Gd-EOB-DTPA-MRCP to localize bile leakage after liver trauma and surgery: impact on treatment and outcome.

OBJECTIVES: Bile leakage (BL) is a challenging complication after hepatobiliary surgery and liver trauma. Gadolinium ethoxybenzyl (Gd-EOB-DTPA)-enhanced magnetic resonance cholangiopancreatography (MRCP) is used to diagnose BL non-invasively. We assessed the value of Gd-EOB-DTPA-MRCP in the detection of postoperative and post-traumatic BL hypothesizing that exact identification of the leakage site is pivotal for treatment planning and outcome. METHODS: We retrospectively enrolled 39 trauma and postoperative patients who underwent Gd-EOB-DTPA-MRCP for suspected BL. Three readers rated the presence of BL and leakage site (intraparenchymal, central, peripheral ± aberrant or disconnected ducts). Imaging findings were compared to subsequent interventional procedures and their complexity and outcome. RESULTS: BL was detected in Gd-EOB-DTPA-MRCP in 25 of patients and was subsequently confirmed. Sites of BL differed significantly between postoperative (central [58%] and peripheral [42%]) and trauma patients (intraparenchymal [100%]; p < 0.001). Aberrant or disconnected ducts were diagnosed in 8%/26% of cases in the postoperative subgroup. Inter-rater agreement for the detection and localization of BL was almost perfect (Κ = 0.85 and 0.88; p < 0.001). Intraparenchymal BL required significantly less complex interventional procedures (p = 0.002), whereas hospitalization and mortality did not differ between the subgroups (p > 0.05). CONCLUSIONS: Gd-EOB-DTPA-MRCP reliably detects and exactly locates BL in postoperative and trauma patients. Exact localization of biliary injuries enables specific treatment planning, as intraparenchymal leakages, which occur more frequently after trauma, require less complex interventions than central or peripheral leaks in the postoperative setting. As a result of specific treatment based on exact BL localization, there was no difference in the duration of hospitalization or mortality. CLINICAL RELEVANCE STATEMENT: Gd-EOB-DTPA-MRCP is a reliable diagnostic tool for exactly localizing iatrogenic and post-traumatic biliary leakage. Its precise localization helps tailor local therapies for different injury patterns, resulting in comparable clinical outcomes despite varying treatments. KEY POINTS: • Gd-EOB-DTPA-MRCP enables adequate detection and localization of bile leakages in both postoperative and post-traumatic patients. • The site of bile leakage significantly impacts the complexity of required additional interventions. • Intraparenchymal bile leakage is commonly seen in patients with a history of liver trauma and requires less complex interventions than postoperative central or peripheral bile leakages, while hospitalization and mortality are similar.

Combined CT-guided high-dose-rate brachytherapy (CT-HDRBT) and transarterial chemoembolization with irinotecan-loaded microspheres improve local tumor control and progression-free survival in patients with unresectable colorectal liver metastases compared with mono-CT-HDRBT.

Purpose: To compare the effectivity and toxicity of monotherapy with computed tomography-guided high-dose-rate brachytherapy (CT-HDRBT) vs. combination therapy of transarterial chemoembolization with irinotecan (irinotecan-TACE) and CT-HDRBT in patients with large unresectable colorectal liver metastases (CRLM) with a diameter of > 3 cm. Material and methods: Forty-four retrospectively matched patients with unresectable CRLM were treated either with mono-CT-HDRBT or with a combination of irinotecan-TACE and CT-HDRBT (n = 22 in each group). Matching parameters included treatment, disease, and baseline characteristics. National Cancer Institute Common Terminology Criteria for Adverse Events (version 5.0) were used to evaluate treatment toxicity and the Society of Interventional Radiology classification was applied to analyze catheter-related adverse events. Statistical analysis involved Cox regression, Kaplan-Meier estimator, log-rank test, receiver operating characteristic curve analysis, Shapiro-Wilk test, Wilcoxon test, paired sample t-test, and McNemar test. P-values < 0.05 were deemed significant. Results: Combination therapy ensued longer median progression-free survival (PFS: 5/2 months, p = 0.002) and significantly lower local (23%/68%, p < 0.001) and intrahepatic (50%/95%, p < 0.001) progress rates compared with mono-CT-HDRBT after a median follow-up time of 10 months. Additionally, tendencies for longer local tumor control (LTC: 17/9 months, p = 0.052) were found in patients undergoing both interventions. After combination therapy, aspartate and alanine aminotransferase toxicity levels increased significantly, while total bilirubin toxicity levels showed significantly higher increases after monotherapy. No catheter-associated major or minor complications were identified in each cohort. Conclusions: Combining irinotecan-TACE with CT-HDRBT can improve LTC rates and PFS compared with mono-CT-HDRBT in patients with unresectable CRLM. The combination of irinotecan-TACE and CT-HDRBT shows satisfying safety profiles.

