidance, and terminology for imaging and pathologic findings. Methods are addressed for standardizing reporting of technique, follow-up, complications, and clinical results. As noted in the original document from 2003, adherence to the recommendations will improve the precision of communications in this field, leading to more accurate comparison of technologies and results, and ultimately to improved patient outcomes. Online supplemental material is available for this article .
Summary Many management strategies exist for neuroendocrine liver metastases. These strategies range from surgery to ablation with various interventional radiology procedures, and include both ...regional and systemic therapy with diverse biological, cytotoxic, or targeted agents. A paucity of biological, molecular, and genomic information and an absence of data from rigorous trials limit the validity of many publications detailing management. This Review represents the views from an international conference, for which 15 expert working groups prepared evidence-based assessments addressing specific questions, and from which an independent jury derived final recommendations. The aim of the conference was to review the existing approaches to neuroendocrine liver metastases, assess the evidence on which management decisions were based, develop internationally acceptable recommendations for clinical practice (when evidence was available), and make recommendations for clinical and research endeavours. This report represents the final clinical statements and proposals for future research.
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