Normal preoperative levels of gamma-glutamyltransferase predict the absence of common bile duct stones in patients scheduled for laparoscopic cholecystectomy: a retrospective cohort study.

Laparoscopic cholecystectomy, nowadays, is considered the gold standard option for management in patients diagnosed with symptomatic cholelithiasis. Nevertheless, some patients may have coexisting choledocholithiasis, which manifests later in life with grave complications such as cholangitis and pancreatitis. The objective of this study is to evaluate the role of preoperative gamma-glutamyltransferase (GGT) in predicting choledocholithiasis in patients undergoing laparoscopic cholecystectomy. Method: A total of 360 patients with symptomatic cholelithiasis based on diagnosis aided with abdominal ultrasound were included in the study. The study design was a retrospective cohort. Patients were evaluated based on a comparison between findings of per-operative cholangiogram and laboratory measure of GGT. Result: The mean age of study participants was 47.22 (±28.41) years. Mean GGT levels were 121.54 (±87.91) U/l. One hundred (27.7%) participants had raised GGT. But only 19.4% had been diagnosed with filling defect positive on cholangiogram. The predictability of GGT for positive cholangiogram is statistically significant at less than 0.001 with an area under the curve of 0.922 (0.887-0.957), sensitivity of 95.7%, specificity of 88.6%, and accuracy of 90%. The standard error reported (0.018) was found to be relatively low. Conclusion: Based on the provided information, it is concluded that GGT plays an important role in predicting the coexistence of choledocholithiasis in symptomatic cholelithiasis and can be used in the setting where the facility of per-operative cholangiogram is not available.

Imaging Utilization Patterns and Injury Characteristics Associated with Electric Standing Scooters in a Major Urban Area.

BACKGROUND: The recent proliferation of electric standing scooters in major urban areas of the United States has been accompanied by injuries of varying severity and nature, representing a growing public health concern. OBJECTIVE: Our aim was to characterize imaging utilization patterns for injuries associated with electric scooter (e-scooter) use, including their initial emergency department (ED) management. METHODS: We conducted a retrospective review of the electronic medical record for all patients presenting to affiliated EDs for e-scooter-related injuries between July 2018 and April 2020. Demographics, date and time of presentation, imaging study type, resultant injury, and procedural details were recorded. RESULTS: Ninety-seven patients were included; mean age was 27.6 years. Of these, 55 patients (57%) had injuries identified on imaging and 40% of all imaging studies were positive. Most identified injuries (61%) were musculoskeletal, with a small number of neurological (2%) and genitourinary (1%) injuries. The highest prevalence of presentations occurred in August; most patients (72%) presented between 3 pm and 1 am and granular peaks were between 12 am and 1 am and 5 pm and 6 pm. CONCLUSIONS: Patients presenting with e-scooter injuries have a high likelihood of injury to the radial head, nasal bone, and malleoli. Emergency physicians should be especially vigilant for injuries in these areas at presentation. Visceral injuries are uncommon but may be severe enough to warrant surgery.

Liver Transplantation Following Yttrium-90 Radioembolization: 15-Year Experience in 207-Patient Cohort.

BACKGROUND AND AIMS: Radioembolization (yttrium-90 [Y90]) is used in hepatocellular carcinoma (HCC) as a bridging as well as downstaging liver-directed therapy to curative liver transplantation (LT). In this study, we report long-term outcomes of LT for patients with HCC who were bridged/downstaged by Y90. APPROACH AND RESULTS: Patients undergoing LT following Y90 between 2004 and 2018 were included, with staging by United Network for Organ Sharing (UNOS) tumor-node-metastasis criteria at baseline pre-Y90 and pre-LT. Post-Y90 toxicities were recorded. Histopathological data of HCC at explant were recorded. Long-term outcomes, including overall survival (OS), recurrence-free survival (RFS), disease-specific mortality (DSM), and time-to-recurrence, were reported. Time-to-endpoint analyses were estimated using Kaplan-Meier. Univariate and multivariate analyses were performed using a log-rank test and Cox proportional-hazards model, respectively. During the 15-year period, 207 patients underwent LT after Y90. OS from LT was 12.5 years, with a median time to LT of 7.5 months [interquartile range, 4.4-10.3]. A total of 169 patients were bridged, whereas 38 were downstaged to LT. Respectively, 94 (45%), 60 (29%), and 53 (26%) patients showed complete, extensive, and partial tumor necrosis on histopathology. Three-year, 5-year, and 10-year OS rates were 84%, 77%, and 60%, respectively. Twenty-four patients developed recurrence, with a median RFS of 120 (95% confidence interval, 69-150) months. DSM at 3, 5, and 10 years was 6%, 11%, and 16%, respectively. There were no differences in OS/RFS for patients who were bridged or downstaged. RFS was higher in patients with complete/extensive versus partial tumor necrosis (P < 0.0001). For patients with UNOS T2 treated during the study period, 5.2% dropped out because of disease progression. CONCLUSIONS: Y90 is an effective treatment for HCC in the setting of bridging/downstaging to LT. Patients who achieved extensive or complete necrosis had better RFS, supporting the practice of neoadjuvant treatment before LT.

