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Supplementary Tables 1-3 and Table A-1, Figure 1, Appendix and Information from The BATTLE Trial: Personalizing Therapy for Lung Cancer

Supplementary Figure 1: Heatmap of the 68 non-small cell lung cancer cell lines with EGFR wild-type used to train the Sorafenib Sensitivity Signature; Supplementary Figure 2: Heatmap of the 37 patients with EGFR mutant tumors using the Sorafenib Sensitivity signature; yes: disease control at 8 weeks; no: no disease control at 8 weeks.

Purpose: To report the clinical efficacy of sorafenib and to evaluate biomarkers associated with sorafenib clinical benefit in the BATTLE (Biomarker-Integrated Approaches of Targeted Therapy for Lung Cancer Elimination) program.Patients and Methods: Patients with previously treated non–small cell lung cancer (NSCLC) received sorafenib until progression or unacceptable toxicity. Eight-week disease control rate (DCR), progression-free survival (PFS), and overall survival (OS) were assessed. Prespecified biomarkers included K-RAS, EGFR, and B-RAF mutations, and EGFR gene copy number. Gene expression profiles from NSCLC cell lines and patient tumor biopsies with wild-type EGFR were used to develop a sorafenib sensitivity signature (SSS).Results: A total of 105 patients were eligible and randomized to receive sorafenib. Among 98 patients evaluable for eight-week DCR, the observed DCR was 58.2%. The median PFS and OS were 2.83 [95% confidence interval (CI), 2.04–3.58] and 8.48 months (95% CI, 5.78–10.97), respectively. Eight-week DCR was higher in patients with wild-type EGFR than patients with EGFR mutation (P = 0.012), and in patients with EGFR gene copy number gain (FISH-positive) versus patients FISH-negative (P = 0.048). In wild-type EGFR tumors, the SSS was associated with improved PFS (median PFS 3.61 months in high SSS vs. 1.84 months in low SSS; P = 0.026) but not with eight-week DCR. Increased expression of fibroblast growth factor-1, NF-κB, and hypoxia pathways were identified potential drivers of sorafenib resistance.Conclusion: Sorafenib demonstrates clinical activity in NSCLC, especially with wild-type EGFR. SSS was associated with improved PFS. These data identify subgroups that may derive clinical benefit from sorafenib and merit investigation in future trials. Clin Cancer Res; 19(24); 6967–75. ©2013 AACR.

Vaccination-associated adenopathy is a frequent imaging finding after administration of COVID-19 vaccines that may lead to a diagnostic conundrum in patients with manifest or suspected cancer, in whom it may be indistinguishable from malignant nodal involvement. To help the medical community address this concern in the absence of studies and evidence-based guidelines, this paper offers recommendations developed by a multidisciplinary panel of experts from three of the leading tertiary care cancer centers in the United States. According to these recommendations, some routine imaging examinations, such as those for screening, should be scheduled before or at least 6 weeks after the final vaccination dose to allow for any reactive adenopathy to resolve. However, there should be no delay of other clinically indicated imaging (e.g., for acute symptoms, short-interval treatment monitoring, urgent treatment planning or complications) due to prior vaccination. The vaccine should be administered on the side contralateral to the primary or suspected cancer, and both doses should be administered in the same arm. Vaccination information (date(s) administered, injection site(s), laterality, and type of vaccine) should be included in every pre-imaging patient questionnaire, and this information should be made readily available to interpreting radiologists. Clear and effective communication between patients, radiologists, referring physician teams and the general public should be considered of the highest priority when managing adenopathy in the setting of COVID-19 vaccination. Summary COVID-19-vaccination–related adenopathy is a frequent imaging finding that may lead to a diagnostic conundrum in patients with manifest or suspected cancer, in whom it may be indistinguishable from malignant nodal involvement. This special report offers recommendations developed by a multidisciplinary panel of experts from three of the leading tertiary care cancer centers in the United States.

AIM To report on the multidisciplinary approach, focusing specifically on the role of the interventional radiologist (IR), used to support the Biomarker-integrated Approaches of Targeted Therapy for Lung Cancer Elimination (BATTLE) and BATTLE-2 trials. MATERIALS AND METHODS Patients who underwent percutaneous image-guided biopsy for the BATTLE and BATTLE-2 trials were reviewed. A radiology-based, three-point, lesion-scoring system was developed and used by two IRs. Lesions were given a score of 3 (most likely to yield sufficient material for biomarker analysis) if they met the following criteria: size >2 cm, solid mass, demonstrated imaging evidence of viability, and were technically easy to sample. Lesions not meeting all four criteria were scored 2 with the missing criteria noted as negative factors. Lesions considered to have risks that outweighed potential benefits receive a score of 1 and were not biopsied. Univariate and multivariate analyses were performed to evaluate the score's ability to predict successful yield for biomarker adequacy. RESULTS A total of 555 biopsies were performed. The overall yield for analysis of the required biomarkers was 86.1% (478/555), and 84% (268/319) and 88.9% (210/236) for BATTLE and BATTLE-2, respectively (p=0.09). Lesions receiving a score of 3 were adequate for biomarker analysis in 89% of cases. Lesions receiving a score of 2 with more than two negative factors were adequate for molecular analysis in 69.2% (IR1, p=0.03) and 74% (IR2, p=0.04) of cases. The two IRs scored 78.4% of the lesions the same indicating moderate agreement (kappa=0.55; 95% confidence interval [CI]: 0.48, 0.61). CONCLUSIONS IRs add value to clinical trial teams by optimising lesions selected for biopsy and biomarker analysis.

