RESUMO
PURPOSE: To report outcomes in patients with intrahepatic cholangiocarcinoma treated with yttrium-90 resin microspheres (transarterial radioembolization [TARE]) from a multicenter, prospective observational registry. MATERIALS AND METHODS: Ninety-five patients (median age, 67 years [interquartile range {IQR}, 59-74]; 50 men) were treated in 27 centers between July 2015 and August 2020. Baseline demographic characteristics included imaging findings, performance status, and previous systemic or locoregional treatments. Dosimetry method was tracked. Overall survival (OS) and progression-free survival were calculated using the Kaplan-Meier method. The best imaging response was calculated using the Response Evaluation Criteria in Solid Tumors v1.1. Grade ≥3 toxicities were assessed using Common Terminology Criteria for Adverse Events v5. Cox regression analysis was performed. RESULTS: Fifty-two of 86 (60%) patients had multifocal tumors, and 24/89 (27%) had extrahepatic tumors. The median index tumor diameter was 7.0 cm (IQR, 4.9-10 cm). The activity calculation method was reported in 59/95 (62%) patients, with body surface area being the most frequently used method (45/59, 76%). Median OS for the cohort was 14 months (95% confidence interval, 12-22). OS at 3, 6, 12, and 24 months was 94%, 80%, 63%, and 34%, respectively. Median OS was longer in patients without cirrhosis (19.1 vs 12.2 months, P = .05). Cirrhosis, previous chemotherapy (OS, 19.1 vs 10.6 months for treatment-naïve; P = .07), and imaging response at 6 months (OS, 16.4 vs 9.5 months for no response; P = .06) underwent regression analysis. Imaging response predicted OS at regression (hazard ratio, 0.39; P = .008). Grade 3-4 bilirubin toxicities were noted in 5 of 72 (7%) patients. Grade 3 albumin toxicity was noted in 1 of 72 (1.4%) patients. CONCLUSIONS: Objective response at 6 months predicted longer OS after TARE for intrahepatic cholangiocarcinoma. The incidence of liver function toxicity was <10%.
Assuntos
Neoplasias dos Ductos Biliares , Colangiocarcinoma , Embolização Terapêutica , Neoplasias Hepáticas , Masculino , Humanos , Idoso , Colangiocarcinoma/diagnóstico por imagem , Colangiocarcinoma/radioterapia , Radioisótopos de Ítrio , Embolização Terapêutica/métodos , Ductos Biliares Intra-Hepáticos , Neoplasias dos Ductos Biliares/diagnóstico por imagem , Neoplasias dos Ductos Biliares/radioterapia , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/radioterapia , Neoplasias Hepáticas/tratamento farmacológico , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Hepatic hemangiomas are common benign liver tumors. While the majority are small and require no treatment, giant hemangiomas are characterized as measuring greater than 4-6 cm in size and may require intervention. Surgical resection and enucleation have been described historically as the treatment for giant hemangiomas requiring intervention. Additionally, limited data exists about the treatment of hemangiomas measuring greater than 20 cm, particularly in regards to transarterial chemoembolization. We present a case of a super-giant hemangioma measuring greater than 20 cm treated with transarterial chemoembolization alone.
RESUMO
Immune checkpoint inhibitors (ICIs) are the current guideline recommended treatment for many malignancies considered to be terminal. Despite considerable advances, their utility remains limited, and the field requires synergistic partners to further improve outcomes. Oncolytic viruses (OV) are emerging as contenders for the role of the synergistic agent of choice due to their multi-mechanistic effect on activating the tumor 'cold' immune microenvironment. Herpes simplex virus 1, a naturally selective OV, is the most advanced virotherapeutic compound in clinical applications for use in combination with ICI. We here present the case of a 72 year-old patient with a heavily pre-treated, advanced maxillary sinus squamous cell cancer with distant metastases who developed complete response (CR) with only three administrations of a programmed death 1 inhibitor after treatment interference by a severe herpes zoster infection, based on the related alpha-herpesvirus varicella zoster virus (VZV). This exceptional response has been followed and confirmed with imaging studies over more than 5 years. Although the patient had several favorable predictors for response to immunotherapy, we reason that the exceptional response may in part be secondary to the serendipitous VZV infection. Documented cases of cancer patients that achieved CR after few administrations of treatment with ICI are rare, with most reporting follow up of just over 1 year or less. In this case, it is conceivable that the interference of the infection with VZV, soon after the start of immunotherapy with ICI, led to a lasting antitumor immunity and sustained CR. This hypothesis is supported by the concept of 'oncolytic immunotherapy' which is reviewed in this manuscript. In addition, persistence of a TP53 mutation found in a liquid biopsy, despite clinical and radiologic remission, is discussed.