Correction to: Prognosticating Survival in Hepatocellular Carcinoma with Elevated Baseline Alpha-fetoprotein Treated with Radioembolization Using a Novel Laboratory Scoring System: Initial Development and Validation.

The name of the eleventh author is listed incorrectly in the published article as Nitin Kataraya. The correct name is Nitin Katariya.

Safety and efficacy of radioembolization with glass microspheres in hepatocellular carcinoma patients with elevated lung shunt fraction: analysis of a 103-patient cohort.

BACKGROUND: Technetium-99m macroaggregated albumin is used to estimate lung shunt fraction (LSF) prior to yttrium-90 (Y90). Studies have debated the safety and efficacy of Y90 in patients with LSF > 15%. We aimed to assess the role of Y90 in hepatocellular carcinoma (HCC) with LSF > 15%. METHODS: With IRB approval, we searched our prospectively acquired database of HCC patients with Y90 treated with LSF > 15%. Median LSF and liver and lung doses were calculated. The response was assessed using RECIST. Overall survival (OS) was calculated from date of first Y90. RESULTS: A total of 103 HCC patients underwent Y90. The median baseline LSF was 24.4% (IQR 18.1-28.8). Patients exhibited multifocal disease (59/103, 60%) and median tumor size of 7.85 cm (IQR 5.2, 10.57). BCLC class was A, B, C, and D in 7 (7%), 5 (5%), 85 (83%), and 6 (6%) patients, respectively. The median liver dose was 84.6 Gy (IQR 57.4, 107.55). The median lung dose per session and cumulatively was 22.9 Gy (IQR 15-28) and 29.5 Gy (IQR 20.5-44.3). Thirty-three patients (32%) demonstrated partial response, 57 stable disease, and 13 (13%) had progressive disease. The median OS was 7.3 months (95% CI 5.3, 11.47). Twenty patients (19%) had non-specific pulmonary symptoms (cough, shortness of breath, wheezing) in the 1-year post-Y90. The median time to the appearance of non-specific pulmonary symptoms was 63 days (range 7-224). Thoracic imaging demonstrated no pulmonary fibrosis/injury following treatment in any patient. CONCLUSION: Y90 can be performed in patients with LSF > 15%. The RECIST response was identified in 32% of the patients. In isolation, LSF > 15% should not deter from treatment with Y90.

Prognostic Role of Albumin, Bilirubin, and ALBI Scores: Analysis of 1000 Patients with Hepatocellular Carcinoma Undergoing Radioembolization.

Introduction: We compared the efficacy of the ALBI (albumin-bilirubin) score to the established Child-Pugh (CP) grade in hepatocellular carcinoma (HCC) patients treated with yttrium-90 radioembolization (Y90). We further assessed the individual contributions of albumin and bilirubin to survival prediction. Methods: 1000 consecutive HCC patients treated with Y90 were included. Overall survival (OS) was assessed using Kaplan Meier analysis. Sub-stratification analyses were performed using CP and ALBI and in subgroups determined by United Network for Organ Sharing (UNOS) or Barcelona Clinic Liver Cancer (BCLC) staging. The independent impact (hazard ratio (HR)) of ALBI, CP, albumin, and bilirubin on survival was assessed using Cox proportional hazards analysis. Results: Median OS for ALBI 1, 2, and 3 grades was 46.7, 19.1, and 8.8 months, respectively. The HR for death for ALBI 2 vs. ALBI 1 was 3.39 (1.75-6.57); ALBI 3 vs. ALBI 1 was 7.58 (3.89-14.79); and the c-index was 0.623. Median OS for CP A, B, and C was 21.7, 11.3, and 6.0 months, respectively. The HR for death for CP B vs. CP A was 2.04 (1.71-2.43); CP C vs. CP A was 3.27 (2.08-5.14); and the c-index was 0.616. Stratified OS showed unique prognostic groups identified by ALBI within CP-B and CP-C. Median OS for albumin grades 1, 2, and 3 was 46.0, 17.1, and 9.1 months, respectively. Median OS for bilirubin grades 1, 2, and 3 was 15.6, 21.0, and 5.8 months, respectively. The HR for death for albumin 2 vs. 1 was 2.48 (1.81-3.41); albumin 3 vs. 1 was 4.74 (3.44-6.54); and the c-index was 0.640. The HR for death for bilirubin 2 vs. 1 was 1.09 (0.82-1.44); bilirubin 3 vs. 1 was 2.37 (1.66-3.40); and the c-index was 0.533. Conclusions: ALBI outperforms CP in survival prognosis in Y90 treated patients. On sub-analyses, serum albumin (not bilirubin) appears to be the main driver of survival prediction. Our study supports the prognostic ability of ALBI and may suggest a role of albumin alone as a biomarker for patients with HCC.

