Multidisciplinary Recommendations Regarding Post-Vaccine Adenopathy and Radiologic Imaging: Radiology Scientific Expert Panel.

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 special report 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 (eg, 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 preimaging 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.

Comparison of Real-Time Fluorescence Confocal Digital Microscopy With Hematoxylin-Eosin-Stained Sections of Core-Needle Biopsy Specimens.

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.

Comprehensive Complication Index Validates Improved Outcomes Over Time Despite Increased Complexity in 3707 Consecutive Hepatectomies.

OBJECTIVE: The aim of this study was to evaluate trends over time in perioperative outcomes for patients undergoing hepatectomy. BACKGROUND: As perioperative care and surgical technique for hepatectomy have improved, the indications for and complexity of liver resections have evolved. However, the resulting effect on the short-term outcomes over time has not been well described. METHODS: Consecutive patients undergoing hepatectomy during 1998 to 2015 at 1 institution were analyzed. Perioperative outcomes, including the comprehensive complication index (CCI), were compared between patients who underwent hepatectomy in the eras 1998 to 2003, 2004 to 2009, and 2010 to 2015. RESULTS: The study included 3707 hepatic resections. The number of hepatectomies increased in each era (794 in 1998 to 2003, 1402 in 2004 to 2009, and 1511 in 2010 to 2015). Technical complexity increased over time as evidenced by increases in the rates of major hepatectomy (20%, 23%, 30%, P < 0.0001), 2-stage hepatectomy (0%, 3%, 4%, P < 0.001), need for portal vein embolization (5%, 9%, 9%, P = 0.001), preoperative chemotherapy for colorectal liver metastases (70%, 82%, 89%, P < 0.001) and median operative time (180, 175, 225 minutes, P < 0.001). Significant decreases over time were observed in median blood loss (300, 250, 200 mL, P < 0.001), transfusion rate (19%, 15%, 5%, P < 0.001), median length of hospitalization (7, 7, 6 days, P < 0.001), rates of CCI ≥26.2 (20%, 22%, 16%, P < 0.001) and 90-day mortality (3.1%, 2.6%, 1.3%, P < 0.01). On multivariable analysis, hepatectomy in the most recent era 2010 to 2015 was associated with a lower incidence of CCI ≥26.2 (odds ratio 0.7, 95% confidence interval 0.6-0.8, P < 0.0001). CONCLUSION: Despite increases in complexity over an 18-year period, continued improvements in surgical technique and perioperative outcomes yielded a resultant decrease in CCI in the most current era.

Factors impacting technical success rate of image-guided intra-arterial therapy in rat orthotopic liver tumor model.

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.

Planned Treatment of Advanced Metastatic Disease with Completion Ablation After Hepatic Resection.

PURPOSE: 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]"). METHODS: 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). RESULTS: 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. CONCLUSION: 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.

Comprehensive biomarker analysis and final efficacy results of sorafenib in the BATTLE trial.

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.

Feasibility of image-guided transthoracic core-needle biopsy in the BATTLE lung trial.

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.

Use of research biopsies in clinical trials: are risks and benefits adequately discussed?

PURPOSE: Although the incorporation of research biopsies into clinical trials is increasing, limited information is available about how study protocols and informed consents integrate and describe their use. METHODS: All therapeutic clinical trials in which image-guided research biopsies were performed from January 1, 2005, to October 1, 2010, were identified from an interventional radiology database. Data from study protocols and informed consents were extracted and analyzed. Procedural complications were recorded. RESULTS: A total of 57 clinical trials were identified, of which 38 (67%) contained at least one mandatory biopsy. The analysis of the research biopsy tumor tissue was a study end point in 95% of trials. The primary indication for a research biopsy was for integral biomarker analysis in 32% and for correlative science in 68% of trials. A statistical analytic plan for the correlative science research biopsy tumor tissue was mentioned in 26%, described as exploratory in 51%, and not mentioned in 23% of trials. For studies with mandatory biopsies, biopsy was an eligibility criterion in 71% of trials, and a statistical justification for the research biopsy sample size was present in 50% of trials. A total of 745 research biopsies were performed on 576 patients. Overall and major complication rates were 5.2% (39 of 745 biopsies) and 0.8% (six of 745 biopsies), respectively. Complication rates for intrathoracic and abdominal/pelvic solid organ biopsies were 17.1% (36 of 211 biopsies) and 1.6% (three of 189 biopsies), respectively. Site-stratified research biopsy-related risks were discussed in five consents. CONCLUSION: A better representation of the risks and benefits of research biopsies in study protocols and informed consents is needed.