This diagnostic study investigates real-time acquisition of fluorescence confocal microscopy of interventional radiology–guided specimens in the radiology suite and compares accuracy of diagnoses with hematoxylin-eosin (H&E)–stained sections among patients undergoing core-needle biopsy., Key Points Question Can fluorescence confocal microscopy be used for immediate evaluation of interventional radiology–guided core-needle biopsy in real time at the bedside in the radiology suite? Findings In this diagnostic study of 105 patients undergoing core-needle biopsy, fluorescence confocal microscopy images were acquired in a mean of 7 minutes, were similar to hematoxylin-eosin–stained tissue sections, and were of acceptable quality in 101 (96.2%). The accuracy of fluorescence confocal microscopy diagnosis compared with the criterion standard of hematoxylin-eosin–stained tissue sections was 95.2% for pathologist 1, 85.7% for pathologist 2, and 96.2% for consensus between them. Meaning These findings suggest that fluorescence confocal microscopy can be used for real-time bedside evaluation of interventional radiology–guided core-needle biopsy with high accuracy in a range of medical settings for procuring high-quality specimens in 1 hospital visit., Importance Strategies to procure high-quality core-needle biopsy (CNB) specimens are critical for making basic tissue diagnoses and for ancillary testing. Objectives To investigate acquisition of fluorescence confocal microscopy (FCM) images of interventional radiology (IR)–guided CNB in real time in the radiology suite and to compare the accuracy of FCM diagnoses with those of hematoxylin-eosin (H&E)–stained CNB sections. Design, Setting, and Participants In this diagnostic study, FCM imaging of IR-guided CNBs was performed in the radiology suite at a major cancer center for patients with an imaging abnormality from August 1, 2016, to April 30, 2019. The time taken to acquire FCM images and the quality of FCM images based on percentage of interpretable tissue with optimal resolution was recorded. The FCM images were read by 2 pathologists and categorized as nondiagnostic, benign/atypical, or suspicious/malignant; these diagnoses were compared with those made using H&E-stained tissue sections. Cases with discrepant diagnosis were reassessed by the pathologists together for a consensus diagnosis. Data were analyzed from June 3 to July 19, 2019. Interventions Each IR-guided CNB was stained with 0.6mM acridine orange, subjected to FCM imaging, and then processed to generate H&E-stained sections. Main Outcomes and Measures Mean time taken for acquisition of FCM images, quality of FCM images based on interpretable percentage of the image, and accuracy of diagnostic categorization based on FCM images compared with H&E-stained sections. Results A total of 105 patients (57 male [54.3%]; mean [SD] age, 63 [13] years) underwent IR-guided CNBs in a mean (SD) of 7 (2) minutes each. The FCM images showed at least 20% of the tissue with optimal quality in 101 CNB specimens (96.2%). The FCM images were accurately interpreted by the 2 pathologists in 100 of 105 cases (95.2%) (2 false-positive and 3 false-negative) and 90 of 105 cases (85.7%) (6 false-positive and 9 false-negative). A reassessment of 14 discordant diagnoses resulted in consensus diagnoses that were accurate in 101 of 105 cases (96.2%) (1 false-positive and 3 false-negative). Conclusions and Relevance The ease of acquisition of FCM images of acceptable quality and the high accuracy of the diagnoses suggest that FCM may be useful for rapid evaluation of IR-guided CNBs. This approach warrants further investigation.

Transcatheter hepatic arterial chemoembolization (TACE) is the current standard of care for intermediate stage hepatocellular carcinoma (HCC) patients. To study the effects of TACE in the tumor immune microenvironment, an immunocompetent rat model is required. The purpose of this study was to determine factors influencing technical success during hepatic arterial catheterization in immunocompetent orthotopic rat liver models. To this end, 91 Sprague-Dawley and eighty-three F344 rats underwent transcatheter hepatic arterial embolization using a transcarotid approach and were divided into a non-tumor-bearing (n = 41) and tumor-bearing (n = 133) groups. Vascular diameters of the hepatic arterial branches were evaluated from angiographic images. Catheterization of the proper hepatic artery (PHA) was achieved in 92% of the tumor-bearing and 68.3% of the non-tumor-bearing rats. We found a strong positive association between the diameter of the PHA and animals’ body weight in both groups (P < 0.005), independently of the rat’s strain. Results of the logistic regression model predicting a successful catheter placement into the PHA according to the animal’s weight indicate that successful PHA catheterization is likely to be achieved in tumor-bearing animals weighing ≥ 250 g and > 308 g in non-tumor-bearing rats, with a sensitivity and specificity of 91.3% and 100.0% and 96.4% and 92.3%, respectively. In conclusion, animal’s body weight at the time of catheterization is the principal determinant of technical success for transcatheter arterial embolization. Familiarity with these technical factors during animal selection will improve TACE technical success rates.

The aim of this study is to describe a modified treatment strategy with image-guided percutaneous ablation after hepatic resection as a completion method to surgical eradication of liver metastases (“completion ablation [CA]”). We conducted a retrospective analyses of patients who underwent CA within 180 days from the liver surgical resection to eradicate liver metastases present on the pre-surgical cross-sectional imaging or identified during intraoperative ultrasound that were not resected due to various reasons. Lesions treated with CA were evaluated for local tumor progression (LTP). Patients were evaluated for hepatic- and overall-recurrence-free survivals (hepatic-RFS and overall-RFS, respectively) and overall survival (OS). Sixteen patients (10 females; median age 55 years, range 28–69) underwent CA of 21 lesions (median size 8 mm, range 6 to 22). Indications for the use of CA were small future liver remnant in 10 (63%), inability to identify the lesion during surgical exploration in 3 (19%), and technical difficulty of resection in 3 (19%) patients. No liver-related complications were recorded following the surgical resection or the CA procedures. Primary and secondary CA efficacy rates were 95 and 100%, respectively. LTP was 0% at a median clinical follow-up of 27 months (range 4.0–108 months). Five-year hepatic-RFS, overall-RFS, and OS were 36, 16, and 51%, respectively. The use of CA as a complement to surgical resection is safe and effective. Such approach could potentially expand the surgical candidacy for patients with limited liver functional reserve and reduce postoperative morbidity and mortality in this selected patient population with more advanced disease.

Purpose: To report the clinical efficacy of sorafenib and to evaluate biomarkers associated with sorafenib clinical benefit in the BATTLE (Biomarker-Integrated Approaches of Targeted Therapy for Lung Cancer Elimination) program. Patients and Methods: Patients with previously treated non–small cell lung cancer (NSCLC) received sorafenib until progression or unacceptable toxicity. Eight-week disease control rate (DCR), progression-free survival (PFS), and overall survival (OS) were assessed. Prespecified biomarkers included K-RAS, EGFR, and B-RAF mutations, and EGFR gene copy number. Gene expression profiles from NSCLC cell lines and patient tumor biopsies with wild-type EGFR were used to develop a sorafenib sensitivity signature (SSS). Results: A total of 105 patients were eligible and randomized to receive sorafenib. Among 98 patients evaluable for eight-week DCR, the observed DCR was 58.2%. The median PFS and OS were 2.83 [95% confidence interval (CI), 2.04–3.58] and 8.48 months (95% CI, 5.78–10.97), respectively. Eight-week DCR was higher in patients with wild-type EGFR than patients with EGFR mutation (P = 0.012), and in patients with EGFR gene copy number gain (FISH-positive) versus patients FISH-negative (P = 0.048). In wild-type EGFR tumors, the SSS was associated with improved PFS (median PFS 3.61 months in high SSS vs. 1.84 months in low SSS; P = 0.026) but not with eight-week DCR. Increased expression of fibroblast growth factor-1, NF-κB, and hypoxia pathways were identified potential drivers of sorafenib resistance. Conclusion: Sorafenib demonstrates clinical activity in NSCLC, especially with wild-type EGFR. SSS was associated with improved PFS. These data identify subgroups that may derive clinical benefit from sorafenib and merit investigation in future trials. Clin Cancer Res; 19(24); 6967–75. ©2013 AACR.