Technical Aspects and Practical Approach Toward Same-Day Y90 Radioembolization in the Management of Hepatocellular Carcinoma.

Radioembolization with Yttrium-90 (Y90) has been proven safe and effective for the treatment of primary and secondary hepatic malignancies. Standard protocols have necessitated planning angiography with Technetium-99m macroaggregated albumin (Tc99m MAA) administration/scan typically 1-2 weeks prior to the radioembolization therapy. The intent of this practice is to ensure appropriate patient selection and treatment candidacy while also confirming best dosimetry approaches. At our center, we started performing "same-day Y90" in 2008; in a subset of international patients with travel hardship, we performed the planning and treatment procedures consecutively on the same day. In this article, we reveal our practical approach to treating patients on the same day as planning angiography. With more than 160 same-day procedures completed between 2008 and 2017, the safety and efficacy of such a paradigm has been established at our center. This approach is appealing to patients, their families, and referring physicians. Appropriate patient selection and proper preprocedure planning based on baseline imaging are key elements in successful same-day radioembolization treatments.

Prognosticating Survival in Hepatocellular Carcinoma with Elevated Baseline Alpha-fetoprotein Treated with Radioembolization Using a Novel Laboratory Scoring System: Initial Development and Validation.

AIMS: To investigate laboratory parameters as predictors of overall survival (OS) for hepatocellular carcinoma (HCC) treated with radioembolization and develop/validate a scoring system. METHODS: With IRB approval, we included all patients with baseline alpha-fetoprotein (AFP) > 100 ng/dL from our prospectively acquired HCC radioembolization database. Neutrophil-lymphocyte ratio, albumin-bilirubin (ALBI), and AFP were measured at baseline and at 1-, 3-, and 6-month post-radioembolization Landmarks. OS was assessed from these Landmarks. Univariate/multivariate analyses were performed to evaluate OS predictability of these parameters. Baseline Imaging, Laboratory, and Combination scoring systems were developed. Developing/validating groups were created to investigate/validate the score's OS predictability. Time-dependent receiver operating characteristics (ROC) were evaluated. Patients were stratified into groups I, II, and III by using 25th and 75th percentile cutoffs according to change in Laboratory Score from baseline. RESULTS: 345/401 (86%), 238/401 (59%), and 167/401 (42%) patients had laboratory parameters available at the 1-, 3-, and 6-month Landmarks, respectively. ALBI and AFP were significant OS prognosticators at all Landmarks. The Laboratory Score [ALBI + (0.3 × LnAFP)] was developed/internally validated to predict OS from these Landmarks. Areas under the curve of time-dependent ROCs of the Baseline Imaging vs. Laboratory scores in predicting patient OS post 3 and 6 months Landmarks were 0.56 versus 0.82 and 0.57 versus 0.77, respectively. OS differences in groups I, II, and III according to change in Laboratory Score from baseline were significant (p < 0.001). CONCLUSIONS: Post-radioembolization AFP and ALBI scores were significant OS prognosticators. A decrease in post-therapeutic Laboratory Score, which combines AFP and ALBI, correlates with an improved OS.

MR imaging findings of the prostate gland following prostate artery embolization: results from a prospective phase 2 study.

