Radioablation of Hepatic Metastases from Renal Cell Carcinoma With Image-guided Interstitial Brachytherapy.

BACKGROUND/AIM: High-dose-rate interstitial brachytherapy (iBT) has been shown to provide high tumor control rates in the treatment of primary or secondary malignancies at various sites. The objective of this study was to evaluate the efficacy and safety of image-guided iBT in patients with metastatic renal cell carcinoma (mRCC). MATERIALS AND METHODS: A total of 14 patients with a cumulative number of 54 unresectable RCC liver metastases after treatment with computed tomography (CT)- or open magnetic resonance imaging (MRI)-guided iBT using an iridium-192 source (single fraction irradiation) were included in this retrospective study. RESULTS: Local tumor control rate was 92.6% during a median follow-up of 10.2 months (range=2.4-73.6 months). Median progression-free survival after iBT was 3.4 months (range=1.0-27.8 months). Median overall survival was 51.2 months (range=10.2-81.5 months). No severe adverse events (grade 3 or more) were recorded. CONCLUSION: Image-guided iBT is a safe and feasible treatment in patients with mRCC.

Interstitial Brachytherapy in Combination With Previous Transarterial Embolization in Patients With Unresectable Hepatocellular Carcinoma.

BACKGROUND/AIM: Treatment of patients with large hepatocellular carcinoma (HCC) remains challenging and survival in advanced tumor stages is limited. This study was conducted to investigate the efficacy of embolization followed by computed tomography (CT)-guided interstitial high-dose-rate brachytherapy (CT-HDRBT) in patients with unresectable HCC. PATIENTS AND METHODS: A total of 47 patients undergoing CT-HDRBT were divided into 2 groups: i) patients previously treated with transarterial chemoembolization (TACE) and ii) patients treated with bland transarterial embolization (TAE). The primary endpoint was overall survival (OS), while secondary endpoints were the time to progression (TTP) and the local progression rate. RESULTS: A total of 78 lesions were treated. The mean size of the main tumors was 58.3 mm. The median OS in TACE and TAE groups was 28.9 months and 32.3 months, respectively (p=NS). The median OS of patients classified as BCLC stage A using the Barcelona Clinic Liver Cancer classification system (BCLC) was 32.3 months, while the median OS of patients in BCLC stage B and C was 36.9 and 17.7 months, respectively. The local progression rate was 7.7% (6/78), with no statistically significant difference between TACE and TAE. The median TTP was significantly longer in the TACE group compared to the TAE group (11.7 months and 10.3 months, respectively). CONCLUSION: Treatment with transarterial embolization and subsequent CT-HDRBT leads to a very promising survival rate for patients with unresectable HCC.

Image-guided Interstitial Brachytherapy in the Management of Metastasized Anal Squamous Cell Carcinoma.

BACKGROUND/AIM: Interstitial brachytherapy (IBT) has been shown to provide high tumor control rates in metastatic colorectal carcinoma. Our aim was to evaluate efficacy and safety of IBT in patients with metastatic anal squamous cell carcinoma (mASCC). PATIENTS AND METHODS: Seven patients with a total of 38 unresectable ASCC metastases (28 liver, nine lung, one nodal metastases) were treated with computed tomographic or open magnetic resonance imaging-guided IBT using an iridium-192 source. Clinical and image-based follow-up were performed every 3 months after treatment. RESULTS: Local tumor control rate was 97.4% during a median follow-up of 15.2 months. Median progression-free survival was 3.3 months (range=2.5-32.6 months). Median overall survival after IBT was 25.2 months (range=6.5-51.0 months). No severe adverse events (grade 3 or more) were recorded. CONCLUSION: Image-guided IBT is a safe and particularly effective treatment in patients with mASCC and might provide a well-tolerated therapeutic option in a multidisciplinary setting.

Radioembolisation in Europe: A Survey Amongst CIRSE Members.

INTRODUCTION: Radioembolisation of liver tumours demands many choices from the physician regarding planning of treatment and subsequent follow-up. METHODS: An online questionnaire was distributed amongst all members of the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) to investigate the current state of radioembolisation practice. RESULTS: The survey was completed by 60 centres. The increasing number of radioembolisation procedures may reflect that radioembolisation is increasingly recognised as a valuable treatment option in European cancer guidelines. Imaging modalities play an important role in decision making. Furthermore, there seems to be a trend towards less coil-embolisation of non-target vessels. In addition, type of microsphere, model for dose calculation, complications and future developments are evaluated in this article. CONCLUSIONS: This survey provides insight into the current state of radioembolisation practice across Europe.

Anatomic variants of arteries often coil-occluded prior to hepatic radioembolization.

BACKGROUND: Prior to radioembolization (RE) treatment of malignant liver lesions, many interventionalists occlude the right gastric artery (RGA), the cystic artery (CA), and the gastroduodenal artery (GDA) to prevent radioactive microspheres from entering non-target vessels. PURPOSE: To systematically analyze anatomic variants of arteries that are important to know for the interventional radiologist performing RE of the liver. MATERIAL AND METHODS: The computed tomography (CT) angiographies and conventional angiographies of 166 patients evaluated for RE were retrospectively analyzed for the presence of anatomic variants of the RGA, GDA, and CA. RESULTS: The RGA was found to arise from the left hepatic artery in 42% of cases, from the proper hepatic artery in 40%, from the GDA in 10%, from the right hepatic artery in 4%, and from the common hepatic artery in 3% of cases. The GDA originated in the common hepatic artery in 97% of cases, in the left hepatic artery in 2%, and in the celiac trunk in 1% of cases. The CA arose from the right hepatic artery in 96% of cases and from the GDA in 2% of cases; in 2% of our study population, the gallbladder was supplied by small branches from the liver parenchyma. CONCLUSION: Variant anatomy of the RGA is common, while it is quite rare for the GDA and CA. Knowledge of the variations of liver supplying arteries helps the interventionalist to embolize necessary vessels prior to RE.

