Search

Neuroendocrine tumors are a heterogeneous group of malignancies with diverse biological and clinical behavior. Locoregional treatments available for the initial and temporal management of neuroendocrine tumors involving the liver include transarterial embolization, transarterial chemoembolization, selective internal radiotherapy, and ablative techniques. These therapies are best employed as part of a multidisciplinary management team focusing on appropriate histopathology, timing, and individuality of each intervention.

Chronic noncyclic pelvic pain is a complex clinical problem with multiple etiologies. A multidisciplinary team approach is necessary to optimize treatment. This chapter will focus on noncyclic pain due to ovarian and internal iliac varices, now classified in the group of pelvic venous disorders. In the literature, reported treatments have included medical therapy, surgical therapy, and transcatheter embolotherapy. The latter treatment option is emphasized. Clinical aspects, imaging, outcomes, complications of treatment, and technical aspects are reviewed.

Aim: The aim of this study was to report a case of metastatic uveal melanoma in which radioembolized nodular liver metastases decreased in size while infiltrative sinusoidal metastases progressed, leading to jaundice without obstruction of the biliary ducts. Methods: The relevant clinical features, imaging, and histopathologic findings of this case are reviewed. Results: A 61-year-old Caucasian male with a history of uveal melanoma of the left eye status post plaque brachytherapy developed numerous liver metastases. After progression on systemic therapies, he underwent palliative radioembolization. Despite some radiographic improvement in the liver metastases, he developed hyperbilirubinemia without biliary tract obstruction or signs of liver failure. A biopsy of radiographically normal liver demonstrated extensive sinusoidal infiltration with melanoma. Conclusions: Distinct angiographic and histopathologic growth patterns of metastatic uveal melanoma differ in their amenability to radioembolization. Sinusoidal infiltration may lead to hyperbilirubinemia in the absence of overt obstruction or liver failure.

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy in the world, with over 14 million cases in 2012 and an expected growth to 22 million over the next 20 years [1–3]. It develops secondary to intrinsic liver diseases such as viral hepatitis, alcoholic cirrhosis, steatohepatitis, biliary cirrhosis, or other rarer causes. It represents the third most common etiology of cancer-related deaths in the world and the seventh most common etiology in the United States [3, 4]. As most patients have concomitant chronic liver disease leading to the development of HCC, management of the disease becomes more complicated. Staging and treatment options are impacted not only by the extent of the tumor but also by the patient’s liver function and performance status. Because the majority of patients present with unresectable disease, locoregional therapies, including image-guided percutaneous ablation and image-guided transcatheter tumor therapies, play an important role in the management of patients with HCC.

Background Single institution reports demonstrate variable safety profiles when liver-directed therapy with Yttrium-90 (Y-90) is followed by hepatectomy. We hypothesized that in well-selected patients, hepatectomy after Y90 is feasible and safe. Methods Nine institutions contributed data for patients undergoing Y90 followed by hepatectomy (2008–2017). Clinicopathologic and perioperative data were analyzed, with 90-day morbidity and mortality as primary endpoints. Results Forty-seven patients were included. Median age was 59 (20–75) and 62% were male. Malignancies treated included hepatocellular cancer (n = 14; 30%), colorectal cancer (n = 11; 23%), cholangiocarcinoma (n = 8; 17%), neuroendocrine (n = 8; 17%) and other tumors (n = 6). The distribution of Y-90 treatment was: right (n = 30; 64%), bilobar (n = 14; 30%), and left (n = 3; 6%). Median future liver remnant (FLR) following Y90 was 44% (30–78). Resections were primarily right (n = 16; 34%) and extended right (n = 14; 30%) hepatectomies. The median time to resection from Y90 was 196 days (13–947). The 90-day complication rate was 43% and mortality was 2%. Risk factors for Clavien-Dindo Grade>3 complications included: number of Y-90-treated lobes (OR 4.5; 95% CI1.14–17.7; p = 0.03), extent of surgery (p = 0.04) and operative time (p = 0.009). Conclusions These data demonstrate that hepatectomy following Y-90 is safe in well-selected populations. This multi-disciplinary treatment paradigm should be more widely studied, and potentially adopted, for patients with inadequate FLR.

