Transarterial chemoembolization alone or followed by bevacizumab for treatment of colorectal liver metastases.

AIMS: Bevacizumab (B) in association with systemic chemotherapy is commonly used for the treatment of colorectal cancer liver metastases. The aim of this study was to monitor tumor response, overall survival (OS) and progression-free survival (PFS) of patients with colorectal cancer liver metastases treated with transarterial chemoembolization (TACE) + B compared with TACE alone and to correlate the results with KRAS mutational status. PATIENTS & METHODS: This was an observational multicentric case-control study (NCT03732235) on the efficacy and safety of B administered after TACE. RESULTS: The disease control rate was significantly higher for the TACE + B than the TACE alone group (p < 0.001). KRAS wild-type patients had a significantly better disease control rate than those with KRAS mutations in the TACE + B group. Median OS and PFS were similar for the TACE + B and TACE groups, whereas median time to progression was significantly higher for the TACE + B group (p < 0.01). CONCLUSION: The combination of TACE with B may improve tumor response and delay disease progression.

Biliary involvement in liver metastases: long-term experience with biliary biopsy from a single center.

OBJECTIVE: To investigate long-term results of biliary biopsy performed with transluminal forceps in the setting of metastatic biliary involvement. MATERIALS AND METHODS: Between September 2014 and June 2019, 25 patients-18 males (72%)-with a mean age of 65 ± 15 years, underwent 26 biliary biopsy procedures with a dedicated forceps system. All patients presented with obstructive jaundice that was suspected of being malignant and underwent pre-procedural magnetic resonance cholangiopancreatography. The biopsies were performed during percutaneous placement of an internal-external biliary drainage catheter, under fluoroscopic guidance. RESULTS: The technical success rate was 96% (corresponding to 25 of the 26 procedures). The histological diagnosis was inflammatory biliary stricture in five cases, pancreatic adenocarcinoma in six, liver metastases from colorectal cancer in eight, and hepatocellular carcinoma in three, the biliary mucosa being categorized as normal in three cases. In one case, the sample was considered insufficient and the procedure was successfully repeated, after which a diagnosis of pancreatic adenocarcinoma was made. Over a follow-up period of 6-48 months, there were five false-negative results: two findings of inflammatory biliary stricture were later identified as liver metastases from breast and gastric cancer, respectively; and all three patients in which the biliary mucosa was categorized as normal were subsequently diagnosed with metastatic hilar lymph nodes. The procedure was found to have a sensitivity of 77%, a specificity of 100%, and an overall accuracy of 80%. The complication rate was 11.5% (mild, transient hemobilia occurring in three cases). CONCLUSION: Percutaneous transluminal forceps biopsy is a safe, effective, minimally invasive procedure for histological characterization in patients presenting with obstructive jaundice due to a non-primary biliary tumor.

OBJETIVO: Investigar os resultados a longo prazo da biópsia endobiliar realizada com um pinça tipo fórceps transluminal no diagnóstico de neoplasia biliar metastática. MATERIAIS E MÉTODOS: Entre setembro de 2014 e junho de 2019, 25 pacientes - 18 homens (72%), com idade média de 65 ± 15 anos) - foram submetidos a 26 procedimentos de biópsia endobiliar com um conjunto dedicado. Todos os pacientes apresentaram icterícia obstrutiva, suspeita de malignidade e colangiorressonância pré-procedimento. Os procedimentos foram realizados durante o posicionamento percutâneo da drenagem biliar interna-externa, sob orientação fluoroscópica. RESULTADOS: A taxa de sucesso técnico foi de 96% (25 casos), com diagnóstico histológico de estenose benigna (inflamatória) em cinco casos, adenocarcinoma pancreático em seis casos, metástases hepáticas retais no cólon em oito casos, carcinoma hepatocelular em três casos e de mucosa biliar normal em três casos. Em um caso a amostra foi considerada insuficiente pelo patologista (um adenocarcinoma pancreático) e o procedimento foi repetido com sucesso. O seguimento de 6 a 48 meses mostrou cinco casos falso-negativos, em particular dois casos de metástases hepáticas retais sem cólon (câncer de mama e gástrico) e três linfonodos hilares metastáticos. A análise estatística revelou sensibilidade de 77%, especificidade de 100% e precisão geral de 80%. A taxa de complicações foi de 11,5% (três casos com hemobilia transitória). CONCLUSÃO: A biópsia biliar transluminal realizada com pinça tipo fórceps é um procedimento minimamente invasivo, seguro e eficaz para caracterização histológica em pacientes que apresentam icterícia obstrutiva no diagnóstico de neoplasia biliar metastática.

