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PURPOSE: To evaluate safety and efficacy of radiation segmentectomy (RS) with (90)Y glass microspheres in patients with limited metastatic liver disease not amenable to resection or percutaneous ablation. METHODS: Patients with ≤3 tumors treated with RS from 6/2015–12/2017 were included. Target tumor radiation dose was > 190 Gy based on Medical Internal Radiation Dose (MIRD) dosimetry. Tumor response, local tumor progression (LTP), LTP-free survival (LTPFS) and disease progression rate in the treated segment were defined using Choi and RECIST 1.1 criteria. Toxicities were evaluated using modified SIR criteria. RESULTS: Ten patients with 14 tumors underwent 12 RS. Median tumor size was 3 cm (range, 1.4–5.6). Median follow-up was 17.8 months (range, 1.6–37.3). Response rates per Choi and RECIST 1.1 criteria were 8/8 (100%) and 4/9 (44%), respectively. Overall LTP rate was 3/14 (21%) during the study period. One-, two- and three -year LTPFS was 83%, 83% and 69%, respectively. Median LTPFS was not reached. Disease progression rate in the treated segment was 6/18 (33%). Median overal survival was 41.5 months (IQR, 16.7–41.5). Median delivered tumor radiation dose was 293 Gy (range, 163–1303). One major complication was recorded in a patient post-Whipple procedure who suffered anaphylactic reaction to prophylactic cefotetan and liver abscess in RS region 6.5 months post-RS. All patients were alive on last follow-up. CONCLUSION: RS of ≤ 3 hepatic segments can safely provide a two-year local tumor control rate of 83% in selected patients with limited metastatic liver disease and limited treatment options. Optimal dosimetry methodology requires further investigation.

To define positron emission tomography/computed tomography (PET/CT) imaging characteristics during follow-up of patients with metastatic breast cancer (MBC) treated with yttrium-90 (Y90) radioembolization (RE). From January 2011 to October 2017, 30 MBC patients underwent 38 Y90 glass or resin RE treatments. Pre-RE PET/CT was performed on average 51 days before RE. There were 68 PET/CTs performed after treatment. Response was assessed using modified PERCIST criteria focusing on the hepatic territory treated with RE, normalizing SUVpeak to the mean SUV of liver uninvolved by tumor. An objective response (OR) was defined as a decrease in SUVpeak by at least 30%. Of the 68 post-RE scans, 6 were performed at 0–30 days, 15 at 31–60 days, 9 at 61–90 days, 13 at 91–120 days, 14 scans at 121–180 days, and 11 scans at > 180 days after RE. Of the 30 patients, 25 (83%) achieved OR on at least one follow-up. Median survival was 15 months after the first RE administration. Highest response rates occurred at 30–90 days, with over 75% of cases demonstrating OR at that time. After 180 days, OR was seen in only 25%. There was a median TTP of 169 days among responders. In MBC, follow-up PET/CT after RE demonstrates optimal response rates at 30–90 days, with progression noted after 180 days. These results help to guide the timing of imaging and also to inform patients of expected outcomes after RE.

Estimate the incidence of nontarget embolization (NTE) as identified on immediate post-hepatic artery embolization CT. Two hundred hepatic embolizations performed with particles alone (bland embolization) in 147 patients between August 16, 2013 and August 26, 2014 with immediate post-procedure CT were retrospectively reviewed. Arterial anatomy, vessels treated, imaging findings of NTE, patient demographics, length of hospital stay following embolization, and procedure-related complications were recorded. The data were analyzed using two-sided t-tests and chi-squared tests. Evidence of NTE was seen on post-procedure CT in 64 of 200 cases (64/200, 32%). Six organs were affected, with 69 discrete sites in 64 patients. The majority (49/69, 71.0%) involved the gallbladder. The mean length of hospital stay (LOS) for patients with and without NTE was 2.9 ± 1.5 nights (range 1–7) and 2.9 ± 2.3 nights (range 0–21), respectively (P = 0.81). NTE was more common following embolization of replaced or accessory hepatic vessels. There were three complications in the NTE group (3/64, 4.7%) following the embolization procedure, one of which was cholecystitis directly related to NTE. The other two were one incidence each of contrast-induced nephropathy and pneumonia. In the group without NTE, seven complications occurred (7/136, 5.1%, P = 0.889), including one death resulting from hepatic failure, two gastrointestinal bleeds, two hepatic abscesses, flash pulmonary edema, and pancreatitis. Unanticipated NTE is not uncommon after bland hepatic artery embolization, particularly after treating accessory or replaced vessels, but does not increase complications or LOS. Level 2b, Retrospective Cohort.

