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Purpose To evaluate the safety and efficacy of 2 locoregional therapies (LRTs) including hepatic artery embolization (HAE) and transarterial radioembolization (TARE) in the treatment of patients with metastatic ovarian cancer to the liver. Material and Methods From October 2010 to May 2019, the data of 15 consecutive patients (median age, 54 years ± 9.8; range, 35–78 years) with hepatic metastatic ovarian cancer who were treated with either HAE (n = 6; 40%) or TARE (n = 9; 60%) were reviewed. The most common histopathologic type was epithelial ovarian carcinoma (80%). The most common chemotherapy regimens used prior to embolization included carboplatin, paclitaxel, cisplatin, and bevacizumab. Patients received a mean of 4 lines ± 3 (range, 1–9) of chemotherapy. All patients with serous carcinoma were resistant to platinum at the time of embolization. Indications for embolization were progression of disease to the liver while receiving chemotherapy in 14 (93.3%) patients and palliative pain control in 1 patient. Results The overall response rates at 1, 3, and 6 months were 92.4%, 85.6%, and 70%, respectively. Median overall survival from the time of LRT was 9 (95% confidence interval [CI], 4–14) months. Median local tumor progression was 6.4 months ± 5.03 (95% CI, 3.3–9.5). No grade 3–5 adverse events were detected in either group. Conclusions HAE and TARE were well tolerated in patients with metastatic ovarian cancer to the liver and possibly ensured prolonged disease control in heavily treated, predominantly in patients resistant to platinum. Larger numbers are needed to verify these data.

PURPOSE: To determine how particle density affects dose distribution and outcomes after lobar radioembolization. METHODS: Matched pairs of patients, treated with glass versus resin microspheres, were selected by propensity score matching (114 patients), in this single-institution retrospective study. For each patient, tumor and liver particle density (particles/cm(3)) and dose (Gy) were determined. Tumor-to-normal ratio was measured on both (99m)Tc-MAA SPECT/CT and post-(90)Y bremsstrahlung SPECT/CT. Microdosimetry simulations were used to calculate 1(st) percentile dose, which is the dose in the cold spots between microspheres. Local progression-free survival (LPFS) and overall survival were analyzed. RESULTS: As more particles were delivered, doses on (90)Y SPECT/CT became more uniform throughout the treatment volume: tumor and liver doses became more similar (p=0.04), and microscopic cold spots between particles disappeared. For hypervascular tumors (tumor-to-normal ratio ≥ 2.6 on MAA scan), delivering fewer particles (

PURPOSE: To validate an immuno-fluorescent assay (IFA) detecting residual viable tumor as intraprocedural thermal ablation (TA) zone assessment and demonstrate its prognostic value for local tumor progression after colorectal liver metastases (CLM) TA. MATERIALS AND METHODS: This prospective, IRB-approved study included 99 patients with 155 CLMs ablated between November 2009 and January 2019. Tissue samples from the ablation zone (AZ) center and minimal margin underwent immunofluorescent microscopic examination interrogating cellular morphology and mitochondrial viability (IFA) within 30 minutes after ablation. The same tissue samples were subsequently evaluated with standard morphological and immunohistochemical (IHC) methods. Sensitivity, specificity, and overall accuracy of IFA versus standard morphological and IHC examination were calculated. Local tumor progression (LTP)-free survival rates were evaluated for 12-month follow-up period. RESULTS: Of the 311 tissue samples stained, 304 (98%) were deemed evaluable. 27% (81/304) of specimens were considered positive for the presence of viable tumor. The accuracy of IFA was 94% (286/304). Sensitivity and specificity were 100% (63/63) and 93% (223/241), respectively. The 18 false-positive IFA assessments corresponded to samples that included viable cholangiocytes. The 12-month LTP-free survival was 59% vs 78% for IFA positive vs negative for viable tumor AZs, respectively (P

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.

Colorectal cancer (CRC) is responsible for approximately 10% of cancer-related deaths in the Western world. Liver metastases are frequently seen at the time of diagnosis and throughout the course of the disease. Surgical resection is often considered as it provides long-term survival; however, few patients are candidates for resection. Percutaneous ablative therapies are also used in the management of this patient population. Different thermal ablation (TA) technologies are available including radiofrequency ablation, microwave ablation (MWA), laser, and cryoablation. There is growing evidence about the role of interventional oncology and image-guided percutaneous ablation in the management of metastatic colorectal liver disease. This article aims to outline the technical considerations, outcomes, and rational of TA in the management of patients with CRC liver metastases, focusing on the emerging role of MWA.