To prospectively evaluate percutaneous image-guided nerve cryoablation for treatment of refractory phantom limb pain (PLP) in a pilot cohort for purposes of deriving parameters to design a larger, randomized, parallel-armed, controlled trial.From January 2015 to January 2016, 21 patients with refractory PLP underwent image-guided percutaneous cryoneurolysis procedures. Visual analog scale scores were documented at baseline and 7, 45, and 180 days after the procedure. Responses to a modified Roland Morris Disability Questionnaire were documented at baseline and 7 and 45 days after the procedure.Technical success rate of the procedures was 100%. There were 6 (29%) minor procedure-related complications. Disability scores decreased from a baseline mean of 11.3 to 3.3 at 45-day follow-up (95% confidence interval 5.8, 10.3; P.0001). Pain intensity scores decreased from a baseline mean of 6.2 to 2.0 at long-term follow-up (95% confidence interval 2.8, 5.6; P.0001).Image-guided percutaneous nerve cryoablation is feasible and safe and may represent a new efficacious therapeutic option for patients with phantom pains related to limb loss.

Primary and metastatic liver cancers are responsible for considerable morbidity and mortality, and many patients are not curable at presentation. Therefore, new therapies such as radioembolization with yttrium 90 ((90)Y)-labeled microspheres are an alternative method to treat patients with unresectable primary or secondary liver tumors. Patient selection, treatment technique, and early recognition of potential complications are the keys for successful patient outcomes. The activity of administered (90)Y microspheres depends on multiple variables, including the tumor burden, the volume of the liver lobe to be treated, the type of (90)Y microspheres, and the hepatopulmonary shunt fraction. Preprocedural planning relies on the results of cross-sectional imaging to determine the extent of disease, tumoral and nontumoral liver volumes, patency of the portal vein, and the degree of extrahepatic disease. A multidisciplinary approach that combines expertise in cross-sectional imaging, nuclear medicine, and flow dynamics is critical to adequately target malignant tissue. Preprocedural multimodality imaging, particularly combined single photon emission computed tomography (SPECT) and computed tomography (CT) imaging (SPECT/CT), may be used to identify nontarget imaging patterns that, if recognized, can potentially be corrected with either branch vessel embolization or catheter repositioning. Postprocedural multimodality imaging is also useful to confirm the appropriate delivery of (90)Y microspheres, enabling early identification of potential complications and the adequacy of microsphere distribution, thereby optimizing planning for subsequent therapies.

Purpose To demonstrate the safety and feasibility of an anterior approach for percutaneous fiducial marker placement for stereotactic beam radiation therapy of pancreatic head adenocarcinoma. Materials and Methods Five patients (age range, 53-70 years; mean age, 59 y) with borderline resectable pancreatic adenocarcinoma were enrolled for a phase II clinical trial (WCI-1998-11), which includes a combination of 5-Fluorouracil, Oxaliplatin, and Irinotecan (FOLFIRINOX) chemotherapy regiment, followed by stereotactic beam radiation therapy (SBRT), and then surgical resection with a Whipple procedure. For guidance of SBRT, we placed 1.2cm x 3mm soft tissue gold markers through a 17-gauge ETW x 20 cm needle in an orthogonal plane within 1-2 cm surrounding these tumors prior to SBRT under CT guidance. The route of placement of the fiducial markers was an anterior approach through several of the organs residing anterior to the pancreas, such as the stomach and liver. Technical success was assessed when post CT placement demonstrated all fiducial markers surrounding the mass resided 1-2 cm around the tumor in an orthogonal configuration without evidence of migration, as well as deemed appropriate for guidance of SBRT by Radiation Oncology. Patients were followed clinically and with labs, as well as imaging for post procedural complications. Results Percutaneous Fiducial Marker placement was technically successful in all 5 patients (100.0%). All patients tolerated the procedure well, without clinical or imaging evidence for post procedural complications, despite numerous transhepatic and transgastric approaches. Additionally, there were no evidence for migration of these markers and three of the five patients have been successfully treated with SBRT, which resulted in decrease of tumor size, allowing these patients to receive surgical resection Conclusion Percutaneous fiducial marker placement surrounding pancreatic head adenocarcinomas was deemed safe and feasible from an anterior approach, despite traversing through the liver and/or the stomach to obtain appropriate placement.