Radioembolization for Treatment of Hepatocellular Carcinoma: Current Evidence and Patterns of Utilization.

Primary liver malignancy, of which hepatocellular carcinoma (HCC) is the most common type, is the second most common cause of death due to cancer worldwide. Given the historically poor prognosis of liver cancer, there has been major research on its treatment options, with significant advancements over the last decade. Transarterial radioembolization (TARE) is a locoregional treatment option for HCC that involves transarterial delivery of the ß-emitter yttrium-90 via resin or glass microspheres to arterialized tumor vasculature, delivering a tumoricidal dose to the tumor. The recent 2022 update of the Barcelona Clinic Liver Cancer (BCLC) treatment algorithm features a more prominent role for locoregional treatment, including the incorporation of radioembolization for very-early-stage (BCLC-0) and early-stage (BCLC-A) diseases. This review provides a contemporary summary of the evolving role of TARE in treatment of HCC in light of recent and upcoming trials.

Vascular complications related to image-guided percutaneous thermal ablation of hepatic tumors

Percutaneous thermal ablation of hepatic tumors is accepted as a safe, reliable, and cost-effective therapeutic option for treating hepatocellular carcinoma and hepatic metastases. However, operators should be familiar with the myriad of vascular and non-vascular complications that can occur post-ablation and that are described in the literature. This review will focus on the various vascular complications related to percutaneous thermal ablation of hepatic tumors and discuss strategies to avoid and manage these complications.

Real-World Data on Clinical Outcomes of Patients with Liver Cancer: A Prospective Validation of the National Cancer Centre Singapore Consensus Guidelines for the Management of Hepatocellular Carcinoma.

INTRODUCTION: Real-world management of patients with hepatocellular carcinoma (HCC) is crucially challenging in the current rapidly evolving clinical environment which includes the need for respecting patient preferences and autonomy. In this context, regional/national treatment guidelines nuanced to local demographics have increasing importance in guiding disease management. We report here real-world data on clinical outcomes in HCC from a validation of the Consensus Guidelines for HCC at the National Cancer Centre Singapore (NCCS). METHOD: We evaluated the NCCS guidelines using prospectively collected real-world data, comparing the efficacy of treatment received using overall survival (OS) and progression-free survival (PFS). Treatment outcomes were also independently evaluated against 2 external sets of guidelines, the Barcelona Clinic Liver Cancer (BCLC) and Hong Kong Liver Cancer (HKLC). RESULTS: Overall treatment compliance to the NCCS guidelines was 79.2%. Superior median OS was observed in patients receiving treatment compliant with NCCS guidelines for early (nonestimable vs. 23.5 months p < 0.0001), locally advanced (28.1 vs. 22.2 months p = 0.0216) and locally advanced with macrovascular invasion (10.3 vs. 3.3 months p = 0.0013) but not for metastatic HCC (8.1 vs. 6.8 months p = 0.6300), but PFS was similar. Better clinical outcomes were seen in BCLC C patients who received treatment compliant with NCCS guidelines than in patients with treatment only allowed by BCLC guidelines (median OS 14.2 vs. 7.4 months p = 0.0002; median PFS 6.1 vs. 4.0 months p = 0.0286). Clinical outcomes were, however, similar for patients across all HKLC stages receiving NCCS-recommended treatment regardless of whether their treatment was allowed by HKLC. CONCLUSION: The high overall compliance rate and satisfactory clinical outcomes of patients managed according to the NCCS guidelines confirm its validity. This validation using real-world data considers patient and treating clinician preferences, thus providing a realistic analysis of the usefulness of the NCCS guidelines when applied in the clinics.

Intra-Arterial Therapy for Unresectable Colorectal Liver Metastases: A Meta-Analysis.

