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BACKGROUND: Huge (>10 cm) hepatocellular carcinoma is burdened by elevated mortality due to its peculiar characteristics and delayed diagnosis. Liver resection is considered the gold standard although survival is poor. Recently, some different strategies have been evaluated to improve results in tumor recurrence and survival. The aim of this research is to identify which strategy offers the best results in terms of overall survival for resectable huge hepatocellular carcinoma. METHODS: A systematic review and network meta-analysis of 13 studies was conducted from PubMed, Embase, Scopus, Cochrane Library, and Web of Science databases including research comparing two or more treatments to manage huge hepatocellular carcinoma. Results were synthesized through forest plots and risk of bias assessed with the CINeMA framework as recommended. RESULTS: The association of liver resection and transcatheter arterial chemoembolization confers a significant improvement in survival compared to liver resection alone (HR: 0.55) while transcatheter arterial chemoembolization, radioembolization, and ethanol ablation alone were associated to decreased overall survival. Within-study bias, indirectness and incoherence were the domains mainly affected by concerns in risk of bias analysis. CONCLUSION: Multimodal treatment including liver resection and transcatheter arterial chemoembolization increases survival in patients with resectable huge hepatocellular carcinoma.
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Carcinoma Hepatocelular , Quimioembolização Terapêutica , Hepatectomia , Neoplasias Hepáticas , Metanálise em Rede , Humanos , Carcinoma Hepatocelular/terapia , Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/patologia , Terapia Combinada , Neoplasias Hepáticas/terapia , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/patologia , Fatores de Risco , Resultado do TratamentoRESUMO
PURPOSE: This study aims to investigate the uptake of transradial approach (TRA) and outpatient setting for transarterial chemoembolization (TACE) and transarterial radioembolization (TARE) in the treatment of hepatocellular carcinoma (HCC) among French interventional radiology centers. MATERIALS AND METHODS: This cross-sectional study was based on a 34-question survey assessing center activity, radial access, and outpatient care. The survey was developed by a working group, tested by two external experts, and distributed to active members of two French radiological societies via a web-based self-reporting questionnaire in March 2022. The survey remained open for eight weeks, with two reminder emails sent to non-responders. Only one answer per center was considered. RESULTS: Of the 44 responding centers, 39% (17/44) performed TRA for TACE and/or TARE, with post-procedure patient comfort as main motivation. Among the 27 centers not performing TRA, 33% (9/27) reported a lack of technical experience, but all 27 intended to adopt TRA within two years. Only six centers performed TACE or TARE in an outpatient setting. Reasons limiting its implementation included TACE for HCC not being a suitable intervention (61%, 27/44) and organizational barriers (41%, 18/44). Among centers not performing outpatient TACE or TARE, 34% (13/38) said "No," 34% (13/38) said "Maybe," and 32% (12/38) said "Yes" when asked about adopting it within two years. CONCLUSION: French interventional radiologists have low TRA uptake for HCC treatment, but TRA adoption potential exists. Respondents were uncertain about performing TACE or TARE in an outpatient setting within a 2-year horizon.
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Carcinoma Hepatocelular , Quimioembolização Terapêutica , Neoplasias Hepáticas , Humanos , Carcinoma Hepatocelular/diagnóstico por imagem , Carcinoma Hepatocelular/terapia , Carcinoma Hepatocelular/patologia , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/terapia , Neoplasias Hepáticas/patologia , Pacientes Ambulatoriais , Radiologia Intervencionista , Estudos Transversais , Quimioembolização Terapêutica/métodos , Resultado do Tratamento , Radioisótopos de Ítrio , Assistência AmbulatorialRESUMO
Radiomics is a discipline that involves studying medical images through their digital data. Using "artificial intelligence" algorithms, radiomics utilizes quantitative and high-throughput analysis of an image's textural richness to obtain relevant information for clinicians, from diagnosis assistance to therapeutic guidance. Exploitation of these data could allow for a more detailed characterization of each phenotype, for each patient, making radiomics a new biomarker of interest, highly promising in the era of precision medicine. Moreover, radiomics is non-invasive, cost-effective, and easily reproducible in time. In the field of oncology, it performs an analysis of the entire tumor, which is impossible with a single biopsy but is essential for understanding the tumor's heterogeneity and is known to be closely related to prognosis. However, current results are sometimes less accurate than expected and often require the addition of non-radiomics data to create a performing model. To highlight the strengths and weaknesses of this new technology, we take the example of hepatocellular carcinoma and show how radiomics could facilitate its diagnosis in difficult cases, predict certain histological features, and estimate treatment response, whether medical or surgical.
