RESUMO
OBJECTIVE: To conduct a meta-analysis to assess the efficacy of intravascular ultrasound (IVUS) during transjugular intrahepatic portosystemic shunt (TIPS) creation. METHODS: MEDLINE and Embase databases were queried until July 2022 for comparative studies reporting procedure metrics for TIPS creation with or without IVUS guidance. Meta-analysis was performed with random-effects modelling for total procedural time, time to portal venous access, fluoroscopy time, iodinated contrast volume use, air kerma, dose area product, and number of needle passes. Intraoperative procedure-related complications were also reviewed. RESULTS: Of 95 unique records initially identified, 6 were eligible for inclusion. A total of 194 and 240 patients underwent TIPS with and without IVUS guidance. Pooled analyses indicated that IVUS guidance was associated with reduced total procedure time (SMD -0.76 [95% CI -1.02, -0.50] P < .001), time to portal venous access (SMD -0.41 [95% CI -0.67, -0.15] P = .002), fluoroscopy time (SMD, -0.54 [95% CI -1.02, -0.07]; P = .002), contrast volume use (SMD, -0.89 [95% CI -1.16, -0.63]; P < .001), air kerma (SMD, -0.75 [95% CI -1.11, -0.38]; P < .001) and dose area product (SMD, -0.98 [95% CI -1.77, -0.20]; P = .013). A total of 4.2 and 7.8 needle passes were required in the IVUS and non-IVUS group, respectively (SMD, -0.60 [95% CI -1.42, 0.21]; P = .134). Pooled complication rates were 15.2% (12/79) and 21.4% (28/131), respectively. CONCLUSION: IVUS guidance during TIPS creation improves procedural metrics including procedural time, contrast usage, and radiation exposure. ADVANCES IN KNOWLEDGE: (1) The use of IVUS during TIPS is associated with shorter procedural time, lower contrast usage, and radiation exposure. (2)The use of IVUS is not associated with higher complication rates.
Assuntos
Derivação Portossistêmica Transjugular Intra-Hepática , Ultrassonografia de Intervenção , Derivação Portossistêmica Transjugular Intra-Hepática/métodos , Humanos , Ultrassonografia de Intervenção/métodos , Fluoroscopia/métodos , Meios de Contraste , Duração da CirurgiaRESUMO
PURPOSE: To assess the safety and effectiveness of using modified radiation lobectomy (mRL) to treat primary hepatic tumors located in the right hepatic lobe (Segments V-VIII) and to determine future liver remnant (FLR) hypertrophy. MATERIALS AND METHODS: A retrospective review was performed at a single institution to include 19 consecutive patients (7 females, 12 males) who underwent single-session mRL for right-sided primary hepatic tumors: 15 received segmentectomy plus lobectomy (segmental dose of >190 Gy and lobar dose of >80 Gy); 4 were treated with the double-segmental approach (dominant segments of >190 Gy and nondominant segments of >80 Gy). Treated tumors included 13 hepatocellular carcinoma (HCC), 4 cholangiocarcinoma (CCA), and 2 mixed-type HCC-CCA with a median dominant tumor size of 5.3 cm (interquartile range [IQR], 3.7-7.3 cm). FLR of the left hepatic lobe was measured at baseline, T1 (4-8 weeks), T2 (2-4 months), T3 (4-6 months), and T4 (9-12 months). RESULTS: Objective tumor response and tumor control were achieved in 17 of the 19 (89.5%) and 18 of the 19 (94.7%) patients, respectively. FLR hypertrophy was observed at T1 (median, 47.8%; P = .025), T2 (median, 48.4%; P = .012), T3 (median, 50.4%; P = .015), and T4 (median, 59.1%; P < .001). Patients without cirrhosis demonstrated greater hypertrophy by 6 months (median, 55.8% vs 47.2%; P = .031). One patient developed a Grade 3 adverse event (ascites requiring paracentesis) at 1-month follow-up. Grade ≥2 serum toxicities were associated with worse baseline Child-Pugh Score, serum albumin, and total bilirubin (P < .05). Among 7 patients who underwent neoadjuvant mRL, 2 underwent resection and 1 received liver transplant. CONCLUSIONS: mRL appears safe and effective for treatment of right-sided primary hepatic tumors with the benefit of promoting FLR hypertrophy.