PURPOSE: To evaluate the efficacy of hepatic arterial infusion (HAI), conventional transarterial chemoembolization, drug-eluting embolic transarterial chemoembolization (DEE-TACE), transarterial radioembolization, and their combinations with systemic chemotherapy (SCT) for unresectable colorectal liver metastases. METHODS: A search was conducted on Embase, Scopus, PubMed, and Web of Science for prospective nonrandomized studies and randomized controlled trials (RCTs) from inception to June 20, 2020. Survival data of patients were recovered from original Kaplan-Meier curves by exploiting a graphical reconstructive algorithm. One-stage meta-analyses were conducted for the median overall survival (OS), survival rates (SRs), and restricted mean survival time (RMST), whereas two-stage meta-analyses of proportions were conducted to determine response rates (RRs) and conversion to resection rates (CRRs). RESULTS: A total of 71 prospective nonrandomized studies and 21 RCTs were identified, comprising 6,695 patients. Among patients treated beyond the first-line, DEE-TACE + SCT (n = 152) had the best survival outcomes of median OS of 26.5 (95% confidence interval [CI], 22.5-29.1) months and a 3-year RMST of 23.6 (95% CI, 21.8-25.5) months. Upon further stratification by publication year, DEE-TACE + SCT appeared to consistently have the highest pooled SRs at 1 year (81.9%) and 2 years (66.1%) in recent publications (2015-2020). DEE-TACE + SCT and HAI + SCT had the highest pooled RRs of 56.7% (I2 = 0.90) and 62.6% (I2 = 0.87) and pooled CRRs of 35.5% (I2 = 0.00) and 30.3% (I2 = 0.80), respectively. CONCLUSIONS: Albeit significant heterogeneity, the paucity of high-quality evidence, and the noncomparative nature of all analyses, the overall evidence suggests that patients treated with DEE-TACE + SCT have the best oncological outcomes and greatest potential to be converted for resection.

Perfluorobutane contrast-enhanced ultrasonography: a new standard for ultrasonography-guided thermal ablation of sonographically occult liver tumours?

INTRODUCTION: Image-guided thermal ablation, preferably with ultrasonography (US), is increasingly used for treatment of small liver tumours. Perfluorobutane-contrast-enhanced US (pCEUS) is a promising tool that may allow for targeting of tumours that are otherwise imperceptible on greyscale US. Although pCEUS has been reported to be effective, the literature has been limited outside of Japan and South Korea. We aimed to provide data that supports the use of pCEUS in the thermal ablation of sonographically occult liver tumours. METHODS: We conducted a retrospective single-centre study of 35 consecutive patients who underwent pCEUS-guided ablation of 48 liver tumours with a median size of 1.2 cm. Periprocedural, one-month post-treatment and relevant follow-up imaging studies were reviewed. Electronic records were also obtained, with long-term follow-up data of 12-28 months being available for 32 patients. RESULTS: 36 (75%) tumours that were imperceptible on greyscale US became visible with pCEUS. Overall, complete tumour ablation at one month was 89%. 1 (3%) patient developed a major complication following treatment, while 6 (17%) had minor post-treatment complaints. The local tumour progression rate was 17%, with a median time of 14 months. CONCLUSION: pCEUS has a role in US-guided thermal ablation of liver tumours, offering a high technical success rate that is comparable to reported data. Additional benefits may include improved procedural time and freedom from ionising radiation.

Repurposing the power injectable peripherally inserted central catheter as a tunnelled, non-cuffed, centrally inserted central venous catheter in oncological patients for short- to mid-term vascular access: A pilot study.

OBJECTIVES: Usual short- to mid-term vascular accesses for oncologic patients include the peripherally inserted central catheter and non-tunnelled centrally inserted central catheters, inserted in the supraclavicular or infraclavicular area. Peripherally inserted central catheters can be restrictive in active patients; supraclavicular non-tunnelled centrally inserted central catheters are not ideal in terms of exit site location and cosmesis, while infraclavicular non-tunnelled centrally inserted central catheters may be associated with puncture-related complications. In this pilot study, we have evaluated the off-label use of peripherally inserted central catheters as a tunnelled supraclavicular centrally inserted central catheter. METHODS: Ten patients were recruited for this prospective study. A non-cuffed, power injectable peripherally inserted central catheter was inserted via a short subcutaneous tunnel into the internal jugular vein using the peel-away sheath and introducer as a tunneller. Puncture wounds were closed with tissue glue. Patients were followed up for comfort scores, dwell time and complications. RESULTS: The median dwell time was 94 days (mean of 113 days). One catheter was removed due to systemic fungemia, resulting in an acceptable complication rate of 0.97 per 1000 catheter days.Mean patient-reported comfort scores was 16 (out of 20). Pressurised injections for computer tomography imaging were performed in five patients without complications. CONCLUSION: Despite limited numbers, this method appears to be safe and well accepted with low complication rates. This modified vascular access is low profile, easily concealed, readily removable and compatible with pressure injector and uses a commonly found catheter in a modified fashion. Larger prospective trials will be needed to ascertain if it can be a standard of care for oncological patients.

