Image-guided microwave thermoablation of hepatic tumours using novel robotic guidance: an early experience.

OBJECTIVE: To evaluate and compare novel robotic guidance and manual approaches based on procedural accuracy, procedural time, procedural performance, image quality as well as patient dose during image-guided microwave thermoablation. METHOD: The study was prospectively performed between June 2013 and December 2013 using 70 patients. Forty randomly selected patients (group 1) were treated with manual guidance and 30 patients (group 2) were treated using a novel robotic guidance. Parameters evaluated were procedural accuracy, total procedural time, procedural performance, quantitative/qualitative image quality and patient dose. Two-sided Student's t test and Wilcoxon rank-sum test were used to test the significance of the data and p values less than 0.05 were considered statistically significant. RESULT: Accuracy parameters were significantly higher in group 2 (all p < 0.05). Total procedural time showed a mean time difference of 3 min (group 2 > group 1; p = 0.0008). Volume CT dose index and dose-length product were significantly lower for group 2 compared to group 1 (all p < 0.05) for CT fluoroscopy imaging. Total procedural performance score was higher for group 2 compared to group 1 (p = 0.0001). Image quality parameters were insignificant between examined groups. CONCLUSION: The novel robotic guided approach improved the accuracy of targeting the target tumour, reduced patient dose and increased procedural performance (which influences the procedural safety) during ablation. KEY POINTS: • Few reports are available in the literature regarding robotic-assisted liver microwave ablation. • The robotic guided approach improved accuracy of localizing the target tumour. • Radiation dose on patients was reduced with the robotic guidance. • Numbers of insertions and readjustments were reduced, lowering chances of complications.

Ablation therapy of hepatocellular carcinoma: a comparative study between radiofrequency and microwave ablation.

PURPOSE: The aim of the study is to retrospectively evaluate and compare the therapeutic response of Radiofrequency (RF) and Microwave (MW) ablation therapy of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: 53 consecutive patients (42 males, 11 females; mean age 59 years, range: 40-68, SD: 4.2) underwent CT-guided percutaneous RF and MW ablation of 68 HCC liver lesions. The morphologic tumor response (number, location and size) was evaluated by magnetic resonance imaging. The follow-up protocol was 24 h post-ablation then within 3 monthly intervals post-ablation in the first year and 6 monthly intervals thereafter. RESULTS: Complete therapeutic response was noted in 84.4% (27/32) of lesions treated with RFA and in 88.9% (32/36) of lesions treated with MW ablation (P = 0.6). Complete response was achieved in all lesions ≤2.0 cm in diameter in both groups. There was no significant difference in rates of residual foci of HCC lesions between RF and MW ablation groups (P = 0.15, Log-rank test). Recurrence rate for 3, 6, 9, and 12 months in patients with HCC who underwent RF ablation compared with MW ablation were 6.3%, 3.1%, 3.1% versus 0%, 5.6%, 2.8%, and 2.8%. Progression-Free Survival rates for treated patients with RF ablation of 1, 2, and 3 years were 96.9%, 93.8%, and 90.6% and treated with MW ablation therapy were 97.2%, 94.5%, and 91.7, respectively (P = 0.98). CONCLUSION: In conclusion, RF and MW ablation therapy showed no significant difference in the treatment of HCC regarding the complete response, rates of residual foci of untreated disease, and recurrence rate.

CT volumetric assessment of pulmonary neoplasms after radiofrequency ablation: when to consider a second intervention?

PURPOSE: To determine the minimal follow-up time point to predict therapeutic response to radiofrequency (RF) ablation of lung tumors. MATERIALS AND METHODS: A retrospective study design was approved by the institutional review board. From January 2008 to January 2010, 78 patients (46 men and 32 women; mean age, 58.9 y) underwent computed tomography (CT)-guided percutaneous RF ablation of pulmonary malignancies. A single RF multitined electrode was used to treat 100 index tumors, 6 primary lesions, and 94 metastatic lesions. CT volumetric measurements of ablated tumors were made before ablation and 24 hours, 3-6 weeks, 3 months, 6 months, 9 months, and 12 months after ablation. An unpaired t test and Spearman rank correlation coefficient were used to analyze the volumetric changes. RESULTS: Complete successful ablation was achieved in 80% of index tumors. The mean time to detection of tumor residue or recurrence tumor residue or recurrence was 6.7 months after ablation. In successfully ablated lesions, the mean volume before ablation was 1.81 cm(3) (standard deviation [SD], 1.71); in failed ablation lesions, the mean volume before ablation was 2.58 cm(3) (SD, 2.8) (P = .42). The earliest statistically significant follow-up time point that showed a difference in the volumetric measurements of failed and successful ablations as well as the earliest significant correlation with the 12-month point was 3 months (P = .025, Spearman R = 0.72). Secondary tumor control after repeat ablation was statistically significant for lesions ablated at a 3-month interval (four out of five lesions) (P = .04). CONCLUSIONS: CT volumetric assessment of ablated tumors revealed that 3 months was the earliest time point that may determine the response of a pulmonary ablation or repeat intervention.