RESUMO
Translational Relevance: Evaluation of targeted therapies is urgently needed for the majority of patients with metastatic/recurrent head and neck squamous cell carcinoma (HNSCC) who progress after immunochemotherapy. Erlotinib, a targeted inhibitor of epidermal growth factor receptor pathway, lacks FDA approval in HNSCC due to inadequate tumor response. This study identifies two potential avenues to improve tumor response to erlotinib among patients with HNSCC. For the first time, this study shows that an increased erlotinib dose of 300 mg in smokers is well-tolerated and produces similar plasma drug concentration as the regular dose of 150 mg in non-smokers, with increased study-specific defined tumor response. The study also highlights the opportunity for improved patient selection for erlotinib treatment by demonstrating that early in-treatment [18]FDG PET/CT is a potential predictor of tumor response, with robust statistical correlations between metabolic changes on early in-treatment PET (4-7 days through treatment) and anatomic response measured by end-of-treatment CT. Purpose: Patients with advanced HNSCC failing immunochemotherapy have no standard treatment options. Accelerating the investigation of targeted drug therapies is imperative. Treatment with erlotinib produced low response rates in HNSCC. This study investigates the possibility of improved treatment response through patient smoking status-based erlotinib dose optimization, and through early in-treatment [18]FDG PET evaluation to differentiate responders from non-responders. Experimental design: In this window-of-opportunity study, patients with operable HNSCC received neoadjuvant erlotinib with dose determined by smoking status: 150 mg (E150) for non-smokers and 300 mg (E300) for active smokers. Plasma erlotinib levels were measured using mass spectrometry. Patients underwent PET/CT before treatment, between days 4-7 of treatment, and before surgery (post-treatment). Response was measured by diagnostic CT and was defined as decrease in maximum tumor diameter by ≥ 20% (responders), 10-19% (minimum-responders), and < 10% (non-responders). Results: Nineteen patients completed treatment, ten of whom were smokers. There were eleven responders, five minimum-responders, and three non-responders. Tumor response and plasma erlotinib levels were similar between the E150 and E300 patient groups. The percentage change on early PET/CT and post-treatment PET/CT compared to pre-treatment PET/CT were significantly correlated with the radiologic response on post-treatment CTs: R=0.63, p=0.0041 and R=0.71, p=0.00094, respectively. Conclusion: This pilot study suggests that early in-treatment PET/CT can predict response to erlotinib, and treatment with erlotinib dose adjusted according to smoking status is well-tolerated and may improve treatment response in HNSCC. These findings could help optimize erlotinib treatment in HNSCC and should be further investigated. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT00601913, identifier NCT00601913.
Assuntos
Angiografia , Carcinoma Hepatocelular/diagnóstico por imagem , Cateterismo Periférico , Inibidores do Fator Xa/administração & dosagem , Artéria Femoral , Técnicas Hemostáticas/instrumentação , Neoplasias Hepáticas/diagnóstico por imagem , Pirazóis/administração & dosagem , Piridonas/administração & dosagem , Dispositivos de Oclusão Vascular , Idoso , Repouso em Cama , Carcinoma Hepatocelular/terapia , Cateterismo Periférico/efeitos adversos , Inibidores do Fator Xa/efeitos adversos , Humanos , Neoplasias Hepáticas/terapia , Masculino , Valor Preditivo dos Testes , Punções , Pirazóis/efeitos adversos , Piridonas/efeitos adversos , Resultado do TratamentoRESUMO
The rapidly evolving field of interventional oncology comprises both diagnostic and therapeutic procedures for the treatment of various malignancies. With respect to the liver, the most commonly utilized therapeutic procedures include thermal tumor ablation and transarterial embolization. Transarterial embolization techniques include bland embolization, chemoembolization and radioembolization. To safely and effectively perform these transarterial therapies, the interventional radiologist must have a thorough understanding of relevant arterial anatomy and proficiency in optimally delivering the pertinent embolic agent. This article will discuss various angiographic techniques as well as provide a detailed review of relevant hepatic arterial anatomy.