Management of arterial dissections in 12 patients during transarterial chemoembolization and yttrium-90 selective internal radiotherapy for primary and secondary liver tumours.

OBJECTIVE: To describe rates and management strategies of arterial dissections in transarterial chemoembolization (TACE) and Yttrium-90 selective internal radiotherapy (90Y SIRT) for primary and secondary liver tumours. MATERIALS AND METHODS: This retrospective review included 1377 hepatic angiographies between May 2010 and June 2015 in a single centre for TACE and 90Y SIRT of liver tumours. The angiogram results, management, treatment outcomes and follow-up angiography/imaging findings were recorded. RESULTS AND DISCUSSION: Twelve cases of arterial dissections (12/1377, 0.87%) were documented. Three dissections (3/633, 0.47%) occurred during TACE, seven (7/449, 1.56%) during pre-treatment planning angiographies (PTPA) for 90Y SIRT, and two (2/249, 0.80%) during the treatment procedure of 90Y SIRT. The preferred management strategy was to manoeuvre past the dissection and complete the procedure, which was achieved in six patients (50%). Angioplasty with stenting was performed in one patient. In three patients, the procedure was held off for up to 3 months to allow the dissection to heal before repeating the procedure. A dissection that occurred during PTPA was detected only when the patient returned for 90Y SIRT. PTPA was immediately repeated for this patient. The last patient opted for sorafenib. Residual 50% stenosis was seen in one patient on follow-up hepatic angiography, but he was otherwise asymptomatic. In the remaining patients, no residual dissection or clinical sequelae was observed on follow-up. CONCLUSION: Arterial dissection is a rare but important complication of transarterial locoregional therapy. Where possible, attempts should be made at completing the therapy. Deferring treatment can be considered as dissections usually heal within 3 months. LEVEL OF EVIDENCE: Level 4, case series.

Letter to the editor: Comment on a case report of thermal injury to spinal cord, a rare complication of percutaneous microwave spine tumour ablation.

Microwave ablation of the spine is an effective treatment option for patients with symptomatic osseous metastases. It is an increasingly common procedure in clinical practice and can be performed in conjunction with other procedures such as vertebroplasty and nerve root blocks. Multiple studies have demonstrated the safety and efficacy of the percutaneous ablation; however potential complications can arise. Thermal injury to the spinal cord is a rare but serious known complication which has severe consequences to the patient. Multiple strategies can be adopted to reduce the rate of complications. We aim to discuss the various technical considerations when performing percutaneous ablation of spinal tumours to decrease the risks of complications.

Catheter-Directed Computed Tomography Hepatic Angiography for Yttrium-90 Selective Internal Radiotherapy of Hepatocellular Carcinoma Reduces Prophylactic Embolization of Extrahepatic Vessels.