Ultra-low dose dual-source high-pitch computed tomography of the paranasal sinus: diagnostic sensitivity and radiation dose.

BACKGROUND: Today's gold standard for diagnostic imaging of inflammatory diseases of the paranasal sinus is computed tomography (CT). PURPOSE: To evaluate diagnostic sensitivity and radiation dose of an ultra-low dose dual-source CT technique. MATERIAL AND METHODS: Paranasal sinuses of 14 cadaveric heads were independently evaluated by two readers using a modern dual-source CT with lowest reasonable dosage in high-pitch mode (100 kV, 10 mAs, collimation 0.6 mm, pitch value 3.0). Additionally the head part of an anthropomorphic Alderson-Rando phantom was equipped with thermoluminiscent detectors to measure radiation exposure to the eye lenses and thyroid gland. RESULTS: Diagnostic accuracy regarding sinusoidal fluid, nasal septum deviation, and mucosal swelling was 100%. Mastoid fluid was detected in 76% and 92%, respectively. In the phantom study, average measured eye lens dosage was 0.64 mGy; radiation exposure of the thyroid gland was 0.085 mGy. CONCLUSION: Regarding evaluation of inflammatory diseases of the paranasal sinus this study indicates sufficient accuracy of the proposed CT protocol at a very low dosage level.

Repeated chemoembolization followed by laser-induced thermotherapy for liver metastasis of breast cancer.

OBJECTIVE: The purpose of this study was to evaluate local tumor control and survival after use of a downstaging protocol of repeated transarterial chemoembolization (TACE) with two chemotherapeutic combinations followed by laser-induced thermotherapy in the care of patients with liver metastasis of breast cancer. SUBJECTS AND METHODS: This prospective study included 161 patients with liver metastasis of breast cancer origin. TACE (mean, 3.5 [SD, 1.3] sessions per patient; range, 1-9 sessions) was performed as downstaging treatment to achieve the size and number of metastatic lesions that met the requirements for laser-induced thermotherapy (diameter < 5 cm, number ≤ 5). The TACE protocol was performed with either mitomycin C alone (n = 53) or mitomycin C in combination with gemcitabine (n = 108). RESULTS: In response to TACE overall, the mean reduction in diameter based on the longest diameter of the target lesions was 27%. The difference between diameter reduction in the mitomycin C group and that in the mitomycin C-gemcitabine group was not statistically significant (p = 0.65). The mean survival time of all patients was 32.5 months, calculation starting from the first TACE treatment. The mean local tumor control period calculated as of completion of therapy was 13 months, and the mean time to progression was 8 months. In the mitomycin-gemcitabine group, mean time to progression was 10.7 months, and in the mitomycin group it was 6.9 months (p = 0.5). CONCLUSION: TACE can be used for sufficient downstaging of liver metastatic lesions of breast cancer to allow laser-induced thermotherapy. A combination of mitomycin C and gemcitabine seems to improve the reduction achieved with TACE.

Transarterial chemoembolization (TACE) with mitomycin C and gemcitabine for liver metastases in breast cancer.