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PRIMARY OBJECTIVE: Recently, selective internal radiation therapy using yttrium-90 (Y90) glass microspheres (TheraSphere™) was approved for reimbursement by health authorities in France. The PROACTIF study aims to gather data on effectiveness, patient quality of life, and safety with use of Y90 glass microspheres in real-world clinical settings in France. INCLUSION CRITERIA: Patient with a diagnosis of hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (iCC), and/or metastatic colorectal cancer (mCRC) who was treated with a dose of Y90 glass microspheres that has been reimbursed in France and who do not oppose use of their personal medical data. EXCLUSION CRITERIA: If data collection is opposed, treatment is reimbursed but not administered, or treatment is administered but not reimbursed. OUTCOME MEASURES: Primary outcome measures include overall survival from time of Y90 glass microsphere treatment and quality of life, as assessed using the Functional Assessment of Cancer Therapy- Hepatobiliary questionnaire. ESTIMATED NUMBER OF PATIENTS TO BE INCLUDED: This is an open study and there is no set number of patients; 115 have already been enrolled. PLANNED SUBGROUP ANALYSES: Analyses will be stratified by disease state (HCC, iCC, or mCRC). Subgroups to be analyzed include age group, unilobar/bilobar disease at baseline, Eastern Cooperative Oncology Group (ECOG) status at baseline, liver tumor burden at baseline, target lesion size, and standard versus multi-compartment personalized dosimetry treatment. PLANNED RECRUITMENT AND OBSERVATION PERIOD: Recruitment includes patients who are prescribed and treated with a commercial vial of Y90 glass microspheres between 01 January 2019 and 31 December 2024. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04069468.
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Neoplasias dos Ductos Biliares , Carcinoma Hepatocelular , Colangiocarcinoma , Neoplasias Colorretais , Embolização Terapêutica , Neoplasias Hepáticas , Ductos Biliares Intra-Hepáticos , Carcinoma Hepatocelular/radioterapia , Colangiocarcinoma/radioterapia , Ensaios Clínicos Fase IV como Assunto , Neoplasias Colorretais/radioterapia , Humanos , Neoplasias Hepáticas/radioterapia , Microesferas , Estudos Prospectivos , Qualidade de Vida , Sistema de Registros , Resultado do Tratamento , Radioisótopos de Ítrio/uso terapêuticoRESUMO
BACKGROUND: Careful selection of hepatocellular carcinoma (HCC) patients prior to chemoembolization treatment is a daily reality, and is even more necessary with new available therapeutic options in HCC. AIM: To propose two new models to better stratify patients and maximize clinical benefit: "6 and 12" and "pre/post-TACE-predict" (TACE, transarterial chemoembolization). METHODS: We evaluated and compared their performance in predicting overall survival with other systems {Barcelona Clinic Liver Cancer (BCLC), Albumin-Bilirubin (ALBI) and NIACE [Number of tumor(s), Infiltrative HCC, alpha-fetoprotein, Child-Pugh (CP), and performance status]} in two HCC French cohorts of different stages enrolled between 2010 and 2018. RESULTS: The cohorts included 324 patients classified as BCLC stages A/B (cohort 1) and 137 patients classified as BCLC stages B/C (cohort 2). The majority of the patients had cirrhosis with preserved liver function. "Pre-TACE-predict" and "6 and 12" models identified three distinct categories of patients exhibiting different prognosis in cohort 1. However, their prognostic value was no better than the BCLC system or NIACE score. Liver function based on CP and ALBI grades significantly impacted patient survival. Conversely, the "post-TACE-predict" model had a higher predictive value than other models. The stratification ability as well as predictive performance of these new models in an intermediate/advanced stage population was less efficient (cohort 2). CONCLUSION: The newly proposed "Pre-TACE-predict" and "6 and 12" models offer an interesting stratification into three categories in a recommended TACE population, as they identify poor candidates, those with partial control and durable response. The models' contribution was reduced in a population with advanced stage HCCs.
