Search

We report a case of safe and successful yttrium-90 resin microsphere radioembolization in a patient with a long history of multiple recurrent colon cancer hepatic metastases progressing after hepatic resections, hepatic arterial chemotherapy, and multiple regimens of systemic chemotherapy. One month prior to radioembolization, a biliary stent was placed above the level of the ampulla to relieve tumor-related biliary obstruction and normalize bilirubin levels.

Background PNH is associated with abdominal vein thrombosis, which can cause splenomegaly and hypersplenism. The combination of thrombosis, splenomegaly, and thrombocytopenia (TST) is challenging because anticoagulants are indicated but thrombocytopenia may increase the bleeding risk. Splenectomy could alleviate thrombocytopenia and reduce portal pressure, but it can cause post-operative thromboses and opportunistic infections. We therefore sought to determine whether selective splenic artery embolization (SSAE) is a safe and effective alternative to splenectomy for TST in patients with PNH. Methods Four patients with PNH and TST received successive rounds of SSAE. By targeting distal vessels for occlusion, we aimed to infarct approximately 1/3 of the spleen with each procedure. Results Three of 4 patients had an improvement in their platelet count, and 3 of 3 had major improvement in abdominal pain/discomfort. The one patient whose platelet count did not respond had developed marrow failure, and she did well with an allo-SCT. Post-procedure pain and fever were common and manageable; only one patient developed a loculated pleural effusion requiring drainage. One patient, who had had only a partial response to eculizumab, responded to SSAE not only with an improved platelet count, but also with an increase in hemoglobin level and decreased transfusion requirement. Conclusions These data indicate that SSAE can decrease spleen size and reverse hypersplenism, without exposing the patient to the complications of splenectomy. In addition, SSAE probably reduces the uptake of opsonised red cells in patients who have had a limited response to eculizumab, resulting in an improved quality of life for selected patients.

Background: In most instances, advanced neuroendocrine tumors follow an indolent course. Hepatic metastases are common, and although they can cause significant pain, incapacitating endocrinopathy, and even death, they are usually asymptomatic. The appropriate timing and efficacy of interventions, such as hepatic artery emobolization (HAE) and operation, remain controversial. Study Design: The records of 85 selected patients referred for treatment of hepatic neuroendocrine tumor metastases between 1992 and 1998 were reviewed from a prospective database. A multidisciplinary group of surgeons, radiologists, and oncologists managed all patients. Overall survival among this cohort is reported and prognostic variables, which may be predictive of survival, are analyzed. Results: There were 37 men and 48 women, with a median age of 52 years. There were 41 carcinoid tumors, 26 nonfunctional islet cell tumors, and 18 functional islet cell tumors. Thirty-eight patients had extrahepatic metastases, and in 84% of patients, the liver metastases were bilobar. Eighteen patients were treated with medical therapy or best supportive care, 33 patients underwent HAE, and 34 patients underwent hepatic resection. Both the HAE-related mortality and the 30-day operative mortality rates were 6%. By univariate analysis, earlier resection of the primary tumor, curative intent of treatment, and initial surgical treatment were associated with prolonged survival (p Conclusions: Hepatic metastases from neuroendocrine tumors are best managed with a multidisciplinary approach. Both HAE and surgical resection provide excellent palliation of hormonal and pain symptoms. In select patients, surgical resection of hepatic metastases may prolong survival, but is rarely curative.

Diagnostic imaging plays an essential role in management of hepatobiliary tumors. High resolution images provided by computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound (US) allow detection of tumor within the liver. CT arterial portography remains the standard for detection of small lesions in the range of 1.5 cm, but noninvasive techniques such as contrast-enhanced helical CT and MR hold promise for comparable lesion detection. MRI provides lesion characterization for differentiation of benign and malignant tumors. Lesion characterization has been further improved by faster CT and MR techniques that allow imaging in both arterial and portal venous phases for characterization of lesions based on the rate and pattern of enhancement. Functional imaging such as 2-fluoro-2-deoxy-D-glucose-positron-emission tomography (FDG-PET) is increasingly utilized for detection of intrahepatic tumor and extrahepatic disease. Accuracy of FDG-PET for extrahepatic disease is better than conventional imaging and has been shown to change management in a significant number of patients. Imaging is also invaluable for surgical planning. Segmental anatomy is well shown by CT, MRI, and US. CT or MR angiography with newer 3D techniques delineate vascular variants and areas of encasement or occlusion by tumor. Biliary involvement at the hilus may be shown by US and MR cholangiography. Imaging detection of vascular involvement, bile duct extension, and lobar atrophy may alter the surgical approach.

SummaryCase-control studies have yielded conflicting results regarding the relative risk of venous thromboembolism associated with the factor V R2 allele. We calculated odds ratios in 581 patients and 469 agematched controls. The odds ratio for the R2 allele in patients relative to controls was 1.21 (95% CI 0.84 to 1.74). These results do not support the hypothesis that the R2 allele is a risk factor for venous thromboembolism. There was no relationship between factor V levels and R2 carrier status. Normalised APC sensitivity ratios were not lower in carriers of the R2 allele. In an in vitro model progressive APC resistance was observed with factor V levels of 60% and less but ratios less than 2.4 (equivalent to a normalised ratio of 0.73) did not occur until factor V levels were less than 20%. The relationship between APC resistance and factor V level was not observed in a factor VIII-independent model.