Assuntos
Angiografia/métodos , Antineoplásicos/administração & dosagem , Quimioembolização Terapêutica/métodos , Embolização Terapêutica/métodos , Artéria Hepática/anatomia & histologia , Neoplasias Hepáticas/terapia , Radiografia Intervencionista , Compostos Radiofarmacêuticos/administração & dosagem , Radioisótopos de Ítrio/administração & dosagem , HumanosRESUMO
PURPOSE: The aim of this study was to determine whether a self-referred population screened by an interventional radiology (IR) clinic and a non-IR, physician-referred population differed with regard to suitability for uterine artery embolization (UAE) for symptomatic leiomyomas on the basis of preprocedure MRI. METHODS: This was an institutional review board-approved, HIPAA-compliant retrospective study of 301 women evaluated in an IR clinic for possible UAE from January 2009 to September 2012. Subjects were retrospectively divided into two groups: self-referred via direct marketing (group A, n = 203; mean age, 41.8 years; range, 22-58 years) and physician referred (group B, n = 98; mean age, 42.9 years; range, 30-65 years). RESULTS: There was no significant difference between groups in presenting symptoms (multiple symptoms, bleeding, bulk-related symptoms, pain). After initial screening, 73.4% of group A (149 of 203) and 79.6% of group B (78 of 98) underwent MRI (P = .242). On the basis of MRI findings, 91.3% of group A (136 of 149) and 94.9% of group B (74 of 78) had uterine leiomyomas (P = .328). Adenomyosis without leiomyoma was present in 4.0% of group A (6 of 149) and 3.8% of group B (3 of 78) (P = .947). Incidental findings requiring further clinical or imaging evaluation were found in 20.8% of group A (31 of 149) and 24.4% of group B (19 of 78) (P = .539). After MRI, 41.6% of group A (62 of 149) and 48.7% of group B (38 of 78) proceeded to UAE (P = .306). CONCLUSIONS: After initial screening, similar proportions of self-referred and physician-referred patients were candidates for UAE. The rates of confirmed leiomyomas and incidental findings on MRI were similar between groups.
Assuntos
Leiomioma/epidemiologia , Leiomioma/terapia , Imagem por Ressonância Magnética Intervencionista/estatística & dados numéricos , Autorreferência Médica/estatística & dados numéricos , Embolização da Artéria Uterina/estatística & dados numéricos , Neoplasias Uterinas/epidemiologia , Neoplasias Uterinas/terapia , Adulto , Feminino , Humanos , Achados Incidentais , Leiomioma/diagnóstico por imagem , Marketing de Serviços de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , North Carolina/epidemiologia , Pelve/diagnóstico por imagem , Pelve/patologia , Prevalência , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos , Neoplasias Uterinas/diagnóstico por imagem , Revisão da Utilização de Recursos de SaúdeRESUMO
Management of primary and secondary hepatic malignancy is a complex problem. Achieving optimal care for this challenging population often requires the involvement of multiple medical and surgical disciplines. Because of the wide variety of potential therapies, treatment protocols for various malignancies continue to evolve. Consequently, development of appropriate therapeutic algorithms necessitates consideration of medical options, such as systemic chemotherapy; surgical options, such as resection or transplantation; and loco-regional therapies, such as thermal ablation and transarterial embolization techniques. This article provides a review of treatment strategies for the three most common subtypes of hepatic malignancy treated with loco-regional therapies: hepatocellular carcinoma, neuroendocrine metastases, and colorectal metastases. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
Assuntos
Quimioembolização Terapêutica/normas , Quimiorradioterapia/normas , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/terapia , Guias de Prática Clínica como Assunto , Radiologia/normas , Medicina Baseada em Evidências , Humanos , Sociedades Médicas , Resultado do Tratamento , Estados UnidosRESUMO
The optimal treatment for patients with biliary obstruction varies depending on the underlying cause of the obstruction, the clinical condition of the patient, and anticipated long-term effects of the procedure performed. Endoscopic and image-guided procedures are usually the initial procedures performed for biliary obstructions. Various options are available for both the radiologist and endoscopist, and each should be considered for any individual patient with biliary obstruction. This article provides an overview of the current status of radiologic procedures performed in the setting of biliary obstruction and describes multiple clinical scenarios that may be treated by radiologic or other methods. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
Assuntos
Neoplasias dos Ductos Biliares/diagnóstico , Neoplasias dos Ductos Biliares/terapia , Colestase/diagnóstico , Colestase/terapia , Diagnóstico por Imagem/normas , Descompressão Cirúrgica , Drenagem , Endoscopia do Sistema Digestório , Medicina Baseada em Evidências/normas , Humanos , Radiologia Intervencionista/normas , StentsRESUMO