This study aimed to evaluate whether rapid fluorescent tissue examination immediately after colorectal cancer liver metastasis (CLM) ablation correlates with standard pathologic and immunohistochemical (IHC) assessments. This prospective, National Institutes of Health-supported study enrolled 34 consecutive patients with 53 CLMs ablated between January 2011 and December 2014. Immediately after ablation, core needle sampling of the ablation zone was performed. Tissue samples were evaluated with fluorescent viability (MitoTracker Red) and nuclear (Hoechst) stains. Confocal microscope imaging was performed within 30 min after ablation. The same samples were subsequently fixed and stained with hematoxylin and eosin (H&E). Identified tumor cells underwent IHC staining for proliferation (Ki67) and viability (OxPhos). The study pathologist, blinded to the H&E and IHC assessment, evaluated the fluorescent images separately to detect viable tumor cells. Sensitivity, specificity, and overall concordance of the fluorescent versus H&E and IHC assessments were calculated. A total of 63 tissue samples were collected and processed. The overall concordance rate between the immediate fluorescent and the subsequent H&E and IHC assessments was 94% (59/63). The fluorescent assessment sensitivity and specificity for the identification of tumor cells were respectively 100% (18/18) and 91% (41/45). The study showed a high concordance rate between the immediate fluorescent assessment and the standard H&E and IHC assessment of the ablation zone. Given the documented prognostic value of ablation zone tissue characteristics for outcomes after ablation of CLM, the fluorescent assessment offers a potential intra-procedural biomarker of complete tumor ablation.

Background Although snaring technique is a commonly used tool in the interventional radiologists’ armamentarium, there are no reports of its use in an extra-vascular space to achieve access across a pseudoaneurysm that was otherwise non-traversable. Case presentation We describe a case of an iliac-enteric fistula between a ruptured pseudoaneurysm of the external iliac artery and a surrounding contained colonic perforation, where access across the pseudoaneurysm was achieved only after snaring of the microwire from within the contained colonic perforation and back into the intra-vascular space, allowing the placement of a covered stent and control of the bleeding. Conclusions The described technique may be useful in situations where other, more conventional, endovascular techniques fail to achieve access across the bleeding pseudoaneurysm. While it was life-saving in this case, this technique should only be used in very limited scenarios, specifically in the palliative setting and when surgical management is not an option.

The goal of this study was to develop and evaluate a volumetric three-dimensional (3D) approach to improve the accuracy of ablation margin assessment following thermal ablation of hepatic tumors. The 3D margin assessment technique was developed to generate the new 3D assessment metrics: volumes of insufficient coverage (VICs) measuring volume of tissue at risk post-ablation. VICs were computed for the tumor and tumor plus theoretical 5- and 10-mm margins. The diagnostic accuracy of the 3D assessment to predict 2-year local tumor progression (LTP) was compared to that of manual 2D assessment using retrospective analysis of a patient cohort that has previously been reported as a part of an outcome-centered study. Eighty-six consecutive patients with 108 colorectal cancer liver metastases treated with radiofrequency ablation (2002–2012) were used for evaluation. The 2-year LTP discrimination power was assessed using receiver operating characteristic area under the curve (AUC) analysis. A 3D assessment of margins was successfully completed for 93 out of 108 tumors. The minimum margin size measured using the 3D method had higher discrimination power compared with the 2D method, with an AUC value of 0.893 vs. 0.790 (p = 0.01). The new 5-mm VIC metric had the highest 2-year LTP discrimination power with an AUC value of 0.923 (p = 0.004). Volumetric semi-automated 3D assessment of the ablation zone in the liver is feasible and can improve accuracy of 2-year LTP prediction following thermal ablation of hepatic tumors. • More accurate prediction of local tumor progression risk using volumetric 3D ablation zone assessment can help improve the efficacy of image-guided percutaneous thermal ablation of hepatic tumors. • The accuracy of evaluation of ablation zone margins after thermal ablation of colorectal liver metastases can be improved using a volumetric 3D semi-automated assessment approach and the volume of insufficient coverage assessment metric. • The new 5-mm volume-of-insufficient-coverage metric, indicating the volume of tumor plus 5-mm margin that remained untreated, had the highest 2-year local tumor progression discrimination power.