Non-Invasive Imaging Biomarkers to Predict the Hepatopulmonary Shunt Fraction Before Transarterial Radioembolization in Patients with Hepatocellular Carcinoma.

Purpose: To identify disease-specific profiles comprising patient characteristics and imaging biomarkers on contrast-enhanced (CE)-computed tomography (CT) that enable the non-invasive prediction of the hepatopulmonary shunt fraction (HPSF) in patients with hepatocellular carcinoma (HCC) before resin-based transarterial radioembolization (TARE). Patients and Methods: This institutional review board-approved (EA2/071/19) retrospective study included 56 patients with HCC recommended for TARE. All patients received tri-phasic CE-CT within 6 weeks prior to an angiographic TARE evaluation study using technetium-99m macroaggregated albumin. Imaging biomarkers representative of tumor extent, morphology, and perfusion, as well as disease-specific clinical parameters, were used to perform data-driven variable selection with backward elimination to generate multivariable linear regression models predictive of HPSF. Results were used to create clinically applicable risk scores for patients scheduled for TARE. Additionally, Cox regression was used to identify independent risk factors for poor overall survival (OS). Results: Mean HPSF was 13.11% ± 7.6% (range: 2.8- 35.97%). Index tumor diameter (p = 0.014) or volume (p = 0.034) in combination with index tumor non-rim arterial phase enhancement (APHE) (p < 0.001) and washout (p < 0.001) were identified as significant non-invasive predictors of HPSF on CE-CT. Specifically, the prediction models revealed that the HPSF increased with index lesion diameter or volume and showed higher HPSF if non-rim APHE was present. In contrast, index tumor washout was associated with decreased HPSF levels. Independent risk factors of poorer OS were radiogenomic venous invasion and ascites at baseline. Conclusion: The featured prediction models can be used for the initial non-invasive estimation of HPSF in patients with HCC before TARE to assist in clinical treatment evaluation while potentially sparing ineligible patients from the angiographic shunt evaluation study.

Transaneurysmal Occlusion of Complicated Common Femoral Artery Pseudoaneurysms Using the Angio-Seal Closure Device-A Promising Technique.

PURPOSE: Pseudoaneurysm (PSA) developing after catheter examinations is one of the most frequent vascular complications and a nonsurgical technique with utmost low risk of complications is warranted. Our aim was to investigate the technical feasibility, success, and safety of transaneurysmal occlusion of complicated post-interventional common femoral artery (CFA) PSA using the Angio-Seal Closure Device (ASCD) and a technique that we describe as the transaneurysmal (TA) maneuver. MATERIAL AND METHODS: We used the Angio-Seal (Terumo, Tokyo, Japan) Closure System to manage complicated PSAs in patients who would otherwise have needed surgery after failure of all conservative therapies. The TA maneuver was performed in 14 consecutive patients from July 2021 to July 2022. After ultrasound-guided puncture of the PSA close to its neck, the CFA was entered radiographically with micro-guidewires, and the neck of the PSA was closed with the ASCD after changing the sheaths and wires. All patient had to wear a pressure dressing until the next day, when successful closure was verified by sonography. RESULTS: All procedures were performed with technical success and without any complications. No patient had to undergo surgery. All sonographies on the next day confirmed complete absence of perfusion within the PSA and normal flow conditions of the CFA and vessels below. CONCLUSION: The TA maneuver a promising minimally invasive procedure for closing complicated PSA of the CFA after catheter examination.

MR Imaging Volumetric Response after Yttrium-90 Radioembolization for Colorectal Liver Metastases: Predictability at Baseline and Correlation with Survival.

PURPOSE: To prove the utility of magnetic resonance (MR) imaging response as a surrogate end point of treatment efficacy and survival after yttrium-90 transarterial radioembolization (TARE) for colorectal liver metastases (CRLMs), and to investigate whether outcomes can be predicted at baseline using MR imaging or clinical variables. MATERIALS AND METHODS: A total of 50 (135) patients with TARE for CRLMs between August 2008 and January 2020 and peri-interventional MR imaging within defined timeframes were included for tumor segmentation. Pretreatment and posttreatment target tumor volumes were measured according to the volumetric Response Evaluation Criteria In Solid Tumors (vRECIST) and the quantitative European Association for the Study of the Liver (qEASL) criteria. Cox regression models were used to analyze the impact of MR morphologic response, vascularity at baseline, and clinical variables on patient survival. Logistic regression analyses were used to evaluate the predictors of MR morphologic response at baseline. RESULTS: The median survival was 337 days (95% confidence interval [CI], 243-431). As opposed to the vRECIST, the application of the qEASL criteria 3 months after the treatment allowed for a significant (P < .05) separation of the survival curves for partial response, stable disease, and progressive disease with a median survival of 412 days (95% CI, 57-767) in responders. High tumor burden and technetium-99m lung shunt significantly decreased the probability of survival. MR morphologic response was not predictable at baseline using imaging or clinical data. CONCLUSIONS: MR response according to the qEASL criteria outperformed the vRECIST in measuring the biologic impact of TARE and predicting patient survival. Baseline contrast enhancement did not predict MR response to treatment, which may reflect elevated dose requirements in tumors with a high proportion of viable tumor volume.

