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PURPOSE: To compare the technical success and complication rates of push versus pull gastrostomy tubes in cancer patients, and to examine their dependence on operator experience. MATERIALS AND METHODS: A retrospective review was performed of 304 cancer patients (170 men, 134 women; mean age 60.3 ±12.6 [SD], range: 19–102 years) referred for primary gastrostomy tube placement, 88 (29%) of whom had a previously unsuccessful attempt at percutaneous endoscopic gastrostomy (PEG) placement. Analyzed variables included method of insertion (push versus pull), indication for gastrostomy, technical success, operator experience, and procedure-related complications within 30 days of placement. RESULTS: Gastrostomy tubes were placed for feeding in 189 patients and palliative decompression in 115 patients. Technical success was 91%: 78% after endoscopy had previously been unsuccessful and 97% when excluding failures associated with prior endoscopy. In the first 30 days, there were 29 minor complications (17.2%) associated with push gastrostomies, and only 8 minor complications (7.5%) with pull gastrostomies (P < 0.05). There was no significant difference in major complications (push gastrostomy 5.3%, pull gastrostomy 5.6%). For decompressive gastrostomy tubes, the pull technique resulted in lower rates of both minor and major complications. There was no difference in complications or technical success rates for more versus less experienced operators. CONCLUSION: Pull gastrostomy tube placement had a lower rate of complications than push gastrostomy tube placement, especially when the indication was decompression. The technical success rate was high, even after a failed attempt at endoscopic placement. Both the rates of success and complications were independent of operator experience.

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

Background The objective of this study was to examine the current treatment for liver abscess and to assess the factors associated with failure of percutaneous drainage. Study Design Records of 58 patients with pyogenic hepatic abscess, from 1998 to 2009, were examined. Clinicopathologic variables were analyzed as predictors of failure of percutaneous drainage using multivariable logistic regression. The results of surgical intervention after failure of percutaneous treatment were also examined. Results Fifty-one patients (88%) had a history of malignancy including pancreas (36%), cholangiocarcinoma (17%), colon (12%), and gallbladder (10%). Recent hepatic artery embolization or radiofrequency ablation preceded development of abscess in 13 patients (22%). Fifteen patients (26%) had evidence of biliary tract communication, and 14 of 15 (93%) of these patients had concomitant biliary tract obstruction. Percutaneous drainage was successful in 38 patients (66%) with a median drain dwell time of 26 days (range 3 to 319 days). Five patients (9%) required operative intervention and 2 of these patients (3% overall) died postoperatively from septic complications. Fifteen patients (26%) died with percutaneous drains in place; 9 (60%) of these patients died of cancer progression without evidence of sepsis. Independent predictors of failure of percutaneous drainage included abscesses containing yeast (p = 0.003) and communication of the abscess cavity with the biliary tree (p = 0.02). Conclusions Pyogenic hepatic abscess was treated successfully in the majority of patients with advanced malignancy, although mortality remained high. The presence of yeast and communication with an untreated obstructed biliary tree were associated with failure of percutaneous drainage. The need for surgical salvage was associated with a high mortality.

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.

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 To evaluate the potential of two models of bilirubin decay to predict response to drainage in patients who underwent biliary drainage to lower serum bilirubin prior to chemotherapy. Materials and Methods IRB-approved retrospective review identified 77 patients with malignant biliary obstruction who underwent a single biliary drainage to decrease bilirubin prior to chemotherapy administration and who had at least four subsequent serum bilirubin determinations (regardless of value) at 7-10 day intervals for the first 4 weeks following the procedure. Data were analyzed in both mono-exponential (ME) (bilirubin level is described in terms of pure exponential decay) and mono-exponential-static (MS) (bilirubin level is described in terms of exponential decay followed by an inflection point where the bilirubin level levels off to a constant value) models. Responders were defined as patients who achieved total serum bilirubin levels Results Across all patients, the MS model had better fit with total serum bilirubin values after drainage than the ME model (R2 0.82 vs 0.62, respectively). When patients were stratified into responders and non-responders, the MS model similarly had better fit to patient data (responders: R2 0.91 v 0.71; non-responders R2 0.66 v 0.45). Parameters extracted from both models (ME and MS) suggest that both estimated pre-drainage bilirubin (10.4 and 10.7 mg/dL, respectively) and the exponential decay rate (0.14 and 0.22 mg/dL/day) of responders was significantly different from the estimated pre-drainage bilirubin (15.0 and 15.1 mg/dL) (P=0.0003 and P Conclusion Models of bilirubin response to percutaneous drainage may be useful to provide early clinical separation of responders from non-responders, prompting additional drainage or internalization of drainage when clinically appropriate.