Biliary involvement in liver metastases: long-term experience with biliary biopsy from a single center / Envolvimento biliar nas metástases hepáticas: experiência a longo prazo com biópsia endobiliar em um único centro

Abstract Objective: To investigate long-term results of biliary biopsy performed with transluminal forceps in the setting of metastatic biliary involvement. Materials and Methods: Between September 2014 and June 2019, 25 patients-18 males (72%)-with a mean age of 65 ± 15 years, underwent 26 biliary biopsy procedures with a dedicated forceps system. All patients presented with obstructive jaundice that was suspected of being malignant and underwent pre-procedural magnetic resonance cholangiopancreatography. The biopsies were performed during percutaneous placement of an internal-external biliary drainage catheter, under fluoroscopic guidance. Results: The technical success rate was 96% (corresponding to 25 of the 26 procedures). The histological diagnosis was inflammatory biliary stricture in five cases, pancreatic adenocarcinoma in six, liver metastases from colorectal cancer in eight, and hepatocellular carcinoma in three, the biliary mucosa being categorized as normal in three cases. In one case, the sample was considered insufficient and the procedure was successfully repeated, after which a diagnosis of pancreatic adenocarcinoma was made. Over a follow-up period of 6-48 months, there were five false-negative results: two findings of inflammatory biliary stricture were later identified as liver metastases from breast and gastric cancer, respectively; and all three patients in which the biliary mucosa was categorized as normal were subsequently diagnosed with metastatic hilar lymph nodes. The procedure was found to have a sensitivity of 77%, a specificity of 100%, and an overall accuracy of 80%. The complication rate was 11.5% (mild, transient hemobilia occurring in three cases). Conclusion: Percutaneous transluminal forceps biopsy is a safe, effective, minimally invasive procedure for histological characterization in patients presenting with obstructive jaundice due to a non-primary biliary tumor.

Resumo Objetivo: Investigar os resultados a longo prazo da biópsia endobiliar realizada com um pinça tipo fórceps transluminal no diagnóstico de neoplasia biliar metastática. Materiais e Métodos: Entre setembro de 2014 e junho de 2019, 25 pacientes - 18 homens (72%), com idade média de 65 ± 15 anos) - foram submetidos a 26 procedimentos de biópsia endobiliar com um conjunto dedicado. Todos os pacientes apresentaram icterícia obstrutiva, suspeita de malignidade e colangiorressonância pré-procedimento. Os procedimentos foram realizados durante o posicionamento percutâneo da drenagem biliar interna-externa, sob orientação fluoroscópica. Resultados: A taxa de sucesso técnico foi de 96% (25 casos), com diagnóstico histológico de estenose benigna (inflamatória) em cinco casos, adenocarcinoma pancreático em seis casos, metástases hepáticas retais no cólon em oito casos, carcinoma hepatocelular em três casos e de mucosa biliar normal em três casos. Em um caso a amostra foi considerada insuficiente pelo patologista (um adenocarcinoma pancreático) e o procedimento foi repetido com sucesso. O seguimento de 6 a 48 meses mostrou cinco casos falso-negativos, em particular dois casos de metástases hepáticas retais sem cólon (câncer de mama e gástrico) e três linfonodos hilares metastáticos. A análise estatística revelou sensibilidade de 77%, especificidade de 100% e precisão geral de 80%. A taxa de complicações foi de 11,5% (três casos com hemobilia transitória). Conclusão: A biópsia biliar transluminal realizada com pinça tipo fórceps é um procedimento minimamente invasivo, seguro e eficaz para caracterização histológica em pacientes que apresentam icterícia obstrutiva no diagnóstico de neoplasia biliar metastática.