Background As therapy for non–small-cell lung cancer (NSCLC) patients becomes more personalized, additional tissue in the form of core-needle biopsies (CNBs) for biomarker analysis is increasingly required for determining appropriate treatment and for enrollment into clinical trials. We report our experience with small-caliber percutaneous transthoracic (PT) CNBs for the evaluation of multiple molecular biomarkers in BATTLE (biomarker-integrated approaches of targeted therapy for lung cancer elimination), a personalized, targeted therapy NSCLC clinical trial. Methods The medical records of patients who underwent PTCNB for consideration of enrollment in BATTLE were reviewed for diagnostic yield of 11 predetermined molecular markers and procedural complications. Univariate and multivariate analyses of factors related to patient and lesion characteristics were performed to determine possible influences on diagnostic yield. Results One hundred and seventy PTCNBs were performed using 20-gauge biopsy needles in 151 NSCLC patients screened for the trial. The biopsy specimens of 82.9% of the patients were found to have adequate tumor tissue for analysis of the required biomarkers. On multivariate analysis, metastatic lesions were 5.4 times more likely to yield diagnostic tissue as compared with primary tumors ( p = 0.0079). Pneumothorax and chest tube insertion rates were 15.3% and 9.4%, respectively. Conclusions Image-guided 20-gauge PTCNB is safe and provides adequate tissue for analysis of multiple biomarkers in the majority of patients being considered for enrollment into a personalized, targeted therapy NSCLC clinical trial. Metastatic lesions are more likely to yield diagnostic tissue as compared with primary tumors.

Background In patients with primary colorectal cancer (CRC) or unresectable metastatic CRC, midgut embryonic origin is associated with worse prognosis. The impact of embryonic origin on survival after ablation of colorectal liver metastases (CLM) is unclear. Methods We identified 74 patients with CLM who underwent percutaneous ablation during 2004–2015. Survival and recurrence after ablation of CLM from midgut origin (n = 18) and hindgut origin (n = 56) were analyzed. Prognostic value of embryonic origin was evaluated. Results Recurrence-free survival (RFS) and overall survival (OS) after percutaneous ablation were worse in patients from midgut origin (3-year RFS: 5.6% vs. 24%, P = 0.004; 3-year OS: 25% vs. 70%, P 0.001). In multivariable analysis, factors associated with worse OS were midgut origin (hazard ratio [HR] 4.87, 95% CI 2.14–10.9, P 0.001), multiple CLM (HR 2.35, 95% CI 1.02–5.39, P = 0.044), and RAS mutation (HR 2.78, 95% CI 1.25–6.36, P = 0.013). At a median follow-up of 25 months, 56 patients (76%) had developed recurrence, 16 (89%) with midgut origin and 40 (71%) with hindgut origin ( P = 0.133). Recurrent disease was treated with local therapy in 20 patients (36%), 2 (13%) with midgut origin and 18 (45%) with hindgut origin ( P = 0.022). Conclusion Compared to CLM from hindgut origin tumors, CLM from midgut origin tumors were associated with worse survival after ablation, which was partly attributable to the fact that patients with hindgut origin were more frequently candidates for local therapy at recurrence.

Background. Research biopsies are crucial for exploring the impact of novel agents on putative targets. The current study assesses the safety and success rate associated with performing such biopsies. Methods. We reviewed the medical records of 155 consecutive patients who had one or more research biopsies as part of a phase I trial from September 2004 to October 2009. Results. Of 281 research biopsies performed, 118 were paired before and after treatment biopsies (total = 236 biopsies). The most common sites of biopsy were superficial lymph node (19.9%), followed by liver (16.4%), and then soft tissue (15.7%). Ultrasound-guided biopsies were the most frequent type (53.7%). Among 142 patients who consented for mandatory biopsy, 86.6% had the biopsy performed, compared with 4.4% of 911 patients offered a biopsy on an optional basis (p < .0001). Biopsy was obtained most frequently on industry-sponsored trials; lack of funding on nonindustry trials was the most common reason that biopsies were not obtained. Of 281 single biopsies, only 4 (1.4%) had complications: pneumothorax requiring chest tube placement (n = 2), infection requiring admission (n = 1), and arrhythmia with hypotension (n = 1). All but one biopsy was successful in obtaining tissue. No deaths were attributable to biopsy. Conclusions. Our experience demonstrates that research biopsies in early phase clinical trials are safe (1.4% risk of serious complications), and a higher percentage of patients underwent mandatory biopsies (86.6%) compared with that of the patients with optional biopsies (4.4%).

BACKGROUND: Because of their proximity to the pulmonary artery or vein, hilar lymph nodes are routinely biopsied with endobronchial or endoscopic ultrasonography (EUS)-guided fine-needle aspiration biopsy (FNAB). Computed tomography (CT)-guided percutaneous needle biopsy (PNB) allows the operator to acquire a larger core needle biopsy (CNB) when initial samples are inconclusive, when the suspected disease is not optimally diagnosed with FNAB, or when biomarkers are required. The purpose of this study was to retrospectively evaluate the sensitivity and accuracy of CT-guided PNB in patients with hilar adenopathy. METHODS: The authors identified 80 patients who underwent 81 CT-guided PNBs of pulmonary hilar lesions from October 2002 through December 2006 and retrospectively reviewed their medical and imaging records. The PNB sensitivity and accuracy were calculated in each case, and each case was reviewed for complications, including pneumothorax and subsequent thoracostomy tube insertion. RESULTS: PNB included FNAB and CNB in 81 (100%) and 14 (17%) procedures, respectively. Data on 69 PNB specimens (67 FNAB specimens and 13 CNB specimens) were available for statistical analysis. Overall, PNB had a sensitivity of 91.4% (95% confidence interval [CI], 81.0%-97.1%) and an accuracy rate of 92.8% (95% CI, 83.9%-97.1%). Pneumothoraxes occurred in 39 patients (48%), 26 (32%) of whom required thoracostomy tube insertion. CONCLUSIONS: CT-guided PNB of pulmonary hilar lesions has high sensitivity and accuracy and represents a viable alternative for endobronchial ultrasound- or EUS-guided FNAB when larger biopsy samples are required for diagnosis or biomarker analysis. However, the procedure can result in high rates of pneumothorax. Cancer 2010;116:1974–80. V C 2010 American Cancer Society.