Assuntos
Carcinoma Hepatocelular , Embolização Terapêutica , Hepatectomia , Neoplasias Hepáticas , Humanos , Masculino , Feminino , Neoplasias Hepáticas/radioterapia , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/cirurgia , Estudos Retrospectivos , Pessoa de Meia-Idade , Idoso , Resultado do Tratamento , Carcinoma Hepatocelular/radioterapia , Carcinoma Hepatocelular/patologia , Carcinoma Hepatocelular/diagnóstico por imagem , Carcinoma Hepatocelular/cirurgia , Hepatectomia/efeitos adversos , Embolização Terapêutica/efeitos adversos , Colangiocarcinoma/radioterapia , Colangiocarcinoma/diagnóstico por imagem , Colangiocarcinoma/cirurgia , Colangiocarcinoma/patologia , Compostos Radiofarmacêuticos/administração & dosagem , Compostos Radiofarmacêuticos/efeitos adversos , Fatores de Tempo , Carga Tumoral , Neoplasias dos Ductos Biliares/radioterapia , Neoplasias dos Ductos Biliares/diagnóstico por imagem , Neoplasias dos Ductos Biliares/patologia , Neoplasias dos Ductos Biliares/cirurgia , Radioisótopos de Ítrio/administração & dosagem , Radioisótopos de Ítrio/efeitos adversos , Hipertrofia , Adulto , Regeneração HepáticaRESUMO
OBJECTIVE: To compare treatment volumes reconstructed from hybrid Angio-CT catheter-directed infusion imaging and Couinaud anatomic model as well as the implied differences in Y-90 radiation dosimetry. METHODS: Patients who underwent transarterial radioembolization (TARE) using Y-90 glass microspheres with pretreatment CT or MRI imaging as well as intraprocedural angiography-CT (Angio-CT) were analysed. Treatment volumes were delineated using both tumoural angiosomes (derived from Angio-CT) and Couinaud anatomic landmarks. Segmental and lobar treatment volumes were calculated via semi-automated contouring software. Volume and dose differences were compared by the two-tailed Student t test or Wilcoxon signed-rank test. Factors affecting volume and dose differences were assessed via simple and/or multiple variable linear regression analysis. RESULTS: From September 2018 to March 2021, 44 patients underwent 45 lobar treatments and 38 patients received 56 segmental treatments. All target liver lobes and all tumours were completely included within the field-of-view by Angio-CT. Tumour sizes ranged between 1.1 and 19.5 cm in diameter. Segmental volumes and treatment doses were significantly different between the Couinaud and Angio-CT volumetry methods (316 vs 404 mL, P < .0001 and 253 vs 212 Gy, P < .01, respectively). Watershed tumours were significantly correlated with underestimated volumes by the Couinaud anatomic model (P < .001). There was a significant linear relationship between tumour diameter and percent volume difference (R2 = 0.44, P < .0001). The Couinaud model overestimated volumes for large tumours that exhibited central hypovascularity/necrosis and for superselected peripheral tumours. CONCLUSIONS: Angio-CT may confer advantages over the Couinaud anatomic model and enable more accurate, personalized dosimetry for TARE. ADVANCES IN KNOWLEDGE: Angio-CT may confer advantages over traditional cross-sectional and cone-beam CT imaging for selective internal radiation therapy planning.