PURPOSE: To assess changes in imaging and volume characteristics of the prostate gland by magnetic resonance (MR) following prostatic artery embolization (PAE) for benign prostate hyperplasia. METHODS: With IRB approval, we analyzed prospectively acquired MR data of PAE patients at baseline and 6-month following treatment from 2015 to 2017. We reviewed prostate MRs looking for sequelae of embolization [changes in signal intensity and/or enhancement, infection/inflammation, infarction, edema, and change in intravesical prostatic protrusion (IPP)]. We calculated the total volume (TV) and central gland volumes (CGV) using DynaCAD® and measured change in volumes. Analyses were performed using SPSS with p < 0.05 considered significant. RESULTS: Forty-three patients (n = 43) met our inclusion criteria. 93% (30/43) and 100% (43/43) showed a decrease in TV and CGV at 6-months respectively. At baseline, median TV was 86 cc (range 29.4-232) and median CGV was 54.4 cc (range 12.9-165.5). Median decrease in TV was 18.2% (CI 13.3-27.2) (p = 0.0001) and median decrease in CGV was 26.7% (CI 20.4-35.9) (p = 0.0001). Thirty-seven percent (16/43) of patients had IPP at baseline; 100% showed a decrease in size of median lobe at follow-up. At 6-month follow-up, 33% (14/43) showed imaging features of infarction, 79% (34/43) had decrease in T2-signal intensity, and 51% (22/43) showed a decrease in enhancement. None had edema, peri-prostatic fat changes or infection/inflammation. CONCLUSION: PAE causes a statistically significant reduction in the TV and CGV. There is also a reduction of the degree of IPP. Non-specific findings of infarction, decrease in T2-signal, and enhancement were also seen.

Outcomes of Surgical Resection after Radioembolization for Hepatocellular Carcinoma.

PURPOSE: To longitudinally study clinical and radiologic outcomes of patients with hepatocellular carcinoma (HCC) who underwent yttrium-90 transarterial radioembolization (TARE) as a bridge to surgical resection. MATERIALS AND METHODS: TARE was performed in 31 patients with HCC before resection. Of patients, 25 underwent major hepatic resection (16 received right hepatectomy and 9 received trisegmentectomy), and 6 underwent partial hepatectomy. Clinical outcomes after TARE and after resection were recorded. Future liver remnant (FLR) was calculated before and after TARE, and actual liver remnant volume was calculated after resection. Radiologic response after TARE and pathologic necrosis were assessed. Overall and recurrence-free survivals after resection were estimated. RESULTS: Median time between TARE and resection was 2.9 months (interquartile range [IQR]: 2-5 months). Median FLR hypertrophy after TARE (and before resection) was 23.3% (IQR:10%-48%) for patients who had radiation lobectomy and 9% (IQR: 6%-25%) for patients who had radiation segmentectomy (P = .037). Median augmented hypertrophy of the liver remnant 3 months after resection was 72% (IQR:45%-88%) in patients who had radiation lobectomy and 94% (IQR: 72%-146%) in patients who had radiation segmentectomy. Complete, 50%-99%, and < 50% pathologic tumor necrosis was identified in 14 (45%), 10 (32%), and 7 (23%) tumors. Disease control was achieved in all 31 patients. Survival rates at 1 and 3 years were 96% and 86%, respectively. Median recurrence-free survival was 34.2 months (95% confidence interval,18.7-34.2). CONCLUSIONS: TARE can serve as a safe bridge to resection providing FLR hypertrophy and disease control.

Prostate Artery Embolization for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: Results From a Prospective FDA-Approved Investigational Device Exemption Study.

OBJECTIVE: To evaluate the safety and efficacy of prostate artery embolization (PAE) for lower urinary tract symptoms (LUTS) attributed to benign prostatic hyperplasia (BPH). METHODS: A prospective, single-center, open-label FDA-approved study was conducted to evaluate the safety and efficacy of PAE for LUTS secondary to BPH. We enrolled men ≥ 45, prostate volume > 40 g, International prostate symptom score (IPSS) > 13, peak flow rate (Qmax) ≤ 12 mL/s, and voided volume ≥ 125 mL. Patients were evaluated with questionnaires (IPSS, quality-of-life [QoL], International index of erectile function, and male sexual health questionnaire for ejaculatory dysfunction) and clinical measures (postvoid residual volume and Qmax at baseline 1, 3, and 12 months) after PAE. Baseline and 6-month total prostate (TV) and central gland (CG) volumes were obtained. RESULTS: 45 patients (mean volume: 99 cc, range: 30-214 g) were treated over the course of the 3-year study. At 1 month, there were improvements in IPSS (23.6 ± 6.1 to 12.0 ± 5.9, P < .0001), QoL (4.8 ± 0.9 to 2.6 ± 1.6, P < .0001), Qmax (5.8 ± 1.0 to 12.4 ± 6.8,P < .0001). At 3 months, there were improvements in IPSS (10.2 ± 6.0, P < .0001), QoL (2.4 ± 1.6, P < .0001) and Qmax (15.3 ± 12.3, P < .0001). At 6 months, there were improvements in IPSS (11.0 ± 7.6, P < .0001) and QoL (2.3 ± 1.7, P < .0001). At 1 year, there were improvements in IPSS (12.4 ± 8.4,P < .0001) and QoL (2.6 ± 1.6, P < .0001). There were reductions in postvoid volume residues: baseline 157 ± 45, 1 month 123 ± 47, P = .057, 3 months 127 ± 114, P = .34, 6 months 112±116, P = .002 and 1 year 109±116 P = .025. Median decreases in TV and CG were 18% (CI: 13-27) (P = 0.0001) and 27% (CI: 20-36)(P = 0.0001), respectively. Self-limited adverse events included dysuria (n = 13), hematuria (n = 6), hematospermia (n = 2), urinary frequency (n = 3) and retention (n = 2). No severe adverse events, nontarget embolization, or adverse effects on erectile function or sexual health. CONCLUSION: This prospective clinical trial demonstrates that PAE is safe and efficacious for BPH, with significant improvement in LUTS and reduction in TV and CG volumes.