Phase I clinical trial of systemically administered TUSC2(FUS1)-nanoparticles mediating functional gene transfer in humans.

BACKGROUND: Tumor suppressor gene TUSC2/FUS1 (TUSC2) is frequently inactivated early in lung cancer development. TUSC2 mediates apoptosis in cancer cells but not normal cells by upregulation of the intrinsic apoptotic pathway. No drug strategies currently exist targeting loss-of-function genetic abnormalities. We report the first in-human systemic gene therapy clinical trial of tumor suppressor gene TUSC2. METHODS: Patients with recurrent and/or metastatic lung cancer previously treated with platinum-based chemotherapy were treated with escalating doses of intravenous N-[1-(2,3-dioleoyloxy)propyl]-N,N,N-trimethylammonium chloride (DOTAP):cholesterol nanoparticles encapsulating a TUSC2 expression plasmid (DOTAP:chol-TUSC2) every 3 weeks. RESULTS: Thirty-one patients were treated at 6 dose levels (range 0.01 to 0.09 milligrams per kilogram). The MTD was determined to be 0.06 mg/kg. Five patients achieved stable disease (2.6-10.8 months, including 2 minor responses). One patient had a metabolic response on positron emission tomography (PET) imaging. RT-PCR analysis detected TUSC2 plasmid expression in 7 of 8 post-treatment tumor specimens but not in pretreatment specimens and peripheral blood lymphocyte controls. Proximity ligation assay, performed on paired biopsies from 3 patients, demonstrated low background TUSC2 protein staining in pretreatment tissues compared with intense (10-25 fold increase) TUSC2 protein staining in post-treatment tissues. RT-PCR gene expression profiling analysis of apoptotic pathway genes in two patients with high post-treatment levels of TUSC2 mRNA and protein showed significant post-treatment changes in the intrinsic apoptotic pathway. Twenty-nine genes of the 82 tested in the apoptosis array were identified by Igenuity Pathway Analysis to be significantly altered post-treatment in both patients (Pearson correlation coefficient 0.519; p<0.01). CONCLUSIONS: DOTAP:chol-TUSC2 can be safely administered intravenously in lung cancer patients and results in uptake of the gene by human primary and metastatic tumors, transgene and gene product expression, specific alterations in TUSC2-regulated pathways, and anti-tumor effects (to our knowledge for the first time for systemic DOTAP:cholesterol nanoparticle gene therapy). TRIAL REGISTRATION: ClinicalTrials.gov NCT00059605.

Outcomes of research biopsies in phase I clinical trials: the MD anderson cancer center experience.

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%).

Air travel after biopsy-related pneumothorax: is it safe to fly?

PURPOSE: To evaluate the safety of air travel after percutaneous transthoracic needle biopsy (PTNB). MATERIALS AND METHODS: The study population included 179 patients who underwent 183 PTNBs followed by air travel within 14 days of the procedure. Patients were contacted after their flight and asked to complete a brief telephone survey that assessed for the development of respiratory symptoms during air travel. RESULTS: No patient reported experiencing an in-flight medical event that required emergent, in-flight medical attention or flight diversion. Postbiopsy pneumothorax developed in 65 patients. Of patients with postbiopsy pneumothorax, including patients with radiographic evidence of residual pneumothorax, 50 (77%) traveled within 4 days of the final postbiopsy chest radiograph. Worsening of existing respiratory symptoms or the development of new respiratory symptoms during or after the flight was reported in 14 of 183 patients (8%). CONCLUSIONS: This study shows that air travel after biopsy-related pneumothorax can occur safely before radiographic resolution of pneumothorax and as soon as 24 hours after PTNB.