Intrinsic involvement of bile ducts, by metastatic colorectal adenocarcinoma growing from within or invading the lumen of bile ducts, is not a well recognized pattern of tumor growth. Clinical, radiographic, operative, and histopathologic aspects of 15 patients with intrabiliary colorectal metastases were described. Fourteen patients were explored for possible hepatic resection. Two had jaundice, two radiographic evidence of an intrabiliary filling defect, 10 intraoperative evidence of intrabiliary tumor, and six microscopic evidence of intrabiliariy tumor. Eleven patients underwent hepatic resection. Five of the resected patients developed hepatic recurrence. Four patients were explored for possible repeat resection. One had jaundice, one radiographic evidence of an intrabiliary filling defect, all had intraoperative evidence of intrabiliary tumor, and three microscopic evidence of intrabiliary tumor. Three patients underwent repeat hepatic resection. All patients with preoperative jaundice and radiographic evidence of an intrabiliary filling defect were unresectable. Overall, actuarial five-year survival is 33% for those patients resected versus 0% for those not resected. Intraoperative recognition of intrabiliary tumor at exploration for hepatic resection was more common than clinical, radiographic, or histopathologic recognition. More diligent examination of resected liver tissue by the surgeon and pathologist may increase identification of bile duct involvement and aid in achieving adequate tumor clearance.

Purpose To evaluate treatment outcome with respect to the indication for treatment in patients with neuroendocrine tumors metastatic to the liver undergoing hepatic artery embolization with polyvinyl alcohol (PVA) particles. Materials and Methods Charts and radiographs were reviewed of 35 patients undergoing 63 separate sessions of embolotherapy between January 1993 and July 1997. Patient demographics, tumor type, indication for embolization, and complications were recorded. Symptomatic and morphologic responses to therapy were noted, as well as duration of response. Results Fourteen men and 21 women underwent embolization of 21 carcinoid and 14 islet cell tumors metastatic to the liver. These patients underwent 63 separate episodes of embolotherapy. Of 48 episodes that could be evaluated, response to treatment was noted following 46 episodes (96%). The duration of response was longest in patients treated for hormonal symptoms with (17.5 months) or without (16 months) pain, and was shortest (6.2 months) when the indication was pain alone. Complications occurred after 11 of the 63 embolizations (17%), including four (6%) deaths. Cumulative 5-year survival following embolotherapy was 54%. Conclusion Hepatic artery embolization with PVA particles is beneficial for patients with neuroendocrine tumors metastatic to the liver and may be used for control of pain as well as hormonal symptoms. This therapy should be used cautiously when more than 75% of the hepatic parenchyma is replaced by tumor.

Purpose To evaluate the outcome of all patients undergoing particle embolization for hepatocellular carcinoma at a single institution from January 1, 1993, through December 31, 1995. Materials and Methods The charts and radiographs of all patients undergoing particle embolization during the study period were reviewed. The following information was collected: patient demographics, Child class and Okuda stage, number of embolization treatment sessions, length of hospital stay, complications related to the embolization procedure, including postembolization syndrome, current patient status, and date of death. Results Forty-six patients underwent 86 embolization sessions during the study period. Postembolization syndrome developed after 70 of the 86 sessions (81%); in four cases (4.6%) this required treatment that extended the patient's hospital stay. Three other complications occurred (3.5%), including a splenic infarct and two episodes of transient hepatic failure, all treated supportively. There was one death within 30 days, but it was not directly attributable to embolotherapy. Follow-up was available for all of the patients who underwent treatment. Thirty-four patients were classified as Child class A, and 12 were classified as Child class B. Thirty patients were classified as Okuda stage I, 14 were classified as Okuda stage II, and two were classified as Okuda stage III. Overall actuarial survival was 50% at 1 year and 33% at 2 years. There was a statistically significant difference in survival between Okuda stage I and stage II patients, but not between Child class A and class B patients. Conclusion Particle embolization for hepatocellular carcinoma is well tolerated and demonstrates actuarial survival of 50% at 1 year and 33% at 2 years.

A new factor V mutation associated with resistance to activated protein C and thrombosis (factor V Cambridge, Arg306→Thr) was found in one patient from a carefully selected group of 17 patients with venous thrombosis and confirmed APC resistance in the absence of the common Gln506 mutation. The Arg306 mutation was also present in a first degree relative who also had APC resistance. Other potential causes of APC resistance, such as a mutation at the Arg679 site and the factor V HR2 haplotype, were excluded. Subsequent screening of 585 patients with venous thromboembolism and 226 blood donors did not show any other individual with this mutation. Factor VThr306 is the first description of a mutation affecting the Arg306 APC cleavage site and is the only mutation, other than factor V Leiden (Arg506→Gln), that has been found in association with APC resistance. This finding confirms the physiologic importance of the Arg306 APC-cleavage site in the regulation of the prothrombinase complex. It also supports the concept that APC resistance and venous thrombosis can result from a variety of genetic mutations affecting critical sites in the factor V cofactor.