Patients with recurrence after complete resection of colorectal liver metastases (CLM) are considered for repeat resection as a potential salvage therapy (PST). However, outcomes for this approach are not well defined. We sought to analyze the natural history of recurrence and PST in a large cohort of patients with long-term follow-up. Recurrence patterns, treatments, and outcomes in consecutive patients undergoing resection for colorectal liver metastases were analyzed retrospectively. PST was defined as repeat resection of all recurrent disease and effective salvage therapy (EST) as free of disease for 36 months after last PST. Factors associated with PST, EST, and outcomes were analyzed. Of 952 patients who underwent resection, 594 (62 %) experienced recurrence (median interval = 13 months). Initial recurrences involved liver (n = 157,26 %), lung (n = 167,28 %), multiple sites (n = 171,29 %), and other single sites (n = 99,17 %). PST was performed in 160 (27 %) of 594, most commonly with a single site of recurrence (n = 149). Young age (p = 0.01), negative initial resection margin (p = 0.003), initial tumor size

To compare CT fluoroscopy-guided manual and CT-guided robotic positioning system (RPS)-assisted needle placement by experienced IR physicians to targets in swine liver.Manual and RPS-assisted needle placement was performed by six experienced IR physicians to four 5 mm fiducial seeds placed in swine liver (n = 6). Placement performance was assessed for placement accuracy, procedure time, number of confirmatory scans, needle manipulations, and procedure radiation dose. Intra-modality difference in performance for each physician was assessed using paired t test. Inter-physician performance variation for each modality was analyzed using Kruskal-Wallis test.Paired comparison of manual and RPS-assisted placements to a target by the same physician indicated accuracy outcomes was not statistically different (manual: 4.53 mm; RPS: 4.66 mm; p = 0.41), but manual placement resulted in higher total radiation dose (manual: 1075.77 mGy/cm; RPS: 636.4 mGy/cm; p = 0.03), required more confirmation scans (manual: 6.6; RPS: 1.6; p0.0001) and needle manipulations (manual: 4.6; RPS: 0.4; p0.0001). Procedure time for RPS was longer than manual placement (manual: 6.12 min; RPS: 9.7 min; p = 0.0003). Comparison of inter-physician performance during manual placement indicated significant differences in the time taken to complete placements (p = 0.008) and number of repositions (p = 0.04) but not in other study measures (p0.05). Comparison of inter-physician performance during RPS-assisted placement suggested statistically significant differences in procedure time (p = 0.02) and not in other study measures (p0.05).CT-guided RPS-assisted needle placement reduced radiation dose, number of confirmatory scans, and needle manipulations when compared to manual needle placement by experienced IR physicians, with equivalent accuracy.

The purpose of the study is to determine the efficacy of hepatic artery embolization (HAE) as a therapy for gastrointestinal stromal tumor (GIST) in patients who are refractory to imatinib and sunitinib. After institutional review board approval, a retrospective review revealed 11 patients with GIST metastatic to the liver who underwent 15 HAEs between February 2002 and May 2013. These patients were stratified into two groups according to the previous treatment: (a) those treated with HAE as second-line treatment after failing first-line imatinib (n = 3) and (b) those treated with HAE as third-line therapy after failing first-line imatinib and second-line sunitinib (n = 8). Initial therapeutic response, overall survival (OS), progression-free survival (PFS), and safety were evaluated. Initial therapeutic response rates at 3 months after HAE were 27.3 % (95 % confidence interval (CI), 6.0–61.0 %) by Response Evaluation Criteria in Solid Tumor (RECIST) version 1.0 and 45.5 % (95 % CI, 16.7–76.6 %) by modified RECIST (mRECIST). The median OS and PFS after HAE were 14.9 and 3.9 months in group A and 23.8 and 3.4 months in group B, respectively. No procedure-related mortality or major complication was observed. HAE is an effective and well-tolerated therapeutic option for GIST liver metastases. Although larger studies are necessary, HAE should be considered as an alternative or adjuvant to third-line or even second-line systemic treatment.