Radioembolization Super Survivors: Extended Survival in Non-operative Hepatocellular Carcinoma.

PURPOSE: To identify baseline characteristics and long-term prognostic factors in non-transplant patients with unresectable hepatocellular carcinoma (HCC) who had prolonged survival after treatment with yttrium-90 radioembolization (Y90). MATERIALS AND METHODS: Sixty-seven "Super Survivors" (defined as ≥ 3-year survival after Y90) were identified within our 1000-patient Y90 database (2003-2017). Baseline imaging and follow-up occurred at 1 month and every 3 months thereafter. Overall survival (OS) was calculated with Kaplan-Meier estimates with log-rank test in subgroups: Child-Pugh (CP) score, distribution of disease, portal vein thrombus (PVT), and technique (segmental vs lobar Y90). RESULTS: Median age 69.5 years (range 45-94 years); 69% male; 60% solitary HCC; 79% unilobar disease; 12% PVT; 10% ascites; Barcelona Clinic Liver Cancer Stage A-54%/B-28%/C-16%/D-2%; CP A-70%/B-28%/C-2%. Longest baseline tumor diameter was 5.4 ± 4.0 cm (mean ± SD). All patients had an imaging response (either partial or complete response). Median OS was 67.5 months (95% CI 55.2-82.5). CP score and main PVT stratified median OS (p = 0.0007 and p = 0.0187, respectively). Beyond 3 years, segmental versus lobar Y90 was associated with improved OS with a median OS of 80.2 versus 46.7 months, respectively (p = 0.0024). Dosing > 200 Gy was not a significant predictor of improved OS. CONCLUSIONS: Super Survivors spanning the BCLC staging system maintained durable OS after radioembolization that was stratified by the extent of underlying liver disease. The common variable among all patients was an imaging response. Segmental versus lobar Y90 may have a long-term associated OS benefit.

Radiation Segmentectomy: Potential Curative Therapy for Early Hepatocellular Carcinoma.

Purpose To report long-term outcomes of radiation segmentectomy (RS) for early hepatocellular carcinoma (HCC). The authors hypothesized that outcomes are comparable to curative treatments for patients with solitary HCC less than or equal to 5 cm and preserved liver function. Materials and Methods This retrospective study included 70 patients (median age, 71 years; range, 22-96 years) with solitary HCC less than or equal to 5 cm not amenable to percutaneous ablation who underwent RS (dose of >190 Gy) between 2003 and 2016. Patients who underwent subsequent curative liver transplantation were excluded to eliminate this confounding variable affecting survival. Radiologic response of time to progression and median overall survival were estimated by using the Kaplan-Meier method per the guidelines of the European Association for the Study of the Liver (EASL) and the World Health Organization (WHO). Results Seventy patients were treated with RS over 14 years. Sixty-three patients (90%) showed response by using EASL criteria, of which 41 (59%) showed complete response. Fifty patients (71%) achieved response by using WHO criteria, of which 11 (16%) achieved complete response. Response rates at 6 months were 86% and 49% by using EASL and WHO criteria, respectively. Median time to progression was 2.4 years (95% confidence interval: 2.1, 5.7), with 72% of patients having no target lesion progression at 5 years. Median overall survival was 6.7 years (95% confidence interval: 3.1, 6.7); survival probability at 1, 3, and 5 years was 98%, 66%, and 57%, respectively. Overall survival probability at 1, 3, and 5 years was 100%, 82%, and 75%, respectively, in patients with baseline tumor size less than or equal to 3 cm (n = 45) and was significantly longer than in patients with tumors greater than 3 cm (P = .026). Conclusion RS provides response rates, tumor control, and survival outcomes comparable to curative-intent treatments for selected patients with early-stage HCC who have preserved liver function. © RSNA, 2018 Online supplemental material is available for this article.