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BACKGROUND AND AIM: Transarterial chemoembolization with drug-eluting microspheres (DEM-TACE) is recommended for patients with BCLC stage B hepatocellular carcinoma (HCC) and stage 0-A unsuitable for curative treatments. We assessed efficacy and safety along with hepatobiliary toxicities (HBT) of DEM-TACE using a novel microsphere, LifePearlTM, loaded with anthracyclines. MATERIALS AND METHODS: 97 patients diagnosed with HCC were prospectively enrolled and treated using LifePearlTM loaded with doxorubicin (77%) or idarubicin (23%). Safety and tolerability were assessed using CTCAE, HBT by CT/MRI scans, and tumor response by applying modified Response Evaluation Criteria in Solid Tumors (mRECIST). Follow-up was after 2 years. RESULTS: Adverse events (AE) were reported in 73.2% of patients, majority being Grade 1-2. Grade ≥ 3 AE reported in 13.4% of patients were mainly related to postembolization syndrome. HBT were observed after 15.5% (29/187) of the DEM-TACEs. Objective response and disease control rates were 81% and 99%, respectively, as the best responses. Survival rates at one and two years were 81% and 66%, respectively, while the median overall survival (OS) was not reached. Median progression free survival was 13.7 months (95% CI: 11.3; 15.6) and median time to TACE untreatable progression was 16.7 months (95% CI: 12.7; not estimable (n.e.)). CONCLUSIONS: DEM-TACE using LifePearlTM provides a high tumor response rate in HCC patients. HBT rates within or below previously reported results for cTACE and DEM-TACE indicate a good safety profile for LifePearlTM. The trial was registered in ClinicalTrials.gov National Library of Medicine (ID: NCT03053596).
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INTRODUCTION: Patients with liver metastasis from uveal melanoma have a poor prognosis. Efficacy and safety of hepatic transarterial chemoembolization (TACE) using melphalan and microspheres was evaluated. MATERIALS AND METHODS: Monocentric retrospective study of all consecutive patients treated by TACE using melphalan and 250µm calibrated microspheres between 2004 and 2016. Radiological response was assessed according to RECIST 1.1, modified (m)-RECIST and EASL on contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI). The primary endpoint was overall survival (OS). Liver metastasis response, hepatic, extrahepatic and global progression free survival (PFS) complications were evaluated with the common terminology criteria for adverse events version 4.0 (CTCAE 4.0) and survival factors were secondary endpoints. RESULTS: Thirty-four patients underwent 138 TACE (4; 4.1 sessions; range 1-9). Median OS was 16.5 months (mean 21.6 months). Liver metastasis response combining partial and complete response was 42.4%, 97%, 97% with RECIST 1.1, mRECIST, EASL, respectively. There were 58 severe (CTCAE≥3) but manageable complications in 28 patients, except for 1 toxic death. CONCLUSION: For patients with liver metastases from uveal melanoma ineligible for local treatments, TACE using melphalan may be performed as first line therapy in metastatic miliary disease from uveal melanomas with careful supportive care.
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Antineoplásicos Alquilantes/administração & dosagem , Quimioembolização Terapêutica/métodos , Neoplasias Hepáticas/terapia , Melanoma/terapia , Melfalan/administração & dosagem , Microesferas , Neoplasias Uveais/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Feminino , Humanos , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/secundário , Masculino , Melanoma/diagnóstico por imagem , Melanoma/mortalidade , Melanoma/secundário , Pessoa de Meia-Idade , Prognóstico , Intervalo Livre de Progressão , Critérios de Avaliação de Resposta em Tumores Sólidos , Estudos Retrospectivos , Resultado do Tratamento , Neoplasias Uveais/mortalidadeRESUMO
BACKGROUND: In patients undergoing major liver resection, portal vein embolization (PVE) has been widely used to induce hypertrophy of the non-embolized liver in order to prevent post-hepatectomy liver failure. PVE is a safe and effective procedure, but does not always lead to sufficient hypertrophy of the future liver remnant (FLR). Hepatic vein(s) embolization has been proposed to improve FLR regeneration when insufficient after PVE. The sequential right hepatic vein embolization (HVE) after right PVE demonstrated an incremental effect on the FLR but it implies two different procedures with no time gain as compared to PVE alone. We have developed the so-called liver venous deprivation (LVD), a combination of PVE and HVE during the same intervention, to optimize the phase of liver preparation before surgery. The main objective of this randomized phase II trial is to compare the percentage of change in FLR volume at 3 weeks after LVD or PVE. METHODS: Patients eligible to this multicenter prospective randomized phase II study are subjects aged from 18 years old suffering from colo-rectal liver metastases considered as resectable and with non-cirrhotic liver parenchyma. The primary objective is the percentage of change in FLR volume at 3 weeks after LVD or PVE using MRI or CT-Scan. Secondary objectives are assessment of tolerance, post-operative morbidity and mortality, post-hepatectomy liver failure, rate of non-respectability due to insufficient FLR or tumor progression, per-operative difficulties, blood loss, R0 resection rate, post-operative liver volume and overall survival. Objectives of translational research studies are evaluation of pre- and post-operative liver function and determination of biomarkers predictive of liver hypertrophy. Sixty-four patients will be included (randomization ratio 1:1) to detect a difference of 12% at 21 days in FLR volumes between PVE and LVD. DISCUSSION: Adding HVE to PVE during the same procedure is an innovative and promising approach that may lead to a rapid and major increase in volume and function of the FLR, thereby increasing the rate of resectable patients and limiting the risk of patient's drop-out. TRIAL REGISTRATION: This study was registered on clinicaltrials.gov on 15th February 2019 (NCT03841305).