The purpose of this study was to evaluate the efficacy of transarterial chemoembolization (TACE) using different drug combinations in the treatment of breast cancer liver metastases in terms of local tumor control and survival rate. A total of 208 patients (mean age 56.4 years, range 29-81) with unresectable hepatic metastases of breast cancer were repeatedly treated with TACE at 4-week intervals. In total, 1,068 chemoembolizations were performed (mean 5.1 sessions/patient, range 3-25). The chemotherapy protocol consisted of mitomycin-C only (8 mg/m(2); n = 76), mitomycin-C with gemcitabine (n = 111), and gemcitabine only (1,000 mg/m(2); n = 21). Embolization was performed with lipiodol and starch microspheres. Tumor response was evaluated by MRI according to RECIST criteria. Survival rates were calculated using Kaplan-Meier method. For all protocols, local tumor control was partial response 13% (27/208), stable disease 50.5% (105/208), and progressive disease 36.5% (76/208). The 1-, 2-, and 3-year survival rates after TACE were 69, 40, and 33%. Median and mean survival times from the start of TACE were 18.5 and 30.7 months. Treatment with mitomycin-C only showed median and mean survival times of 13.3 and 24 months, with gemcitabine only they were 11 and 22.3 months, and with a combination of mitomycin-C and gemcitabine 24.8 and 35.5 months. TACE is an optional therapy for treatment of liver metastases in breast cancer patients with better results from the combined chemotherapy protocol.

Repeated transarterial chemoembolization in the treatment of liver metastases of colorectal cancer: prospective study.

PURPOSE: To evaluate local tumor control and survival data after transarterial chemoembolization with different drug combinations in the palliative treatment of liver metastases in patients with colorectal cancer. MATERIALS AND METHODS: The study was approved by institutional review board, and informed consent was obtained from all patients included in the study. A total of 463 patients (mean age, 62.5 years; range, 34.7-88.1 years) with unresectable liver metastases of colorectal cancer that did not respond to systemic chemotherapy were repeatedly treated with chemoembolization in 4-week intervals. In total, 2441 chemoembolization procedures were performed (mean, 5.3 sessions per patient). Of 463 patients, 67.4% had multiple (five or more) metastases, 8% had one metastasis, 10.4% had two metastases, and 14.3% had three or four metastases. The local chemotherapy protocol consisted of mitomycin C alone (n = 243), mitomycin C with gemcitabine (n = 153), or mitomycin C with irinotecan (n = 67). Embolization was performed with lipiodol and starch microspheres for vessel occlusion. Tumor response was evaluated with magnetic resonance imaging. The change in tumor size was calculated and the response was evaluated according to the Response Evaluation Criteria in Solid Tumors. Survival rates from first diagnosis and from first chemoembolization session were calculated according to the Kaplan-Meier method. Follow-up imaging was performed until patient death. RESULTS: Evaluation of local tumor control resulted in partial response (68 patients [14.7%]), stable disease (223 patients [48.2%]), and progressive disease (172 patients [37.1%]). The 1-year survival rate after chemoembolization was 62%, and the 2-year survival rate was 28%. Median survival from date of diagnosis of liver metastases was 38 months and from the start of chemoembolization treatment was 14 months. There was no statistically significant difference between the three treatment protocols. CONCLUSION: Chemoembolization is a minimally invasive therapy option for palliative treatment of liver metastases in patients with colorectal cancer, with similar results among three chemoembolization protocols.

Three-dimensional reconstructed contrast-enhanced MR angiography for internal iliac artery branch visualization before uterine artery embolization.

PURPOSE: To evaluate the feasibility of three-dimensional (3D) reconstructed contrast-enhanced (CE) magnetic resonance (MR) angiography in mapping the pelvic arteries in women before uterine artery embolization (UAE). MATERIALS AND METHODS: CE MR angiography studies before UAE in 49 women (age range, 38-57 years; mean, 47.04 y +/- 4.7 [SD]) who underwent UAE for uterine leiomyomas between February 2005 and February 2007 were retrospectively evaluated by two radiologists in consensus. Studies were performed on a 1.5-T MR unit with a 3D fast low-angle shot sequence in the coronal direction. Reconstruction was performed with 3D computed tomographic angiography reconstruction software. RESULTS: In the current study, 98 internal iliac arteries (IIAs) from 49 women were studied. The superior and inferior gluteal arteries were visualized in all cases (N = 98; 100%), the lateral sacral artery in 86 cases (88%), the iliolumbar artery in 84 (86%), the obturator artery in 81 (83%), the internal pudendal artery in 96 (98%), and the uterine artery in 95 (97%). The superior vesical and middle rectal arteries were seen in 21 (21%) and 11 (11%) cases, respectively. The mean length of the uterine artery was 12.56 cm (range, 4.6-22.2 cm), and it showed the longest traceable length among all branches. The uterine artery showed five patterns of origin. The superior gluteal artery showed constant origin from the posterior division of the IIA, whereas the iliolumbar and obturator arteries showed the most variations in origin. CONCLUSIONS: Three-dimensional reconstructed CE MR angiography can detect most branches of the IIA in addition to their point of origin. Therefore, it can be used as a mapping tool of the pelvic arterial tree before UAE.