Assuntos
Carcinoma Hepatocelular , Embolização Terapêutica , Neoplasias Hepáticas , Humanos , Carcinoma Hepatocelular/radioterapia , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/radioterapia , Radioisótopos de Ítrio/uso terapêutico , Estudos Transversais , Estudos Retrospectivos , Tomografia Computadorizada de Feixe Cônico/métodos , Angiografia , Radiometria/métodos , Embolização Terapêutica/métodos , MicroesferasRESUMO
PURPOSE: To identify factors of incomplete treatment after segmental transarterial radioembolization (TARE) for treatment-naive and solitary hepatocellular carcinoma (HCC). MATERIALS AND METHODS: A total of 75 consecutive patients (age, 68.5 years [SD ± 8.0]; 25/75 [33.3%] women) with treatment-naive, solitary HCC underwent segmental or subsegmental TARE with glass microspheres (tumor size, 3.8 cm [SD ± 2.2]; administered dose, 222.6 Gy [SD ± 123.9]) at a single institution from November 2015 to June 2022. Radiologic response and progression-free survival (PFS) were assessed as per modified Response Evaluation Criteria in Solid Tumors. RESULTS: Complete treatment was achieved in 48 of 75 (64.0%) patients (mean follow-up, 33.2 months [SD ± 27.4]). Patients with incomplete treatment (27/75, 36%) presented with larger tumor size (5.0 [SD ± 2.5] vs 3.1 [SD ± 1.6] cm; P = .0001), with more tumors located in the watershed zone (81.5% vs 41.7%; P = .001). These patients were less likely to be bridged to transplant or resection (22.2% vs 52.1%; P = .015). Watershed tumors demonstrated worse target tumor PFS (median PFS, 19 months vs not reached; P = .0104) and overall PFS (9.1 months vs not reached; P = .0077). Watershed location was associated with worse PFS among tumors >3 cm in size (8.4 months vs not reached; P = .035) but not in tumors ≤3 cm in size (52.2 months vs not reached; P = .915). CONCLUSIONS: Tumor size and watershed location were associated with incomplete treatment after segmental TARE for HCC. Watershed tumors were associated with worse PFS, particularly tumors larger than 3 cm. These tumors may require careful treatment planning and repeated treatments to ensure a durable response.
Assuntos
Carcinoma Hepatocelular , Progressão da Doença , Embolização Terapêutica , Neoplasias Hepáticas , Microesferas , Intervalo Livre de Progressão , Compostos Radiofarmacêuticos , Carga Tumoral , Humanos , Carcinoma Hepatocelular/patologia , Carcinoma Hepatocelular/radioterapia , Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/diagnóstico por imagem , Carcinoma Hepatocelular/terapia , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/radioterapia , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/terapia , Feminino , Masculino , Idoso , Pessoa de Meia-Idade , Fatores de Tempo , Embolização Terapêutica/efeitos adversos , Embolização Terapêutica/mortalidade , Estudos Retrospectivos , Compostos Radiofarmacêuticos/administração & dosagem , Compostos Radiofarmacêuticos/efeitos adversos , Fatores de Risco , Radioisótopos de Ítrio/administração & dosagem , Radioisótopos de Ítrio/efeitos adversos , Resultado do TratamentoRESUMO
OBJECTIVE: Histotripsy is a focused ultrasound therapy that ablates tissue via the action of bubble clouds. It is under investigation to treat a number of ailments, including renal tumors. Ultrasound imaging is used to monitor histotripsy, though there remains a lack of definitive imaging metrics to confirm successful treatment outcomes. In this study, a convolutional neural network (CNN) was developed to segment ablation on ultrasound images. METHODS: A transfer learning approach was used to replace classification layers of the residual network ResNet-18. Inputs to the classification layers were based on ultrasound images of ablated red blood cell phantoms. Digital photographs served as the ground truth. The efficacy of the CNN was compared to subtraction imaging, and manual segmentation of images by two board-certified radiologists. RESULTS: The CNN had a similar performance to manual segmentation, though was improved relative to segmentation with subtraction imaging. Predictions of the network improved over the course of treatment, with the Dice similarity coefficient less than 20% for fewer than 500 applied pulses, but 85% for more than 750 applied pulses. The network was also applied to ultrasound images of ex vivo kidney exposed to histotripsy, which indicated a morphological shift in the treatment profile relative to the phantoms. These findings were consistent with histology that confirmed ablation of the targeted tissue. CONCLUSION: Overall, the CNN showed promise as a rapid means to assess outcomes of histotripsy and automate treatment. SIGNIFICANCE: Data collected in this study indicate integration of CNN image segmentation to gauge outcomes for histotripsy ablation holds promise for automating treatment procedures.