Early experience using an online reporting system for interventional radiology procedure-related complications integrated with a digital dictation system.

The absence of user-friendly systems for reporting complications is a major barrier to improving quality assurance (QA) programs in interventional radiology (IR) services. We describe the implementation of a QA application that is completely integrated with the radiology dictation system. We implemented an IR QA process as a module within the electronic medical record and radiologist dictation system applications used at our institution. After a radiologist completes a dictation, he or she must select from a drop-down list of complications before proceeding to the next case. Delayed QA events can be entered using the same applications. All complication entries are sent to a database, which is queried to run reports. During the study period, all the 20,034 interventional procedures were entered in the QA database, 1,144 complications were reported, 110 (9.6%) of which were classified as major. Although majority of the complications (996) were entered at the time of dictation, 148 complications (12.9%) were entered afterwards. All major complications were referred to the IR peer review committee, and 30 of these were discussed in the morbidity and mortality meetings. We studied post-lung-biopsy pneumothorax and chest tube rates and initiated a quality improvement process based on the results.The integration of the IR QA reporting system into the workflow process and the mandatory requirements for completion has the potential to minimize the work effort required to enter complication data, and improve participation in the QA process.

The BATTLE trial: personalizing therapy for lung cancer.

UNLABELLED: The Biomarker-integrated Approaches of Targeted Therapy for Lung Cancer Elimination (BATTLE) trial represents the first completed prospective, biopsy-mandated, biomarker-based, adaptively randomized study in 255 pretreated lung cancer patients. Following an initial equal randomization period, chemorefractory non-small cell lung cancer (NSCLC) patients were adaptively randomized to erlotinib, vandetanib, erlotinib plus bexarotene, or sorafenib, based on relevant molecular biomarkers analyzed in fresh core needle biopsy specimens. Overall results include a 46% 8-week disease control rate (primary end point), confirm prespecified hypotheses, and show an impressive benefit from sorafenib among mutant-KRAS patients. BATTLE establishes the feasibility of a new paradigm for a personalized approach to lung cancer clinical trials. SIGNIFICANCE: The BATTLE study is the first completed prospective, adaptively randomized study in heavily pretreated NSCLC patients that mandated tumor profiling with "real-time" biopsies, taking a substantial step toward realizing personalized lung cancer therapy by integrating real-time molecular laboratory findings in delineating specific patient populations for individualized treatment.

Accuracy and sensitivity of computed tomography-guided percutaneous needle biopsy of pulmonary hilar lymph nodes.

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.

CT-guided percutaneous lung biopsies in patients with haematologic malignancies and undiagnosed pulmonary lesions.

We searched the electronic patient database at The University of Texas M. D. Anderson Cancer Center for patients who underwent computed tomography (CT)-guided needle biopsy between January 2001 and December 2005. Inclusion criteria were a known history of haematologic malignancy and a newly detected, undiagnosed pulmonary lesion on chest CT that required tissue sampling for diagnosis; 213 met these criteria. We analysed the biopsy results for diagnostic yield, factors affecting diagnostic yield and effect on treatment. Of 213 procedures, 191 (89.7%) yielded sufficient material for pathologic analysis; 130 (60%) yielded specific diagnoses, while 61 (28.6%) yielded nonspecific benign diagnoses. Lesions larger than 1 cm, cavitary lesions and lung masses were more likely to yield a specific diagnosis than were lesions smaller than 1 cm, lung nodules and consolidations. The most common specific diagnoses were malignancy (62.8%) and infection (34.3%). The latter was more common in patients with leukaemia, cavitary lung lesions or consolidations, active underlying malignancy, neutropenia, respiratory signs and symptoms and/or fever, bone marrow transplant recipients, and in patients receiving chemotherapy. Lung lesions discovered upon follow-up imaging in patients who did not have any respiratory signs/symptoms or fever were mostly malignant. Therapeutic changes were more likely after a specific diagnosis than after a nonspecific diagnosis or a nondiagnostic biopsy (88.4% vs. 18.1%; p < 0.0001). CT-guided lung biopsy has a high diagnostic yield in patients with haematologic malignancies that present with unexplained pulmonary lesions and provides a specific diagnosis in a majority of these patients, leading to therapeutic changes.