Background . This study was performed to assess chemical shift magnetic resonance imaging (CSMRI) for characterizing adrenal masses in patients with lung cancer, and to compare charges associated with two algorithms for assessing adrenal masses in these patients. Methods . Forty-two patients with lung cancer underwent both CSMRI (using in-phase and opposed-phase gradient echo images) and computed tomography-guided percutaneous biopsy of adrenal masses. Adrenal-to-spleen signal intensity ratios on the opposed-phase images were correlated with histopathologic results. The normalized charges for two algorithms were compared. In algorithm A, computed tomography-guided biopsy is used first to evaluate an adrenal mass; in algorithm B, CSMRI is used first, followed by computed tomography-guided biopsy only if CSMRI findings are not diagnostic of adenoma. Results . Biopsy showed 24 (57%) adrenal adenomas and 18 (43%) metastases. Chemical shift magnetic resonance imaging was 96% sensitive for adenoma and 100% specific. The average normalized charges associated with algorithm A were $1,905 per patient versus $1,890 with algorithm B. Conclusions . Initial use of CSMRI in evaluating an adrenal mass in lung cancer patients can obviate biopsy in 55% of patients, and its charges are similar to those for performing computed tomography-guided biopsy in all patients.

The most commonly detected hypercoagulable state involves an abnormal factor V protein synthesized by the liver in which arginine at position 506 is replaced by glutamine as a result of a single-point mutation in the factor V gene (factor V Leiden). Liver transplantation is complicated by hepatic vascular thrombosis in up to 15% of cases, resulting in graft loss in most instances. This retrospective study examined the effect of the factor V Leiden mutation on the risk of hepatic vessel thrombosis after liver transplantation. The mutation was sought by polymerase chain reaction and Mnl I digestion of DNA where available from 214 recipients and 276 donors receiving 319 liver transplants. No donors or patients were homozygous for the factor V Leiden mutation. The prevalence of the heterozygous mutation was 19 of 276 (6.9%) in donors and 19 of 214 (8.9%) in recipients. Forty-one thrombotic episodes occurred after transplantation in the 276 transplants in which donor DNA was available for analysis; 22 involved the hepatic artery, 9 involved the portal vein, and 10 were deep venous thromboses. A donor factor V Leiden mutation was detected in the donor in 6 of 41 (14.6%) with any thrombotic event compared with 13 of 235 (5.5%) without (P = 0.03). The relative risk of any thrombosis with this mutation was therefore 2.32 (95% confidence interval [CI], 1.12-4.81). The factor V Leiden mutation was present in the donor in 4 of 31 (12.9%) cases complicated by hepatic vessel thrombosis (which always led to graft loss or death) and 15 of 245 (6.1%) cases without (P = 0.16). The relative risk of hepatic vessel thrombosis in the presence of this allele was therefore 2.00 (95% CI, 0.78-5.14). As anticipated, the presence of this allele in the recipient was not associated with deep venous or hepatic vessel thrombosis. The factor V Leiden mutation in the donor liver is not a major risk factor for hepatic vessel thrombosis and subsequent graft loss after liver transplantation.

This study was performed to compare two proposed algorithms used when evaluating an adrenal mass discovered during staging evaluation of a patient with a known malignancy. Such evaluation was meant to lead to determination of the relative charges associated with each algorithm.Fifty-four patients with known malignancies who required evaluation of an adrenal mass underwent both chemical shift imaging (CSI) and CT-guided for CSI. The hospital charges incurred for each procedure and any associated complications were normalized using national relative-value scale charges and conversion factors. A decision analysis was performed to compare the relative charges that would have been incurred if adrenal MR imaging had been performed in all patients, followed by CT-guided biopsy only in those patients with MR findings not diagnostic of adrenocortical adenoma, and the relative charges incurred if only CT-guided adrenal biopsy had been performed in every patient.Twenty-three (43%) of 54 adrenal masses were shown to be metastases by CT-guided biopsy. The sensitivity and specificity of CSI for the diagnosis of adrenocortical adenoma were 94% and 100%, respectively. The charges incurred by performing MR imaging as the initial examination with subsequent CT-guided biopsy only in those patients with CSI findings not diagnostic of adenoma would have been similar to those incurred by first performing CT-guided adrenal biopsy in every patient.CSI is an accurate, noninvasive technique for evaluating adrenal masses in patients with cancer. If CT-guided biopsy is used only when CSI is not diagnostic of adrenocortical adenoma, the associated charges would be virtually the same as when CT-guided biopsy is performed as the first test in every patient. Moreover, biopsies could have been avoided in 54% of these patients.

Purpose The authors determined the incidence and cause of obstructive jaundice requiring percutaneous biliary drainage (PBD) occurring in patients treated with hepatic artery infusional (HAI) chemotherapy. The radiographic findings in the different causes of obstruction are characterized, and predictors of outcome are identified. Materials and Methods Charts and radiographs were reviewed for 30 patients who developed obstructive jaundice while receiving HAI chemotherapy and who subsequently required biliary drainage. The cause of obstruction, complications related to PBD, and survival from the time of PBD were recorded for each patient. Results Of 282 patients treated with HAI chemotherapy, 30 (10.6%) developed obstructive jaundice requiring PBD. Obstruction was related to chemotherapy-induced biliary sclerosis in 24 patients (80%). Five patients (17%) had bleeding complications related to PBD. Average survival was 32 weeks after biliary drainage. All four patients who had bilomas at the time of PBD had been treated with high-dose mitomycin, and lived an average of 10 weeks after the procedure. Conclusion Chemotherapy-induced biliary sclerosis is the most common cause of obstructive jaundice in patients receiving HAI chemotherapy. These patients have a higher incidence of bleeding complications and may develop pseudoaneurysms remote from the ductal puncture site. Development of intrahepatic bilomas is associated with high-dose mitomycin-C treatment, and the presence of a biloma at the time of PBD is a poor prognostic indicator.