We evaluated the efficacy of embolotherapy including hepatic arterial embolization and chemoembolization in patients with imatinib-resistant gastrointestinal stromal tumors with progressive liver metastases.Medical records and computed tomography images of patients with imatinib-resistant gastrointestinal stromal tumor with progressive liver metastases who underwent embolotherapy from January 2002 through January 2007 were retrospectively reviewed. Response was assessed by Response Evaluation Criteria in Solid Tumors and modified CT response criteria that assessed tumor density changes. Progression-free survival in the liver and overall survival rates were calculated from the date of the initial embolotherapy session using the Kaplan-Meier method. Correlations between disease status or treatment variables and survival were tested in univariate and multivariate analyses using the log-rank test, and the Cox proportional hazards model, respectively.Fourteen patients with gastrointestinal stromal tumor who had been treated with imatinib for 7 to 61 months underwent 26 sessions of embolotherapy. Radiologic response could be evaluated in 13 patients. On the basis of response evaluation criteria in solid tumors, 1 patient demonstrated a partial response and the remaining 12 patients demonstrated stable disease. On the basis of the modified CT response criteria, 7 patients demonstrated a partial response and 6 patients demonstrated stable disease. Progression-free survival rates in the liver were 78.7%, 31.4%, and 31.4% at 6 months, 1, and 3 years, respectively; the median progression-free survival time was 7.0 months. Overall survival rates were 78.6%, 45.8%, and 45.8% at 6 month, 1 year, and 3 year, respectively; the median overall survival time was 9.7 months. Patients who had progressive extrahepatic metastases at the time of treatment and those who received only 1 embolotherapy treatment had shorter OS than did patients with liver-only progression and those who received 2 or more treatment sessions, respectively.Hepatic arterial embolization and chemoembolization induced radiologic response or disease stabilization in most patients with imatinib-resistant gastrointestinal stromal tumor with progressive liver metastases. Patients with progressive extrahepatic metastases or those who are not amenable to more than 1 embolotherapy sessions, however, did not demonstrate an appreciable survival benefit following embolotherapy.

The aim of this study was to evaluate the efficacy of outpatient management of postbiopsy pneumothoraces with small-caliber chest tubes and to assess the factors that influence the need for prolonged drainage or additional interventions. We evaluated the medical records of patients who were treated with small-caliber chest tubes attached to Heimlich valves for pneumothoraces resulting from image-guided transthoracic needle biopsy to determine the hospital admission rates, the number of days the catheters were left in place, and the need for further interventions. We also evaluated the patient, lesion, and biopsy technique characteristics to determine their influence on the need for prolonged catheter drainage or additional interventions. Of the 191 patients included in our study, 178 (93.2%) were treated as outpatients. Ten patients (5.2%) were admitted for chest tube-related problems, either for underwater suction (n = 8) or for pain control (n = 2). No further interventions were required in 146 patients (76.4%), with successful removal of the chest tubes the day after the biopsy procedure. Prolonged catheter drainage (mean, 4.3 days) was required in 44 patients (23%). Nineteen patients (9.9%) underwent additional interventions for management of pneumothorax. Presence of emphysema was noted more frequently in patients who required additional interventions or prolonged chest tube drainage than in those who did not (51.1% vs. 24.7%; p = 0.001). We conclude that use of the Heimlich valve allows safe and successful outpatient treatment of most patients requiring chest tube placement for postbiopsy pneumothorax. Additional interventions or prolonged chest tube drainage are needed more frequently in patients with emphysema in the needle path.

Yttrium-90 microspheres have been recently approved by the Food and Drug Administration and have become available to physicians in the United States for the treatment of hepatic neoplasia. Published results regarding the benefits of 90 Y radioembolotherapy within the rapidly evolving landscape of systemic therapies for advanced unresectable colorectal cancer are limited. In that context, outcomes in patients who have received the recently approved biologic agents bevacizumab and cetuximab in addition to chemotherapy are unknown. This report briefly describes the authors' treatment experience with this cohort of patients.

Purpose Portal vein embolization (PVE) is used to induce liver hypertrophy for surgical candidates with marginal future liver remnant (FLR) volumes. We compared the feasibility, safety, and effectiveness of a transarterial approach for PVE (TA-PVE) with those of a transhepatic approach for PVE (TH-PVE) in a swine model. Materials and methods Ten experimental pigs (TA-PVE, n = 5; TH-PVE, n = 5) and six controls (TA, n = 3; TH, n = 3) were studied. For TA-PVE, a microcatheter was advanced into arteries supplying the left and left middle hepatic lobes. A 3 to 1 Ethiodol-ethanol mixture was infused into selected arteries to cross the arterioportal peribiliary plexus and remain within the portal veins (PVs). For TH-PVE, PVs in the same lobar distribution were embolized with 355- to 500-μm polyvinyl alcohol particles and coils. Controls were similarly catheterized for saline infusion. Computed tomography with volumetry was performed before and 7, 14, 21, and 28 days after PVE to assess FLR hypertrophy (absolute FLR volume change and FLR/total liver volume [TLV]). Computed tomographic volumetry, laboratory data, and histopathology were compared between groups. Results All procedures were technically successful. The increases in mean absolute FLR volume (TA-PVE, 148 ± 84 cm 3 ; TH-PVE, 62 ± 19 cm 3 ; P = .082), mean FLR hypertrophy (TA-PVE, 93.2%; TH-PVE, 48.4%; P = .178), and mean FLR/TLV (TA-PVE, 31.0%; TH-PVE, 16.2%; P = .130) from day 0 to day 28 between experimental groups were better for TA-PVE. Changes in laboratory data among all groups were minimal. Two complications occurred from TA-PVE (right gastric artery embolization [ n = 2] without sequela) and two from TH-PVE (acute segmental right PV thrombosis [ n = 1]; death 3 weeks after PVE of unknown cause [ n = 1]). Conclusions Transarterial portal vein embolization is feasible, safe, and effective for inducing future liver remnant hypertrophy in swine and may represent an improvement over previously reported transhepatic portal vein embolization methods.

In this study, the authors evaluated whether the pretransplant portal venous administration of UV-B irradiated donor alloantigen would induce tolerance to long peripheral nerve allografts in a swine model. They completed nerve allograft transplantation between four swine of separate lineages. Regeneration across the nerve allografts was followed for 10 months postoperatively. Sequential IN VITRO assays demonstrated the successful and prolonged suppression of the recipient immune response to donor antigen following antigen inoculation. Histomorphometric analysis demonstrated successful regeneration across the long nerve allografts in the pretreated recipients, but not across allografts in unimmunosuppressed recipients. A single pretransplant antigen delivery protocol has the potential to replace chronic medicinal immunosuppressant therapy and its associated morbidities. Furthermore, tolerance to long nerve allografts has immediate applicability to clinical requirements for bridging multiple, complex, long nerve gaps.