OBJECTIVES: To determine the rate of prophylactic embolization of extrahepatic vessels in patients undergoing yttrium-90 selective internal radiotherapy (90Y SIRT) for hepatocellular carcinoma (HCC) with the use of catheter-directed computed tomography hepatic angiography (CD-CTHA). MATERIALS AND METHODS: This retrospective study included 186 HCC patients who received 90Y SIRT from May 2010 to June 2015 in a single institution. All procedures were performed in a hybrid angiography-CT suite equipped with digital subtraction angiography (DSA) and CD-CTHA capabilities. CD-CTHA was performed during pre-treatment hepatic angiography. 90Y SIRT was administered approximately 2 weeks later. Selective prophylactic embolization of extrahepatic vessels was performed if extrahepatic enhancement was seen on CD-CTHA or if an extrahepatic vessel opacified on DSA/CD-CTHA despite the final microcatheter position for 90Y microsphere delivery being beyond the origin of this vessel. RESULTS: Thirty-five patients (18.8%) required selective embolization of extrahepatic vessels. Technical success of 90Y SIRT was 99.5%. Two patients (1.1%) developed radiation-induced gastrointestinal ulceration, and one (0.54%) developed radiation-induced pneumonitis. Extrahepatic uptake of 90Y microspheres was seen in the gallbladder of one patient without significant complications. CONCLUSION: The use of CD-CTHA in 90Y SIRT of HCC was associated with a low rate of prophylactic embolization of extrahepatic vessels while maintaining a high technical success rate of treatment and low rate of complications. LEVEL OF EVIDENCE: Level 4, case series.

National Cancer Centre Singapore Consensus Guidelines for Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is the 6th most common cancer in the world, but the second most common cause of cancer death. There is no universally accepted consensus practice guidelines for HCC owing to rapid developments in new treatment modalities, the heterogeneous epidemiology and clinical presentation of HCC worldwide. However, a number of regional and national guidelines currently exist which reflect practice relevant to the epidemiology and collective experience of the consensus group. In 2014, clinicians at the multidisciplinary Comprehensive Liver Cancer Clinic (CLCC) at the National Cancer Centre Singapore (NCCS) reviewed the latest published scientific data and existing international and regional practice guidelines, such as those of the National Comprehensive Cancer Network, American Association for the Study of Liver Diseases and the Asian Pacific Association for the Study of the Liver, and modified them to reflect local practice. These would serve as a template by which treatment outcomes can be collated and benchmarked against international data. The NCCS Consensus Guidelines for HCC have been successfully implemented in the CLCC since their publication online on 26(th) September 2014, and the guidelines allow outcomes of treatment to be compared to international data. These guidelines will be reviewed periodically to incorporate new data.

An assessment of the feasibility and effectiveness of an e-learning module in delivering a curriculum in radiation protection to undergraduate medical students.

PURPOSE: Integrating radiation protection (RP) education in the undergraduate medical curriculum is gaining importance and is mandatory in certain jurisdictions. An e-learning module for RP was developed at the authors' medical school and was integrated into year 4 of the 5-year undergraduate medical program. The aim of this study was to investigate its impact on RP knowledge, student preferences for various teaching methods, self-assessment of RP knowledge, and perceptions of career prospects in radiology. Likert-type 5-point scale evaluations and general comments about the RP module and various methods of teaching were also obtained. METHODS: An e-learning module in RP was designed and presented to year 4 medical undergraduates. All students were required to complete premodule and postmodule questionnaires. RESULTS: Eighty-nine percent (n = 113) and 99% (n = 126) of the 127 medical students successfully completed and returned the premodule and postmodule questionnaires, respectively. After the e-learning module, students' postmodule RP knowledge had improved significantly. Analysis of postmodule RP knowledge suggested that a favorable self-assessment of knowledge of RP, perception of career prospects in radiology, and completion of the e-learning module with an increased number of sessions were factors predictive of improved RP knowledge. Students expressed a preference for didactic lectures and clinical attachment for instruction in RP over e-learning. CONCLUSIONS: The development of an e-learning module in RP is feasible and results in improved knowledge of RP among medical undergraduates. Combining e-learning and more traditional educational programs such as a clinical radiology rotation is likely to improve student experience.

HER-2 positive and p53 negative breast cancers are associated with poor prognosis.

p53 and HER-2 coexpression in breast cancer has been controversial. These markers were tested using immunohistochemistry and HercepTest. HER-2 expression is related to reduced breast cancer survival (p = .02) . p53 expression relates to HER-2 expression (p = .029). Coexpression between p53 and HER-2 has no relation to prognosis. On univariate and multivariate analysis, combination of HER-2 positive and p53 negative expression was associated with a poor prognosis (p = .018 and p = .027, respectively), while the combination of HER-2 negative and p53 positive expression was associated with a favorable prognosis (p = .022 and p = .010, respectively). Therefore the expression of these markers should be considered collectively.