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Neoplasias Colorretais/patologia , Embolização Terapêutica/métodos , Hepatectomia/efeitos adversos , Falência Hepática/prevenção & controle , Neoplasias Hepáticas/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Adulto , Ensaios Clínicos Fase II como Assunto , Neoplasias Colorretais/cirurgia , Embolização Terapêutica/efeitos adversos , Feminino , Seguimentos , Hepatomegalia/etiologia , Humanos , Fígado/irrigação sanguínea , Fígado/patologia , Fígado/fisiologia , Fígado/cirurgia , Falência Hepática/etiologia , Neoplasias Hepáticas/secundário , Regeneração Hepática , Masculino , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto , Veia Porta , Complicações Pós-Operatórias/etiologia , Cuidados Pré-Operatórios/métodos , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do TratamentoRESUMO
The last decade has seen important developments in the treatment of metastatic colorectal cancer (mCRC). In this scenario, interventional locoregional treatments could play an expanding role offering safe and effective integrated options in the continuum-of-care offering curative as well as palliative approaches. Based on ESMO guidelines, the toolbox of ablative treatments also includes intra-arterial palliative options, like chemoembolization, that can be offered as an alternative option in patients failing the available chemotherapeutic regimens. However, to date, there is still a limited use of chemoembolization in clinical practice. Based on this background, a comprehensive review of the methodologic and technical considerations as well as clinical indications and future perspectives seems to be useful with the aim to demonstrate the field's value of the procedure, highlight their advantages, and ensure an increased role in treatment management of patients with colorectal liver metastases.
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Previous observations have reported controversial conclusions regarding cell dose and survival endpoints after allogeneic hematopoietic stem cell transplantation (HSCT). We conducted a retrospective analysis on 414 adult patients (median age 54 years, range, 18-74 years) with acute myeloid leukemia (AML) in first and second complete remission. They received a T-cell replete allogeneic HSCT from haploidentical donors, using peripheral blood stem cells, between 2006-2018. Median number of infused CD34+ was 6.58 × 106 /kg (range, 2.2-31.2 × 106 /kg). Graft-vs-host disease (GVHD) prophylaxis was post-transplant cyclophosphamide in 293 patients and anti-lymphocyte serum in 121 patients. Conditioning was myeloablative in 179 patients and reduced-intensity in 235 patients. After a median follow-up of 23.3 months (range, 12.1-41.8 months), 2-year overall survival (OS) was 64.5% (95% CI 59.3%-69.7%) with leukemia-free survival (LFS) of 57.3% (95% CI 51.8%-62.7%) and non-relapse mortality (NRM) of 23.3% (95% CI 19%-27.7%). Grades III-IV acute GVHD day+100 incidence was 14.6% while extensive chronic GVHD was 14.4% at 2-years. Thirteen (3.2%) patients experienced graft failure. We found the optimal CD34+/kg threshold defining high (n = 334) vs low cell dose (n = 80) at 4.96 × 106 . Recipients of >4.96 × 106 /kg CD34+ cells experienced less NRM (Hazard ratio [HR] 0.48; 95% CI 0.30-0.76) and prolonged LFS (HR 0.63; 95% CI 0.43-0.91) and OS (HR 0.60; 95% CI 0.40-0.88) compared to those in the lower cell dose cohort. Larger cohort studies are needed to confirm these findings.
