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Purpose: To identify common gene mutations in patients with neuroendocrine liver metastases (NLM) undergoing transarterial embolization (TAE) and establish relationship between these mutations and response to TAE., Materials and Methods: Patients (n = 51; mean age 61 y; 29 men, 22 women) with NLMs who underwent TAE and had available mutation analysis were identified. Mutation status and clinical variables were recorded and evaluated in relation to hepatic progression-free survival (HPFS) (Cox proportional hazards) and time to hepatic progression (TTHP) (competing risk proportional hazards). Subgroup analysis of patients with pancreatic NLM was performed using Fisher exact test to identify correlation between mutation and event (hepatic progression or death) by 6 months. Changes in mutation status over time and across specimens in a subset of patients were recorded., Results: Technical success of TAE was 100%. Common mutations identified were MEN1 (16/51; 31%) and DAXX (13/51; 25%). Median overall survival was 48.7 months. DAXX mutation status (hazard ratio = 6.21; 95% confidence interval [CI], 2.67-14.48; P < .001) and tumor grade (hazard ratio = 3.05; 95% CI, 1.80-5.17; P < .001) were associated with shorter HPFS and TTHP on univariate and multivariate analysis. Median HPFS was 3.6 months (95% CI, 1.7-5.3) for patients with DAXX mutation compared with 8.9 months (95% CI, 6.6-11.4) for patients with DAXX wild-type status. In patients with pancreatic NLMs, DAXX mutation status was associated with hepatic progression or death by 6 months (P = .024). DAXX mutation status was concordant between primary and metastatic sites., Conclusions: DAXX mutation is common in patients with pancreatic NLMs. DAXX mutation status is associated with shorter HPFS and TTHP after TAE., (Copyright © 2018 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe imaging response and survival after radioembolization for metastatic breast cancer and to delineate genetic predictors of imaging responses and outcomes., Materials and Methods: This retrospective study included 31 women (average age, 52 y) with liver metastasis from invasive ductal carcinoma who underwent resin and glass radioembolization (average cumulative dose, 2.0 GBq ± 1.8) between January 2011 and September 2017 after receiving ≥ 3 lines of chemotherapy. Twenty-four underwent genetic profiling with MSK-IMPACT or Sequenom; 26 had positron-emission tomography (PET)/CT imaging before and after treatment. Survival after the first radioembolization and 2-4-month PET/CT imaging response were assessed. Laboratory and imaging features were assessed to determine variables predictive of outcomes. Unpaired Student t tests and Fisher exact tests were used to compare responders and nonresponders categorized by changes in fluorodeoxyglucose avidity. Kaplan-Meier survival analysis was used to determine the impact of predictors on survival after radioembolization., Results: Median survival after radioembolization was 11 months (range, 1-49 mo). Most patients (18 of 26; 69%) had complete or partial response based on changes in fluorodeoxyglucose avidity. Imaging response was associated with longer survival (P = .005). Whereas 100% of patients with PI3K pathway mutations showed an imaging response, only 45% of wild-type patients showed a response (P = .01). Median survival did not differ between PI3K pathway wild-type (10.9 mo) and mutant (undefined) patients (P = .50)., Conclusions: These preliminary data suggest that genomic profiling may predict which patients with metastatic breast cancer benefit most from radioembolization. PI3K pathway mutations are associated with improved imaging response, which is associated with longer survival., (Copyright © 2018 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the safety and efficacy of percutaneous peritoneovenous shunt (PPVS) placement in treating intractable chylous ascites (CA) in patients with cancer., Materials and Methods: Data from 28 patients with refractory CA treated with PPVS from April 2001 to June 2015 were reviewed. Demographic characteristics, technical success, efficacy, laboratory values, and complications were recorded. Univariate and multivariate logistic regression analysis was performed., Results: Technical success was 