Radiation exposure during uterine artery embolization: effective measures to minimize dose to the patient.

PURPOSE: Evaluation of patient radiation exposure during uterine artery embolization (UAE) and literature review to identify techniques minimizing required dose. METHODS: A total of 224 of all included 286 (78 %) women underwent UAE according to a standard UAE-protocol (bilateral UAE from unilateral approach using a Rösch inferior mesenteric and a microcatheter, no aortography, no ovarian artery catheterization or embolization) and were analyzed for radiation exposure. Treatment was performed on three different generations of angiography systems: (I) new generation flat-panel detector (N = 108/151); (II) classical image amplifier and pulsed fluoroscopy (N = 79/98); (III) classical image amplifier and continuous fluoroscopy (N = 37/37). Fluoroscopy time (FT) and dose-area product (DAP) were documented. Whenever possible, the following dose-saving measures were applied: optimized source-object, source-image, and object-image distances, pulsed fluoroscopy, angiographic runs in posterior-anterior direction with 0.5 frames per second, no magnification, tight collimation, no additional aortography. RESULTS: In a standard bilateral UAE, the use of the new generation flat-panel detector in group I led to a significantly lower DAP of 3,156 cGy × cm(2) (544-45,980) compared with 4,000 cGy × cm(2) (1,400-13,000) in group II (P = 0.033). Both doses were significantly lower than those of group III with 8,547 cGy × cm(2) (3,324-35,729; P < 0.001). Other reasons for dose escalation were longer FT due to difficult anatomy or a large leiomyoma load, additional angiographic runs, supplementary ovarian artery embolization, and obesity. CONCLUSIONS: The use of modern angiographic units with flat panel detectors and strict application of methods of radiation reduction lead to a significantly lower radiation exposure. Target DAP for UAE should be kept below 5,000 cGy × cm(2).

Uterine artery embolization in single symptomatic leiomyoma: do anatomical imaging criteria predict clinical presentation and long-term outcome?

BACKGROUND: Uterine artery embolization (UAE) has proven to be an effective treatment alternative for women suffering from symptomatic uterine leiomyomas. However, long-term clinical evaluation reveals treatment failure in approximately 25% of patients. To cope with the great variability in the extent of leiomyoma disease former studies are based on the simplifying assumption that the largest leiomyoma mainly causes the symptoms. PURPOSE: To evaluate whether anatomical characteristics in women with a single symptomatic leiomyoma influence clinical presentation and outcome after UAE. MATERIAL AND METHODS: Ninety-one patients with a single leiomyoma underwent UAE. Age, uterine and fibroid volume, fibroid location, and clinical symptoms (bleeding- and/or bulk-related symptoms) were documented. The need for reinterventions (i.e. repeat UAE, hysterectomy, myomectomy) and unchanged or worsened symptoms after UAE were classified as treatment failure (TF). Contrast-enhanced magnetic resonance imaging (MRI) 48-72 h after UAE was available in 38 women. The rate of fibroid infarction was determined and patients were assigned to one of three groups: complete (100%), almost complete (90-99%), or partial infarction (<90%). Cox regression analysis (CRA) was used to determine the influence of morphological and clinical parameters on outcome. RESULTS: Follow-up was available in 79/91 (87%) women (median age, 42 years; range, 33-56 years) at a median of 5 years (range, 3.1-9.2 years) after UAE. Anatomical leiomyoma criteria neither connected to specific clinical presentation nor influenced clinical outcome. Younger women showed a higher risk for TF with every year older lowering the risk by the factor of 0.86 (P = 0.024). Subgroup analysis showed predictive value of fibroid infarction with a cumulative survival free from TF of 91% for complete vs. 0% for partial infarction (P < 0.001). CONCLUSION: Even in women with single leiomyomas, anatomical criteria do not specify clinical presentation or predict clinical outcome. Younger patient age and incomplete fibroid infarction relate to higher rates of TF.

Clinical long-term outcome after uterine artery embolization: sustained symptom control and improvement of quality of life.

PURPOSE: To evaluate long-term clinical efficacy of uterine artery embolization (UAE) for uterine fibroids with respect to symptom control and improvement in quality of life. MATERIALS AND METHODS: Between October 2000 and October 2007, 380 consecutive women underwent UAE. To determine long-term efficacy, the rate of reinterventions (ie, repeat UAE, hysterectomy, myomectomy) and the clinical response regarding symptoms related to bleeding and bulk were documented. Persistence, worsening, or recurrence of symptoms and reinterventions were classified as treatment failure (TF). The cumulative rate of freedom from TF was determined by Kaplan-Meier analysis. Cox regression was used to identify possible clinical or morphologic predictors of outcome. Secondary outcome measures were changes in disease-specific quality of life and onset of menopause. RESULTS: Follow-up was available for a median of 5.7 years (range, 3.1-10.1 y) after treatment in 304 of 380 (80%) patients. There were 54 TFs with subsequent reintervention in 46 women. Kaplan-Meier analysis revealed a cumulative TF rate of 23.3% after 10 years. Cox regression demonstrated a significantly higher likelihood of TF in patients<40 years old compared with patients>45 years old (hazard ratio, 2.28; P = .049). Women without TF showed sustained normalization of disease-specific quality of life (P <.001). Cessation of menstruation at a median age of 51 years was reported by 57 (22.8%) of 250 women. CONCLUSIONS: UAE leads to long-term control of fibroid-related symptoms and normalization of quality of life in approximately 75% of patients. Younger women seem to have a higher risk of TF than older women closer to menopause.