BACKGROUND. The efficacy of hepatic artery chemoembolization (HACE) was evaluated for gastrointestinal stromal tumors (GISTs) metastatic to the liver. METHODS. Records for patients with metastatic GIST who underwent HACE between January 1993 and March 2005 were reviewed and cross-sectional images were used to determine objective tumor response. Progression-free survival in the liver (PFS-liver) and overall survival (OS) were calculated with the Kaplan–Meier method. Patient, tumor, and treatment variables were analyzed to identify factors influencing survival. RESULTS. Of the 110 patients identified, the radiologic response to HACE could be evaluated in 85 patients, 12 of whom (14%) demonstrated partial responses, 63 of whom (74%) demonstrated stable disease, and 10 of whom (12%) demonstrated progressive disease. PFS-liver rates were 31.2%, 8.2%, and 5.4% at 1, 2, and 3 years, respectively; the median PFS time was 8.2 months. OS rates were 62% at 1 year, 32% at 2 years, and 20% at 3 years; the median OS time was 17.2 months. Patients who had >5 liver metastases and received only 1 HACE treatment were found to have a shorter PFS compared with patients with fewer metastases or those who received ≥2 HACE sessions. Extensive liver involvement, the presence of extrahepatic metastases, and progression of liver disease after HACE were associated with poor OS. Use of imatinib prolonged OS time. CONCLUSIONS. HACE produced a durable tumor response or disease stabilization in the majority of patients with GISTs metastatic to liver. Extent of liver disease, presence of extrahepatic disease, number of embolization treatments, and use of imatinib were found to have prognostic influence on PFS, OS, or both. Cancer 2006. © 2006 American Cancer Society.

The purpose of this article is to report our clinical experience with out-of-plane computed-tomography (CT)-guided biopsies using a magnetic-field-based navigation system. Between February 2002 and March 2003, 20 patients underwent CT-guided biopsy in which an adjunct magnetic-field-based navigation system was used to aid an out-of-plane biopsy approach. Eighteen patients had an underlying primary malignancy. All biopsies involved the use of a coaxial needle system in which an outer 18G guide needle was inserted to the lesion using the navigation system and an inner 22G needle was then used to obtain fine-needle aspirates. Complications and technical success were recorded. Target lesions were located in the adrenal gland (n = 7), liver (n = 6), pancreas (n = 3), lung (n = 2), retroperitoneal lymph node (n = 1), and pelvis (n = 1). The mean lesion size (maximum transverse diameter) was 26.5 mm (range: 8-70 mm) and the mean and median cranial-caudal distance, between the transaxial planes of the final needle tip location and the needle insertion site, was 40 mm (range: 18-90 mm). Needle tip positioning was successfully placed within the lesion in all 20 biopsies. A diagnosis of malignancy was obtained in 14 biopsies. Benign diagnoses were encountered in the remaining six biopsies and included a benign adrenal gland (n = 2), fibroelastic tissue (n = 1), hepocytes with steatosis (n = 2) and reactive hepatocytes (n = 1). No complications were encountered. A magnetic-field-based navigation system is an effective adjunct tool for accurate and safe biopsy of lesions that require an out-of-plane CT approach.

Management of hepatic malignancies is a ubiquitous medical problem. Surgical resection of primary or metastatic liver cancer, with or without adjuvant chemotherapy, is the most effective method for enhancing survival; however, hepatic malignancies in the vast majority of patients are unresectable both at initial manifestation and at recurrence. In these patients, palliative cytoreductive therapies may help to retard tumor progression and therefore favorably alter the course of the disease. Since hepatic neoplasms are principally supplied by the hepatic artery, various arterially delivered cytotoxic agents have been developed to achieve these objectives. Recently, the Food and Drug Administration approved the transarterial administration of yttrium-90 microspheres for liver-directed therapy. Effective use of these devices requires knowledge of the accumulated clinical experience and a dedicated multidisciplinary effort to ensure optimal outcomes and avoid therapy-specific life-threatening complications. © ...

PURPOSE Responses to liver-directed therapy with yttrium 90 microspheres (SIR-Spheres) and adjuvant intraarterial chemotherapy have occurred in patients with unresectable colorectal hepatic metastases who had received less than one chemotherapy regimen. Now, SIR-Spheres are being used to treat patients with advanced disease who have received multiple chemotherapy regimens. A retrospective analysis was performed to determine the technical feasibility of SIR-Sphere treatment in this population. MATERIALS AND METHODS The medical records of 12 patients with hepatic metastatic disease and intrahepatic progression after multiple chemotherapy regimens for unresectable colorectal hepatic metastases who were treated with one or two infusions of SIR-Spheres were retrospectively analyzed for demographics, tumor characteristics, treatment details, response, and survival. RESULTS Twelve patients underwent 17 outpatient infusions of SIR-Spheres. Percent hepatic tumor volume was less than 25% in four patients, 25%–50% in three, and more than 50% in five. Treatment in 11 patients with bilobar disease was accomplished via single infusions in six cases and sequential unilobar infusions in five patients. A single infusion was used to treat unilobar disease in the remaining patient. Median prescribed dose was 39.6 mCi (mean, 37.2 mCi; range, 17–67.5 mCi); the prescribed dose exceeded the delivered dose in six infusions (35%) as a result of embolic arterial occlusion. Radiologic response was stable in five of nine patients. Carcinoembryonic antigen levels decreased in four of seven patients. Four patients received chemotherapy concomitantly or after completion of treatment. Gastric ulceration in one patient was managed nonoperatively. Median survival times from diagnosis and treatment were 24.6 and 4.5 months, respectively. CONCLUSIONS Treatment with SIR-Spheres induces responses in patients with advanced unresectable colorectal hepatic metastases after multiple chemotherapy regimens. Inability to deliver the prescribed dose is related to the embolic effect of SIR-Spheres.

PURPOSE To report the safety, technical success, and effectiveness of percutaneous radiofrequency (RF) ablation for renal tumors. MATERIALS AND METHODS The authors retrospectively reviewed the medical records and imaging studies of 29 consecutive patients (18 men, 11 women; mean age, 65 ± 2.62 years) with 30 renal tumors (mean diameter, 3.5 ± 0.24 cm) who underwent percutaneous RF ablation at their institution from September 2001 to March 2004. All procedures were performed with computed tomography guidance with general anesthesia, and all patients were admitted to the hospital for overnight observation. Technical success, complications, and their management were recorded. Technique effectiveness was assessed by imaging and clinical follow up. RESULTS Overall, 88 overlapping ablations were performed (mean, 2.6 ± 0.16 ablations per tumor per session) in 34 sessions. There were four major complications (12%). Three patients had gross hematuria and urinary obstruction, all were successfully treated. One patient had persistent anterior abdominal wall weakness. There were also two minor complications (6%) without significant clinical sequelae. One patient had gross hematuria which resolved spontaneously, another patient had transient paresthesia of the anterior abdominal wall. There were no significant changes in renal function after RF ablation. The intent of RF ablation was eradication of the primary tumor in 27 patients and treatment of gross hematuria in the other two. Technical success was achieved in all cases. Follow-up images were available for 26 patients. The primary tumor was completely ablated in 23 of 24 patients (96%) in whom eradication of the primary tumor was attempted (follow up period: mean, 10 months, median 7 months). The two patients treated for hematuria remained asymptomatic for 6 and 27 months each. CONCLUSION Percutaneous RF ablation for renal tumors is safe and well tolerated. High technical success rates are expected. Early reports of the technique's effectiveness are promising.