Short- and long-term evaluation of disease-specific symptoms and quality of life following uterine artery embolization of fibroids.

BACKGROUND: The purpose of this study is to evaluate uterine artery embolization (UAE) for the management of symptomatic uterine leiomyomas regarding changes in quality of life after treatment in a large patient collective. This study retrospectively analyzed prospectively acquired standardized questionnaires of patients treated with UAE. Clinical success was evaluated before and after embolization. Patients were stratified into short- (≤ 7 months) and long-term (> 7 months) follow-up groups depending on the time of completion of the post-interventional questionnaire. Uterine leiomyomas were furthermore divided into small (< 10 cm) and large (≥ 10 cm) tumors based on the diameter of the dominant fibroid. RESULTS: A total of 245 patients were included into the final data analysis. The Kaplan-Meier analysis showed a cumulative clinical success rate of 75.8% after 70 months until the end of follow-up (9.9 years). All questionnaire subscales showed a highly significant clinical improvement from baseline to short- and long-term follow-up (p < 0.001). Patients with small fibroids showed a significantly better response to UAE in multiple subcategories of the questionnaire than patients with fibroids ≥ 10 cm who had a twofold higher probability of re-intervention in the Cox-regression model. CONCLUSIONS: UAE is an effective treatment method for symptomatic fibroids that leads to quick relief of fibroid-related symptoms with marked improvement of quality of life and is associated with a low risk for re-interventions. Patients with small fibroids tend to show a better response to UAE compared to patients with large fibroids. Trial registration Charité institutional review board, EA4/167/20. Registered 27 November 2020-Retrospectively registered. https://ethikkommission.charite.de/.

Splenic artery steal syndrome in patients with orthotopic liver transplant: Where to embolize the splenic artery?

PURPOSE: This study compared proximal and distal embolization of the splenic artery (SA) in patients with splenic artery steal syndrome (SAS) after orthotopic liver transplantation (OLT) regarding post interventional changes of liver function to identify an ideal location of embolization. METHODS AND MATERIALS: 85 patients with SAS after OLT treated with embolization of the SA between 2007 and 2017 were retrospectively reviewed. Periinterventional DSA was used to assess treatment success and to stratify patients according to the site of embolization. Liver function was assessed using following laboratory values: bilirubin, albumin, gamma-glutamyl transferase, glutamat-pyruvat-transaminase (GPT), glutamic-oxaloacetic transaminase (GOT), Alkaline Phosphatase (ALP), aPTT, prothrombin time and thrombocyte count. Descriptive statistics were used to summarize the data. Median laboratory values of pre, 1- and 3-days, as well as 1-week and 1-month post-embolization were compared between the respective embolization sites using linear mixed model regression analysis. RESULTS: All procedures were technically successful and showed an improved blood flow in the hepatic artery post-embolization. Ten Patients were excluded due to re -intervention or inconsistent image documentation. Pairwise comparison using linear mixed model regression analysis showed a significant difference between proximal and distal embolization for GPT (57.0 (IQR 107.5) vs. 118.0 (IQR 254.0) U/l, p = 0.002) and GOT (48.0 (IQR 48.0) vs. 81.0 (IQR 115.0) U/l, p = 0.008) 3-days after embolization as well as median thrombocyte counts 7-days after embolization (122 (IQR 108) vs. 83 (IQR 74) in thousands, p = 0.014). For all other laboratory values, no statistically significant difference could be shown with respect to the embolization site. CONCLUSION: We conclude that long-term outcomes after embolization of the SA in the scenario of SAS after OLT are irrespective of the site of embolization of the SA, whereas a proximal embolization potentially facilitates earlier normalization of liver function. Choice of technique should therefore be informed by anatomical conditions, safety considerations and preferences of the interventionalist.

Yttrium-90 radioembolization for unresectable hepatocellular carcinoma: predictive modeling strategies to anticipate tumor response and improve patient selection.