Management of hepatic malignancy is a challenging clinical problem involving several different medical and surgical disciplines. Because of the wide variety of potential therapies, treatment protocols for various malignancies continue to evolve. Consequently, development of appropriate therapeutic algorithms necessitates consideration of medical options, such as systemic chemotherapy; surgical options, such as resection or transplantation; and locoregional therapies, such as thermal ablation and transarterial embolization. The authors discuss treatment strategies for the 3 most common subtypes of hepatic malignancy treated with locoregional therapies: hepatocellular carcinoma, neuroendocrine metastases, and colorectal metastases. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
Assuntos
Diagnóstico por Imagem/normas , Neoplasias Hepáticas/diagnóstico , Neoplasias Hepáticas/terapia , Oncologia/normas , Guias de Prática Clínica como Assunto , Radiologia/normas , Humanos , Estados UnidosRESUMO
Pulmonary and mediastinal masses represent a wide range of pathologic processes with very different treatment options. Although advances in imaging (such as PET and high-resolution CT) help in many cases with the differential diagnosis of thoracic pathology, tissue samples are frequently needed to determine the best management for patients presenting with thoracic masses. There are many options for obtaining tissue samples, each of which has its own set of benefits and drawbacks. The purposes of this report are to present the most current evidence regarding biopsies of thoracic nodules and masses and to present the most appropriate options for select common clinical scenarios. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
Assuntos
Diagnóstico por Imagem , Neoplasias Pulmonares/diagnóstico , Doenças Torácicas/diagnóstico , Biópsia/métodos , Técnica Delphi , Diagnóstico Diferencial , Medicina Baseada em Evidências , Humanos , Doenças do Mediastino/diagnóstico , Radiografia IntervencionistaRESUMO
PURPOSE: To assess the impact of various marketing techniques on the referral pattern for uterine fibroid embolization (UFE) at an academic interventional radiology practice over a 1-year period. MATERIALS AND METHODS: All referrals to the interventional radiology clinic for UFE from January 1, 2009, to December 31, 2009, were retrospectively reviewed. A standard intake sheet was completed by the interventional clinic secretary at the time of initial patient contact that included the source of the referral (radio, television, newspaper, mailing, Internet, physician, friend, other). All patients who proceeded to consultation were seen in the interventional radiology clinic by attending interventional radiologists in a university-based academic center. The referral pattern was analyzed with respect to the number of patients who contacted the clinic, the number of actual clinic visits, the number of magnetic resonance (MR) imaging examinations performed before and after the procedure, the total number of embolization cases performed, and the subsequent downstream revenue. RESULTS: During the 1-year period, 344 patients contacted the interventional radiology clinic regarding UFE resulting in 171 consultations and 100 pelvic MR imaging examinations performed before the procedure. Sixty-two patients proceeded to UFE, and 32 patients underwent follow-up pelvic MR imaging. These results show a significant increase from eight cases the previous year and are presumably attributable almost entirely to the directed marketing campaign. The marketing initiative consisted primarily of print and radio advertisements, with the latter being the most effective. The total advertising cost for the year was approximately $24,706, of which $20,520 was for radio advertisements. The radio advertisements generated 69% (237 of 344) of the referrals and 69% (43 of 62) of the UFE procedures. Using Medicare reimbursement rates, the radio advertisements generated $281,994 in UFE technical fees and $50,329 in MR imaging technical fees. CONCLUSIONS: Direct patient marketing techniques can promote significant growth for a fibroid embolization practice. In our market, radio advertisements proved to be the most cost-effective strategy.
Assuntos
Leiomioma/terapia , Marketing de Serviços de Saúde/estatística & dados numéricos , Meios de Comunicação de Massa/estatística & dados numéricos , Radiologia Intervencionista/estatística & dados numéricos , Encaminhamento e Consulta/estatística & dados numéricos , Embolização da Artéria Uterina/estatística & dados numéricos , Neoplasias Uterinas/terapia , Centros Médicos Acadêmicos/estatística & dados numéricos , Honorários e Preços , Feminino , Custos Hospitalares , Humanos , Reembolso de Seguro de Saúde , Internet/estatística & dados numéricos , Leiomioma/patologia , Imageamento por Ressonância Magnética/estatística & dados numéricos , Marketing de Serviços de Saúde/economia , Meios de Comunicação de Massa/economia , Jornais como Assunto/estatística & dados numéricos , North Carolina , Serviços Postais/estatística & dados numéricos , Rádio/estatística & dados numéricos , Radiologia Intervencionista/economia , Encaminhamento e Consulta/economia , Estudos Retrospectivos , Televisão/estatística & dados numéricos , Fatores de Tempo , Resultado do Tratamento , Embolização da Artéria Uterina/economia , Neoplasias Uterinas/patologiaRESUMO
Historically, treatment for symptomatic lower extremity varicose veins has consisted primarily of surgical stripping of pathologic veins. Over the past 2 decades, therapeutic options for lower extremity varicose veins has greatly expanded and now includes several percutaneous and endovascular techniques. This article will discuss the pathophysiology, clinical significance and current therapy for varicose veins.