BACKGROUND The objective of this study was to determine the prognostic variables that influence response and survival in patients with metastatic neuroendocrine tumors who are treated with hepatic arterial embolization (HAE) or chemoembolization (HACE). METHODS Patients with metastatic neuroendocrine tumors who underwent HAE or HACE were included in this retrospective study. Follow-up imaging studies were compared with baseline imaging to determine the radiologic response. Progression-free survival (PFS) and overall survival (OS) were calculated using the Kaplan–Meier method. Univariate and multivariate analyses were performed to assess the prognostic variables that affected response and survival. RESULTS The study included 69 patients with carcinoid tumors and 54 patients with pancreatic islet cell carcinomas. Patients who had carcinoid tumors had a higher response rate (66.7% vs. 35.2%; P = 0.0001) and had longer PFS (22.7 mos vs. 16.1 mos; P = 0.046) and OS (33.8 mos vs. 23.2 mos; P = 0.012) compared with patients who had islet cell carcinomas. For patients with carcinoid tumors, multivariate analysis identified male gender as the only independent risk factor for poor survival (P = 0.05). Octreotide was predictive marginally for PFS (P = 0.06). Patients who were treated with HAE had a higher response rate than patients who were treated with HACE (P = 0.004). For patients with islet cell carcinoma, an intact primary tumor, ≥ 75% liver involvement, and extrahepatic metastases were associated with reduced OS in the univariate analysis; the presence of bone metastases was the only risk factor (P = 0.031) in the multivariate analysis. Patients who were treated with HACE had a prolonged OS (31.5 mos vs. 18.2 mos) and improved response (50% vs. 25%) compared with patients who were treated with HAE, although the differences did not reach statistical significance. CONCLUSIONS Patients with carcinoid tumors had better outcomes than patients with islet cell carcinomas. The addition of intraarterial chemotherapy to HAE did not improve the outcome of patients with carcinoid tumors, but it seemed to benefit patients with islet cell carcinomas. In patients who had carcinoid tumors, male gender predicted a poor outcome, and a trend toward prolonged PFS was observed in patients who received concomitant octreotide. An intact primary tumor, extensive liver disease, and bone metastases were associated with reduced survival in patients with islet cell carcinomas. Cancer 2005. © 2005 American Cancer Society.

Purpose. To evaluate the biologic effects of SU6668 in patients with solid tumors using comprehensive measures of pharmacokinetics (PK), functional imaging, and tissue correlative studies. Experimental design. Eligible patients with tumors accessible for core needle biopsy were treated with SU6668 at doses of 200 or 400 mg/m2/day. Functional computed tomography (CT) scan and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) were performed at baseline and repeated 4 weeks and 12 weeks after treatment for analysis of tumor angiogenesis. The PK was analyzed using a high-performance liquid chromatography assay. Tumor specimens obtained via core needle biopsy at baseline and 4 weeks later were analyzed for the biologic effects of SU6668. Results. Six of a total of seven patients received treatment for at least 3 months and underwent comprehensive correlative studies, including PK, imaging, and tissue biopsy. Functional CT showed that five of six patients had decreased blood flow in tumors in response to treatment, and DCE-MRI results indicated significant change of area under the signal intensity vs. time curve (AUC) and/or maximum slope (maximum rate of signal intensity change) in two of four patients evaluated with this technique. PK studies showed that the mean apparent oral clearance (Cloral) measured on day 1 was 6.3 ± 2.7 L/hr/m2, yielding a mean AUC of 16.6 ± 4.3 mg/L·hr. By day 22, the Cloral was 40% more than that observed on day 1. Conclusion. It is feasible to evaluate the biologic effects of antiangiogenic agents using comprehensive surrogate measures.

Thirty-three patients with 35 bone lesions suspicious for osteosarcoma underwent image-guided biopsy. Of those 35 biopsies, 12 were performed with use of fluoroscopy or computed tomography (CT) guidance to target the osseous abnormality. Diagnostic magnetic resonance imaging revealed a soft tissue component in 23 cases; in these cases, biopsies were performed with use of ultrasonography (US) to target the soft tissue component of the tumor. Of the 35 tumors in which biopsy was performed, 33 (94%) were definitively diagnosed as osteosarcoma by image-guided biopsy. All 23 US-guided biopsies resulted in definitive diagnosis. Two of the 12 fluoroscopy- or CT-guided biopsies (17%) were inconclusive.

BACKGROUND Inferior vena cava (IVC) filters have proven to be a viable alternative to anticoagulation therapy for the prevention of life-threatening pulmonary emboli (PE) for patients who have contraindications to anticoagulation therapy. The clinical benefit of placing IVC filters in patients with advanced-stage cancer is controversial. The current study reported the authors' experience with IVC filters in patients with cancer. METHODS Between January 2000 and May 2003, IVC filters were placed in 308 patients with venous thromboembolic (VTE) disease. Of these patients, 267 had solid tumors and 41 had liquid tumors. Outcome was reviewed retrospectively with regards to patient survival as well as procedural and filter-related complications. Patients with solid and liquid tumors were used to generate Kaplan–Meier estimates for survival and the probability of surviving 30, 90, and 365 days was also calculated. The prognostic effect of age, primary malignancy, gender, extent of disease, indication, admission to the intensive care unit, and IVC thrombus on overall survival was also evaluated using univariate and multivariate Cox models for patients with solid tumors. RESULTS The median survival periods for patients with solid and liquid tumors were 145 days and 207 days, respectively. The probability of survival at 30, 90, and 365 days was 0.81, 0.60, and 0.35, respectively, for patients with solid tumors and 0.85, 0.67, and 0.48, respectively, for patients with liquid tumors. There was no statistically significant difference in survival based on primary malignancy for solid tumors (P = 0.628) or between solid and liquid tumors (P = 0.16). For patients with solid tumors, a statistically significant difference in survival was found by extent of disease (P = 0.002). Patients with solid tumors classified as local disease (n = 15), locally advanced disease (n = 95), and widely metastatic or disseminated disease (n = 153) had a probability of survival at 30 days of 0.93, 0.87, and 0.76, respectively. Compared with patients with local disease, patients with metastatic or disseminated disease were 3.7 times more likely to die (P = 0.013). Patients with a history of deep venous thrombosis (DVT) and hemorrhage were 2 times more likely to die than patients with DVT and no history of hemorrhage (P = 0.0057). Documented complications occurred in 22 of 308 (7.1%) patients and included PE (n = 4), new caval thrombosis (n = 14), retroperitoneal hemorrhage (n = 2), and maldeployed filters (n = 2). CONCLUSIONS IVC filters were shown to be safe and highly effective in preventing PE-related deaths in patients with cancer with VTE disease. Patients with a history of DVT and bleeding or metastatic/disseminated stage of disease had the lowest survival after IVC filter placement. Cancer 2004. © 2004 American Cancer Society.