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Antígenos CD34/metabolismo , Transplante de Células-Tronco Hematopoéticas/métodos , Leucemia Mieloide Aguda/terapia , Células-Tronco de Sangue Periférico/fisiologia , Condicionamento Pré-Transplante/métodos , Transplante Haploidêntico/métodos , Doença Aguda , Adulto , Idoso , Europa (Continente) , Feminino , Humanos , Leucemia Mieloide Aguda/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Sleeve gastrectomy (SG) is the most frequently performed bariatric intervention worldwide, and obese patients have a higher risk of developing reflux symptoms compared with the general population [1, 2]. One of the controversies of SG is to perform it in patients with gastroesophageal reflux disease (GERD). Some studies have shown that SG may exacerbate GERD symptoms or even increase the risk of "de novo" postoperative GERD [3, 4]. Laparoscopic Nissen fundoplication is an effective treatment for patients with severe GERD. In order to avoid the Roux-en-Y gastric bypass (RYGB), some authors combined the SG with the Nissen fundoplication in morbid obese patients with GERD [5]. As after SG, postoperative gastric fistula may occur after Nissen SG. Persistent fistula after Nissen SG may be treated by conversion to RYGB. METHODS: We present the case of a 35-year-old woman with long-standing morbid obesity, who presented to our institution seeking management options for her postoperative fistula. In August 2018, she underwent a laparoscopic Nissen SG in another institution. Her initial weight was 107 kg, height 172 cm, and body mass index (BMI) 36.27 kg/m2. At the 7th postoperative day, she complained of severe abdominal pain and fever. A computed tomography (CT) scan was performed showing a massive supra-mesocolic pneumoperitoneum. An explorative laparoscopy was performed with evidence of a generalized peritonitis without identification of the orifice of the leak. Peritoneal lavage of the abdominal cavity was done and the patient was transferred to our institution. An upper gastrointestinal endoscopy was performed with evidence of a fistula on the gastric longitudinal staple line (8 mm in diameter), and a stenosis of about 15 mm on the distal gastric tube. A double pig-tail was placed. After 14 days, the patient underwent a gastric pneumatic dilatation of the stenosis placed at the antro-fundic region, without complications. Three months later, the fistula was persistent; therefore, after a careful nutritional and psychological evaluation and discussion with the patient, we decided to perform a conversion to a RYGB. The valve of the Nissen fundoplication was identified and divided using a stapler. The orifice of the fistula was identified. Resection of this valve, including the orifice of the fistula and the gastric tube, was done using a blue-load stapler ECHELON FLEX™ GST (Ethicon Endo-Surgery, USA) while creating the new gastric pouch. Then, we performed a Roux-en-Y gastric bypass with a 150-cm alimentary limb and a 50-cm biliary limb. The Petersen and the mesenteric defects were closed. RESULTS: The blood loss was less than 100 cc and the operative time was 240 min. The postoperative period was smooth and uneventful; the patient was started on liquid diet on the second postoperative day and discharged at day 8. At 1 month postoperatively, the patient has lost 16 kg and the %EWL was 36.53%, %TWL 14.95% with a BMI of 30.84 kg/m2. At 6 months postoperatively, the patient lost 24 kg, with a BMI at 26 kg/m2. She does not complain of GERD, no vomiting, no abdominal pain, and no diarrhea. CONCLUSIONS: In cases of fistulas after Nissen SG, the surgery becomes more tedious and difficult. Conversion to RYGB seems a feasible and effective option to treat chronic fistula after Nissen SG.
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Gastrectomia/efeitos adversos , Derivação Gástrica , Fístula Gástrica/etiologia , Laparoscopia/efeitos adversos , Obesidade Mórbida/cirurgia , Complicações Pós-Operatórias/etiologia , Adulto , Índice de Massa Corporal , Feminino , Humanos , ReoperaçãoRESUMO
INTRODUCTION: This document is a summary of the French intergroup guidelines regarding the management of metastatic colorectal cancer (mCRC) published in January 2019, and available on the French Society of Gastroenterology website (SNFGE) (www.tncd.org). METHODS: This collaborative work was realized by all French medical and surgical societies involved in the management of mCRC. Recommendations are graded in three categories (A, B and C), according to the level of evidence found in the literature, up until December 2018. RESULTS: The management of metastatic colorectal cancer has become complex because of increasing available medical, radiological and surgical treatments alone or in combination. The therapeutic strategy should be defined before the first-line treatment, mostly depending on the presentation of the disease (resectability of the metastases, symptomatic and/or threatening disease), of the patient's condition (ECOG PS, comorbidities), and tumor biology (RAS, BRAF, MSI). The sequence of targeted therapies also seems to have an impact on the outcome (angiogenesis inhibition beyond progression). Surgical resection of metastases was the only curative intent treatment to date, joined recently by percutaneous tumor ablation tools (radiofrequency, microwave). Localized therapies such as hepatic intra-arterial infusion, radioembolization and hyperthermic intraperitoneal chemotherapy, also have seen their indications specified (liver-dominant disease and resectable peritoneal carcinomatosis). New treatments have been developed in heavily pretreated patients, increasing overall survival and preserving quality of life (regorafenib and trifluridine/tipiracil). Finally, immune checkpoint inhibitors have demonstrated high efficacy in MSI mCRC. CONCLUSION: French guidelines for mCRC management are put together to help offer the best personalized therapeutic strategy in daily clinical practice, as the mCRC therapeutic landscape is complexifying. These recommendations are permanently being reviewed and updated. Each individual case must be discussed within a multidisciplinary team (MDT).