34 months (95%CI1⁄426.2-56.7) respectively. Median TTUP was 56 months (95%CI1⁄429-58). OS at 1 year was 89.0 3.3%, 2 year-OS was 78.0% 4.9% and median OS was 7 years (95% CI 1⁄4 3.6 7.1). Response rate was 74%, 75%, 59%, and 40% in first, second, third and subsequent line with a trend for better response in patient who received TACE early (p1⁄40.07), as well as when tumor liver involvement was below 75% (p1⁄40.08). There was no difference in overall response rate between DEBTACE versus Lipiodol-TACE with 70% and 60% (p1⁄40.31) respectively. Conclusion: We demonstrated very high response rate and prolonged TTP probably linked with TACE used early in the course of the disease (63% in 1st or 2nd line). No differences were found in the response rates according to TACE technique, while higher liver toxicity was reported with DEB-TACE.

Safety and efficacy of percutaneous cecostomy for treatment of large bowel obstruction in adult cancer patients S.O. Tewari, G. Getrajdman, A.M. Covey, E.N. Petre, M.R. Weiser, R.H. Thornton, L.A. Brody, C.T. Sofocleous, M. Maybody, W. Alago, Jr., A. Aguado, R.H. Siegelbaum, J.C. Durack, J.P. Erinjeri, H. Yarmohammadi, K.T. Brown, S.B. Solomon; Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY; Surgery, Memorial SloanKettering Cancer Center, New York, NY

Purpose: HCCs bridging two or more Couinaud segments of the liver (watershed tumors) have a higher propensity of recruiting multiple segmental arteries, sometimes recognizable on angiography at the time of TACE or recruited soon after. Our hypothesis is that fewer patients in this subgroup (WS) achieve complete response (CR, mRECIST) after TACE, resulting in more TACE sessions, a shorter time to local recurrence and increased risk of disease progression exceeding Milan criteria for transplant eligibility. Materials and Methods: Transplant eligible patients listed with MELD exception points for HCC who underwent TACE as their INITIAL/i4 locoregional treatment at our institution were included in this retrospective review. Local response to TACE using mRECIST was recorded for the index tumor or, when other lesions were present, the largest tumor. Time to local recurrence and drop out due to disease progression was recorded in this transplant eligible population. Index tumors treated subsequently with another modality (e.g. ablation) were censored. Results: A total of 85 patients (52 WS, 33 non-WS) were identified. Patient demographics and tumor size were similar in both groups. CR was achieved after a single session of TACE in 85% of non-WS tumors compared to 56% of WS tumors (p1⁄40.01). Residual disease treated with additional TACE resulted in subsequent CR in a minority of patients (13% and 3%, WS and non-WS, respectively), while the rest progressed or were treated with an alternative modality. Even following CR after the initial TACE, local recurrence was seen earlier in the WS group (median 337 days) compared to the non-WS group (median 484 days). Finally, tumor progression outside the Milan criteria led to transplant ineligibility in 21% of the patients with WS tumors compared to 12% in the non-WS patients but did not reach statistical significance. Conclusion: HCCs located in watershed regions of the liver have a poor response to TACE, requiring multiple TACE sessions. The time to recurrence is shorter and may subsequently lead to transplant ineligibility due to disease progression. Aggressive, possibly multimodality, treatment of these tumors may be warranted.