Survival Analysis of Advanced HCC Treated with Radioembolization: Comparing Impact of Clinical Performance Status Versus Vascular Invasion/Metastases.

PURPOSE: In this study, we aim to compare the effects of prognostic indicators on survival analysis for Barcelona Clinic Liver Cancer (BCLC) C patients undergoing yttrium-90 radioembolization (Y-90). METHODS: A prospectively acquired database (2003-2017) for BCLC C hepatocellular carcinoma (HCC) patients that underwent radioembolization with Y-90 was searched. The criteria for BCLC C status (Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 1 or 2, metastases, and/or portal vein thrombosis (PVT)) were recorded. Kaplan-Meier survival analyses were performed from the date of the first radioembolization with Y-90, censored to curative treatment, to determine median overall survival (OS). Cox regression hazards model was used for multivariate analyses. Significance was set at P < 0.05. RESULTS: 547 BCLC C patients treated with radioembolization with Y-90 had a median OS of 10.7 months (range: 9.5-12.9). 43% (233 of 547) patients classified as BCLC C solely by their ECOG PS had a median OS of 19.4 months (14.7-23.7); 57% (314 of 547) patients with PVT/metastases had a median OS of 7.7 months (6.7-8.7). On multivariate analysis, ECOG PS was not found to be a statistically significant prognostic indicator of OS in BCLC C whereas metastases and PVT exhibited hazards ratios (95%CI) of 0.51 (0.38-0.69) and 0.49 (0.38-0.63), respectively (P < 0.0001). CONCLUSION: Patients classified as BCLC C due to ECOG PS 1 demonstrated longer survival when compared to those presenting with PVT, metastases and/or ECOG PS 2. Hence, ECOG PS 1, as an isolated variable, may not be a true indicator of advanced disease.

Pretransplant Intra-arterial Liver-Directed Therapy Does Not Increase the Risk of Hepatic Arterial Complications in Liver Transplantation: A Single-Center 10-Year Experience.

PURPOSE: To investigate the association between pretransplant intra-arterial liver-directed therapy (IAT) for hepatocellular carcinoma (HCC) and hepatic arterial complications (HAC) in orthotopic liver transplantation (OLT) [namely hepatic artery thrombosis (HAT) and/or the need for hepatic arterial conduit]. METHODS: A total of 175 HCC patients (mean age: 60 years) underwent IAT with either transarterial chemoembolization or yttrium-90 (90Y) transarterial radioembolization prior to OLT between 2003 and 2013. A matched control cohort of 159 HCC patients who underwent OLT without prior IAT was selected. Incidence of HAC in both cohorts was investigated. The categorical differences between both cohorts were calculated by chi-square test. RESULTS: Among the 175 patients (chemoembolization, n = 82; radioembolization, n = 93), 8 (5%) required conduits due to HA disease (chemoembolization, n = 6; radioembolization, n = 2), 3 (2%) developed HAT (chemoembolization, n = 2; radioembolization, n = 1). Eleven of 175 patients (6.7%) had HAC. Of the 159 control patients, 6 (4%) needed conduits for HA disease and 3 (2%) developed HAT. Nine of 159 patients (5.7%) had HAC. Chi-square analysis between the IAT cohort and the control group yielded a p value of 0.810. When comparing chemoembolization to radioembolization, p = 0.076 (not significant at p < 0.05). CONCLUSION: Although aggressive pretransplant radioembolization and chemoembolization are both utilized in most liver transplant centers, neither appears to increase the risk of peri-transplant hepatic arterial complications in HCC patients.

Radioembolization for hepatocellular carcinoma: Statistical confirmation of improved survival in responders by landmark analyses.