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Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/terapia , Metástase Neoplásica/diagnóstico , Metástase Neoplásica/terapia , Neoplasias Colorretais/patologia , Terapia Combinada , França , Humanos , Metástase Neoplásica/patologia , Estadiamento de Neoplasias , Qualidade de Vida , Sociedades MédicasRESUMO
Background A prior in vitro study showed that idarubicin was the most cytotoxic agent for hepatocellular carcinoma (HCC) cell lines. Idarubicin-loaded beads for transarterial chemoembolization (TACE) were previously evaluated for the appropriate dose in a phase I dose-escalation study. Purpose To evaluate objective response rate (ORR), safety, and survival after TACE by using idarubicin-loaded beads for unresectable HCC. Materials and Methods This prospective single-arm phase II study was conducted between January 2015 and January 2017. Participants with unresectable HCC were included in the trial and underwent TACE with idarubicin-eluting beads. The primary end point was 6-month ORR assessed with independent central review by using modified Response Evaluation Criteria in Solid Tumors. Secondary end points were best ORR during the first 6 months, overall survival, progression-free survival, time to progression, and safety. A two-stage Fleming statistical design was used. Results Forty-six study participants (mean age, 71.2 years ± 10.2; six women and 40 men) were included; 44 participants underwent at least one TACE session. The 6-month ORR was 52% (23 of 44). The best ORR achieved was 68% (30 of 44). Fourteen of 44 (32%) participants underwent a curative treatment after TACE. Median progression-free survival, time to progression, and overall survival were 6.6 months, 9.5 months, and 18.6 months, respectively. TACE was discontinued for toxicity in four of 44 (9%) participants. The most frequent grade 3-4 adverse events were elevated aspartate aminotransferase (14 of 44, 32%), elevated γ-glutamyl transpeptidase (eight of 44, 18%), hyperbilirubinemia (seven of 44, 16%), elevated alanine aminotransferase (seven of 44, 16%), and pain (seven of 44, 16%). Conclusion Idarubicin-eluting beads showed a good safety profile and promising objective response rate and time to progression when used as part of a transarterial chemoembolization regimen for unresectable hepatocellular carcinoma. © RSNA, 2019 See also the editorial by Padia in this issue.
