Search

Background In patients with primary colorectal cancer (CRC) or unresectable metastatic CRC, midgut embryonic origin is associated with worse prognosis. The impact of embryonic origin on survival after ablation of colorectal liver metastases (CLM) is unclear. Methods We identified 74 patients with CLM who underwent percutaneous ablation during 2004–2015. Survival and recurrence after ablation of CLM from midgut origin (n = 18) and hindgut origin (n = 56) were analyzed. Prognostic value of embryonic origin was evaluated. Results Recurrence-free survival (RFS) and overall survival (OS) after percutaneous ablation were worse in patients from midgut origin (3-year RFS: 5.6% vs. 24%, P = 0.004; 3-year OS: 25% vs. 70%, P 0.001). In multivariable analysis, factors associated with worse OS were midgut origin (hazard ratio [HR] 4.87, 95% CI 2.14–10.9, P 0.001), multiple CLM (HR 2.35, 95% CI 1.02–5.39, P = 0.044), and RAS mutation (HR 2.78, 95% CI 1.25–6.36, P = 0.013). At a median follow-up of 25 months, 56 patients (76%) had developed recurrence, 16 (89%) with midgut origin and 40 (71%) with hindgut origin ( P = 0.133). Recurrent disease was treated with local therapy in 20 patients (36%), 2 (13%) with midgut origin and 18 (45%) with hindgut origin ( P = 0.022). Conclusion Compared to CLM from hindgut origin tumors, CLM from midgut origin tumors were associated with worse survival after ablation, which was partly attributable to the fact that patients with hindgut origin were more frequently candidates for local therapy at recurrence. [ABSTRACT FROM AUTHOR]

Purpose: To assess the impact of a novel balloon occlusion technique on time and dose metrics during Y90 radioembolization (Y90 RE) Materials and Methods: Prior to July 2011, Y90 RE was performed following standard coil embolization of all hepatoenteric collaterals. After July 2011, a technique was introduced whereby a temporary occlusion balloon was inflated in the common hepatic artery, resulting in hepatopedal flow in hepatoenteric collaterals, eliminating the need for coil embolization. A retrospective review of sequential patients who underwent Y90 RE before and after the introduction of the balloon occlusion technique was performed. Data were gathered from the radiology information system and the electronic medical record. Only patients with Michel’s classification type 1 anatomy were included. Results: 22 coil embolization patients and 21 balloon occlusion patients were included. The logarithms of the data were analyzed using two-tailed t-tests as the data followed log-normal distributions. The geometric means of fluoroscopy time (FT, 30.5 vs 13.9 min, -54%), dose area product (DAP, 735.0 vs 597.3 Gy-cm2, -19%), reference air kerma (Kar, 3,006 vs 2,397 mGy, -20%), and number of DSA runs (#DSA, 19.5 vs 18.0, -7.7%) all decreased in the balloon occlusion group versus the coil embolization group, however only the decrease in FT was statistically significant (FT: p<0.0001; DAP: p=0.261; Ka,r: p=0.202; #DSA: p=0.479). The lack of significance of the decreases in DAP and Kar was attributed to the much lower Kar rate in fluoroscopy compared to DSA (50-80x), and the fact that a similar number of angiograms are acquired regardless of the technique used. Conclusion: Use of a temporary occlusion balloon catheter versus coil embolization significantly decreased fluoroscopy time during Y90 RE. A larger sample size is necessary to determine if this technique results in reductions in DAP and Kar that are significant. [Copyright &y& Elsevier]

Purpose: To evaluate the safety and efficacy of performing drug-eluting beads transarterial chemoembolization (DEB-TACE) through the cystic artery to treat hepatic tumors adjacent to the gallbladder fossa supplied by this vessel. Materials and Methods: This is a bi-institutional analysis of 7 patients (hepatocellular carcinoma (n=6), metastatic melanoma (n=1)) submitted to DEB-TACE through the cystic artery with doxorubicin loaded at 25 mg/mL LC BeadTM (bead size 100 - 300 µm). DEB-TACE was performed selectively via the cystic artery with a 2.8-F or 2.4-F catheter until tumor devascularization was achieved. Post-treatment clinical and imaging findings were utilized to identify and classify adverse events (AE) utilizing The National Cancer Institute Common Terminology Criteria for Adverse Events (Version 4). Imaging response assessment was performed utilizing the mRECIST criteria. Results: Mean overall DEB-TACE sessions per patient was 3.6 (range 1-6). All 7 patients had one DEB-TACE session through the cystic artery. One patient had a previous embolization session via the cystic artery utilizing 250 µm bland embolization particles. Target lesions were located on segments IV (n=6) and V (n=1). Mean lesion size was 4.1 cm (range 2.8-6.5 cm). A mean dose of 17 mg of doxorubicin (range 7.5-42 mg) was delivered through the cystic artery. The median hospital length of stay after cystic artery DEB-TACE sessions was 0.6 day (range 0-1 day). Mean immediate imaging follow-up period was 31 days (range 28-53 days). No grade 3, 4 or 5 AEs were identified. Post-embolization syndrome grade 1 or 2 was observed in all patients. No radiological findings suggestive of gallbladder injury were identified on imaging follow-up. Liver explant evaluation of the gallbladder in one patient demonstrated presence of beads within gallbladder wall with signs of chronic cholecystitis. Imaging response assessment of the target lesions treated through the cystic artery demonstrated: complete response (n=2), partial response (n=3), stable disease (n=1) and progressive disease (n=1). Conclusion: DEB-TACE via the cystic artery was shown to be safe and effective in this small 7-patient series. [Copyright &y& Elsevier]