PURPOSE: We sought to evaluate the safety and the diagnostic success rate of percutaneous biopsies performed under intra-procedural 18F-deoxyglucose (FDG) positron-emission tomography/computed tomography (PET/CT) guidance for lesions difficult to see with conventional cross-sectional imaging. METHODS: From 2011 to 2013, consecutive clinically indicated percutaneous PET/CT-guided biopsies of 106 masses (mean size, 3.3 cm; range, 0.7–15.9 cm; SD, 2.9 cm) in bones (n=33), liver (n=26), soft tissues (n =18), lung (n=15) and abdomen (n =14) were reviewed. The biopsy procedures were performed following injection of a mean of255 MBq(SD, 74) FDG. Mean maximal standardized uptake value (SUV) of lesions was 8.8 (SD, 6.3). A systematic review of the histo-pathological results and outcomes was performed. RESULTS: Biopsies were positive for malignancy in 76 cases (71.7 %, 76/106) and for benign tissue in 30 cases (28.3 %, 30/106). Immediate results were considered adequate for 100 PET/CT biopsies (94.3 %, 100/106) requiring no further exploration, and for the six others (5.7 %, 6/106) benign diagnoses were confirmed after surgery (n=4) or follow-up (n=2). The consequent overall sensitivity and the diagnostic success of biopsy were therefore 100 %. No significant differences in terms of detection of malignancy were observed between the different locations. Lesions > 2 cm or with SUV>4 were not significantly more likely to be malignant. Complications occurred after four biopsies (3.7 %, 4/106). CONCLUSION: Intra-procedural PET/CT guidance appears as a safe and effective method and allows high diagnostic success of percutaneous biopsies for metabolically active lesions.

Traditional options for management of inguinal lymph node (ILN) metastases include surgery, radiation therapy or chemotherapy, often in combination [1]. However, patient prognosis and outcomes may be more dependent upon cancer biology than the type and extent of treatment. Over time, nodal disease in the groin may either cease to respond to chemotherapy or maximal radiation treatment doses may be reached without achieving complete local control. Surgical options, including ilio-inguinal or combined superficial and deep groin dissections, can carry a complication rate as high as 50% [2-4]; mainly related to wound dehiscence. Repeated surgical interventions may induce regional scarring, limiting the efficacy of subsequent procedures [5]. Percutaneous thermal ablation is a treatment option that has recently shown promise for local tumor control in musculoskeletal structures and soft tissues as alternatives or adjuncts to surgery, radiation or chemotherapy [6]. However, the literature examining the role of ablation in the management of lymph node metastases is limited [7; 8]. In this report we describe successful palliation of pain associated with numerous recurrent inguinal nodal metastases over time using image guided percutaneous cryoablation. A 62 year-old man initially presented with palpable bilateral inguinal masses and painful constipation. Imaging studies revealed lymphadenopathy and a 4 cm tumor of the anal canal. Diagnosis of a high grade neuroendocrine carcinoma was confirmed by a colonoscopic biopsy, which showed chromogranin positivity, partially TTF1 positivity, and negative staining for CK20 and CDX2 markers. Subsequent PET-CT imaging confirmed a hypermetabolic 4cm tumor (SUV 11) of the anal canal with presacral (SUV 12.7), perirectal (SUV 9.8) and bilateral inguinal (SUV 13.5) lymphadenopathy. The patient was initially treated with chemotherapy (14 cycles of carboplatin; 3 doses cisplatin and 1 dose of irinotecan) but progressed when adverse effects of irinotecan (diarrhea) developed and chemotherapy was discontinued. Radiation was subsequently delivered to the pelvis (and bilateral inguinal lymph nodes (50.4 Gy) in combination with systemic capecitabine. Fifteen months after radiotherapy, an abdominoperineal resection and left groin dissection was performed in an attempt to palliate a painful recurrent tumor in the anal canal and enlarged left inguinal lymph nodes. Surgical pathology revealed high grade neuroendocrine carcinoma with 1/15 positive regional lymph nodes and 0/8 positive left ILN. A 6-month postoperative PET-CT demonstrated an FDG avid (SUV 6.5) right ILN that was subsequently surgically resected. However, CT two months later revealed a new enlarged right ILN. Further surgery was not recommended due to anticipated procedural difficulty related to scarring. Additional radiotherapy was contraindicated due to cumulative radiation dose and chemotherapy options were limited due to previous adverse effects and expected toxicity. Percutaneous ablation was proposed to address the patient's groin pain associated with a growing right inguinal lymph node. The first cryoablation procedure was performed under Computed Tomography (CT)-guidance and general anesthesia two months after the last surgical lymph node dissection. A single 2.4 mm percutaneous cryoprobe (Endocare PCS-24, Healthtronics, Austin, TX, USA) was introduced into the mass. Prior to freezing, the external iliac artery and vein were displaced from the ablation zone by percutaneous CT-guided injection of a dilute mixture of normal saline and omnipaque 350 contrast dye. For superficial nodes, normal saline was injected subcutaneously to prevent ice ball contact with the skin surface. Intermittent low-dose CT was performed during the cryoablation cycles (10 minute freeze, 6 minute active thaw, 10 minute freeze and 6 minute active thaw), showing good coverage of the targeted lymph node by the ice ball without imaging evidence of ice extension to the skin. No complications occurred and the patient was observed in the hospital prior to same day discharge. A few weeks later, the patient again reported bilateral groin swelling from additional nodes. A second cryoablation procedure was performed on both sides of the pelvis, treating 2 new distinct metastatic sites 2 months after the first ablation (figure 1 - representative intraprocedural image). PET-CT imaging follow-up 8 months later showed reduction in size of the treated nodes and minimal low-level FDG uptake at each ablation site (SUV