Hepatic arterial embolization and chemoembolization for imatinib-resistant gastrointestinal stromal tumors.

OBJECTIVES: We evaluated the efficacy of embolotherapy including hepatic arterial embolization and chemoembolization in patients with imatinib-resistant gastrointestinal stromal tumors with progressive liver metastases. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Bronchial artery embolization for the management of hemoptysis in oncology patients: utility and prognostic factors.

PURPOSE: To evaluate the utility of bronchial artery embolization (BAE) in the oncology population and determine prognostic factors. MATERIALS AND METHODS: This is a retrospective review of 30 consecutive oncology patients (20 men, 10 women; mean age, 60 years) who were referred for BAE for the management of hemoptysis from 1992 to 2007. RESULTS: The amount of hemoptysis at initial embolization was massive (frank blood >300 mL per 24 hours) in 13 patients (43%), moderate (frank blood <300 mL per 24 hours) in 15 (50%), and trivial (blood-tinged sputum) in two (7%). Eighteen patients (60%) had a primary intrathoracic malignancy, seven (23%) had pulmonary metastases, and five (17%) had no evidence of malignant disease in the lung. The technical success rate, defined as the ability to selectively embolize the abnormal vessel, was 86% (32 of 37 procedures). Clinical response categories and complications were defined according to the guidelines established by the SIR Standards of Practice Committee. The major complication rate was 3%, including one case of spinal cord infarction. BAE provided symptom palliation with an immediate decrease or resolution of bleeding in 24 out of 27 patients (89%). The 30-day mortality rate for this cohort was 30%, and the median survival was 5.5 months. Survival was significantly better in patients with non-tumor-related hemoptysis than in those with tumor-related bleeding (P = .004). There was no significant difference in median survival between patients with massive hemoptysis and those with moderate/mild hemoptysis (P = .81), between patients with an emergent procedure and those with a non-emergent procedure (P = .39), and between patients who had previously undergone radiation therapy and those who had not (P = .4). CONCLUSIONS: BAE is safe and effective for the oncologic patient population. In patients with tumor-related hemoptysis, the prognosis remains poor; however, for the subset of oncology patients whose hemoptysis is not related to malignant disease in the lung, the survival is significantly better.

Percutaneous image-guided splenic biopsy in the oncology patient: an audit of 156 consecutive cases.

PURPOSE: To assess the safety and diagnostic accuracy of percutaneous image-guided splenic biopsy in patients known to have or suspected of having malignancy. MATERIALS AND METHODS: Data from all image-guided splenic biopsies performed at a single institution from January 1992 to March 2007 were retrospectively reviewed. One hundred fifty-six splenic biopsies were performed in 147 patients (78 male and 69 female patients; mean age, 54.9 years; age range, 13-81 years). The most common indications for biopsy were suspected recurrent lymphoma (n = 101, 64.7%), suspected metastatic disease (n = 39, 25%), and unknown diagnosis (n = 16, 10.3%). All biopsies were performed with computed tomographic (n = 86), ultrasonographic (n = 68), or fluoroscopic (n = 2) guidance. Most biopsies (91%) were performed with 22-gauge needles, with a mean of 2.8 passes. The mean lesion size was 3.2 cm (range, 0.8-13 cm). Final diagnosis was confirmed with splenectomy (n = 39), histopathologic correlation with concurrent biopsy or surgical specimen (n = 52), or clinical or imaging follow-up ranging from 2 weeks to 14 years (n = 44). Complications were recorded. RESULTS: Sufficient tissue for pathologic analysis was obtained in 144 of the 156 biopsies (diagnostic yield, 92.3%). The overall sensitivity, specificity, and diagnostic accuracy were 83.4%, 87.8%, and 84.7%, respectively. Complications occurred in 26 biopsies (16.7%), with a 1.9% (n = 3) major complication rate and a 14.7% (n = 23) minor complication rate. Splenectomy was necessary in two patients. CONCLUSIONS: Splenic biopsy in the evaluation of new or recurrent neoplasm is a minimally invasive procedure with low complication rates and a high diagnostic yield.