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.

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.

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.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.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.DAXX mutation is common in patients with pancreatic NLMs. DAXX mutation status is associated with shorter HPFS and TTHP after TAE.

OBJECTIVES: To assess safety and efficacy of (90)Y resin microspheres administration using undiluted non-ionic contrast material (UDCM) {100% 0mnipaque-300 (Io-hexol)} in both the “B” and “D” lines. MATERIALS AND METHODS: We reviewed all colorectal cancer liver metastases patients treated with (90)Y resin micro-spheres radioembolization (RAE) from 2009 to 2017. As of April 2013, two experienced operators started using UDCM (study group) instead of standard sandwich infusion (control group). Occurrence of myelosuppression (leukopenia, neutropenia, erythrocytopenia or/and thrombocytopenia), stasis, nontarget delivery (NTD), median fluoroscopy radiation dose (FRD), median infusion time (IT), liver progression-free (LPFS) and overall survivals (OS) was evaluated. Complications within 6 months post-RAE were reported according to CTCAE v3.0 criteria. RESULTS: Study and control groups comprised 23(28%) and 58(72%) patients, respectively. Median follow-up was 9.1 months. There was no statistically significant difference in myelosuppression incidence within 6 months post-RAE between groups. Median FRD and IT for study and control groups were 44.6 vs. 97.35 Gy/cm(2) (p = 0.048) and 31 vs. 39 min (p = 0.006), respectively. A 38% lower stasis incidence in study group was not significant (p = 0.34). NTD occurred in 1/27(4%) study vs. 5/73(7%) control group procedures (p =1). Grade 1–2 and grade 3–4 toxicities between study and control group patients were 36%(8/22) vs. 45%(26/58), p = 0.61 and 9%(2/22) vs. 16%(9/58), p = 0.72, respectively. There was no difference in LPFS and OS between groups. CONCLUSION: Administration of (90)Y resin microspheres using UDCM in both lines is safe and effective, resulting in lower fluoroscopy radiation dose and shorter infusion time, without evidence of myelosuppression or increased stasis incidence.

Purpose To describe ablation of bone, liver, lung, and soft tissue tumors from oligometastatic breast cancer and to define predictors of local progression and progression-free survival (PFS). Materials and Methods A total of 33 women (mean age 52 ± 12 years old; range, 28–69 years), underwent 46 thermal ablations of liver (n = 35), lung (n = 7), and bone/soft tissue (n = 4) metastases. Mean tumor diameter was 18 ± 15 mm (range, 6–50 mm). Ablations were performed to eradicate all evident sites of disease (n = 24) or to control growing sites in the setting of other stable or responding sites of disease (n = 22). Patient characteristics, ablation margins, imaging responses, and cases of PFS were assessed. Follow-up imaging was performed using contrast-enhanced computed tomography (CT), magnetic resonance (MR) imaging, or positron-emission tomography/ CT. Results Median PFS was 10 months (95% confidence interval [CI], 6.2 –14.5 months), and time to local progression was 11 months (95% CI, 5–16 months). Eight patients (24%) maintained no evidence of disease during a median follow-up period of 39 months. Ablation margin ≥5 mm was associated with no local tumor progression. Longer PFS was noted in estrogen receptor-positive patients (12 vs 4 months; P = .037) and younger patients (12 vs 4 months; P = .039) treated to eradicate all sites of disease (13 vs 5 months; P = .05). Eighteen patients (55%) developed new metastases during study follow-up. Conclusions Thermal ablation of oligometastatic pulmonary, hepatic, bone, and soft tissue tumors can eliminate local tumor progression if margins are ≥5 mm. Longer PFS was observed in patients who were estrogen receptor-positive and patients who were younger and in whom all sites of disease were eradicated.