Surgical resection is the standard treatment for early-stage primary lung cancer and selected cases with pulmonary metastases. However, lung resection may not be possible in patients with compromised pulmonary function, concurrent medical conditions, or previous lung resections. Image-guided ablation has emerged as a less invasive treatment option for unresectable lung tumors that allows for preservation of pulmonary function and promising efficacy. Hereby we describe the indications for and outcomes of image-guided ablation performed for the management of pulmonary malignancies.

No systemic agents that are known to be effective for the treatment of solid-pseudopapillary neoplasm (SPN) are available. We report the prolonged and sustained control of metastatic pancreatic SPN to the liver using hepatic arterial embolization (HAE), where a total of 13 HAE sessions were performed over a 6-year period.

BACKGROUND. The objective of this work was to evaluate the feasibility of histopathological analysis of tissue extracted on multitined electrodes and assess whether tissue characteristics can be used as biomarkers of oncologic outcomes after lung tumor radiofrequency (RF) ablation. METHODS. Treatment-related data regarding RF ablation of lung malignancies at our institution was collected using a Health Insurance Portability and Accountability Act-compliant ablation database. Institutional review board waiver was obtained for this study. Immunohistochemical analysis of tissue extracted from the electrodes after lung tumor RF ablation was performed for proliferation (Ki-67) and apoptosis (caspase-3). Patient, tumor demographics, and ablation parameters were recorded. Local tumor progression-free survival (LPFS), disease-specific survival (DSS), and overall survival (OS) were assessed using Kaplan–Meier methodology. Multivariate analysis determined factors affecting these oncological outcomes. RESULTS. A total of 47 lung tumors in 42 patients were ablated; 30 specimens were classified as coagulation necrosis (CN) and 17 as Ki-67-positive (+) tumor cells (viable). Tumor sizes were similar in the CN and Ki-67+ groups (P = 0.32). Median LPFS was 10 versus 16 months for Ki-67+ and CN groups, and 1-year LPFS was 34 and 75 %, respectively (P = 0.003). Median OS was 20 and 46 months (P = 0.12), and median DSS was 20 and 68 months (P = 0.01) for the Ki-67 + and CN groups, respectively. Identification of Ki-67+ tumor cells more than tripled the risk of death from cancer [hazard ratio (HR) = 3.65; 95 % confidence interval (95 % CI), 1.34-9.95; P = 0.01] and tripled the risk of local tumor progression (LTP) (HR = 3.01; 95 % CI, 1.39–6.49; P = 0.005). CONCLUSIONS. Ki-67+ tumor cells on the electrode after pulmonary tumor RF ablation is an independent predictor of LTP, shorter LPFS, and DSS.