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Antibióticos Antineoplásicos/uso terapêutico , Carcinoma Hepatocelular/terapia , Quimioembolização Terapêutica/métodos , Idarubicina/uso terapêutico , Neoplasias Hepáticas/terapia , Idoso , Idoso de 80 Anos ou mais , Antibióticos Antineoplásicos/administração & dosagem , Antibióticos Antineoplásicos/efeitos adversos , Feminino , Humanos , Idarubicina/administração & dosagem , Idarubicina/efeitos adversos , Masculino , Pessoa de Meia-IdadeRESUMO
OBJECTIVE: To compare diagnostic accuracy of MR-hysterosalpingography (MR-HSG) and conventional hysterosalpingography (X-HSG) in the evaluation of female infertility. METHODS: Forty women received prospectively both X-HSG, the gold standard technique, and MR-HSG on the same day but the order in which they were conducted was randomised. A 1.5 Tesla MRI was performed with classical sequences for pelvic analysis and an additional 3D T1-weighted sequence with intra-uterine injection of gadolinium. Two radiologists independently interpreted X-HSG and MR-HSG according to randomisation, blinded to the other results. They both then performed a second interpretation of MR-HSG blinded to the first reading with a minimum time delay of 1 week. Diagnostic performance of MR-HSG for analysis of tubal and intracavity abnormalities was evaluated by calculating sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV). RESULTS: Twenty-six patients were included. Diagnostic performance of MR-HSG was: Se: 91.7% (95% CI 61.5-99.8); Sp: 92.9% (95% CI 66.1-99.8) ; PPV: 91.7% (95% CI 61.5-99.8); NPV: 92.9% (95% CI 66.1-99.8). Pain analysis showed a significant statistical difference between the two procedures: average VAS for X-HSG was 4.43 (95% CI 3.50-5.36) versus 3.46 (95% CI 2.62-4.31) for MR-HSG, p=0,01. Intra- and inter-rater agreements for detection of tubal or intracavity abnormalities were 0.92 (95% CI 0.78-1.00) and 0.76 (95% CI 0.52-1.00). CONCLUSION: MR-HSG is a well-tolerated technique demonstrating high accuracy in investigating tubal patency and intra-uterine abnormalities for diagnostic work-up of female infertility. KEY POINTS: ⢠MR-hysterosalpingography is an innovative technique. ⢠Hysterosalpingography can be used to investigate tubal patency and intracavity abnormalities. ⢠Hysterosalpingography is a potential 'one-stop-shop' imaging technique for a single comprehensive examination of female infertility.
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Histerossalpingografia/métodos , Infertilidade Feminina/diagnóstico por imagem , Adulto , Doenças das Tubas Uterinas/complicações , Doenças das Tubas Uterinas/diagnóstico por imagem , Feminino , Gadolínio , Humanos , Histerossalpingografia/efeitos adversos , Infertilidade Feminina/etiologia , Imageamento por Ressonância Magnética/efeitos adversos , Imageamento por Ressonância Magnética/métodos , Dor/etiologia , Sensibilidade e Especificidade , Anormalidades Urogenitais/complicações , Anormalidades Urogenitais/diagnóstico por imagem , Doenças Uterinas/complicações , Doenças Uterinas/diagnóstico por imagem , Útero/anormalidades , Útero/diagnóstico por imagemAssuntos
Doenças das Glândulas Suprarrenais/diagnóstico , Neoplasias das Glândulas Suprarrenais/complicações , Hematoma/diagnóstico , Hemorragia/etiologia , Doenças Peritoneais/etiologia , Feocromocitoma/complicações , Doenças das Glândulas Suprarrenais/complicações , Neoplasias das Glândulas Suprarrenais/diagnóstico , Neoplasias das Glândulas Suprarrenais/patologia , Adulto , Diagnóstico Diferencial , Hematoma/complicações , Hemorragia/diagnóstico , Humanos , Masculino , Invasividade Neoplásica , Recidiva Local de Neoplasia/diagnóstico , Doenças Peritoneais/diagnóstico , Feocromocitoma/diagnóstico , Feocromocitoma/patologiaRESUMO
AIM: To prospectively evaluate the performance of Doppler-ultrasonography (US) for the detection of transjugular intrahepatic portosystemic shunt (TIPS) dysfunction within a multicenter cohort of cirrhotic patients. METHODS: This study was conducted in 10 french teaching hospitals. After TIPS insertion, angiography and liver Doppler-US were carried out every six months to detect dysfunction (defined by a portosystemic gradient ≥ 12 mmHg and/or a stent stenosis ≥ 50%). The association between ultrasonographic signs and dysfunction was studied by logistic random-effects models, and the diagnostic performance of each Doppler criterion was estimated by the bootstrap method. This study was approved by the ethics committee of Tours. RESULTS: Two hundred and eighteen pairs of examinations performed on 87 cirrhotic patients were analyzed. Variables significantly associated with dysfunction were: The speed of flow in the portal vein (P = 0.008), the reversal of flow in the right (P = 0.038) and left (P = 0.049) portal branch, the loss of modulation of portal flow by the right atrium (P = 0.0005), ascites (P = 0.001) and the overall impression of the operator (P = 0.0001). The diagnostic performances of these variables were low; sensitivity was < 58% and negative predictive value was < 73%. Therefore, dysfunction cannot be ruled out from Doppler-US. CONCLUSION: The performance of Doppler-US for the detection of TIPS dysfunction is poor compared to angiography. New tools are needed to improve diagnosis of TIPS dysfunction.