Image-guided percutaneous thermal ablation is a widely acceptable local therapy for patients with colorectal liver metastases who are noneligible for surgery or present with recurrence after hepatectomy. The increasing knowledge of factors that affect oncologic outcomes has allowed selected patients with resectable small volume colorectal liver metastases to be treated by thermal ablation with curative intent. The continuous technological evolutions in imaging and image-guidance and the wide implementation of microwave ablation that overcomes most of the limitations of radiofrequency ablation have contributed to this paradigm shift. The importance of patient selection, ablation margin evaluation, and confirmation of complete tumor ablation (A0) are discussed in this article.

role of liver-directed chemotherapy and loco-regional interventions in managing colorectal cancer liver metastases

To review outcomes following microwave ablation (MWA) of colorectal cancer pulmonary metastases and assess predictors of oncologic outcomes.Technical success, primary and secondary technique efficacy rates were evaluated for 50 patients with 90 colorectal cancer pulmonary metastases at immediate, 4-8 weeks post-MWA and subsequent follow-up CT and/or F-18-FDG PET/CT. Local tumor progression (LTP) rate, LTP-free survival (LTPFS), cancer-specific and overall survivals were assessed. Complications were recorded according to SIR classification.Median follow-up was 25.6 months. Median tumor size was 1 cm (0.3-3.2 cm). Technical success, primary and secondary technique efficacy rates were 99, 90 and 92%, respectively. LTP rate was 10%. One-, 2- and 3-year LTPFS were: 93, 86 and 86%, respectively, with median LTPFS not reached. Median overall survival was 58.6 months, and median cancer-specific survival (CSS) was not reached. One-, 2- and 3-year overall and CSS were 94% and 98, 82 and 90%, 61 and 70%, respectively. On univariate analysis, minimal ablation margin (p = 5 mm and/or tumor size 10 ng/ml (p = 0.046) and >= 3 prior chemotherapy lines predicted decreased CSS (p = 0.02). There was no 90-day death. Major complications rate was 13%.MWA with minimal ablation margin >= 5 mm is essential for local control of colorectal cancer pulmonary metastases. Pleural-based metastases and larger tumor size were associated with higher risk of LTP. CEA level and pre-MWA chemotherapy impacted CSS.

To evaluate initial response and overall survival of neuroendocrine tumor (NET) liver metastases initially treated with transarterial embolization (TAE) using spherical particles of different sizes. A single-institution retrospective review was performed of 160 patients with NET liver metastases initially treated with TAE using

Purpose To determine if outpatient medications taken at the time of liver tumor embolization or ablation affect survival. Materials and Methods A retrospective review was done of 2,032 liver tumor embolization, radioembolization, and ablation procedures performed in 1,092 patients from June 2009 to April 2016. Pathology, hepatocellular carcinoma (HCC) stage (American Joint Committee on Cancer), neuroendocrine tumor (NET) grade, initial locoregional therapy, overall survival after initial locoregional therapy, Child-Pugh score, Eastern Cooperative Oncology Group performance status, Charlson Comorbidity Index, and outpatient medications taken at the time of locoregional therapy were analyzed for each patient. Kaplan-Meier survival curves were calculated for patients taking 29 medications or medication classes (including prescription and nonprescription medications) for reasons unrelated to their primary cancer diagnosis. Kaplan-Meier curves were compared using the log-rank test. Results For patients with HCC initially treated with embolization (n = 304 patients), the following medications were associated with improved survival when taken at the time of embolization: beta-blockers ( P = .0007), aspirin ( P = .0008) and other nonsteroidal antiinflammatory drugs ( P = .009), proton pump inhibitors ( P = .004), and antivirals for hepatitis B or C ( P = .01). For colorectal liver metastases initially treated with ablation (n = 172 patients), beta-blockers were associated with improved survival when taken at the time of ablation ( P = .02). Conclusions Aspirin and beta-blockers are associated with significantly improved survival when taken at the time of embolization for HCC. Aspirin was not associated with survival differences after locoregional therapy for NET or colorectal liver metastases, suggesting an HCC-specific effect.

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.

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

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.

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.

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 (9.6fold 31-fold, Po.002). IL-10 also showed a significant increase after ablation (1.9-fold 2.8-fold, Po.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 (454-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 (Po.0003) and primary diagnosis (Po.03) were independent predictors of changes to IL-6 after ablation. Age was the only independent predictor of IL-10 levels after ablation (Po .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.