Editorial Comment: Arterioureteral fistulas occur as a result of inflammatory or ischemic conditions involving the ureter, iliac vessels or both. Secondary (iatrogenic) causes such as surgery for pelvic malignancy or vascular reconstruction predominate (85%). Ureteral obstruction requiring chronic stent placement appears to hasten fistula development (often within 4 months). Massive or pulsatile gross hematuria during stent exchange should suggest the diagnosis. Intraureteral balloon catheter placement across the bleeding site is the first step. Selective iliac angiography often demonstrates pseudoaneurysm but sensitivity is less than 50%. Iliac arterial embolization with vascular bypass grafting has been the traditional surgical approach.1 However, because these patients are notoriously poor operative candidates, endovascular stent-graft technology has recently been attempted and is quickly emerging as a viable alternative to open surgical options, although long-term followup is lacking. The authors recommend proximal urinary diversion and stent removal in conjunction with arterial stent-graft placement as first line therapy. 1. Vandersteen, D. R., Saxon, R. R., Fuchs, E., Keller, F. S., Taylor, L. M., Jr. and Barry, J. M.: Diagnosis and management of ureteroiliac artery fistula: value of provocative arteriography followed by common iliac artery embolization and extraanatomic arterial bypass grafting. J Urol, 158: 754, 1997

Access route planning for computed tomography-guided biopsy of deep pelvic masses remains challenging because vital structures often obstruct the projected needle path. The classical approach through the lower anterior abdominal wall allows access to lesions located anterior, superior, or lateral to the urinary bladder. However, this approach has limitations: Deep masses are difficult to reach because of intervening structures, the bowel or bladder may be unavoidably traversed, and peritoneal transgression is often painful. A transgluteal approach is useful for biopsy of presacral and perirectal lesions and lesions located posterolateral to the bladder. An anterolateral approach through the iliopsoas muscle allows safe extraperitoneal access to external and internal iliac nodes, masses located along the lateral pelvic sidewall, and adnexal lesions. A transosseous (transsacral or transiliac) approach can occasionally be used for otherwise inaccessible lesions. Use of a curved needle, change in patient position, or injection of saline solution to displace intervening structures may also be helpful. Familiarity with normal cross-sectional pelvic anatomy facilitates planning of a safe access route and helps avoid injury to adjacent structures. A thorough understanding of the advantages and disadvantages of each approach allows the clinician to choose the most appropriate approach in a given situation.

To evaluate whether preoperative portal vein embolization (PVE) with polyvinyl alcohol (PVA) particles and coils is safe and effective for inducing lobar hypertrophy in patients with hepatobiliary malignancy.PVE was performed in 26 patients. All patients had malignancy: metastases (n = 11), cholangiocarcinoma (n = 9), hepatocellular carcinoma (n = 5), and gallbladder carcinoma (n = 1). One patient had underlying liver disease caused by hepatitis. PVE was performed if the future liver remnant (FLR) was estimated to be less than 25% of the total liver volume. PVE was performed with a percutaneous transhepatic approach (right, 25 patients; left, one patient). PVA particles and coils were used to occlude the right portal system and veins supplying segment IV to promote FLR hypertrophy (segments I-III +/- IV). FLR hypertrophy was assessed with comparison of computed tomographic scans obtained before and 2-4 weeks after PVE. Effectiveness evaluation was based on changes in absolute FLR size and ratio of FLR to total estimated liver volume (TELV). Safety of PVE and hepatic resection was determined with postprocedure complication rate and median hospital stay.Sixteen patients underwent hepatic resection (right trisegmentectomy [n = 13], right lobectomy [n = 3]) without mortality. Ten patients did not undergo resection (complete remission after medical therapy [n = 1], lack of regeneration [n = 2], extrahepatic disease undetected prior to PVE [n = 7]). Six patients had biliary obstruction; five were treated percutaneously before PVE. No patient developed postembolization syndrome or signs of fulminant hepatic insufficiency after PVE or resection. Two patients had complications after PVE that did not preclude successful resection. Median hospital stays were 1 day (PVE) and 7 days (liver resection). Mean absolute FLR increased from 325.0 to 458.6 cm3 (increase, 41.1%). Mean TELV was 1,784.8 cm3. FLR/TELV ratio increase was 8%.Preoperative PVE with PVA particles and coils is safe and effective for inducing lobar hypertrophy in patients with advanced hepatobiliary malignancy.

PURPOSE The purposes of this study are to report experience with transjugular liver biopsy (TJLB) in patients with hematologic malignancy and severe thrombocytopenia and to determine the incidence of hemorrhage-related complications in patients with prebiopsy and pretransfusion platelet counts of 30 × 10 9 /L or lower to propose a threshold platelet count above which TJLB can be safely performed without transfusion. MATERIALS AND METHODS Medical records and laboratory reports of 50 patients with severe thrombocytopenia who had undergone 51 TJLB procedures and prebiopsy platelet transfusions between August 1999 and September 2001 were retrospectively reviewed. Biopsy success and procedural complications were recorded. RESULTS TJLB was technically successful in 49 of 51 procedures (96%). The mean prebiopsy, pretransfusion platelet count was 17 × 10 9 /L (range, 3−30 × 10 9 /L) and a mean of 11 U (range, 6−32 U) of platelets per patient were transfused. The overall mean postbiopsy platelet count was 38 × 10 9 /L (range, 5−105 × 10 9 /L), but it remained 30 × 10 9 /L or lower in 24 TJLB procedures. No hemorrhage-related complications were encountered, but ventricular fibrillation occurred in one patient during the procedure. CONCLUSION A threshold platelet count for safe TJLB resides below 30 × 10 9 /L. A prospective study is necessary to better define a lower threshold above which TJLB can be performed without platelet transfusion.