Prostate cancer: MR imaging-guided galvanotherapy--technical development and first clinical results.

PURPOSE: To prospectively evaluate the safety and effectiveness of magnetic resonance (MR) imaging-guided galvanotherapy in prostate cancer. MATERIALS AND METHODS: This prospective study was approved and authorized by the institutional review board, and patients gave informed consent. Forty-four men (mean age, 63.1 years) with histologically proved prostate cancer were treated with galvanotherapy. After transgluteal puncture of the prostate with local anesthesia, two MR imaging-compatible electrodes were positioned under MR imaging guidance in the periphery of the right and left lobes of the prostate so that they had direct tumor contact. The patients were treated three times in 1-week intervals, and direct current was applied to the localized cancer in the prostate gland with a total charge of 350 coulombs. Follow-up with laboratory testing (prostate-specific antigen [PSA] levels) and endorectal MR imaging with tumor volume measurement was performed 3, 6, and 12 months after the procedure. The Friedman test was used to compare tumor volumes and PSA levels across the four time points. RESULTS: All patients tolerated MR imaging-guided galvanotherapy well without any major side effects or complications. Six patients had some reversible difficulty with urination, and five reported temporary unilateral leg paresthesia. Tumor volume as determined with MR imaging decreased from a pretherapeutic median of 1.90 to 1.12 cm(3), which corresponded to a significant (P < .01) reduction of 41%. One patient (2%) had complete remission and 18 (41%) had partial remission at follow-up 12 months after therapy. Twenty-three patients (52%) were classified as having stable disease. Two patients (5%) had progressive disease. Median PSA levels decreased in the 12-month control period from 7.05 to 2.4 ng/mL (66%, P < .01). CONCLUSION: MR imaging-guided galvanotherapy is a safe procedure and can result in local control of prostatic carcinoma, with a concomitant reduction in the PSA level. SUPPLEMENTAL MATERIAL: http://radiology.rsnajnls.org/cgi/content/full/245/2/895/DC1.

CT of coronary artery disease.

The clinical relevance of coronary artery disease has considerably driven the recent development of radiologic tools for noninvasive cardiac imaging. Modern multidetector row computed tomographic (MDCT) systems combine high temporal and spatial resolution, electrocardiographic synchronization, and ease of use. In cardiac imaging, MDCT has not only replaced electron-beam CT, but also challenges competing methods such as magnetic resonance imaging, echocardiography, or even coronary catheterization. Noncontrast material-enhanced assessment of atherosclerotic plaques (CT calcium scoring) seems useful for the cardiac risk stratification in asymptomatic patients and monitoring of medical (statin) therapy. Contrast material-enhanced CT coronary angiography has become established as a valuable method for several clinical indications such as evaluation of coronary artery anomalies, bypass patency, or preoperative planning. Particularly, the high negative predictive value of a normal CT coronary angiogram allows reliable exclusion of coronary artery stenosis. Plaque characterization is another promising area of research in MDCT cardiac imaging. However, with current technology a reliable distinction between atheroma and fibroatheroma is impaired by restrictions in spatial resolution. Recent studies indicate that CT angiography may also be suited for other clinical applications such as triage of patients with acute coronary syndrome and inconclusive clinical presentation, patients with symptomatic chest pain, and intermediate risk profile or cardiac risk stratification in asymptomatic patients.

How Effective Are Percutaneous Liver-Directed Therapies in Patients with Non-Colorectal Liver Metastases?