OBJECTIVES: This study aims to better characterize potential responders of Y-90-radioembolization at baseline through analysis of clinical variables and contrast enhanced (CE) MRI tumor volumetry in order to adjust therapeutic regimens early on and to improve treatment outcomes. METHODS: Fifty-eight HCC patients who underwent Y-90-radioembolization at our center between 10/2008 and 02/2017 were retrospectively included. Pre- and post-treatment target lesion volumes were measured as total tumor volume (TTV) and enhancing tumor volume (ETV). Survival analysis was performed with Cox regression models to evaluate 65% ETV reduction as surrogate endpoint for treatment efficacy. Univariable and multivariable logistic regression analyses were used to evaluate the combination of baseline clinical variables and tumor volumetry as predictors of ≥ 65% ETV reduction. RESULTS: Mean patients' age was 66 (SD 8.7) years, and 12 were female (21%). Sixty-seven percent of patients suffered from liver cirrhosis. Median survival was 11 months. A threshold of ≥ 65% in ETV reduction allowed for a significant (p = 0.04) separation of the survival curves with a median survival of 11 months in non-responders and 17 months in responders. Administered activity per tumor volume did predict neither survival nor ETV reduction. A baseline ETV/TTV ratio greater than 50% was the most important predictor of arterial devascularization (odds ratio 6.3) in a statistically significant (p = 0.001) multivariable logistic regression model. The effect size was strong with a Cohen's f of 0.89. CONCLUSION: We present a novel approach to identify promising candidates for Y-90 radioembolization at pre-treatment baseline MRI using tumor volumetry and clinical baseline variables. KEY POINTS: • A decrease of 65% enhancing tumor volume (ETV) on follow-up imaging 2-3 months after Y-90 radioembolization of HCC enables the early prediction of significantly improved median overall survival (11 months vs. 17 months, p = 0.04). • Said decrease in vascularization is predictable at baseline: an ETV greater than 50% is the most important variable in a multivariable logistic regression model that predicts responders at a high level of significance (p = 0.001) with an area under the curve of 87%.

Trans-arterial chemoembolization with degradable starch microspheres (DSM-TACE) versus selective internal radiation therapy (SIRT) in multifocal hepatocellular carcinoma.

BACKGROUND: To date there is no therapy consensus in patients with multifocal hepatocellular carcinoma (mHCC). PURPOSE: To compare outcome of trans-arterial chemoembolization (TACE) with degradable starch microspheres (DSM-TACE) versus selective internal radiation therapy (SIRT) in mHCC. MATERIAL AND METHODS: In this single-center study, 36 patients without portal vein invasion, treated between May 2014 and May 2018, were enrolled retrospectively. Eighteen consecutive patients received DSM-TACE and were matched by age, gender, BCLC stage, Child-Pugh status, and tumor volume and 18 patients underwent SIRT. Overall survival (OS), progression-free survival (PFS), and local tumor control (LTC) were evaluated. Toxicity profiles for both therapies were also evaluated and compared. RESULTS: In the entire collective, median OS was 9.5, PFS 5.0, and LTC 5.5 months. Subgroup analysis revealed an OS of 9.5 months in both groups (P = 0.621). PFS was 6 months for the SIRT and 4 months for the DSM-TACE cohort (P = 0.065). Although not significantly, LTC was lower (4 months) in the SIRT compared to the DSM-TACE cohort (7 months; P = 0.391). When DSM-TACE was performed ≥3 times (n = 11), OS increased, however without statistical difference compared to SIRT, to 11 months, PFS to 7 months, and LTC to 7 months. When DSM-TACE was performed <3 times (n = 7), OS, PFS, and LTC decreased (5 months, P = 0.333; 2 months, P = 0.047; 2 months, P = 0.47). Toxicity profiles and adverse event analysis only revealed a significant difference for nausea and vomiting (more frequent in the SIRT cohort, P = 0.015), while no other parameter showed a significant difference (P > 0.05). CONCLUSION: DSM-TACE might be an alternative to SIRT in multifocal HCC patients as OS, PFS, and LTC did not differ significantly and toxicity profiles seem to be comparable.

The ligamentous injury pattern in acute acromioclavicular dislocations and its impact on clinical and radiographic parameters.