100%, and ascites resolved or symptoms were relieved in 92.3% (26 of 28) of patients. In 13 (46%) patients with urologic malignancies, whose ascites had resulted from retroperitoneal lymph node dissection, the ascites resolved, resulting in shunt removal within 128 days ± 84. The shunt provided palliation of symptoms in 13 of the remaining 15 patients (87%) for a mean duration of 198 days ± 214. Serum albumin levels increased significantly (21.4%) after PPVS placement from a mean of 2.98 g/dL ± 0.64 before the procedure to 3.62 g/dL ± 0.83 (P < .001). The complication rate was 37%, including shunt malfunction/occlusion (22%), venous thrombosis (7%), and subclinical disseminated intravascular coagulopathy (DIC) (7%). Smaller venous limb size (11.5 F) and the presence of peritoneal tumor were associated with a higher rate of shunt malfunction (P < .05). No patient developed overt DIC., Conclusions: PPVS can safely and effectively treat CA in patients with cancer, resulting in significant improvement in serum albumin in addition to palliation of symptoms., (Copyright © 2016 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: To identify factors affecting periprocedural morbidity and mortality and long-term survival following hepatic artery embolization (HAE) of hepatic neuroendocrine tumor (NET) metastases., Materials and Methods: This single-center, institutional review board-approved retrospective review included 320 consecutive HAEs for NET metastases performed in 137 patients between September 1996 and September 2007. Forty-seven HAEs (15%) were performed urgently to manage refractory symptoms in inpatients (urgent group), and 273 HAEs (85%) were elective (elective group). Overall survival (OS) was estimated by Kaplan-Meier methodology. Complications were categorized per Common Terminology Criteria for Adverse Events, version 4.0. Univariate and multivariate analyses were performed to determine independent predictors for OS, complications, and 30-day mortality. The independent factors were combined to develop clinical risk score groups., Results: Urgent HAE (P = .007), greater than 50% liver replacement by tumor (P < .0001), and extrahepatic metastasis (P = .007) were independent predictors for shorter OS. Patients with all three risk factors had decreased OS versus those with none (median, 8.5 vs 86 mo; P < .001). Thirty-day mortality was significantly lower in the elective (1%) versus the urgent group (8.5%; P = .0009). There were eight complications (3%) in the elective group and five (10.6%) in the urgent group (P = .03). Male sex and urgent group were independent factors for higher 30-day mortality rate (P = .023 and P =.016, respectively) and complications (P = .012 and P =.001, respectively)., Conclusions: Urgent HAE, replacement of more than 50% of liver by tumor, and extrahepatic metastasis are strong independent predictors of shorter OS. Male sex and urgent HAE carry higher 30-day mortality and periprocedural morbidity risks., (© 2013 Published by SIR on behalf of The Society of Interventional Radiology.)

Purpose: To identify changes in plasma cytokine levels after image-guided thermal ablation of human tumors and to identify the factors that independently predict changes in plasma cytokine levels., Materials and Methods: Whole-blood samples were collected from 36 patients at three time points: before ablation, after ablation (within 48 hours), and at follow-up (1-5 weeks after ablation). Plasma levels of interleukin (IL)-1α, IL-2, IL-6, IL-10, and tumor necrosis factor (TNF)-α were measured using a multiplex immunoassay. Univariate and multivariate analyses were performed using cytokine level as the dependent variable and sample collection, time, age, sex, primary diagnosis, metastatic status, ablation site, and ablation type as the independent variables., Results: There was a significant increase in the plasma level of IL-6 after ablation compared with before ablation (9.6-fold ± 31-fold, P<.002). IL-10 also showed a significant increase after ablation (1.9-fold ± 2.8-fold, P<.02). Plasma levels of IL-1α, IL-2, and TNF-α were not significantly changed after ablation. Cryoablation resulted in the largest change in IL-6 level (>54-fold), whereas radiofrequency ablation and microwave ablation showed 3.6-fold and 3.4-fold changes, respectively. Ablation of