BACKGROUND: The purpose of this review is to demonstrate the clinical indications, technical developments, and outcome of liver-directed therapies in interventional oncology of non-colorectal liver metastases. METHODS: Liver-directed therapies are classified into vascular transarterial techniques such as chemoperfusion (TACP), chemoembolization (TACE), radioembolization (selective internal radiation therapy (SIRT)), and chemosaturation, as well as thermal ablation techniques like microwave ablation (MWA), radiofrequency ablation (RFA), laser-induced thermotherapy (LITT), cryotherapy, and irreversible electroporation (IRE). The authors searched the database PubMed using the following terms: 'image-guided tumor ablation', 'thermal ablation therapies', 'liver metastases of uveal melanoma', 'neuroendocrine carcinoma', 'breast cancer', and 'non-colorectal liver metastases'. RESULTS: Various combinations of the above-mentioned therapy protocols are possible. In neuroendocrine carcinomas, oligonodular liver metastases are treated successfully via thermal ablation like RFA, LITT, or MWA, and diffuse involvement via TACE or SIRT. Although liver involvement in breast cancer is a systemic disease, non-responding nodular metastases can be controlled via RFA or LITT. In ocular or cutaneous melanoma, thermal ablation is rarely considered as an interventional treatment option, as opposed to TACE, SIRT, or chemosaturation. Rarely liver-directed therapies are used in pancreatic cancer, most likely due to problems such as biliary digestive communications after surgery and the risk of infections. Rare indications for thermal ablation are liver metastases of other primary cancers like non-small cell lung, gastric, and ovarian cancer. CONCLUSION: Interventional oncological techniques play a role in patients with liver-dominant metastases.

Regional chemotherapy of the lung: transpulmonary chemoembolization in malignant lung tumors.

Standard treatment options in patients with lung cancer and pulmonary metastases are surgery, radiotherapy, chemotherapy, and immunotherapy. For reducing clinical complications of surgery and achieving a better local response, transpulmonary chemoembolization of the lungs is a possible interventional technique in which anticancer drugs are administered directly into a tumor through its feeding vessels followed by occlusive agents that are injected through the delivery catheter for blocking the vessel. This allows a longer contact period in the tumor with a higher cytostatic drug concentration. The technique is safe and results present promising local response rates, but the influence on survival is still questionable. This article describes the current role of intravascular therapies in the treatment of pulmonary malignancies.

Quantitative analysis of motion artifacts in high-pitch dual-source computed tomography of the thorax.

PURPOSE: The purpose of this study was to objectively analyze motion artifacts on thoracic computed tomography (CT) with dual-source high-pitch and single-source techniques when using a no-breath-hold technique to examine patients who have difficulty complying with breath-holding instructions. MATERIALS AND METHODS: A total of 120 patients who received CT of the thorax with a free-breathing technique in single-source (16 slices and 128 slices; pitch = 1.2) and dual-source (pitch = 3.0) manners were evaluated retrospectively. In each of the 3 study groups, movements of the diaphragm and pulsations of the aortic root and main pulmonary artery were analyzed for their number and severity (blurred distance). RESULTS: No motion artifacts of the diaphragm were identified using a pitch of 3.0 (compared with n = 14 for single-source CT using 128 slices and n = 24 using 16-slice CT). In single-source examinations, the severity of artifacts was similar between 128-slice CT and 16-slice CT: blurring distance of the lung parenchyma due to diaphragm movements was 14 versus 16 mm, and double contours of the aorta were measured as 8 and 9 mm, respectively. CONCLUSIONS: A high-pitch, dual-source mode is potentially advantageous for evaluating the lung parenchyma and vascular structures in patients who have difficulty complying with breath-holding instructions. Increasing from 16 to 128 slices can significantly reduce the number and severity of motion artifacts.

Radiation exposure to operating staff during rotational flat-panel angiography and C-arm cone beam computed tomography (CT) applications.

PURPOSE: To evaluate the radiation exposure for operating personnel associated with rotational flat-panel angiography and C-arm cone beam CT. MATERIALS AND METHODS: Using a dedicated angiography-suite, 2D and 3D examinations of the liver were performed on a phantom to generate scattered radiation. Exposure was measured with a dosimeter at predefined heights (eye, thyroid, breast, gonads and knee) at the physician's location. Analysis included 3D procedures with a field of view (FOV) of 24 cm × 18 cm (8s/rotation, 20s/rotation and 5s/2 rotations), and 47 cm×18 cm (16s/2 rotations) and standard 2D angiography (10s, FOV 24 cm×18 cm). RESULTS: Measurements showed the highest radiation dose at the eye and thyroid level. In comparison to 2D-DSA (3.9 µSv eye-exposure), the 3D procedures caused an increased radiation exposure both in standard FOV (8s/rotation: 28.0 µSv, 20s/rotation: 79.3 µSv, 5s/2 rotations: 32.5 µSv) and large FOV (37.6 µSv). Proportional distributions were measured for the residual heights. With the use of lead glass, irradiation of the eye lens was reduced to 0.2 µSv (2D DSA) and 10.6 µSv (3D technique with 20s/rotation). CONCLUSION: Rotational flat-panel angiography and C-arm cone beam applications significantly increase radiation exposure to the attending operator in comparison to 2D angiography. Our study indicates that the physician should wear protective devices and leave the examination room when performing 3D examinations.