Does imaging response predict survival in hepatocellular carcinoma (HCC)? We studied the ability of posttherapeutic imaging response to predict overall survival. Over 14 years, 948 patients with HCC were treated with radioembolization. Patients with baseline metastases, vascular invasion, multifocal disease, Child-Pugh > B7, and transplanted/resected were excluded. This created our homogeneous study cohort of 134 patients with Child-Pugh ≤ B7 and solitary HCC. Response (using European Association for Study of the Liver [EASL] and Response Evaluation Criteria in Solid Tumors 1.1 [RECIST 1.1] criteria) was associated with survival using Landmark and risk-of-death methodologies after reviewing 960 scans. In a subanalysis, survival times of responders were compared to those of patients with stable disease (SD) and progressive disease (PD). Uni/multivariate survival analyses were performed at each Landmark. At the 3-month Landmark, responders survived longer than nonresponders by EASL (hazard ratio [HR], 0.46; confidence interval [CI], 0.26-0.82; P = 0.002) but not RECIST 1.1 criteria (HR, 0.70; CI, 0.37-1.32; P = 0.32). At the 6-month Landmark, responders survived longer than nonresponders by EASL (HR, 0.32; CI, 0.15-0.77; P < 0.001) and RECIST 1.1 criteria (HR, 0.50; CI, 0.29-0.87; P = 0.021). At the 12-month Landmark, responders survived longer than nonresponders by EASL (HR, 0.34; CI, 0.15-0.77; P < 0.001) and RECIST 1.1 criteria (HR, 0.52; CI 0.27-0.98; P = 0.049). At 6 months, risk of death was lower for responders by EASL (P < 0.001) and RECIST 1.1 (P = 0.0445). In subanalyses, responders lived longer than patients with SD or PD. EASL response was a significant predictor of survival at 3-, 6-, and 12-month Landmarks on uni/multivariate analyses. CONCLUSION: Response to radioembolization in patients with solitary HCC can prognosticate improved survival. EASL necrosis criteria outperformed RECIST 1.1 size criteria in predicting survival. The therapeutic objective of radioembolization should be radiologic response and not solely to prevent progression. (Hepatology 2018;67:873-883).

Institutional decision to adopt Y90 as primary treatment for hepatocellular carcinoma informed by a 1,000-patient 15-year experience.

Yttrium-90 transarterial radioembolization (TARE) is a locoregional therapy (LRT) for hepatocellular carcinoma (HCC). In this study, we present overall survival (OS) outcomes in a 1,000-patient cohort acquired over a 15-year period. Between December 1, 2003 and March 31, 2017, 1,000 patients with HCC were treated with TARE as part of a prospective cohort study. A comprehensive review of toxicity and survival outcomes was performed. Outcomes were stratified by baseline Child-Pugh (CP) class, United Network for Organ Sharing (UNOS), and Barcelona Clinic Liver Cancer (BCLC) staging systems. Albumin and bilirubin laboratory toxicities were compared to baseline. OS outcomes were reported using censoring and intention-to-treat methodologies. All treatments were outpatient, with a median one treatment per patient. Five hundred six (51%) were CP A, 450 (45%) CP B, and 44 (4%) CP C. Two hundred sixty-three (26%) patients were BCLC A, 152 (15%) B, 541 (54%) C, and 44 (4%) D. Three hundred sixty-eight (37%) were UNOS T1/T2, 169 (17%) T3, 147 (15%) T4a, 223 (22%) T4b, and 93 (9%) N/M. In CP A patients, censored OS for BCLC A was 47.3 (confidence interval [CI], 39.5-80.3) months, BCLC B 25.0 (CI, 17.3-30.5) months, and BCLC C 15.0 (CI, 13.8-17.7) months. In CP B patients, censored OS for BCLC A was 27 (CI, 21-30.2) months, BCLC B 15.0 (CI, 12.3-19.0) months, and BCLC C 8.0 (CI, 6.8-9.5) months. Forty-nine (5%) and 110 (11%) patients developed grade 3/4 albumin and bilirubin toxicities, respectively. CONCLUSION: Based on our experience with 1,000 patients over 15 years, we have made a decision to adopt TARE as the first-line transarterial LRT for patients with HCC. Our decision was informed by prospective data and incrementally reported demonstrating outcomes stratified by BCLC, applied as either neoadjuvant or definitive treatment. (Hepatology 2017).

90Y Radioembolization for Locally Advanced Hepatocellular Carcinoma with Portal Vein Thrombosis: Long-Term Outcomes in a 185-Patient Cohort.