BACKGROUND: Acromioclavicular (AC) joint dislocations are classified according to the Rockwood (RW) classification, which is based on radiographic findings. Several authors have suggested magnetic resonance imaging (MRI) for visualization of the capsuloligamentous structures stabilizing the AC joint. The aim of this study was to describe the ligamentous injury pattern in acute AC joint dislocations by MRI and investigate associations with clinical and radiographic parameters. METHODS: This prospective study included 45 consecutive patients (5 women and 40 men; mean age, 33.6 years [range, 19-65 years]) with an acute AC joint separation (RW type I in 5, RW type II in 8, RW type III in 18, and RW type V in 14). All patients underwent physical examination of both shoulders, and clinical scores (Subjective Shoulder Value, Constant score, Taft score, and Acromioclavicular Joint Instability Score) were used to evaluate the AC joint clinically as well as radiographically. Post-traumatic radiography included bilateral anteroposterior stress views and bilateral Alexander views to evaluate vertical instability and dynamic posterior translation. MRI was performed for assessment of the AC and coracoclavicular (CC) ligaments and the delto-trapezoidal fascia. RESULTS: Radiographic and MRI classifications were concordant in 23 of 45 patients (51%), whereas 22 injuries (49%) were misjudged; of these, 6 (13%) were reclassified to a more severe type and 16 (36%), to a less severe type. The integrity of the CC ligaments was found to have a clinical impact on vertical as well as horizontal translation determined by radiographs and on clinical parameters. Among patients with an MRI-confirmed complete disruption of the CC ligaments, 68% showed a radiographic CC difference > 30% and 75% showed complete dynamic posterior translation. Inferior clinical parameters were noted in these patients as compared with patients with intact CC ligaments or partial disruption of the CC ligaments (Constant score of 67 points vs. 49 points [P < .05] and Acromioclavicular Joint Instability Score of 51 points vs. 23 points [P < .05]). The inter-rater and intra-rater reliability for assessment of the ligamentous injury pattern by MRI was fair to substantial (r = 0.37-0.66). CONCLUSION: The integrity of the CC and AC ligaments found on MRI has an impact on clinical and radiographic parameters.

Tumor Seeding along the Puncture Tract in CT-Guided Interstitial High-Dose-Rate Brachytherapy.

PURPOSE: To quantify the occurrence of tumor seeding in computed tomography (CT)-guided high-dose-rate brachytherapy (HDRBT) and to identify potential risk factors. MATERIALS AND METHODS: CT-HDRBT is a minimally invasive therapeutic option for local ablation of unresectable tumors. The procedure involves CT-guided placement of an enclosed catheter and high-dose-rate brachytherapy using iridium-192. Transcutaneous puncture of a tumor with subsequent retraction of the applicator has the potential risk of tumor seeding along the puncture tract. A total of 1,765 consecutive CT-HDRBT procedures were performed at this center between 2006 and 2017 and were retrospectively analyzed. In addition, a distinction was made between whether the puncture tract was irradiated or not. Follow-up imaging datasets were evaluated for tumor seeding along the former puncture tracts. Descriptive and exploratory statistical analyses of the data were performed. RESULTS: Tumor seeding was observed in 25 cases (25 of 1,765 cases [1.5%]). A total of 0.008 cases occurred per person-age. Patient age was identified as a potential risk factor with an odds ratio of 1.046 (95% confidence interval, 1.003-1.091; P = .04). There were no differences between whether the puncture tract was irradiated or not (P = .552). CONCLUSIONS: Tumor seeding along the puncture tract can occur in CT-HDRBT but is rare.

Feasibility and Safety of CT-Guided High-Dose-Rate Brachytherapy Combined with Transarterial Chemoembolization Using Irinotecan-Loaded Microspheres for the Treatment of Large, Unresectable Colorectal Liver Metastases.

PURPOSE: To evaluate feasibility and safety of combined irinotecan chemoembolization and CT-guided high-dose-rate brachytherapy (HDRBT) in patients with unresectable colorectal liver metastases > 3 cm in diameter. MATERIALS AND METHODS: This prospective study included 23 patients (age, 70 y ± 11.3; 16 men) with 47 liver metastases (size, 62 mm ± 18.7). Catheter-related adverse events were reported per Society of Interventional Radiology classification, and treatment toxicities were reported per Common Terminology Criteria for Adverse Events. Liver-related blood values were analyzed by Wilcoxon test, with P < .05 as significant. Time to local tumor progression, progression-free survival (PFS), and overall survival (OS) were estimated by Kaplan-Meier method. RESULTS: No catheter-related major or minor complications were recorded. Significant differences vs baseline levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT; both P < .001), γ-glutamyltransferase (GGT; P = .013), and hemoglobin (P = .014) were recorded. After therapy, 11 of 23 patients (47.8%) presented with new grade I/II toxicities (bilirubin, n = 3 [13%]; AST, n = 16 [70%]; ALT, n = 18 [78%]; ALP, n = 12 [52%] and hemoglobin, n = 15 [65%]). Moreover, grade III/IV toxicities developed in 10 (43.5%; 1 grade IV): AST, n = 6 (26%), grade III, n = 5; grade IV, n = 1; ALT, n = 3 (13%); GGT, n = 7 (30%); and hemoglobin, n = 1 (4%). However, all new toxicities resolved within 3 months after therapy without additional treatment. Median local tumor control, PFS, and OS were 6, 4, and 8 months, respectively. CONCLUSIONS: Combined irinotecan chemoembolization and CT-guided HDRBT is safe and shows a low incidence of toxicities, which were self-resolving.