BackgroundHepatic arterial infusion (HAI) chemotherapy is an effective treatment for patients with liver malignancy. Extrahepatic perfusion (EHP) after HAI pump placement requires correction prior to starting chemotherapy. The aim of this study was to define the origin of arterial branches causing EHP in order to determine if alterations in surgical technique during pump placement might prevent EHP.MethodsA prospectively maintained, single-centre HAI database was reviewed for all patients (2008–2011) with EHP. The origin of arterial branches causing EHP was classified anatomically and patient outcomes were analysed.ResultsOf the 327 patients with pumps implanted, 24 evidenced EHP. The arterial branch responsible for EHP perfused the duodenum, pancreas and/or stomach. The branch responsible for EHP arose from the proper hepatic artery (PHA), 1st, 2nd, or 3rd order hepatic artery branches in 7, 10, 5 and 2 patients, respectively. The majority of branches beyond the PHA causing EHP (13/17) originated from the right hepatic artery. In 18 patients, aberrant branches were successfully treated with embolization.ConclusionThese findings provide the anatomic basis for prevention of up to one-third of the cases of EHP intra-operatively, decreasing the number of patients who will require additional procedures for correction of EHP post-operatively.

BACKGROUND. Resection has been the standard of care for patients with solitary hepatocellular carcinoma (HCC). Transarterial embolization and percutaneous ablation are alternative therapies often reserved for suboptimal surgical candidates. Here we compare long-term outcomes of patients with solitary HCC treated with resection versus combined embo-ablation. METHODS. We previously reported a retrospective comparison of resection and embo-ablation in 73 patients with solitary HCC

PURPOSE: To compare ultrasound (US) to angiography combined with computed tomography during arterial portography (CTAP) in the preoperative evaluation of the portal vein. MATERIALS AND METHODS: Sixty-three consecutive patients being considered for hepatic resection underwent color and spectral Doppler US and angiography with CTAP before surgery. The main, right, and left portal veins were evaluated separately. A total of 187 veins were assessed for encasement, occlusion, or thrombosis. RESULTS: At surgery, 41 portal veins were abnormal. US allowed detection of 38 of 41 (93%) involved portal veins with 93% sensitivity, 99% specificity, 97% positive predictive value, and 98% negative predictive value. Angiography with CTAP allowed diagnosis of 37 of 41 (90%) involved portal veins with 90% sensitivity, 99% specificity, 95% positive predictive value, and 97% negative predictive value. CONCLUSION: US is comparable to angiography combined with CTAP in evaluation of the portal vein.

Women at high risk of developing breast cancer who attend surveillance programs (SP) overestimate their risk and are highly anxious; those who are anxious are less likely to perform breast self-examination (BSE). We attempted to determine if counseling by a breast surgeon could increase women's accuracy of risk perception and hence decrease their anxiety and increase their likelihood of performing BSE. We also tested the efficacy of a series of four informative newsletters in reducing anxiety. All 145 women who scheduled an initial appointment during one year for our SP were asked to participate; 94 women completed a self-report questionnaire containing validated instruments before their first SP visit. Of these, 41 women were randomly selected to receive the newsletter. Women were mailed follow-up questionnaires at 2 and 4 months after their initial visit. Of the sample, 76% overestimated their risk of developing breast cancer by at least doubling their actual risk as measured with empiric risk tables. Their psychological distress was between 0.5 to 1 standard deviation above normative scores. Being older and having greater confidence in the ability to perform BSE were the only variables that predicted performance of BSE. A follow-up assessment performed 4 months after the initial visit showed a significant improvement in the accuracy of perception of risk (p < 0.01) and a reduction of cancer anxiety (p < 0.05), but no significant change in performance of BSE. The newsletters produced no significant effect. Women attending a breast surveillance program showed a significant improvement in their ability to estimate the risk of developing breast cancer and a reduction in their anxiety after counseling, but no significant change in performance of BSE. The possibility that improvement in risk perception and reduction of cancer anxiety can lead to greater adherence to screening behaviors needs to be tested with a larger number of women and over a longer time period.

Nineteen consecutive patients with malignant hilar obstruction were imaged with angiography, CT portography, and ultrasonography with color and spectral Doppler technique; all had surgical pathologic correlation. At surgery, 12 of 19 patients (63%) were found to have portal vein involvement; 15 of 19 (79%) had parenchymal invasion; and 11 of 19 (58%) had lobar atrophy. Level of biliary obstruction was determined in seven of 19 patients (37%) without drainage catheters. No difference was found between ultrasonography and angiography with CT portography for diagnosis of atrophy, level of bile duct obstruction, hepatic involvement, or venous invasion. Extrahepatic metastases in nine of 19 patients (47%) were poorly predicted by both CT portography and ultrasonography.