To determine the accuracy of percutaneous computed tomography (CT)-guided fine-needle aspiration biopsy (FNAB) of small (or =1.0-cm in diameter) pulmonary lesions.Sixty-one patients (34 men and 27 women) 21-89 years old (mean age, 61.3 years) with lung nodules 1.0 cm or smaller underwent CT-guided transthoracic FNAB. Fifty-seven of the 61 patients had an underlying primary malignancy. Maximum nodule diameters were 0.5-0.7 cm in 10 patients and 0.8-1.0 cm in 51 patients. Cytopathologic evaluation of FNAB samples was immediate in all patients. Sensitivity and accuracy were calculated, and each case was reviewed for complications, including pneumothorax and thoracostomy tube insertion. Four patients were not included in our statistical analysis because of a lack of follow-up information.FNAB samples were adequate for diagnosis in 47 (77%) of 61 patients. Diagnoses were malignancy (n = 29) or suspected malignancy (n = 3) in 52% (n = 32) and benign or atypical findings in 25% (n = 15). Findings were nondiagnostic in 23% (n = 14). Of the 29 patients without evidence of malignancy, 25 had follow-up findings available. Follow-up included chest CT in 16 patients and surgical resection in nine. Four patients were not included in statistical analysis because of a lack of follow-up information. Overall sensitivity was 82% (32 of 39); specificity, 100% (18 of 18); and diagnostic accuracy, 88% (50 of 57) on the basis of 57 patients being evaluable. Results for 47 0.8-1.0-cm lesions were considerably better (sensitivity, 88%; accuracy, 92%) than those for 10 0.5-0.7-cm lesions (sensitivity, 50%; accuracy, 70%). Sensitivity (75% vs 87%) and accuracy (87% vs 89%) also improved when comparing subpleural (or =1.0 cm from pleural surface, n = 30) with deeper (1 cm from pleural surface, n = 27) pulmonary lesions, but the improvement did not indicate statistical significance. Core biopsy did not reveal malignancy in any of the nine patients in whom preliminary cytologic results were inconclusive and did not improve diagnostic yield. Thirty-eight (62%) patients had pneumothorax, with 19 (31%) requiring thoracostomy tube placement.CT-guided FNAB of pulmonary lesions 1.0 cm or smaller can yield high diagnostic accuracy rates approaching those of larger lesions; FNAB of 0.8-1.0-cm lesions that are not subpleural offers the best opportunity for success.

Portal vein embolization (PVE) is increasingly being accepted as a useful procedure in the preoperative treatment of patients selected for major hepatic resection. PVE is performed via either the percutaneous transhepatic or the transileocolic route and is usually reserved for patients whose future liver remnants are too small to allow resection. It is a safe and effective method for inducing selective hepatic hypertrophy of the nondiseased portion of the liver and may thereby reduce complications and shorten hospital stays after resection. A thorough knowledge of hepatic segmentation and portal venous anatomy is essential before performing PVE. In addition, the indications and contraindications for PVE, the methods for assessing hepatic lobar hypertrophy, the means of determining optimal timing of resection, and the possible complications of PVE need to be fully understood before undertaking the procedure. Technique may vary among operators, and further research is necessary to determine the best embolic agents available and the expected rates of liver regeneration for PVE. Nevertheless, as hepatobiliary surgeons become more experienced at performing extended hepatic resections, PVE may be requested more frequently.

This chapter reviews oncologic application of multimodality image-guided treatment (MIGT) in theory and in practice. The basis and promise of multimodality imaging are reviewed with particular emphases on application to cancer therapy. Based on current practice of MIGT as illustrated by clinical examples in Figures 12.1 through 12.4, different experimental approaches, possibilities, and examples are listed. Although many creative combinations of imaging and therapy are possible, the realistic requirements for successful MIGT are enumerated for evaluation of this type of newer technology. Possibilities and limitations of MIGT are reviewed to arrive at a conclusion about a probable course of development of MIGT.

Background Advances in surgery have reduced the mortality rate after major liver resection, but complications resulting from inadequate postresection hepatic size and function remain. Portal vein embolization (PVE) was proposed to induce hypertrophy of the anticipated liver remnant in order to reduce such complications. The techniques, measurement methods and indications for this treatment remain controversial. Methods A Medline search was performed to identify papers reporting the use of PVE before hepatic resection. Techniques, complications and results are reviewed. Results Complications of PVE typically occur in less than 5 per cent of patients. No specific substance (cyanoacrylate, thrombin, coils or absolute alcohol) emerged as superior. The increase in remnant liver volume averages 12 per cent of the total liver. The morbidity rate of resection after treatment is less than 15 per cent and the mortality rate is 6–7 per cent with cirrhosis and 0–6·5 per cent without cirrhosis. Embolization is currently used for patients with a normal liver when the anticipated liver remnant volume is 25 per cent or less of the total liver volume, and for patients with compromised liver function when the liver remnant volume is 40 per cent or less. Conclusion This treatment does not increase the risks associated with major liver resection. It may be indicated in selected patients before major resection. Future prospective studies are needed to define more clearly the indications for this evolving technique.

Purpose To compare the clinical effectiveness of the AngioJet F105 rheolytic catheter to that of surgical thrombectomy for the treatment of thrombosed hemodialysis grafts. Materials and Methods This was a multicenter, prospective, randomized trial comparing technical success, primary patency, and complication rates. A total of 153 patients were enrolled: 82 patients in the AngioJet group and 71 patients in the surgical thrombectomy group. Patient follow-up was performed 24–48 hours, 1 month, and 6 months after the procedures. Results Technical success, as defined by the patient's ability to undergo hemodialysis treatment, was 73.2% for the AngioJet group and 78.8% for the surgical thrombectomy group (P = .41). The primary patency rates of the AngioJet group were 32%, 21%, and 15% at 1, 2, and 3 months, respectively. The primary patency rates for the surgical group were 41%, 32%, and 26% at 1, 2, and 3 months, respectively. This difference approached statistical significance (P = .053). The groups had similar complication rates—14.6% in the AngioJet group and 14.1% in the surgery group—although the surgery group had more major complications (11.3%). In the AngioJet group, there was a transient increase in plasma-free hemoglobin, which normalized within 24–48 hours. Conclusions The AngioJet F105 catheter provides similar clinical results when compared to surgical thrombectomy for the treatment of thrombosed hemodialysis grafts. The difference in patency rates between these two techniques approached statistical significance. In addition, results of both thrombectomy methods were inferior to those suggested by the Dialysis Outcomes Quality Initiative guidelines.

Video-assisted thoracoscopic surgery (VATS) has been used increasingly for the biopsy of pulmonary nodules. In cases where the nodule is small or intrapulmonary, thoracoscopic visualizatio...

To determine the safety and diagnostic accuracy of a provocative protocol with heparin and urokinase to induce bleeding and determine the source in patients with chronic gastrointestinal hemorrhage.Nine patients had gastrointestinal bleeding from an indeterminate source and had negative results from esophagogastroduodenoscopy, colonoscopy, small-bowel examination, and angiography. Ten provocative bleeding studies were performed prospectively. Patients had no clinical evidence of bleeding within 2 days before the study. Intravenous administration of heparin and urokinase was performed systemically during a 4-hour period while scintigraphy was performed continuously. Mesenteric angiography was performed immediately in patients in whom substantial gastrointestinal bleeding was detected at scintigraphy.The provocative protocol was successful in inducing scintigraphically detectable hemorrhage in four (40%) studies within 4 hours. In two of these four studies, the source of hemorrhage was determined and treated with embolization or surgery. Three (30%) studies demonstrated scintigraphic evidence of hemorrhage only at delayed imaging (8-24 hours after initiation of the study). The remaining three (30%) studies did not show active bleeding. No complications occurred, including hemodynamic instability or uncontrollable decreases in hematocrit.Since this protocol with heparin and urokinase enabled determination of the bleeding source in only two of 10 studies, protocol modifications are necessary before this intervention is used widely.