Complications of Computed Tomography-Guided High-Dose-Rate Brachytherapy (CT-HDRBT) and Risk Factors: Results from More than 10 Years of Experience.

PURPOSE: For local ablation of unresectable tumors, computed tomography-guided high-dose-rate brachytherapy (CT-HDRBT) is a minimally invasive therapeutic option involving CT-guided catheter placement and high-dose-rate irradiation with iridium-192. Possible complications are related to transcutaneous puncture, retraction of the applicator, and delivery of brachytherapy. To classify CT-HDRBT in comparison with other minimally invasive therapeutic options, it is essential to know the probability of complications and their risk factors. This study therefore aimed at quantifying the occurrence of complications in CT-HDRBT and identifying potential risk factors. MATERIALS AND METHODS: Over a period of more than 10 years from 2006 to 2017, 1877 consecutive CT-HDRBTs were performed at our center and retrospectively analyzed. In 165 cases, CT-HDRBT was combined with transarterial (chemo-) embolization. Information on complications and potential risk factors was retrospectively retrieved from electronic documentation. Statistical analysis of the data was performed. RESULTS: No complications occurred in 85.6% of the interventions. The most common complications were bleeding (5.6%), infection (2.0%), and prolonged pain (1.5%). Summarized diameter (defined as sum of maximum diameters in axial orientation) of treated tumor lesions (odds ratio 1.008; p < 0.001), target lesion site (odds ratio 1.132; p = 0.033), combined treatment (odds ratio 1.233; p = 0.038), and the presence of biliodigestive anastomosis (BDA) (odds ratio 1.824; p = 0.025) were identified as risk factors. CONCLUSIONS: CT-HDRBT is a safe minimally invasive therapeutic option. Summarized diameter of treated tumor lesions, target lesion site, combined treatment, and presence of BDA are risk factors for complications.

Comparing HCC arterial tumour vascularisation on baseline imaging and after lipiodol cTACE: how do estimations of enhancing tumour volumes differ on contrast-enhanced MR and CT?

OBJECTIVES: In this study, pre-treatment target lesion vascularisation in either contrast-enhanced (CE) CT or MRI and post-treatment lipiodol deposition in native CT scans were compared in HCC patients who underwent their first cTACE treatment. We analysed the impact of stratification according to cTACE selectivity on these correlations. METHODS: Seventy-eight HCC patients who underwent their first cTACE procedure were retrospectively included. Pre-treatment tumour vascularisation in arterial contrast phase and post-treatment lipiodol deposition in native CT scans were evaluated using the qEASL (quantitative tumour enhancement) method. Correlations were analysed using scatter plots, the Pearson correlation coefficient (PCC) and linear regression analysis. Subgroup analysis was performed according to lobar, segmental and subsegmental execution of cTACE. RESULTS: Arterial tumour volumes in both baseline CE CT (R2 = 0.83) and CE MR (R2 = 0.82) highly correlated with lipiodol deposition after cTACE. The regression coefficient between lipiodol deposition and enhancing tumour volume was 1.39 for CT and 0.33 for MR respectively, resulting in a ratio of 4.24. After stratification according to selectivity of cTACE, the regression coefficient was 0.94 (R2 = 1) for lobar execution, 1.38 (R2 = 0.96) for segmental execution and 1.88 (R2 = 0.89) for subsegmental execution in the CE CT group. CONCLUSIONS: Volumetric lipiodol deposition can be used as a reference to compare different imaging modalities in detecting vital tumour volumes. That approach proved CE MRI to be more sensitive than CE CT. Selectivity of cTACE significantly impacts the respective regression coefficients which allows for an innovative approach to the assessment of technical success after cTACE with a multitude of possible applications. KEY POINTS: • Lipiodol deposition after cTACE highly correlates with pre-treatment tumour vascularisation and can be used as a reference to compare different imaging modalities in detecting vital tumour volumes. • Lipiodol deposition also correlates with the selectivity of cTACE and can therefore be used to quantify the technical success of the intervention.

Semi-automatic prostatic artery detection using cone-beam CT during prostatic arterial embolization.