PURPOSE: To assess echo-planar, fast spin-echo (SE), and chemical shift magnetic resonance (MR) imaging in differentiation of adrenal adenomas from malignant adrenal masses in patients with known malignancy. MATERIALS AND METHODS: Sixty-eight adrenal masses (23 malignant, 45 benign) in 68 patients with known malignancy were examined with echo-planar, fast SE with and without fat suppression, and chemical shift pulse sequences. RESULTS: With a cutoff T2 value of 75 msec, the sensitivity of echo-planar imaging for benign lesions was 82%, and specificity was 96%. With a cutoff adrenal mass-to-spleen signal intensity ratio of 0.80, the sensitivity of fast SE imaging for benign lesions was 53%, and specificity was 96%. With a cutoff adrenal mass-to-spleen ratio of 0.55, the sensitivity of chemical shift imaging for benign lesions was 80], and specificity was 100%. CONCLUSION: Chemical shift imaging and calculated T2 values from echo-planar imaging are promising techniques for differentiation of adrenal adenoma...

TPS4146Background: Pexa-Vec (pexastimogene devacirepvec; JX-594) is an oncolytic and immunotherapeutic vaccinia virus designed to selectively replicate in and destroy cancer cells. It causes direct oncolysis accompanied by tumor vascular disruption and anti-tumor immunity mediated by expression of the transgene GM-CSF. SOR, a multi-targeted tyrosine kinase inhibitor, is the standard of care for first-line systemic treatment of advanced HCC. Both preliminary preclinical and clinical data suggest complementary anti-tumor effects of a sequential combination of Pexa-Vec followed by SOR possibly by targeting the tumor vasculature via different mechanisms (Heo et al., Mol Ther 2011). A randomized phase II dose-finding study with 3 Pexa-Vec intratumoral (IT) liver injections in first line advanced HCC patients showed an acceptable safety profile and a significant increase in overall survival (OS) in the highest dose group (109pfu) (Heo et al., Nat Med 2013). Methods: This global, randomized, open-label, phase II...

Peripancreatic fluid collections (PFCs) occur in up to 30 % of patients following partial pancreatic resections. Traditionally, postoperative PFCs are managed via percutaneous drainage (PD). EUS-guided transgastric drainage has been shown to be effective for the management of PFCs secondary to acute pancreatitis. However, there are limited data on the use of EUS-guided drainage (EUSD) for the management of postoperative PFCs.To compare the safety and efficacy of PD versus EUSD of PFCs in patients who have undergone partial pancreatic resections.Retrospective analysis of patients with symptomatic PFCs following pancreatic enucleation or distal pancreatectomy at MSKCC between January 2008 and December 2010. Patients were identified using an electronic medical records query in addition to a prospectively maintained pancreatic surgery complications database.Single, academic, tertiary referral center.Twenty-three patients with symptomatic PFCs following pancreatic enucleation or distal pancreatectomy were retrospectively identified.CT-guided PD versus endoscopic ultrasound-guided drainage (EUSD) MAIN OUTCOME MEASURES: Outcomes included technical success, clinical success, number of interventions, and complications. Technical success was defined as successful localization of the PFC by fine-needle aspiration and placement of a drainage catheter or stent. Clinical success was defined as radiographic resolution of the PFC and removal of the drain or stent, without the need for an alternative drainage procedure or surgery.PD was initially performed in 14 patients and EUSD initially in 9 patients. Three patients with initial PD had recurrence of PFC after removal of the external drain and underwent subsequent EUSD. The mean size of the fluid collections was 10.0 cm in the PD group and 8.9 cm in the EUSD group. Technical success was achieved in all patients in both groups. Clinical success was achieved in 11 of 14 (79 %) patients in the PD group compared with 11 of 11 (100 %) in the EUSD group, with one patient in the EUSD group lost to follow-up. One patient with initial PD required two additional percutaneous procedures before complete PFC resolution. Five EUSD patients required repeat endoscopy for stent revision or necrosectomy. The median number of interventions was two [range 1-5] in the PD group and two [range 1-5] in the EUSD group. The median number of days the drainage catheters were in place was 44.5 [range 2-87] in the PD group versus 57 [range 32-217] in the EUSD group. There were no procedure-related complications in either group. Adverse events in the PD group included splenic artery stump bleeding, pleural effusion, cysto-colonic and cysto-cutaneous fistulae, and persistent catheter site pain. One patient in the EUSD group developed a small-bowel obstruction and bleeding gastric ulcer.Retrospective, nonrandomized study and small numbers.EUSD of postoperative PFCs appears to be safe and technically feasible. This technique appears to be as successful as PD for the management of PFCs with the advantage of not requiring an external drainage apparatus and should be considered as a therapeutic option in this group of patients. Further evaluation, with analysis of cost and quality of life, should be considered in a prospective, randomized trial.