Purpose: Venous thromboembolism (VTE) is a harbinger of poor outcome for patients with cancer. The SIR guidelines for use of IVC filters state that patients with short life expectancies (≤ 6 months) should receive permanent filters. Our purpose was to develop a model for predicting 6 month survival in a cancer population referred for IVC filter placement. Materials and Methods: Clinical and laboratory parameters for patients, who received a permanent or optional IVC filter between January 2009 and December 2011, were reviewed. A Cox proportional hazards model was used to determine the significant predictors of 6 month survival. Results: 405 IVC filters (n=213 permanent filters, n=192 retrievable filters) were placed at a single institution and analyzed. Survival at 6 months was 209/405 (51.6%). The significant predictive factors of 6 month survival were: 1. Cancer stage (local vs metastatic; hazard ratio [HR] 0.184; p=0.0044). 2. Cancer stage (locally advanced vs metastatic; HR 0.435; p=0.0005). 3. Major surgery 30 days before IVC filter placement (HR 0.470; p=0.0021). 4. Planned surgery 30 days after IVC filter placement (HR 0.355; p<0.0001) 5. Albumin (HR 0.540; p<0.0001). These variables can be used to calculate a risk score for patients with VTE and cancer (VTEC) referred for IVC filters (VTEC-IVC) (see Table). Conclusion: Clinical and laboratory parameters can be used to predict 6 month survival in a population of cancer patients with solid malignancies referred for IVC filter placement. The model can be used to help physicians decide on which type of filter to implant (permanent versus optional) and, ultimately, impact IVC filter retrieval rates. [Copyright &y& Elsevier]

Learning Objectives: To review indications, technique, and outcomes from percutaneous transesophageal gastrostomy (PTEG) catheters. We review 12 successfully placed PTEG catheters at our institution over four years. Background: Patients unable to receive percutaneous fluoroscopic gastrostomy (PFG) catheters are at risk for developing long-term complications from indwelling nasogastric (NG) tubes. PTEG catheters are a feasible alternative offering palliative relief for patients needing either venting or feeding support. Clinical Findings/Procedure Details: Once adequate sedation is achieved, a guidewire is passed through an existing NG tube, which is subsequently removed. A 25 mm x 4 cm balloon catheter is then advanced into the stomach. The balloon is insufflated with contrast and withdrawn under fluoroscopy to just below the thoracic inlet. An appropriate access site is chosen on the lower left neck, and a 21-gauge needle is used to puncture the balloon under ultrasound guidance. A 0.018” microwire is passed through the needle and coiled in the balloon. The balloon and microwire are then passed, in tandem, into the gastric lumen and the balloon is disengaged from the microwire. The neck access is then sequentially dilated to accommodate a 14-French, 45-cm Mac Lock catheter (Cook, Bloomington, IN), which is passed into the stomach or jejunum and used for venting or feeding, as appropriate. In our experience, the most commonly encountered malignancy in need of an alternative gastrostomy approach has been metastatic gastric carcinoma (67%), ovarian carcinoma (17%), esophageal carcinoma (8%), and gallbladder carcinoma (8%). Patients survived 40.5 days (mean, range 28-85 days) following placement. Conclusion and/or Teaching Points: PTEG catheters are an essential tool for an interventional radiologist, providing patients an alternative for feeding or venting when direct percutaneous access into the stomach or jejunum is contraindicated. [Copyright &y& Elsevier]

Purpose: The most common serious complication of Y90 radioembolotherapy (Y90 RE) is gastrointestinal ulceration secondary to extrahepatic microsphere deposition. The conventional method to prevent extrahepatic deposition of Y90 microspheres is the coil occlusion of the origins of hepatoenteric arteries. However, this method of exclusion is not possible in all cases. Redirection of blood flow towards the liver (hepatopetal) within hepatoenteric arteries during Y90 RE delivery could achieve the identical intention of prevention of gastrointestinal microsphere deposition. We present the utility of the creating hepatopetal flow within hepatoenteric arteries with use of the balloon occlusion technique at our institution for Y90 RE. Materials and Methods: Between September 2010- December 2012, 62 patients with diagnostic or treatment angiograms with attempted use of the balloon occlusion technique were catalogued. Tumor types included colorectal (18), hepatocellular (22), neuroendocine (17) or other (5). Temporary balloon catheter occlusion of the common hepatic artery was used to transiently create hepatopetal flow within hepatoenteric arteries during both the diagnostic Tc99m MAA (47 patients) and therapeutic Y90 RE (48 patients) delivery. Planar & SPECT nuclear scintigraphy was performed after delivery of the radionuclides. Whole liver, right lobe, left lobe Y90 RE treatments were performed in 40,8 and 2 sessions respectively. Clinical and laboratory follow up at 1, 3 and 6 months and imaging follow up at 3 and 6 months were performed. Results: 50 Y90 RE treatment sessions were performed with use of the balloon technique with either glass (20) or resin (30) microspheres. Post Y90 RE scintigraphy confirmed hepatic only activity. Greater than 80% administration of the prescribed dose of resin microspheres was possible in 22/30 sessions and in 19/20 sessions of glass microspheres. One NCI-CTC grade 2 gastrointestinal ulcer was present at 90 day follow up. Conclusion: Transient common hepatic artery balloon-catheter occlusion provided a reasonably safe, reliable, and reproducible alternative to conventional fibered coil occlusion of patent hepatoenteric arteries to facilitate Tc99m MAA & Y90 RE delivery. [Copyright &y& Elsevier]