BACKGROUND: Due to the broad variability of the prostatic artery (PA), its origin, small calibers, and tortuous courses, prostatic arterial embolization (PAE) is challenging, time-consuming, and results in high radiation doses. PURPOSE: To evaluate the accuracy of PA detection using cone-beam computed tomography (CBCT) performed from the aortic bifurcation in combination with a semi-automatic detection software in comparison to oblique view digital subtraction angiography (DSA) with internal iliac artery (IIA) injection. MATERIAL AND METHODS: Twenty-two consecutive patients were included in this retrospective, IRB-approved study between July and December 2017. CBCT from the aorta and 30° oblique-view DSA from both IIAs were obtained for PA detection. Results of suggested PAs from the semi-automatic vessel detection software after CBCT and IIA DSA were compared. Moreover, dose area product (DAP) was recorded. Statistical analysis included Spearman's correlation, Mann-Whitney U test, and the Wilcoxon test considering P<0.05 as significant. RESULTS: PA type was classified significantly better with CBCT compared to DSA (P=0.047). In IIA DSA, PAs could not be identified in 18% on the left and in 17% on the right side. CBCT detected all PAs, although truncation occurred in 59% because of the limited field of view. Mean DAP of the whole procedure was 257,161.32±127,909.36 mGy*cm2. Mean DAPs were for a single DSA 14,502.51±9,437.67 mGy*cm2 and for one CBCT 15,589.23±2,722.49 mGy*cm2. A mean of 14.82 DSAs and only one CBCT were performed. CBCT accounted for 6% and DSA for 84% of the entire DAP of the procedure. CONCLUSION: CBCT with semi-automatic feeding vessel detection software detects PAs more accurately than IIA DSA and may reduce radiation dose.

Visibility of Hypovascularized Liver Tumors during Intra-Arterial Therapy Using Split-Bolus Single-Phase Cone Beam CT.

PURPOSE: To validate a split-bolus contrast injection protocol for single-phase CBCT in terms of detectability of hypovascular liver tumors compared to digital subtraction angiography (DSA). MATERIALS AND METHODS: In this retrospective, single-center study, 20 consecutive patients with in total 77 hypovascularized tumors referred for intra-arterial therapy received a split-bolus single-phase CBCT. Two readers rated the visibility of the target tumors scheduled for embolization in CBCT and DSA compared to the pre-interventional multiphasic CT or MRI used as reference on a 3-point scoring system (1 = optimal, 3 = not visible) and catheter-associated artifacts (1 = none, 3 = extended). SNR, CNR and contrast values were derived from 37 target tumors in CBCT and MRI. Statistical analysis included the kappa test to determine interrater reliability, the Friedman's test for the inter-modality comparison evaluating tumor visibility in DSA and CBCT as well as for quantitative assessment. Post hoc analysis included the Wilcoxon signed-rank test. p values < 0.05 were considered significant. RESULTS: Ninety percentage of target tumors were rated as visible in CBCT and 37.5% in DSA (p < 0.001). 70.1% of pre-interventionally detected hypovascularized tumors were depicted with CBCT and 31.2% by DSA (p < 0.001). 7.8% of known tumors were outside the FOV. Quantitative assessment showed higher image contrasts in CBCT (1.91 ± 7.01) compared to hepatobiliary-phase MRI (0.29 ± 0.14, p = 0.003) and to portal-venous (p.v.) MRI (0.31 ± 0.13, p < 0.001), but higher CNR for MRI (1.18 ± 0.80; 13.92 ± 15.82; 13.79 ± 6.65). CONCLUSION: In conclusion, the split-bolus single-phase CBCT detects significantly more hypovascularized liver tumors compared to DSA performed through the proper hepatic artery with high image contrasts. LEVEL OF EVIDENCE: Level III, diagnostic study.

Radioablation by Image-Guided (HDR) Brachytherapy and Transarterial Chemoembolization in Hepatocellular Carcinoma: A Randomized Phase II Trial.

BACKGROUND AND AIMS: The aim of this single-center, open-label phase II study was to assess the efficacy of image-guided high-dose-rate (HDR) brachytherapy (iBT) compared with conventional transarterial embolization (cTACE) in unresectable hepatocellular carcinoma. METHODS: Seventy-seven patients were treated after randomization to iBT or cTACE, as single or repeated interventions. Crossover was allowed if clinically indicated. The primary endpoint was time to untreatable progression (TTUP). Eligibility criteria included a Child-Pugh score of ≤ 8 points, absence of portal vein thrombosis (PVT) at the affected liver lobe, and ≤ 4 lesions. Survival was analyzed by using the Cox proportional hazard model with stratification for Barcelona Clinic Liver Cancer (BCLC) stages. RESULTS: Twenty patients were classified as BCLC-A (iBT/cTACE 8/12), 35 as BCLC-B (16/19), and 22 as BCLC-C (13/9). The 1-, 2-, and 3-year TTUP probabilities for iBT compared with cTACE were 67.5% versus 55.2%, 56.0% versus 27.4%, and 29.5% versus 11.0%, respectively, with an adjusted hazard ratio (HR) of 0.49 (95% confidence interval 0.27-0.89; p = 0.019). The 1-, 2-, and 3-year TTPs for iBT versus cTACE were 56.0% versus 28.2%, 23.9% versus 6.3%, and 15.9% versus 6.3%, respectively, with an adjusted HR of 0.49 (0.29-0.85; p = 0.011). The 1-, 2-, and 3-year OS rates were 78.4% versus 67.7%, 62.0% versus 47.3%, and 36.7% versus 27.0%, respectively, with an adjusted HR of 0.62 (0.33-1.16; p = 0.136). CONCLUSIONS: This explorative phase II trial showed a superior outcome of iBT compared with cTACE in hepatocellular carcinoma and supports proceeding to a phase III trial.