Chemoembolization Alone or Associated With Bevacizumab for Therapy of Colorectal Cancer Metastases: Preliminary Results of a Randomized Study.

AIM: to assess efficacy and safety of chemoembolization alone (TACE) and followed by bevacizumab (TACE-B) in patients with colorectal liver metastases (CRC-LM) (NCT03732235). PATIENTS AND METHODS: The study included 30 consecutive patients with CRC-LM. They were informed about the types of treatment available: TACE with irinotecan loaded into polythylene glycol embolics alone or followed by bevacizumab therapy. Each patient underwent self-randomization and 17 chose TACE, whereas 13 chose TACE-B. RESULTS: Tumor response at 3 months was complete response in one (6%) and four (31%) patients, and partial response in two (13%) and six (46%) patients, after TACE and TACE-B, respectively. No complications were observed during TACE. Most TACE-related adverse events were correlated with post-embolic syndrome. CONCLUSION: The preliminary results of the study showed that the TACE-B is feasible and tolerable. This study will be continued in order accrue a larger number of patients and longer follow-up.

Outcomes of percutaneous transluminal biopsy of biliary lesions using a dedicated forceps system.

BACKGROUND: Distinction between benign and malignant biliary obstruction is always challenging. PURPOSE: To evaluate outcomes of percutaneous transluminal biopsy of biliary strictures using a dedicated forceps system. MATERIAL AND METHODS: This prospective, single-center, single-arm study, included 29 consecutive patients (17 men [56.6%]; mean age = 60 ± 9 years), who underwent 30 transluminal biopsies during percutaneous transhepatic biliary drainage (PTBD) due to obstructive jaundice, between September 2014 and January 2017, using a transluminal biliary access and biopsy forceps set. The study's primary efficacy endpoint was technical success and the primary safety endpoint was the procedure-related major complications rate. The study's secondary endpoints were procedure-related minor complication rate, sensitivity, specificity, and diagnostic accuracy for the characterization of malignancy. RESULTS: Tissue samples allowed histological diagnosis in 27/30 procedures (technical success rate 90.0%), as in three cases (10.0%) the sample was characterized as non-diagnostic: one case was suspicious for pancreatic cancer and two cases were cholangiocarcinoma. In one case, biopsy was successfully repeated. The diagnosis was cholangiocarcinoma in 16 cases (53.3%), colorectal metastasis in three cases (10%), pancreatic adenocarcinoma in three cases (10.0%), and inflammation in five cases (16.6%). There were two false-negative cases of inflammation proven to be cholangiocarcinoma, resulting in sensitivity of 91.67%, specificity of 100%, and accuracy of 92.59%. No major complications were noted. There were four cases of hemobilia (13%) which auto-resolved within 48 h. CONCLUSION: Percutaneous transluminal biopsy of biliary strictures during PTBD using the specific forceps system was proven safe and resulted in high technical success and diagnostic accuracy rates.

Polyethylene glycol microspheres loaded with irinotecan for arterially directed embolic therapy of metastatic liver cancer.