melanomas showed the largest change in IL-6 48 hours after ablation (92×), followed by ablation of kidney (26×), liver (8×), and lung (6×) cancers. Multivariate analysis revealed that ablation type (P<.0003) and primary diagnosis (P<.03) were independent predictors of changes to IL-6 after ablation. Age was the only independent predictor of IL-10 levels after ablation (P< .019)., Conclusions: Image-guided thermal ablation of tumors increases plasma levels of IL-6 and IL-10, without increasing plasma levels of IL-1α, IL-2, or TNF-α., (Copyright © 2013 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the rate of early infection for totally implantable venous access devices (TIVADs) placed without antibiotic prophylaxis., Material and Methods: A list of patients who underwent TIVAD placement in 2009 was obtained from the patient archiving and communication system (PACS). This list was cross-referenced to all patients who underwent TIVAD removal from January 1, 2009, through January 30, 2010, to identify TIVADs that were removed within 30 days of placement. Retrospective chart review was performed to record patient demographics, including age, sex, cancer diagnosis, and indication for removal. Concurrent antibiotic therapy, chemotherapy, and laboratory data before and within 30 days of placement were recorded. Central line-associated bloodstream infections (CLABSIs) were identified using U.S. Centers for Disease Control and Prevention (CDC) criteria., Results: There were 1,183 ports placed and 13 removed. CLABSIs occurred in seven (0.6%) patients within 30 days of placement. At the time of TIVAD placement, 81 (7%) patients were receiving antibiotics incidental to the procedure. One patient who received an antibiotic the day of implantation developed a CLABSI. Chemotherapy was administered to 148 (13%) patients on the day of placement., Conclusions: The rate of early infection without antibiotic prophylaxis before TIVAD placement in the interventional radiology suite is < 1%. Based on these data, use of prophylactic antibiotics for TIVAD placement is not recommended., (Copyright © 2012 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe outcomes in patients undergoing percutaneous biliary drainage to reduce total serum bilirubin level for administration of chemotherapy., Materials and Methods: A total of 647 consecutive patients underwent percutaneous biliary drainage between September 2001 and December 2008. In 168, the indication for biliary drainage was to decrease total serum bilirubin level to permit administration of chemotherapy. Of these, 20 were excluded because they had hepatic arterial infusion pumps, leaving 148 patients as the study group. The primary diagnoses for these patients were gallbladder cancer (n = 23), cholangiocarcinoma (n = 21), pancreatic cancer (n = 36), and other metastatic cancers (n = 68). Medical records and imaging studies were reviewed for demographic data, procedural information, pre- and postdrainage total serum bilirubin level levels, 30-day complications, and subsequent biliary procedures., Results: The probability of attaining a total serum bilirubin level of 1 mg/dL or lower by 100 days was 31% (95% CI, 23%-39%). Predrainage total serum bilirubin level of 9 mg/dL or lower (hazard ratio [HR], 3.27; 95% CI, 1.86-5.75; P < .001), 100% liver drainage (HR 2.73, 95% CI, 1.56-4.78; P <.001), and lower predrainage International Normalized Ratio (INR; HR, 0.80; 95% CI, 0.70-0.92; P = .002) were associated with an increased likelihood of attaining a total serum bilirubin level of 1 mg/dL or lower. The most common indication for follow-up was pericatheter leakage, which occurred in nearly one third of cases. During follow-up, patients required three visits per 100 catheter-days, or approximately one per month. Median overall survival in this population was approximately 3.5 months., Conclusions: Only 31% of patients attained a normal serum bilirubin level by 100 days, and median overall survival was 107 days. Careful patient selection is warranted before biliary drainage for this indication. Maximal biliary drainage, a preprocedure total serum bilirubin of less than 9 mg/dL, and a lower INR were factors associated with serum bilirubin normalization in this cohort., (Copyright © 2012 SIR. Published by Elsevier Inc. All rights reserved.)