Primary and metastatic malignancies of the lung: Retrospective analysis of the CT-guided high-dose rate brachytherapy (CT-HDRBT) ablation in tumours <4 cm and ≥4 cm.

BACKGROUND: Minimal invasive local therapies are alternative treatment options in patients with primary and metastatic lung malignancies being not eligible for resection. However, thermal ablations are often limited by large tumour volumes. PURPOSE: To evaluate the efficacy and safety of CT-HDRBT in pulmonary tumours ≥4 cm compared to smaller tumours. MATERIAL AND METHODS: In this retrospective study, 74 consecutive patients (mean age: 63 ± 12; m: 39, w: 35) with a total of 175 tumours treated in 132 interventions were enrolled between October 2003 and September 2016. Primary and assisted local tumour control (LTC), progression free survival (PFS) and overall survival (OS) after first CT-HDBRT were identified for two subgroups with tumours <4 cm (A) as well as ≥4 cm (B) using the Kaplan-Meier-Method. Radiation parameters and side effects were recorded. Log-Rank-Test and Mann-Whitney-U-Test were performed for statistical analyses with p-values <0.05 considered as significant. RESULTS: There was no statistical difference in coverage with prescribed radiation dose (A:19.78 ± 8.62 mm (range 5-39 mm), 99.56 ± 0.99%; B:61.70 ± 21.09 mm (41-100 mm), 94.81 ± 7.19%, p = 0.263). LTC rates after 0.5-,1-,2-,3- and 5-years were higher in A compared to B (A:85%/74%/63%/60%/46%, B:71%/37%/32%/32%/32%) with longer primary (A:11months, B:5months, p = 0.003) and assisted LTC (A:9months B:20months, p = 0.339). Longer OS was observed in A (A:18.5months, B:14.5months, p = 0.011) with longer OS rates (A:96%/87%/60%/48%/19%, B:92%/73%/20%/20%/0%). Complication assessment revealed no bleedings, 16.6% pneumothoraxes and 48.5% of mild radiation fibrosis without clinical symptoms. CONCLUSION: In conclusion, higher LTC and OS were observed in patients with primary lung malignancies <4 cm. Nevertheless, CT-HDRBT is a safe and feasible alternative even in larger tumours ≥4 cm.

Cholangiocarcinoma: CT-guided High-Dose Rate Brachytherapy (CT-HDRBT) for Limited (<4 cm) and Large (>4 cm) Tumors.

BACKGROUND/AIM: Thermal-ablative therapies are limited to tumors of 3-4 cm diameter. The purpose of this study was to evaluate the local tumor control (LTC) of CT-guided High-Dose-Rate-Brachytherapy (CT-HDRBT) for ablation of cholangiocarcinomas (CCA) ≥4 cm compared to smaller tumors. PATIENTS AND METHODS: Sixty-one patients (tumors: 142, interventions: 91) were treated from March 2008 to January 2017. LTC, progression-free survival (PFS) and overall survival (OS) after first CT-HDRBT were identified for two subgroups (A:<4 cm, B:≥4 cm) and the influence of coverage and target-dose were evaluated. Log-Rank- and Mann-Whitney-U-Tests were performed for statistical analyses with p-values <0.05 considered as significant. RESULTS: Better coverage was achieved for smaller tumors (A: 99.22-0.25%, B: 95.10-1.40%, p<0.001). LTC was better in subgroup A (A: 8, B: 6 months, p=0.006). Larger tumors (4-7 cm) with incomplete coverage showed the poorest LTC (p=0.032). There were no statistical significances in PFS (A: 5, B: 3 months, p=0.597) and OS (A:15.5; B:10.0 months, p=0.107). CONCLUSION: CT-HDRBT is sufficient in CCA ≥4 cm, if full coverage with therapeutic doses can be achieved.