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PURPOSE: To assess technical feasibility, safety, and efficacy of the liver venous deprivation (LVD) technique that combines both portal and hepatic vein embolization during the same procedure for liver preparation before major hepatectomy. MATERIALS AND METHODS: Seven patients (mean age:63.6y[42-77y]) underwent trans-hepatic LVD for liver metastases (n = 2), hepatocellular carcinoma (n = 1), intrahepatic cholangiocarcinoma (n = 3) and Klatskin tumour (n = 1). Assessment of future remnant liver (FRL) volume, liver enzymes and histology was performed. RESULTS: Technical success was 100 %. No complication occurred before surgery. Resection was performed in 6/7 patients. CT-scan revealed hepatic congestion in the venous-deprived area (6/7 patients). A mean of 3 days (range: 1-8 days) after LVD, transaminases increased (AST: from 42 ± 24U/L to 103 ± 118U/L, ALT: from 45 ± 25U/L to 163 ± 205U/L). Twenty-three days (range: 13-30 days) after LVD, FRL increased from 28.2 % (range: 22.4-33.3 %) to 40.9 % (range: 33.6-59.3 %). During the first 7 days, venous-deprived liver volume increased (+13.4 %) probably reflecting vascular congestion, whereas it strongly decreased (-21.3 %) at 3-4 weeks. Histology (embolized lobe) revealed sinusoidal dilatation, hepatocyte necrosis and important atrophy in all patients. CONCLUSION: Trans-hepatic LVD technique is feasible, well tolerated and provides fast and important hypertrophy of the FRL. This new technique needs to be further evaluated and compared to portal vein embolization. KEY POINTS: ⢠Twenty-three days after LVD, FRL increased from 28.2 % (range:22.4-33.3 %) to 40.9 % (range:33.6-59.3 %) ⢠During the first 7 days, venous-deprived liver volume increased (+13.4 %) ⢠Venous-deprived liver volume strongly decreased (mean atrophy:229 cc; -21.3 %) at 3-4 weeks ⢠Histology of venous-deprived liver revealed sinusoidal dilatation, hepatocyte necrosis and important atrophy.
Assuntos
Neoplasias dos Ductos Biliares/cirurgia , Embolização Terapêutica/métodos , Hepatectomia , Veias Hepáticas , Neoplasias Hepáticas/cirurgia , Veia Porta , Cuidados Pré-Operatórios/métodos , Adulto , Idoso , Neoplasias dos Ductos Biliares/patologia , Estudos de Viabilidade , Feminino , Humanos , Testes de Função Hepática , Neoplasias Hepáticas/patologia , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
BACKGROUND: Left cardiac chambers dilation, interstitial lung changes and pleural effusions are the characteristics of cardiogenic pulmonary oedema on computed tomography (CT) of the chest but mensuration of the left atrial size is not routinely performed. Cardiac chambers normal dimensions are known to be proportional to the patient's build and anthropomorphic data but adjustment of chambers dimensions to available elements seen on the axial CT images has never been evaluated before. OBJECTIVES: Our objective was to use data easily available on axial images to directly scale the left atrium. We chose to divide the left atrial diameter by the thoracic vertebral diameter, using the latter as a body-mass indicator. As a preliminary study, we aimed to evaluate the range of values of this left atrio-vertebral ratio (LAVR) by comparing patients suffering from cardiogenic pulmonary oedema with patients free of cardiac disease. We hypothesized that if the difference of values in these two populations of patients was significant enough, this ratio would be relevant and could be used as a quick criterion in different clinical situations. METHOD: Two radiologists reviewed CT scans of 32 of patients free of cardiac disease and 40 patients in acute cardiac failure. The maximum diameter of the left atrium at the level of the right inferior pulmonary vein was divided by the vertebral transverse diameter to generate a left atrio-vertebral ratio. Receiver operating characteristic curves identified the threshold associated with pulmonary oedema. MEASUREMENTS AND MAIN RESULTS: The mean LAVR was 1.85 ± 0.27 in asymptomatic patients and 2.48 ± 0.35 in patients with pulmonary oedema. A LAVR of 2.1 yielded 85% sensitivity and 88% specificity for the diagnosis of cardiogenic pulmonary oedema. CONCLUSIONS: LAVR is a simple new measure directly scaling the left atrial diameter to the anthropomorphic characteristics of the patient. In our series, a ratio above 2.1 is strongly associated with cardiogenic pulmonary oedema indirectly suggesting left atrial dilation. The results were significantly different between the two populations of patients (no heart condition versus cardiogenic pulmonary oedema) suggesting a high potential for clinical application.