We report survival outcomes for patients with advanced-stage hepatocellular carcinoma (HCC) with portal vein thrombosis (PVT) treated with 90Y radioembolization. Methods: With institutional review board approval, we searched our prospectively acquired database for 90Y patients treated between 2003 and 2017. Inclusion criteria were patients who had HCC with tumor PVT. Patients with metastases were excluded. Laboratory data were collected at baseline and 1 mo after 90Y radioembolization. Toxicity grades were reported according to the Common Terminology Criteria for Adverse Events, version 4.0, and long-term survival outcomes were reported and stratified by Child-Pugh class (CP). Overall survival was calculated using the Kaplan-Meier method. Multivariate analysis was performed using Cox proportional hazards regression. A subanalysis for patients with a high level of α-fetoprotein (AFP) (>100 ng/dL) was conducted. Results: In total, 185 patients with HCC PVT underwent 90Y radioembolization. Seventy-four (40%) were CP-A, 51 (28%) were CP-B7, and 60 (32%) were ≥CP-B8. New albumin, bilirubin, and alkaline phosphatase grade 3/4 toxicities were, respectively, 3%, 10%, and 0% for CP-A; 14%, 12%, and 6% for CP-B7; and 23%, 32%, and 3% for ≥CP-B8. Median overall survival for CP-A patients was 13.3 mo (95% confidence interval [CI], 8.7-15.7 mo). CP-B7 and ≥CP-B8 patients exhibited median overall survival of 6.9 mo (95% CI, 5.3-10.1 mo) and 3.9 mo (95% CI, 2.9-5.0 mo), respectively. Significant overall survival prognosticators on univariate analysis were albumin, bilirubin, ascites, tumor size 5 cm or smaller, focality, distribution, infiltration, Eastern Cooperative Oncology Group status, AFP level, and PVT extent. Multivariate analysis showed the prognosticators of overall survival to be bilirubin, no ascites, tumor size 5 cm or smaller, solitary lesion, baseline AFP level lower than 100 ng/dL, and Eastern Cooperative Oncology Group status. Of 123 patients with a high AFP level (>100 ng/dL), 12 patients achieved restored normal AFP levels (<13 ng/dL) and exhibited median overall survival of 23.9 mo (95% CI, 20.1-124.1 mo). AFP responders at 1 mo had better overall survival than nonresponders, at 8.5 mo versus 4.8 mo (P = 0.018); AFP responders at 3 mo had overall survival of 13.3 mo, versus 6.9 mo for nonresponders (P = 0.021). Conclusion:90Y radioembolization can serve as a safe and effective treatment for advanced-stage HCC patients with tumor PVT. Overall survival outcomes are affected by baseline liver function, tumor size, and AFP level.

Pictorial essay: imaging findings following Y90 radiation segmentectomy for hepatocellular carcinoma.

Transarterial radioembolization is a novel therapy that has gained rapid clinical acceptance for the treatment of hepatocellular carcinoma (HCC). Segmental radioembolization [also termed radiation segmentectomy (RS)] is a technique that can deliver high doses (> 190 Gy) of radiation selectively to the hepatic segment(s) containing the tumor. The aim of this comprehensive review is to provide an illustrative summary of the most relevant imaging findings encountered after radiation segmentectomy. A 62-patient cohort of Child-Pugh A patients with solitary HCC < 5 cm in size was identified. A comprehensive retrospective imaging review was done by interventional radiology staff at our institution. Important imaging findings were reported and illustrated in a descriptive account. For the purposes of completeness, specific patients outside our initial cohort with unique educational imaging features that also underwent segmentectomy were included in this pictorial essay. This review shows that response assessment after RS requires a learning curve with common drawbacks that can lead to false-positive interpretations and secondary unnecessary treatments. It is important to recognize that treatment responses and pathological changes both are time dependent. Findings such as benign geographical enhancement and initial benign pathological enhancement can easily be misinterpreted. Capsular retraction and segmental atrophy are some other examples of unique post-RS response that are not seen in any other treatment.

Clinical outcomes of Y90 radioembolization for recurrent hepatocellular carcinoma following curative resection.

PURPOSE: To assess safety/efficacy of yttrium-90 radioembolization (Y90) in patients with recurrent hepatocellular carcinoma (HCC) following curative surgical resection. METHODS: With IRB approval, we searched our prospectively acquired database for patients that were treated with Y90 for recurrent disease following resection. Baseline characteristics and bilirubin toxicities following Y90 were evaluated. Intention-to-treat overall survival (OS) and time-to-progression (TTP) from Y90 were assessed. RESULTS: Forty-one patients met study inclusion criteria. Twenty-six (63%) patients had undergone minor (≤3 hepatic segments) resection while 15 (37%) patients underwent major (>3 hepatic segments) resections. Two patients (5%) had biliary-enteric anastomoses created during surgical resection. The median time from HCC resection to the first radioembolization was 17 months (95% CI: 13-37). The median number of Y90 treatment sessions was 1 (range: 1-5). Ten patients received (entire remnant) lobar Y90 treatment while 31 patients received selective (≤2 hepatic segments) treatment. Grades 1/2/3/4 bilirubin toxicity were seen in nine (22%), four (10%), four (10%), and zero (0%) patients following Y90. No differences in bilirubin toxicities were identified when comparing lobar with selective approaches (P = 0.20). No post-Y90 infectious complications were identified. Median TTP and OS were 11.3 (CI: 6.5-15.5) and 22.1 months (CI: 10.3-31.3), respectively. CONCLUSIONS: Radioembolization is a safe and effective method for treating recurrent HCC following surgical resection, with prolonged TTP and promising survival outcomes.