Mechanical soft tissue property validation in tissue engineering using magnetic resonance imaging experimental research.

RATIONALE AND OBJECTIVES: To perform magnetic resonance imaging (MRI) scans regarding material parameter and model validation in computational simulations of mechanical interaction of human soft-tissue with body-supporting devices, enhanced medical prognosis in pressure sore prophylaxis, and comfort optimization in automotive and aircraft seating. MATERIALS AND METHODS: In vivo human gluteal fat and passive muscle tissue material parameters of a volunteer evaluated via combined MRI numerical method and body-supporting foam material parameters employed in finite element (FE) simulations of tissue-support interaction were verified by a defined loading scenario using MRI. MRI of the loaded configurations were performed and compared with simulation results for displacement field information. RESULTS: Deformation of gluteal skin/fat and passive muscle-tissue and support material under interacting loading using numerical simulation complied with the MRI results. Accordance was found for deformed skin surface and internal fat-muscle tissue boundaries by superimposing experimental and numerical outputs. Further evidence of established through in vivo gluteal tissue parameters was thus provided and tissue material isotropy assumption was shown for use in simulated buttock loading interactions. Additionally, a new concept of FE model validation regarding non-MRI-sensitive materials such as polyurethane foam was introduced comprising peripheral surface visualization. CONCLUSION: Imaging techniques are essential in biomechanical modeling and provide key information regarding model validation and validity assessment.

Angioplasty of the pelvic and femoral arteries in PAOD: results and review of the literature.

PURPOSE: Evaluation of percutaneous recanalization of obstructed iliac as well as superficial femoral arteries (SFAs) in patients with peripheral arterial obstructive disease (PAOD). MATERIAL AND METHODS: The data of 195 consecutive patients with 285 obstructions of the common and or external iliac artery as well as the data of 452 consecutive patients with 602 long occlusions (length>5 cm) of the SFA were retrospectively analyzed. The lesions were either treated with percutaneous transluminal angioplasty (PTA) or Excimer laser assisted percutaneous transluminal angioplasty (LPTA). Overall 316 stents were implanted (Nitinol stents: 136; stainless steel stents: 180) in the iliac artery and 669 stents were implanted (Nitinol stents: 311; Easy Wallstents: 358) in the SFA. The follow-up period was 36-65 months (mean 46.98+/-7.11 months) postinterventionally using clinical examination, ABI calculation, and color-coded duplex sonography. Patency rates were calculated on the basis of the Kaplan-Meier analysis. RESULTS: The overall primary technical success rate was 97.89% for the iliac arteries and 92.35% for the SFA. Minor complications (hematoma, distal emboli and vessel dissection) were documented in 11.79% for the iliac arteries and 7.97% for the SFA. The primary patency rate was 90.3% for the iliac and 52.8% for the SFA after 4 years. The secondary patency rate was 96.84% for the iliac and 77.8% for the SFA after 4 years. CONCLUSION: Percutaneous recanalization of iliac and superficial femoral artery obstructions is a safe and effective technique for the treatment of patients with PAOD. By consequent clinical monitoring high secondary patency rates can be achieved. The use of a stents seems to result in higher patency rate especially in the SFA when compared to the literature in long-term follow-up.

Liver metastases of neuroendocrine carcinomas: interventional treatment via transarterial embolization, chemoembolization and thermal ablation.

UNLABELLED: The aim of this review article is to provide a practical clinical guideline for indication, technical aspects, protocol guideline and strategies for the interventional treatment of liver metastases from neuroendocrine tumors and focusing on the results of various protocols of management. The response to therapy, in the published articles, is calculated on the basis of the following clinical parameters; including symptomatic response (SR), biologic response (BR), morphological response (MR), progress free survival (PFS), and survival periods (SP). Transarterial chemoembolization (TACE) has been associated with SR rates of 60-95%, BR of 50-90%, MR of 33-80%, SR of 20-80 months, and a 5-year survival of between 50% and 65%. PFS was also between 18 and 24 months. In the transarterial embolization (TAE) group, SR was similar to the TACE group, MR was 32% and 82%, survival was between 18 and 88 months with a survival rate of 40-67%, and BR was between 50% and 69%. Radiofrequency ablation (RFA), either percutaneous or during surgery, has been associated with SR of 71-95% for a mean duration of 8-10 months, BR of 65%, and mean SP of 1.6 years after ablation. The mean survival following surgical resection for operable cases is 4.26 years+/-S.D.: 1.1. CONCLUSION: The interventional protocols for the management of liver metastases from neuroendocrine tumors: for oligonodular liver metastatic deposits, local resection or RFA and/or LITT is recommended, while in multinodular diseases with higher tumor load, TACE or TAE is recommended.