To determine if the pattern of retained contrast on immediate postprocedure computed tomography (CT) after particle embolization of hepatic tumors predicts modified Response Evaluation Criteria in Solid Tumors (mRECIST) response.This study was approved by the Institutional Review Board with a waiver of authorization. One hundred four liver tumors were embolized with spherical embolic agents (Embospheres, Bead Block, LC Bead) and polyvinyl alcohol. Noncontrast CT was performed immediately after embolization to assess contrast retention in the targeted tumors, and treatment response was assessed by mRECIST criteria on follow-up CT (average time 9.0 ± 7.7 weeks after embolization). Tumor contrast retention (TCR) was determined based on change in Hounsfield units (HUs) of the index tumors between the preprocedure and immediate postprocedure scans; vascular contrast retention (VCR) was rated; and defects in contrast retention (DCR) were also documented. The morphology of residual enhancing tumor on follow-up CT was described as partial, circumferential, or total. Association between TCR variables and tumor response were assessed using multivariate logistic regression.Of 104 hepatic tumors, 51 (49%) tumors had complete response (CR) by mRECIST criteria; 23 (22.1%) had partial response (PR); 21 (20.2%) had stable disease (SD); and 9 (8.7%) had progressive disease (PD). By multivariate analysis, TCR, VCR, and tumor size are independent predictors of CR (p = 0.02, 0.05, and 0.005 respectively). In 75 tumors, DCR was found to be an independent predictor of failure to achieve complete response (p0.0001) by imaging criteria.TCR, VCR, and DCR on immediate posttreatment CT are independent predictors of CR by mRECIST criteria.

Agents such as aflibercept, which target the angiogenic pathway, are of great interest as candidates for the management of metastatic differentiated thyroid cancer. Here, we report a patient who developed a hemorrhagic abdominal pseudoaneurysm shortly after being started on this drug.The patient was a 67-year-old woman being treated with single agent aflibercept (VEGF-Trap) for metastatic thyroid cancer. She had no history of intra-abdominal pathology or vascular disease but had been previously treated with sorafenib. Twelve days after receiving her second dose of aflibercept, she developed vague abdominal pain, which increased in severity and was accompanied by nausea and vomiting. Her symptoms progressed along with a decline in her hematocrit and signs of internal hemorrhaging. An angiogram identified an occluded celiac artery with increased collaterals and a bleeding pseudoaneurysm in the inferior pancreaticoduodenal artery. After the pseudoaneurysm was coiled, the patient stabilized.Anti-angiogenic agents, usually well tolerated, can disrupt the delicate balance of normal endothelium, leading to hemorrhagic and thrombotic complications. The hemorrhage of aberrant vasculature should be included in the differential diagnosis in patients presenting with vague complaints while being treated with anti-angiogenic agents.

To assess the predictive value of examinations of tissue adherent to multitined electrodes on local tumor progression-free survival (LPFS) and overall survival (OS) after liver tumor radiofrequency ablation (RFA).An institutional review board-approved, Health Insurance Portability and Accountability Act-compliant review identified 68 liver tumors treated with RFA in 63 patients with at least 3 years' follow-up. Tissue adherent to the electrode after liver tumor RFA was evaluated with proliferation (Ki-67) and apoptotic (caspase-3) markers. LPFS and OS were evaluated by Kaplan-Meier methodology and the log-rank test. Multivariate analysis assessed the effect of tumor size, pathology, and post-RFA tissue characteristics on LPFS and OS.Post-RFA tissue examination classified 55 of the 68 tumors as completely ablated with coagulation necrosis, with cells positive for caspase-3 and negative for Ki-67 (CN). Thirteen had viable Ki-67-positive tumor cells. Mean liver tumor size was larger in the viable (V) group versus the CN group (3.4 vs. 2.5 cm, respectively; P = .017). For the V and CN groups, respectively, local tumor progression occurred in 12 (92 %) of 13 and 23 (42 %) of 55 specimens. One, 3-, and 5-year LPFS was 8 %, 8 %, and 8 %, and 79 %, 47 %, and 47 % (P.001) for the V and CN groups, respectively. During a 63-month median follow-up, 92 % of patients in the V group and 58 % in the CN group died, resulting in 1-, 3-, and 5-year OS of 92 %, 25 %, and 8 % vs. 92 %, 59 %, and 33 % (P = .032), respectively.Ki-67-positive tumor cells on the electrode after liver tumor RFA is an independent predictor of LPFS and OS. Size, initially thought to be an independent risk factor for local tumor progression in tumors 3-5 cm, does not hold its significance at long follow-up.

PURPOSE Because a family history of cancer constitutes an important risk factor, estimation and communication of cancer risk can facilitate efforts toward early detection and prevention. This review provides a resource for health professionals called to draw upon a multidisciplinary literature to provide quantitative risk estimates to families with cancer. DESIGN Descriptive population-derived, epidemiologic, genetic, genetic epidemiologic, and molecular studies are critically reviewed in the context of cancer genetic counseling. RESULTS Data are presented that document the increased lifetime relative risk to relatives of individuals with cancers of the breast, ovary, colon, prostate, or other sites. In general, risk ratios are poorly suited for clinical counseling. Age-specific absolute risks are presented for first-degree relatives of individuals affected by cancers of the breast, ovary, and colon. The derivation of Mendelian and Bayesian risk estimates in the setting of well-defined cancer family syndromes, and the growing role of DNA testing in more accurately assessing these risks, are discussed. Such carrier testing requires careful psychologic and ethical considerations. CONCLUSION Multidisciplinary cancer genetic counseling is an emerging resource available to physicians who care for families with common adult malignancies.