The study presents preliminary, retrospective experience with bland embolization for hepatic adenomas (HAs) with the use of tris-acryl gelatin microspheres. Eight patients underwent bland embolization for biopsy-proven HAs. A biopsy specimen was taken from only one lesion when multiple lesions were present. Seventeen embolizations were performed for abdominal pain, active bleeding, or prophylaxis against bleeding. Five patients underwent multiple procedures. Technical success rate was 100%. Median follow-up was 24 months (range, 10-40 mo). No growth was observed at follow-up in any treated lesion, and many lesions (13 of 16) regressed. Bland embolization may be safely used for treatment of abdominal pain and bleeding from HAs., (Copyright © 2011 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the clinical outcomes of percutaneous radiofrequency (RF) ablation of colorectal cancer liver metastases (CLMs) that recur after hepatectomy., Materials and Methods: From December 2002 to December 2008, 71 CLMs that developed after hepatectomy were ablated in 56 patients. Medical records and imaging were reviewed to determine technique effectiveness/complete ablation (ie, ablation defect covering the entire tumor on 4-6-week postablation computed tomography [CT]), complications, and local tumor progression (LTP) at the site of ablation. LTP-free and overall survival were calculated by using Kaplan-Meier methodology. A modified clinical risk score (CRS) including nodal status of the primary tumor, time interval between diagnoses of the primary tumor and liver metastases, number of tumors, and size of the largest tumor was assessed for its effect on overall survival and LTP., Results: Tumor size ranged between 0.5 and 5.7 cm. Complete ablation was documented in 67 of 71 cases (94%). Complications included liver abscess (n = 1) and pleural effusion (n = 1). Median overall survival time was 31 months. One-, 2- and 3-year overall survival rates were 91%, 66%, and 41%, respectively. CRS was an independent factor for overall survival (74% for CRS of 0-2 vs 42% for CRS of 3-4 at 2 y; P = .03) and for LTP-free survival (66% for CRS of 0-2 vs 22% for CRS of 3-4 at 1 y after a single ablation; P <.01)., Conclusions: CT-guided RF ablation can be used to treat recurrent CLM after hepatectomy. A low CRS is associated with better clinical outcomes., (Copyright © 2011 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the survival of patients with hepatocellular carcinoma (HCC) treated with a standardized method of transcatheter arterial embolization (TAE) with small embolic particles intended to impart terminal vessel blockade, and to evaluate prognostic factors that impact overall survival., Materials and Methods: A total of 322 patients with HCC who underwent 766 embolizations from January 1997 to December 2004 were retrospectively reviewed. Selective embolization of vessels feeding individual tumors was performed with small (50 microm) polyvinyl alcohol or spherical embolic particles (40-120 microm) intended to cause terminal vessel blockade. Repeat embolization was performed in cases of evidence of persistent viable tumor or development of new lesions. Patient, tumor, and treatment characteristics were prospectively recorded and tested for prognostic significance by univariate and multivariate analysis., Results: The median survival time was 21 months, with 1-, 2-, and 3-year overall survival rates of 66%, 46%, and 33%, respectively. In patients without extrahepatic disease or portal vein involvement by tumor, the overall 1-, 2-, and 3-year survival rates increased to 84%, 66%, and 51%, respectively. Okuda stage, extrahepatic disease, diffuse disease (> or =5 tumors), and tumor size were independent predictors of survival on multivariate analysis. There were 90 complications (11.9%) in 75 patients, including eight deaths (2.5%), within 30 days of embolization., Conclusions: Hepatic arterial embolization with small particles to cause terminal vessel blockade is an effective treatment method for patients with unresectable HCC. These data support our hypothesis that particles alone may be the critical component of catheter-directed embolotherapy.

Purpose: To identify the etiology of inferior epigastric artery injury (IEAI) in patients referred to the interventional radiology service and determine the efficacy of diagnostic imaging and embolization in these patients., Materials and Methods: A retrospective review of patients referred to the interventional radiology departments at three university-affiliated hospitals from 1995 through 2007 was performed. Patients were identified and data were extracted from case log books and the electronic medical record., Results: Twenty IEAIs were identified in 19 patients. The etiology of arterial injury was paracentesis in eight (40%), surgical trauma in three (15%), percutaneous drain placement in three (15%), blunt trauma in two (10%), subcutaneous injection in one (5%), stabbing in one (5%), and unknown in two (10%). Fifteen of 19 patients (79%) had an underlying coagulopathy. The diagnosis was confirmed by contrast medium-enhanced computed tomography (CT) in 14 (70%), tagged red blood cell scan in two (10%), and noncontrast CT in one (5%). Three patients (15%) had no diagnostic imaging. Contrast medium-enhanced CT showed active extravasation in nine of 14 patients (64%) and 13 of 14 exhibited active extravasation on subsequent arteriography. The sensitivity and specificity of contrast medium-enhanced CT for demonstrating active arterial bleeding were 70% and 100%, respectively. All 20 IEAIs were treated with transcatheter embolization, with an overall success rate of 90% and no complications., Conclusions: IEAI is most often an iatrogenic injury in a coagulopathic patient. Contrast medium-enhanced CT can be diagnostic for active bleeding, but in the setting of ongoing hemorrhage a negative study result should not preclude arteriography. Embolization is an effective means to control hemorrhage.