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary hepatic malignancy after hepatocellular carcinoma. Complete surgical resection remains the only potentially curative option for patients with ICC. However, until now, early diagnosis with potential surgical intervention has been the exception rather than the rule with only 30% of patients qualifying for attempted surgical cure. Many patients are unresectable because of disease stage, anatomic conditions, medical comorbidities, and small future remnant liver. Interventional radiology procedures are available for these types of patients with intra-arterial therapies and/or ablative treatments both for curative and for palliative treatment. The goals of interventional therapy are to control local tumor growth, to relieve symptoms, and to improve and preserve quality of life. The choice of treatment depends largely on tumor extent and patient performance. No randomized studies exist to compare treatments. The present review describes the current evidence of the interventional treatments in the management of the ICC. Moreover, interventional procedures available to increase the future liver reserve before surgery were analyzed.

This study was designed to evaluate the relationship between the minimal margin size and local tumor progression (LTP) following CT-guided radiofrequency ablation (RFA) of colorectal cancer liver metastases (CLM).An institutional review board-approved, HIPPA-compliant review identified 73 patients with 94 previously untreated CLM that underwent RFA between March 2003 and May 2010, resulting in an ablation zone completely covering the tumor 4-8 weeks after RFA dynamic CT. Comparing the pre- with the post-RFA CT, the minimal margin size was categorized to 0, 1-5, 6-10, and 11-15 mm. Follow-up included CT every 2-4 months. Kaplan-Meier methodology and Cox regression analysis were used to evaluate the effect of the minimal margin size, tumor location, size, and proximity to a vessel on LTP.Forty-five of 94 (47.9 %) CLM progressed locally. Median LTP-free survival (LPFS) was 16 months. Two-year LPFS rates for ablated CLM with minimal margin of 0, 1-5 mm, 6-10 mm, 11-15 mm were 26, 46, 74, and 80 % (p 0.011). Minimal margin (p = 0.002) and tumor size (p = 0.028) were independent risk factors for LTP. The risk for LTP decreased by 46 % for each 5-mm increase in minimal margin size, whereas each additional 5-mm increase in tumor size increased the risk of LTP by 22 %.An ablation zone with a minimal margin uniformly larger than 5 mm 4-8 weeks postablation CT is associated with the best local tumor control.

Percutaneous biliary drainage (PBD) is used to relieve malignant bile duct obstruction (MBO) when endoscopic drainage is not feasible. Little is known about the effects of PBD on the quality of life (QoL) in patients with MBO. The aim of this study was to evaluate changes in QoL and pruritus after PBD and to explore the variables that impact these changes.Eligible patients reported their QoL and pruritus before and after PBD using the Functional Assessment of Cancer Therapy-Hepatobiliary instrument (FACT-HS) and the Visual Analog Scale for Pruritus (VASP). Instruments were completed preprocedure and at 1 and 4 weeks following PBD.A total of 109 (60 male/49 female) patients enrolled; 102 (94%) had unresectable disease. PBD was technically successful (hepatic ducts cannulated at the conclusion of procedure) in all patients. There were 2 procedure-related deaths. All-cause mortality was 10% (N = 11) at 4 weeks and 28% (N = 31) at 8 weeks post-PBD with a median survival of 4.74 months. The mean FACT-HS scores declined significantly (P.01) over time (101.3, 94.8, 94.7 at baseline, 1 week, 4 weeks, respectively). The VASP scores showed significant improvement at 1 week with continued improvement at 4 weeks (P.01).PBD improves pruritus but not QoL in patients with MBO and advanced malignancy. There is high early mortality in this population.

Hepatic encephalopathy is considered a contraindication to hepatic artery embolization. We describe a patient with a well-differentiated neuroendocrine tumor metastatic to the liver with refractory hepatic encephalopathy and normal liver function tests. The encephalopathy was refractory to standard medical therapy with lactulose. The patient's mental status returned to baseline after three hepatic artery embolization procedures. Arteriography and ultrasound imaging before and after embolization suggest that the encephalopathy was due to arterioportal shunting causing hepatofugal portal venous flow and portosystemic shunting. In patients with a primary or metastatic well-differentiated neuroendocrine tumor whose refractory hepatic encephalopathy is due to portosystemic shunting (rather than global hepatic dysfunction secondary to tumor burden), hepatic artery embolization can be performed safely and effectively.