AIM: To study tumor response, and tolerability of arterially directed embolic therapy (ADET) with polyethylene glycol embolics loaded with irinotecan for the treatment of colorectal cancer liver metastases (CRC-LM). Secondary objectives were to monitor quality of life, time to progression and survival of patients. METHODS: Patients were included in the study if they were affected by CRC-LM, refractory to systemic chemotherapy, treated with ADET using polyethylene glycol embolics, and had liver involvement < 50%. Tumor response, performance status (PS), tumor marker antigens, and quality of life (QoL) were monitored at 1, 3 and 6 mo after ADET. QoL was assessed with the Palliative Performance Scale (PPS). RESULTS: We treated 50 consecutive CRC-LM patients with ADET using polyethylene glycol embolics. Their tumor response one month after ADET was: 28% of complete response (CR), 48% of partial response (PR), 8% stable disease (SD), and 16% of progression. Tumor response 3 mo after ADET was CR 24%, PR 38%, SD 19% and progression disease (PD) 19%. Tumor response 6 mo after ADET was CR 18%, PR 44%, SD 21% and PD 18%. QoL was 90% PPS at each time point. Median time to progression for patients who progressed was 2.5 mo (range 0.8-6). Median follow-up was 14 mo (0.8-25 range). ADETs were performed with no complications. Observed side effects (mild or moderate intensity) were: Pain in 32% of patients, increase of transaminase levels in 20% and fever in 14%, whereas 30% of patients did not complain any adverse event. CONCLUSION: The treatment of unresectable CRC-LM with ADET using polyethylene glycol microspheres loaded with irinotecan was effective in tumor response and resulted in mild toxicity, and good QoL.

Cutting Balloon Angioplasty in the Treatment of Short Infrapopliteal Bifurcation Disease.

PURPOSE: To evaluate the safety, feasibility, and effectiveness of cutting balloon angioplasty in the management of infrapopliteal bifurcation disease. METHODS: Between November 2010 and March 2013, 23 patients (mean age 69.6±9.01 years, range 56-89; 16 men) suffering from critical limb ischemia were treated using cutting balloon angioplasty (single cutting balloon, T-shaped double cutting balloon, or double kissing cutting balloon technique) for 47 infrapopliteal artery bifurcation lesions (16 popliteal bifurcation and 9 tibioperoneal bifurcation) in 25 limbs. Follow-up consisted of clinical examination and duplex ultrasonography at 1 month and every 3 months thereafter. RESULTS: All treatments were technically successful. No 30-day death or adverse events needing treatment were registered. No flow-limiting dissection was observed, so no stent implantation was necessary. The mean postprocedure minimum lumen diameter and acute gain were 0.28±0.04 and 0.20±0.06 cm, respectively, with a residual stenosis of 0.04±0.02 cm. Primary and secondary patency rates were estimated as 89.3% and 93.5% at 6 months and 77.7% and 88.8% at 12 months, respectively; 1-year primary and secondary patency rates of the treated bifurcation were 74.2% and 87.0%, respectively. The survival rate estimated by Kaplan-Meier analysis was 82.5% at 1 year. CONCLUSION: Cutting balloon angioplasty seems to be a safe and effective tool in the routine treatment of short/ostial infrapopliteal bifurcation lesions, avoiding procedure-related complications, overcoming the limitations of conventional angioplasty, and improving the outcome of catheter-based therapy.

Interventional radiological treatment of renal transplant complications: a pictorial review.

Renal transplantation is the treatment of choice for patients with chronic renal failure, which produces a dramatic improvement in the quality of life and survival rates, in comparison to long-term dialysis. Nowadays, new imaging modalities allow early diagnosis of complications, and thanks to the recent developments of interventional techniques, surgery may be avoided in most cases. Knowledge in the types of renal transplant complications is fundamental for a correct pre-operative planning. In this article, we described the most common or clinically relevant renal transplant complications and explained their interventional management.

Proximal aneurysmal neck: dynamic ECG-gated CT angiography--conformational pulsatile changes with possible consequences for endograft sizing.