Purpose: Hepatic artery infusion pumps (HAIPs) ideally provide for homogenous perfusion of the liver with chemotherapeutic agents. Perfusion of extrahepatic organs or asymmetric liver perfusion (ie, "misperfusion") is diagnosed by nuclear scintigraphy and precludes the use of HAIPs. The purpose of this study is to report experience in salvaging HAIPs with arterial embolization., Materials and Methods: A single-center HAIP database was retrospectively reviewed for cases from 1999 to 2005 to identify patients who underwent angiography to treat misperfusion documented by nuclear scintigraphy. Patient demographics, nuclear scintigraphic findings before and after embolization, angiographic findings, embolization variables, and outcomes were recorded. Technical success (defined by cessation of flow to the vessel responsible for misperfusion) and clinical success (ie, successful use of the pump) were calculated., Results: During the study period, 475 HAIPs were implanted. Of those, 43 (9%) had abnormal nuclear scintigraphic findings of misperfusion, but only 32 (7%) had angiographic abnormalities. In eight of 32 cases, hepatic arterial thrombosis and extravasation at the catheter tip were found, which precluded salvage by embolization. In 24 of 32 cases, a vessel presumed responsible for the misperfusion was identified and targeted for embolization. Technical success and clinical success were achieved in 21 of 24 patients (87.5%) and 19 of 24 patients (79%), respectively, who underwent 27 embolization procedures. The three technical failures (12.5%) were the result of inability to catheterize the identified vessel., Conclusions: Percutaneous arterial embolization of a vessel to correct misperfusion shown by nuclear scintigraphy is safe and effective. This approach can be expected to result in HAIP salvage in the majority of patients.

Purpose: The vast majority of hepatocellular carcinomas (HCC) occur in patients with underlying liver dysfunction, making surgical resection available to only a subset of patients with adequate hepatic reserve. This study analyzes the authors' results with bland arterial embolization combined with radiofrequency ablation (RFA) or percutaneous ethanol injection (PEIT) compared with surgical resection for the treatment of solitary HCC up to 7 cm in size., Materials and Methods: A retrospective review of all patients undergoing either surgical resection or bland embolization combined with local ablation for solitary HCC between January 1996 and August 2002 was performed. Progression-free survival rate and overall survival rate were calculated by the Kaplan-Meier method., Results: There were 40 patients who underwent surgical resection and 33 patients who underwent embolization and ablation. Age, gender, and size of the treated lesion were not significantly different between the groups. The embolization/ablation group had more patients classified as Okuda stage II (P<.001). The surgical group had a longer median recurrence-free survival rate (53.1 vs 25.1 months). With a median follow-up of 23 months, the 1-, 3- and 5-year actuarial overall survival rates were 97%, 77%, and 56% for the embolization/ablation group and 81%, 70%, and 58% for the surgical group, respectively. There was no statistical difference in overall survival rates (P=.20)., Conclusions: Bland arterial embolization in combination with ablation is effective in treating solitary HCC lesions up to 7 cm and achieves similar overall survival rates to surgical resection in selected patients.