The purpose of this study was to determine the primary patency of two or more noncoaxial self-expanding metallic Wallstents (Boston Scientific, Natick, MA) and to compare this with the primary patency of a single stent in malignant bile duct obstruction. From August 2002 to August 2004, 127 patients had stents placed for malignant bile duct obstruction. Forty-five patients were treated with more than one noncoaxial self-expanding metallic stents and 82 patients had a single stent placed. Two patients in the multiple-stent group were lost to follow-up. The primary patency period was calculated from the date of stenting until the first poststenting intervention for stent occlusion, death, or the time of last documented follow-up. The patency of a single stent was significantly different from that of multiple stents (P = 0.0004). In the subset of patients with high bile duct obstruction, the patency of a single stent remained significantly different from that of multiple stents (P = 0.02). In the single-stent group, there was no difference in patency between patients with high vs. those with low bile duct obstruction (P = 0.43). The overall median patency for the multistent group and the single-stent group was 201 and 261 days, respectively. In conclusion, the patency of a single stent placed for malignant low or high bile duct obstruction is similar, and significantly longer than, that of multiple stents placed for malignant high bile duct obstruction. Given the median patency of 201 days, when indicated, percutaneous stenting of multiple bile ducts is an effective palliative measure for patients with malignant high bile duct obstruction.

The purpose of this study was to compare rates and patterns of disease progression following percutaneous, image-guided radiofrequency ablation (RFA) and nonanatomic wedge resection for solitary colorectal liver metastases. We identified 30 patients who underwent nonanatomic wedge resection for solitary liver metastases and 22 patients who underwent percutaneous RFA because of prior major hepatectomy (50%), major medical comorbidities (41%), or relative unresectability (9%). Serial imaging studies were retrospectively reviewed for evidence of local tumor progression. Patients in the RFA group were more likely to have undergone prior liver resection, to have a disease-free interval greater than 1 year, and to have had an abnormal carcinoembryonic antigen (CEA) level before treatment. Two-year local tumor progression-free survival (PFS) was 88% in the Wedge group and 41% in the RFA group. Two patients in the RFA group underwent re-ablation, and two patients underwent resection to improve the 2-year local tumor disease-free survival to 55%. Approximately 30% of patients in each group presented with distant metastasis as a component of their first recurrence. Median overall survival from the time of resection was 80 months in the Wedge group vs 31 months in the RFA group. However, overall survival from the time of treatment of the colorectal primary was not significantly different between the two groups. Local tumor progression is common after percutaneous RFA. Surgical resection remains the gold standard treatment for patients who are candidates for resection. For patients who are poor candidates for resection, RFA may help to manage local disease, but close follow-up and retreatment are necessary to achieve optimal results.

A 68-year-old female with colorectal cancer developed a metachronous isolated fluorodeoxyglucose-avid (FDG-avid) segment 5/6 gallbladder fossa hepatic lesion and was referred for percutaneous ablation. Pre-procedure computed tomography (CT) images demonstrated a distended gallbladder abutting the segment 5/6 hepatic metastasis. In order to perform ablation with clear margins and avoid direct puncture and aspiration of the gallbladder, cholecystokinin was administered intravenously to stimulate gallbladder contraction before hydrodissection. Subsequently, the lesion was ablated successfully with sufficient margins, of greater than 1.0 cm, using microwave with ultrasound and FDG PET/CT guidance. The patient tolerated the procedure very well and was discharged home the next day.

A novel 19-gauge, blunt-tipped, side cutting single throw, 70-cm long transjugular needle, specifically designed for transvenous kidney biopsy, was used in seven patients with high risk for bleeding. A mean of 4 device-passes (3-6) per patient resulted in a satisfactory specimen for pathological diagnosis. Immediate post-biopsy nonenhanced CT was performed to evaluate for bleeding at the biopsy site. All patients were observed for 2 hr after the procedure. No clinically significant immediate or late complication was noted.