To report our single-center experience in managing symptomatic lymphoceles after lymphadenectomy for genitourinary and gynecologic malignancy and to compare clinical outcomes of percutaneous catheter drainage (PCD) alone versus PCD with transcatheter povidone-iodine sclerotherapy (TPIS).The medical records of patients who presented for percutaneous drainage of pelvic lymphoceles from February 1999 to September 2007 were retrospectively reviewed. Catheters with prolonged outputs50 cc/day were treated with TPIS. Technical success was defined as the ability to achieve complete resolution of the lymphocele. Clinical success was defined as resolution of the patient's symptoms that prompted the intervention.Sixty-four patients with 70 pelvic lymphoceles were treated. Forty-six patients (71.9 %) had PCD, and 18 patients (28.1 %) had multisession TPIS. The mean initial cavity size was 294.9 cc for those treated with TPIS and 228.2 cc for those treated with PCD alone (range 15-1,600) (p = 0.59). Mean duration of catheter drainage was 19 days (29 days with TPIS, 16 days with PCD, p = 0.001). Mean clinical follow-up was 22.6 months. Technical success was 74.3 % with PCD and 100 % with TPIS. Clinical success was 97 % with PCD and 100 % with TPIS. Postprocedural complications included pericatheter fluid leakage (n = 4), catheter dislodgement (n = 3), catheter occlusion (n = 9), and secondary infection of the collection (n = 4).PCD of symptomatic lymphoceles is an effective postoperative management technique. Initial cavity size is not an accurate predictor of the need for TPIS. When indicated, TPIS is safe and effective with catheter outputs50 cc/day.

To determine the rate of early infection for totally implantable venous access devices (TIVADs) placed without antibiotic prophylaxis.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.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.The rate of early infection without antibiotic prophylaxis before TIVAD placement in the interventional radiology suite is1%. Based on these data, use of prophylactic antibiotics for TIVAD placement is not recommended.

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 Conclusions CT-guided RF ablation can be used to treat recurrent CLM after hepatectomy. A low CRS is associated with better clinical outcomes.

A 72-year-old man was diagnosed with a poorly differentiated hepatic flexure mass seen on routine screening colonoscopy. He underwent a right hemicolectomy and biopsy of a liver lesion noted at laparotomy. Pathology revealed a high-grade neuroendocrine carcinoma in the primary tumor and the liver lesion. Post-operative imaging revealed an isolated FDG avid liver metastases which had not been appreciated pre-operatively. He was treated with combination platinum and etoposide for extensive stage small-cell carcinoma of the colon. After 6 cycles of chemotherapy, the isolated liver lesion remained FDG avid, albeit less than baseline. Radiofrequency ablation of the avid liver lesion was performed. Further, chemotherapy was given as the lesion remained FDG avid. Ablation was repeated and a subsequent biopsy was positive. Chemotherapy resumed for a total of 10 cycles. Repeat PET scan became negative and the patient remains disease-free 7 years from an initial diagnosis of extensive stage small-cell colon cancer with a negative PET scan. Aggressive locoregional treatment is an option in patients with extensive stage small-cell carcinoma of the colon who are left with an oligometastasis after platinum-based systemic chemotherapy.

Objective To determine the time course of liver hypertrophy after portal vein embolization (PVE). Design In a cohort study, computed tomography volumetrics were calculated for livers during a 1-year period after PVE. Setting Tertiary liver cancer treatment center. Patients Ten patients who were subjected to PVE and were found subsequently to not be candidates for liver resection. Intervention Right PVE. Main Outcome Measures Left and right liver volumes. Results The left liver continued growing for the entire first year after PVE, while the right liver continued to atrophy. The total volume remained remarkably constant. Conclusion Early PVE during administration of a course of neoadjuvant therapy would be beneficial for enhanced growth of the liver before liver resection.

Purpose To evaluate hepatic arterial patency after serial bland particle embolization procedures in patients with hepatocellular carcinoma (HCC). Materials and Methods All patients with HCC who underwent five or more hepatic artery bland embolization procedures with permanent particulate and spherical embolic agents between September 1996 and December 2007 were retrospectively reviewed. Data analyzed included patient demographics, vessels embolized, embolic agent used, and duration of arterial patency. Results Forty-three patients were identified who underwent five or more bland embolization procedures in the same arterial distribution. Of the 43 patients examined, 83% ( n = 36) showed no change in the hepatic arterial tree after repeated bland embolization (mean treatment period of 48 months ± 23). Six patients (13%) exhibited occlusion of a fifth-order or more distal vessel after an average of 5 embolizations ± 2 over a period of 34 months ± 27. A single case of vascular occlusion of a fourth-order vessel was observed after five embolizations over a period of 52 months. Conclusions Repeated bland embolization of the hepatic arteries in HCC preserves patency of the hepatic arterial vasculature despite the fact that embolization is carried out to complete stasis.

The authors describe a patient with chronic thromboembolic pulmonary hypertension. At pulmonary angiography, only severe hypertension with pruning of peripheral vessels was seen; the right pulmonary artery appeared normal. Despite the limited use of a nonionic contrast material, the patient died 11 hours after the study. At autopsy, a laminated well-organized thrombus that occupied virtually all of the right pulmonary artery and adhered to the vessel wall was seen. Other modalities should be investigated to help establish the diagnosis of chronic thromboembolic pulmonary hypertension.

Allele frequencies for the insertion/deletion (I/D) polymorphism of the angiotensin-converting enzyme (ACE) gene were determined in a large case–control study of 517 unselected patients with venous thromboembolism and 478 blood donors. The D allele frequency was 0·53 [95% confidence interval (CI) 0·50–0·56] in patients and 0·54 (95% CI 0·50–0·57) in controls, giving an odds ratio for the D allele of 0·97 (95% CI 0·81–1·16). In the same population, the odds ratio for the factor V Leiden mutation (F5G1691A) was 6·9 (95% CI 4·0–11·9). Therefore, the ACE I/D polymorphism is not a risk factor in a representative group of unselected patients with venous thromboembolism. The possibility that the I/D polymorphism is a risk factor for venous thromboembolism specifically after hip replacement cannot be excluded.