Purpose: To evaluate the safety and efficacy of direct computed tomography (CT)-guided fine needle aspiration biopsy (FNAB) of pancreatic and peripancreatic masses via a posterior approach that traverses the inferior vena cava (IVC) or renal vein., Materials and Methods: From January 2000 to July 2003, 55 patients underwent 58 biopsies of masses located within the pancreas (n = 28) or in a peripancreatic location (n = 30) with use of a posterior approach that crossed the IVC or renal vein. Biopsies were performed with needles ranging in size from 18 to 22. Cytology reports and medical records of all patients were retrospectively reviewed to evaluate diagnostic accuracy and complication rates., Results: Masses were safely accessed with a direct (noncoaxial) pathway traversing the IVC (n = 54), renal vein (n = 4), or both (n = 3). Overall diagnostic accuracy was 86% (50 of 58). Cytologic examination was positive for malignancy in 39 of 58 biopsies (67%). Benign lesions were demonstrated in 12 of 58 biopsies. In seven cases (12%), the sample was deemed nondiagnostic. Of those, four were diagnosed later by endoscopy (n = 1), surgical biopsy (n = 2), or repeat FNAB (n = 1). A false-negative result was noted in one case, which was later diagnosed by repeat biopsy. A total of four inadvertent passes through the right renal artery were recorded. CT evidence of perilesional blood was seen in eight of 55 patients (eight of 58 cases). Three of these occurred after a passage via the right renal artery. All patients remained asymptomatic, and no transfusion or change in management was necessary. No other complications occurred., Conclusion: CT-guided noncoaxial FNAB with an approach that traverses the IVC or renal vein is safe and effective in obtaining diagnostic specimens from pancreatic and peripancreatic masses.

The authors to describe the technique and report the results of percutaneous displacement of endoscopically placed plastic biliary endoprostheses into the duodenum at the time of transhepatic intervention in 34 patients. Displacement into the duodenum was effected by simply passing a guide wire through the stent, and then pushing it into the gut with a catheter. Thirty-three of 36 stents (92%) were successfully displaced in this manner. No complications related to stent passage out of the gastrointestinal tract were encountered. Plastic biliary stents can be safely displaced into the duodenum when patients undergo transhepatic biliary procedures, thus avoiding repeated endoscopy.

Purpose: To describe patient- and procedure-related factors associated with post-biopsy pneumothorax and those that require intervention., Materials and Methods: Patient and procedure data from all lung biopsies performed at a single center between January 2000 and July 2001 were recorded prospectively. Data included patient demographics, lesion size, lesion depth from skin, needle size, number of passes, patient position during biopsy, imaging method used (computed tomography/fluoroscopy), if sedation was used, occurrence of pneumothorax and whether the pneumothorax required treatment. Patient charts were retrospectively reviewed to determine smoking history, as well as previous ipsilateral chest surgery or radiation therapy. Univariate and multivariate analysis was performed, and P <.05 was considered significant., Results: Four-hundred fifty-three biopsies were performed on 443 patients. One-hundred six patients (23.4%) had post-biopsy pneumothorax and 31 patients (6.8% overall, 29.2% of pneumothorax group) required intervention. By univariate analysis, increased patient age, smaller lesion size, increased depth from skin, supine position, and no history of surgery were significant predictors of biopsy-related pneumothorax. However, only increased patient age, supine position, no history of ipsilateral surgery, and history of smoking were associated with pneumothorax that required intervention. By multivariate analysis, increased patient age, smaller lesion size, and no history of surgery predicted pneumothorax; supine position, history of smoking, and no history of ipsilateral surgery predicted which patients with pneumothorax would require treatment., Conclusion: Independent risk factors for pneumothorax include increased patient age, smaller lesion size, and no history of surgery. Previous surgery and prone positioning during biopsy appear to provide a "protective effect" against clinically significant post-biopsy pneumothorax.

Without scientific evidence, practice has been to avoid placing chest wall ports ipsilateral to axillary lymph node dissection. Because the lymphatic system in the chest wall drains via both the internal mammary and axillary nodes, it seems that this practice might unduly restrict venous access options. Our study was designed to evaluate outcome after placement of chest wall ports ipsilateral to axillary lymph node dissection in patients with breast cancer. Twenty-eight patients were studied in this retrospective two-institution review. The incidence of lymphedema after port placement (3.6%) was no higher than that reported after axillary lymph node dissection alone.