PURPOSE: To assess the magnitude of variations in size of the proximal neck of the abdominal aortic aneurysm (AAA) in patients selected to undergo endovascular abdominal aortic aneurysm repair (EVAR) and the potential effect on choice of endograft diameter by using 64-section dynamic electrocardiographically (ECG)-gated computed tomographic (CT) angiography. MATERIALS AND METHODS: A prospective single-center study was performed in 40 patients with AAA who underwent both static and dynamic ECG-gated CT angiography. The ethical conduct of the study was approved by the departmental review board, and all patients provided written informed consent. Dynamic ECG-gated data sets were acquired with a low-dose acquisition protocol (100 kV) by using a 0.625-mm-section collimation (40 mL iomeprol [400 mg of iodine per milliliter] versus 80 mL). Pulsatility measurements were taken at suprarenal, juxtarenal, and infrarenal levels within the aneurysmal neck. Manual CT angiographic measurements were performed on modified axial images. On static axial images, one vascular surgeon and one interventional radiologist selected the diameter of the main body of the potential infrarenal stent-graft to implant. The diameter of the main body of the stent-graft selected was compared with the dynamic measurements obtained to calculate the potential relative oversizing performed. RESULTS: A total of 40 patients were enrolled. Significant aortic pulsatility was demonstrated within the aneurysmal neck (mean variation, 9.01% ± 4.81 [standard deviation]; absolute change, 1.83 mm ± 1.01; P < .05). When compared with dynamic measurements, the diameter of the endograft selected on the basis of static images would be potentially changed in 12 of 40 (30%) patients. Comparing the minimum or maximum diameter of the aneurysmal neck with the diameter of the endograft selected on the basis of static images, the relative oversizing performed was considered inadequate in seven of 40 (18%) patients. CONCLUSION: Dynamic ECG-gated CT may provide information in regard to pulsatile motion that could change the diameter of the endograft selected on the basis of static imaging measurements.

CT angiography in stent-graft sizing: impact of using inner vs. outer wall measurements of aortic neck diameters.

PURPOSE: To assess the impact of using inner wall vs. outer wall measurements on stent-graft sizing for endovascular repair of abdominal aortic aneurysm (AAA). METHODS: Preoperative static and electrocardiographically-gated 64-slice computed tomographic angiography (CTA) datasets were acquired on 40 consecutive AAA patients (29 men; mean age 78.9 ± 6 years, range 75-89). On static images, the aortic neck diameters were manually measured twice by 2 readers at 3 clinically relevant levels (supra-, juxta-, and infrarenal). The measurements were obtained from intima-to-intima (inner wall) and from adventitia-to-adventitia (outer wall). Dynamically reconstructed scans were also reviewed in each phase of the cardiac cycle to identify inner and outer minimum/maximum diameters. Using inner and outer wall measurements performed on static images, readers selected the size of a stent-graft that required inner neck diameter measurements and then one that required outer wall diameters. To calculate the relative oversizing, each selected stent-graft size was compared to that obtained using dynamic measurements. Oversizing <4% or >30% was considered inadequate. RESULTS: Mean variations for the inner and outer wall diameters of 9.75% ± 4.01% and 8.66% ± 3.71%, respectively, were recorded on static CTAs; the absolute changes in diameters were 1.82 ± 0.63 mm and 1.91 ± 0.64 mm, respectively. No statistically significant differences were found relative to aortic pulsatility at the 3 levels in the neck for the inner or outer wall diameters. Significant variability was seen between inner (mean 20.8 ± 3.4 mm) vs. outer (mean 23.7 ± 4.3 mm; p < 0.05) wall diameters. Stent-graft sizes significantly changed on the basis of the measurement method and device; for example, using the outer diameter to size a stent-graft that requires an inner diameter reference changed 36% of the selected stent-graft sizes, with ~20% being excessively oversized. Conversely, using the inner diameter to size an outer-diameter-based stent-graft resulted in nearly 40% of the sizes being altered. Based on dynamic measurements, the changes were more dramatic: the oversizing was considered excessive in up to 90% of patients if the measurement method did not match the stent-graft's stipulated reference. CONCLUSIONS: These data suggest that stent-graft sizing should follow the manufacturer's recommendations for using inner or outer diameter references based on dynamic patterns (mean value between diastolic and systolic diameters suggested).