Purpose: To evaluate whether outcomes of trans-arterial chemoembolization (TACE) are inferior in patients 465 years old with hepatocellular carcinoma (HCC). Materials and Methods: A retrospective review of all patients who underwent TACE for the treatment of HCC between 2000 and 2010 was performed. Two groups (o1⁄4 65 years and 465 years of age) were compared based on ChildPugh score (CP), tumor/node/metastasis (TNM) stage, hepatitis B (HBV) or C (HCV) positivity, tumor number and size, number of TACE sessions and regimen used. Imaging outcomes were assessed based on modified Response Evaluation Criteria in Solid Tumors (mRECIST) to calculate tumor response and time to progression (TTP). Tumor response was defined as Complete or Partial Response. Disease control was defined as Stable Disease, and Complete or Partial Response. A p value o1⁄40.002 was deemed statistically significant. Results: A total of 179 treatments were performed in 97 patients, 42 of whom were 4 65. The groups had similar Child-Pugh status (p1⁄40.91), TNM stage (p1⁄40.37), HBV (p1⁄40.57), HCV (p1⁄40.1), tumor number (p1⁄40.27), tumor size (p1⁄40.61), number of treatments (p1⁄40.03) and drug type (p1⁄40.44). Tumor response was observed in 63.6% (35/55) in patients o1⁄465 and 57.1% (24/42) in those 465 (p1⁄40.52). Disease control was achieved in 69.0% (38/55) of patients o1⁄465 and 73.8% (31/42) in those 465 (p1⁄40.61). The mean time to progression was 245 days for patients o1⁄465 and 130.5 days for those 465 (p1⁄40.11). Conclusion: During a similar follow-up period, the efficacy of TACE for the treatment of HCC in elderly patients is comparable with that in a younger population. TACE should be considered a reasonable locoregional therapeutic option in elderly patients with HCC.

Purpose To determine the factors that are independent predictors of subsequent radiologic necrosis following embolotherapy of HCC. Materials and Methods From Dec 2007 and Mar 2012, 101 pts with Okuda stage I or II HCC not amenable to resection, with adequate liver function were randomized to HAE with Bead Block (BB, n=51) or TACE with LC Bead (n=50) loaded with 150 mg of doxorubicin. 72 patients (BB, n=35; LC, n=37) underwent pre-procedure triphasic CT, immediate post-procedure non-contrast CT 15 min after embolization, and followup triphasic CT 3 weeks post treatment. 135 index tumors were assessed. TCR was determined based on change in Hounsfield units (HU) of the index tumors between pre-procedure and immediate post-procedure scans (Grade 0, 120 HU change). Radiologic tumor necrosis was measured on the 3 week followup CT by calculating the ratio of necrotic and overall tumor volumes using semi-automated volumetric analysis software developed at our institution. Univariate and multivariate regression was performed to determine whether demographic factors, tumor characteristics, embolic agent, and TCR were predictors of the degree of necrosis. Results Demographics and initial tumor characteristics between the BB and LC groups were comparable: median age 68 vs 55 (p Conclusion Tumor contrast retention, but not embolic agent, is an independent predictor of radiologic necrosis following embolotherapy for HCC.

9029 Background: PBD is routinely performed to relieve MBO. The clinical effects of drainage have been well documented, but little has been reported about how PBD effects a patient's QoL. Methods: Between October, 2004 and December, 2006, eligible patients (>18 years old, English speaking, clinical diagnosis of MBO) scheduled to undergo PBD at a comprehensive cancer center were invited to participate in a prospective study evaluating QoL using the Functional Assessment of Cancer Therapy Hepatobiliary (FACT-Hep) instrument, comprised of 5 subscales (physical, emotional, functional and social well being, and disease-specific concerns). FACT is the total score of the first four items; FACT-Hep is the total score of all 5 subscales. Patients completed the instrument at baseline, one week and four weeks following PBD. Instruments were scored following FACT guidelines; changes in QoL between these time points were analyzed using a mixed effect model with time as a categorical variable. Results: One hundred twenty five patients consented to participate in this study. Sixteen were not evaluable and were withdrawn from the study. One hundred nine (60 male / 49 female) patients completed the baseline instrument (100%), 57% at one week and 39% at four weeks. Thirty four patients (31%) completed all time points. The most common diagnoses included cholangiocarcinoma (30%), pancreatic cancer (29%), and metastatic colorectal cancer (17%). Mortality was 10% (N=11) at 4 weeks and 28% (N=30) 8 weeks following PBD, with one patient dying from a procedure related complication. The mean FACT scores are indicated in the table below. A declining score is associated with a decline in QoL. Conclusions: PBD for MBO does not improve overall QoL following PBD. Patients have significant disease related mortality within eight weeks of the procedure. [Table: see text] No significant financial relationships to disclose.