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.

BACKGROUND: The objective of this study was to compare the morbidity, mortality, and survival of patients aged

Isolated limb infusion (ILI) is a minimally invasive technique of delivering regional chemotherapy in patients with advanced melanoma or soft-tissue sarcoma of the limb. We report the final results of the first clinical trial of ILI in North America (NCT00004250). Eligible patients had recurrent melanoma or unresectable soft-tissue sarcoma of the limb. Angiographic catheters were positioned just above the knee or elbow of the extremity. General anesthesia was performed, a proximal tourniquet inflated, and a normothermic, low flow, hypoxic infusion of melphalan and dactinomycin circulated through the involved limb for 20 min. Tumor response and morbidity were assessed using standard criteria. Thirty-seven patients were accrued to the trial and 44 ILIs were performed (eight patients had two ILIs); one patient was not treated. Of the 32 evaluable patients, 17 (53%) had a significant response at 3 months: 25% of patients had a complete response and 28% of patients had a partial response. The median duration of complete response was 1 year (5-32 months). Morbidity was acceptable, with peak erythema, edema, and pain experienced at 2 weeks and considered 'moderate' in most patients. No patients developed compartment syndrome or required amputation because of ILI. ILI is well tolerated. More than half of the treated patients experienced a complete or partial response.

To determine whether histopathologic and immunohistochemical features of tissue adherent to electrodes after radiofrequency (RF) ablation of liver malignancies can help predict local tumor progression (LTP).Institutional review board waiver and informed consent were obtained. Histologic and immunohistochemical examinations of tissue adherent to electrodes after RF ablation of liver malignancies were performed, with application of proliferation (Ki-67) and apoptosis (caspase-3) markers. Clinical and technical information were prospectively collected for an HIPAA-registered database. Medical records and imaging were reviewed to determine LTP for treated tumors smaller than 5 cm in diameter. LTP-free and survival rates were assessed with Kaplan-Meier method; differences between groups assessed with permutation log-rank test. Multivariate analysis assessed with Cox regression for factors related to LTP.Sixty-eight malignant tumors treated with RF ablation were identified. Fifty-five tissue specimens were classified as coagulation necrosis (CN), thermal artifact only, or tumor cells positive for caspase-3/negative for Ki-67; and 13 as viable tumor cells (Ki-67 positive). Mean tumor size was larger in viable (3.4 cm) than in CN (2.5 cm) group before treatment (P = .01). For viable and CN groups, LTP occurred in 12 (92%) of 13 and 16 (29%) of 55 specimens, respectively; 1-year LTP-free rates were 0% and 74%, respectively (P.001). Multivariate analysis confirmed that viable cells comprise independent risk factor for LTP (P.001). The odds of LTP is six times greater in viable group compared with CN group for tumors 3-5 cm (hazard ratio: 5.9, 95% confidence interval: 2.4, 14.5) and 10 times greater for tumors smaller than 3 cm (hazard ratio: 10.1, 95% confidence interval: 1.7, 57.5). Median survival was 32.7 months.Evidence of Ki-67-positive tumor cells on the electrode after hepatic RF ablation is an independent predictor of LTP.

Malignant bile duct obstruction is not uncommon, particularly in the later stages of disease, and may result in significant deterioration in the patient's quality of life, particularly if the patient becomes pruritic. Patients who have undergone previous intervention such as surgery with bilioenteric bypass, sphincterotomy, or endoscopic retrograde cholangiopancreatography may present with cholangitis. In addition, obstructive jaundice may preclude the use of certain chemotherapeutic agents either because of increased toxicity or because they require hepatic metabolism or excretion. This article discusses the indications for drainage in this patient population, technical considerations that may be unique to this patient population, and technical suggestions for performing drainage that may be helpful.

OBJECTIVES The objectives of this study are 1) to determine whether the future liver remnant will grow after portal vein embolization (PVE) in patients with colon cancer on concurrent chemotherapy and 2) to determine whether recovery after extended hepatectomy is improved after PVE. PURPOSE Neoadjuvant chemotherapy followed by hepatic resection is an increasingly used therapeutic strategy for curative treatment for colorectal metastases. However, such chemotherapy may result in steatosis, liver damage, and compromised liver regeneration and recovery. This study aims to determine whether PVE can be used during neoadjuvant therapy to enhance growth of future residual liver and to improve postoperative recovery. METHODS From September 1999 to September 2004, 100 patients with colorectal metastases to the liver were subjected to PVE as preparation for extended hepatic resection, 43 of whom were embolized during neoadjuvant chemotherapy. Liver growth was examined by computed tomography volumetric analysis. Clinical outcomes of the 71 patients subsequently resected were compared with 100 consecutive patients subjected to extended resection without PVE (controls). RESULTS After a median wait of 30 +/- 2 days after PVE, patients on neoadjuvant chemotherapy experienced a median contralateral (nonembolized) liver growth of 22% +/- 3% compared with 26% +/- 3% for those without chemotherapy (P = NS). The number of patients with