Review on transarterial chemoembolization in hepatocellular carcinoma: palliative, combined, neoadjuvant, bridging, and symptomatic indications.

The current review provides an overview on the palliative, combined, neoadjuvant, bridging, and symptomatic indications of transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC). It is based on an analysis of the current literature and the experience of the authors on the topic. Chemoembolization combines the infusion of chemotherapeutic drugs with particle embolization. Tumor ischemia raises the drug concentration compared to infusion alone, extends the retention of the chemotherapeutic agent and reduces systemic toxicity. Palliatively, TACE is performed to control symptoms and prolong survival in HCC patients; in some indications TACE allows a local tumor control of 18-63%. For combined indications, excellent results were achieved by combined therapies, such as percutaneous ethanol injection (PEI)/TACE, radiofrequency ablation (RF)/TACE, and laser-induced thermotherapy (LITT)/TACE. As a neoadjuvant therapy prior to liver resection TACE showed 70% tumor control. Though debatable, TACE still plays a role as a bridging tool before liver transplantation. Symptomatic indication of TACE in ruptured HCC showed 83-100% control of bleeding but survival was poor. Thus, TACE represents an important therapeutic tool against HCC in general in addition to its special role in cases of unresectable HCC.

Transarterial chemoembolization in the treatment of hepatoblastoma in children.

Hepatoblastoma is one of the clinical challenges in children, as it is common and frequently unresectable. Chemotherapy can be administered regionally instead of systemically by transarterial chemoembolization (TACE) and thus improve prognosis. The advantages of this technique over systemic chemotherapy led to developing its role from being a palliative or an adjuvant preoperative treatment to being a potentially independent palliative or curative therapeutic option. The technical aspects and complications of a combined transarterial administration of chemotherapeutic and vascular occlusive agents in cases of hepatoblastoma in children are discussed, to give a comprehensive idea about the value of TACE in this context.

Multi-detector row CT coronary angiography: influence of reconstruction technique and heart rate on image quality.

PURPOSE: To prospectively evaluate to what extent image quality in 16-detector row computed tomographic (CT) coronary angiography is a function of the heart rate and the image reconstruction technique used. MATERIALS AND METHODS: A total of 70 patients (49 men, 21 women; mean age, 59.1 years +/- 5.8 [standard deviation]) consecutively underwent multi-detector row CT coronary angiography; 49 patients additionally underwent coronary angiography. Image reconstruction was based on both relative and absolute timing. A total of 20 equidistant relative and absolute image reconstructed intervals were assessed by applying a four-step grading scale. Cluster and discrimination analysis, Spearman correlation analysis, and Wilcoxon and chi2 tests were used for statistical analysis. Institutional review board approval and written informed consent were obtained. RESULTS: Though significantly (P < .001) better image quality was observed for image reconstruction based on absolute timing and in patients with lower heart rates, influence on diagnostic accuracy was not significant. Irrespective of the reconstruction technique used, best image quality was observed in patients with a low heart rate for middiastolic reconstruction intervals (starting points: 61% of R-R interval [range, 40%-75%] and 599.3 msec after R [range, 450-840 msec]) and in patients with a high heart rate for end-systolic or early-diastolic intervals (starting points: 27.3% of R-R interval [range, 10%-45%] and 202.3 msec after R [range, 82-336 msec]). With regard to the vessel section and reconstruction technique, cutoff heart rates of the intervals were 64.0-68.5 beats per minute. Patients with stenoses of more than 50% were identified with 86% sensitivity and specificity, and there was no significant difference between relative and absolute timing (P = .99). CONCLUSION: In multi-detector row CT coronary angiography, image quality depends on the choice of a suited reconstruction interval. In patients with high heart rates, the best image quality can be obtained with end-systolic and early-diastolic intervals; in patients with low heart rates, the best results are achieved with middiastolic intervals.