Increased fluoro-deoxy-D-glucose uptake on positron emission tomography-computed tomography postbronchoalveolar lavage: a potential cause of radiologic misinterpretation.

Cytologic analysis of bronchoalveolar lavage (BAL) fluid is used for lung cancer diagnosis. We describe a patient with a history of rectal carcinoma who presented with a new lung mass. BAL was performed, with positron emission tomography-computed tomography the following day. There was mildly increased fluoro-deoxy-D-glucose uptake in areas of the lung parenchyma with new ground-glass opacification. This created ambiguity in staging, clarified 2 weeks later by a computed tomography showing complete resolution of the ground-glass opacity. Clinicians should be aware that BAL may cause increased pulmonary fluoro-deoxy-D-glucose uptake, making accurate radiologic interpretation problematic. We suggest that to optimize positron emission tomography-computed tomography, studies should not be performed within 24 hours of BAL.

Limited-preparation CT colonography in frail elderly patients: a feasibility study.

OBJECTIVE: Full colonic preparation can be onerous and may be poorly tolerated in frail elderly patients. The purpose of this study was to prospectively assess the image quality and diagnostic yield of limited-preparation CT colonography (CTC) in elderly patients with suspected colorectal cancer who were deemed medically unfit or unsuitable for colonoscopy. SUBJECTS AND METHODS: A prospective study was performed of 67 elderly patients with reduced functional status referred for CTC. Participants were prescribed a limited bowel preparation consisting of a low-residue diet for 3 days, 1 L of 2% oral diatrizoate meglumine (Gastrografin) 24 hours before CTC, and 1 L of 2% oral Gastrografin over the 2 hours immediately before CTC. No cathartic preparation was administered. All colonic segments were graded from 1 to 5 for image quality (1, unreadable; 2, poor; 3, equivocal; 4, good; 5, excellent) and reader confidence. Clinical and conventional colonoscopy follow-up findings were documented, and all colonic and extracolonic pathologic findings were documented. RESULTS: Overall image quality and reader confidence in the evaluation of the colon was rated good or excellent in 84% of the colonic segments. Colonic abnormalities were identified in 12 patients (18%), including four colonic tumors, two polyps, and seven colonic strictures. Incidental extraintestinal findings were detected in 43 patients (64%), including nine patients with lesions radiologically consistent with malignancy. CONCLUSION: Limited-preparation low-dose CTC is a feasible and useful minimally invasive technique with which to evaluate the colon and exclude gross pathology (mass lesions and polyps > 1 cm) in elderly patients with diminished performance status, yielding good to excellent image quality.

Risk and outcome analysis of 1832 consecutively excised basal cell carcinomas in a tertiary referral plastic surgery unit.

BACKGROUND: Basal cell carcinomas are the most prevalent of all skin cancers worldwide and form the majority of the surgical workload for most modern cutaneous malignancy centres. Primary surgical removal of basal cell carcinomas remains the gold standard of treatment but, despite almost two centuries of surgical experience, rates of incomplete surgical excision of up to 50% are still reported. The aim of this study was to assess, quantify and perform comparative analysis of the outcomes and predictive factors of consecutive primarily-excised basal cell carcinomas in a tertiary centre over a six-year period. METHODS: Retrospective audit was conducted on all patients who underwent surgical excision of basal cell carcinomas from January 2000 to December 2005. Assessment parameters included patient biographics, tumour management differences and detailed histopathological analysis of tumour margins and subtypes. RESULTS: One thousand eight hundred and thirty two basal cell carcinomas were excised from 1329 patients over the designated time period. Two hundred and fifty one (14%) lesions were incompletely excised with 135 (7.4%) involving the peripheral margin only, 48 (2.6%) the deep margin only and 41 (2.2%) involving both. Nasal location was the most common predictor of incomplete excision. CONCLUSIONS: Overall basal cell carcinomas excision rates compared favourably with international reported standards but attention to a variety of surgical and histological risk factors may improve this further.