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.

Colorectal cancer (CRC), the second leading cause of cancer death in the United States, occurs in an estimated more than 145,000 patients annually, with almost 50,000 deaths each year. Metastatic liver disease is the cause of death in the majority of them (1,2). Liver-only metastases affect up to one half of patients with CRC (1,2), with approximately 15% (range, 8%–26%) presenting synchronously (3,4) and an additional 15% found metachronously during the next 5 years (3). Colorectal liver metastases (CLMs) are resectable in 20%–25% of patients only; some of the remaining 75%–80% may benefit from “downsizing” therapy, which can result in 10%–20% more patients becoming resectable. Overall survival rates in patients with either primarily or secondarily resectable CLMs can be as high as 58% at 5 years and 15% at 10 years (5,6). Current front-line treatments available to improve downsizing and resectability include systemic therapies (chemotherapy with or without bevacizumab or cetuximab) and pre-operative portal vein embolization (PVE). Other approaches include local ablation therapies, regional intraarterial therapies with embolization (transcatheter arterial chemoembolization, or radio-embolization by selective internal radiation therapy with Yttrium 90-loaded microspheres) or infusion (ie, hepatic arterial infusion [HAI] pump chemotherapy), and external beam radiation therapy (RT). The role of these liver-targeted therapies to promote conversion from unresectable to resectable liver disease remains an evaluation in progress. For the majority of patients with unresectable CRC liver metastases, standard of care is first- and second-line triplet chemotherapy, which is associated with a median survival of 18–24 months (7–10). Multiple single-institution retrospective reports suggest the potential for improvement in survival time by the addition of liver-directed therapies such as chemoembolization, HAI, or radioembolization. This has not been prospectively evaluated in controlled trials, but could potentially represent a major development in Interventional Oncology (IO). The Society of Interventional Radiology (SIR) Foundation has identified the management of metastatic CRC (mCRC) as an emerging inter-ventional radiologic research priority and convened a Research Consensus Panel (RCP) Meeting on October 3, 2011 to establish a prioritized research agenda. This article reports the proceedings from this meeting.

To describe outcomes in patients undergoing percutaneous biliary drainage to reduce total serum bilirubin level for administration of chemotherapy.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.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.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.

Purpose To identify and compare predictors of local tumor progression (LTP)-free survival (LTPFS) after radiofrequency (RF) ablation and microwave (MW) ablation of colorectal liver metastases (CLMs). Materials and Methods This is a retrospective review of CLMs ablated from November 2009 to April 2015 (110 patients). Margins were measured on contrast-enhanced computed tomography (CT) 6 weeks after ablation. Clinical and technical predictors of LTPFS were assessed using a competing risk model adjusted for clustering. Results Technique effectiveness (complete ablation) was 93% (79/85) for RF ablation and 97% (58/60) for MW ablation (P = .47). The median follow-up period was significantly longer for RF ablation than for MW ablation (56 months vs. 29 months) (P .001). There was no difference in the local tumor progression (LTP) rates between RF ablation and MW ablation (P = 0.84). Significant predictors of shorter LTPFS for RF ablation on univariate analysis were ablation margins 5 mm or smaller (P .001) (hazard ratio [HR]: 14.6; 95% confidence interval [CI]: 5.2–40.9) and perivascular tumors ( P = .021) (HR: 2.2; 95% CI: 1.1–4.3); both retained significance on multivariate analysis. Significant predictors of shorter LTPFS on univariate analysis for MW ablation were ablation margins 5 mm or smaller (P .001) (subhazard ratio: 11.6; 95% CI: 3.1–42.7) and no history of prior liver resection (P .013) (HR: 3.2; 95%: 1.3–7.8); both retained significance on multivariate analysis. There was no LTP for tumors ablated with margins over 10 mm (median LTPFS: not reached). Perivascular tumors were not predictive for MW ablation (P = .43). Conclusions Regardless of the thermal ablation modality used, margins larger than 5 mm are critical for local tumor control, with no LTP noted for margins over 10 mm. Unlike RF ablation, the efficiency of MW ablation was not affected for perivascular tumors.

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.

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 μm) polyvinyl alcohol or spherical embolic particles (40–120 μm) 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 (≥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.

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.

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 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.