Assuntos
Ablação por Ultrassom Focalizado de Alta Intensidade , Redes Neurais de Computação , Imagens de Fantasmas , Ultrassonografia , Animais , Ablação por Ultrassom Focalizado de Alta Intensidade/métodos , Ultrassonografia/métodos , Rim/diagnóstico por imagem , Rim/cirurgia , Processamento de Imagem Assistida por Computador/métodosRESUMO
PURPOSE: To calculate the preradioembolic tumor-to-normal (T:N) ratio in hepatocellular carcinoma (HCC) using 2-dimensional (2D) perfusion angiography and compare it with that calculated using technetium-99m macroaggregated albumin (99mTc MAA) single-photon emission computed tomography (SPECT)/computed tomography (CT). MATERIALS AND METHODS: This prospective single-arm study enrolled 15 participants with HCC who underwent 2D perfusion angiography immediately before the enrollment and with the microcatheter located at the same location as 99mTc MAA injection, after which SPECT/CT was performed. Quantitative digital subtraction angiography was used to calculate the area under the curve for the tumor and normal hepatic parenchyma and subsequently calculate the T:N ratio. The T:N ratio was calculated from the 99mTc MAA SPECT/CT and post-yttrium-90 bremsstrahlung SPECT/CT using dosimetry software. RESULTS: The mean participant age was 64.1 years ± 9.8, and the study included 14 (93%) men and 1 (7%) woman. The mean tumor size was 4.1 cm (SD ± 2.4), and all participants received segmental treatments with glass microspheres. The mean T:N ratio calculated by 99mTc MAA SPECT/CT was 2.28 (SD ± 0.89) vs 2.25 (SD ± 0.99) calculated by 2D perfusion angiography (P = .45). For the 13 participants who underwent selective internal radiation therapy (transarterial radioembolization), there was no significant difference between the T:N ratios calculated by 2D perfusion angiography and post-90Y SPECT/CT (2.25 [SD ± 1.05] vs 1.91 [SD ± 0.39]; P = .12). CONCLUSIONS: The T:N ratio calculated by 2D perfusion angiography correlated well with that calculated by 99mTc MAA SPECT/CT.
Assuntos
Carcinoma Hepatocelular , Embolização Terapêutica , Neoplasias Hepáticas , Masculino , Feminino , Humanos , Pessoa de Meia-Idade , Carcinoma Hepatocelular/diagnóstico por imagem , Carcinoma Hepatocelular/radioterapia , Estudos Prospectivos , Tecnécio , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/radioterapia , Neoplasias Hepáticas/patologia , Agregado de Albumina Marcado com Tecnécio Tc 99m , Tomografia Computadorizada por Raios X/métodos , Tomografia Computadorizada com Tomografia Computadorizada de Emissão de Fóton Único , Radioisótopos de Ítrio , Albuminas , Angiografia Digital , Perfusão , Embolização Terapêutica/efeitos adversos , Embolização Terapêutica/métodos , Tomografia Computadorizada de Emissão de Fóton Único/métodos , MicroesferasRESUMO
Intermediate-stage hepatocellular carcinoma (HCC) comprises a heterogeneous group of patients with varying levels of tumor burden. Transarterial chemoembolization was traditionally the mainstay of treatment for intermediate-stage HCC for almost 2 decades. New and emerging treatment options have revolutionized HCC therapy, allowing for broader application to patients with intermediate- and advanced-stage disease. Accordingly, new guidelines acknowledge these options, and intermediate stage HCC can now be treated with surgical, locoregional or systemic therapies, or a combination thereof. Patients will continue to benefit from the development of complex treatment strategies in a multidisciplinary setting to optimize individual outcomes.
Assuntos
Carcinoma Hepatocelular , Quimioembolização Terapêutica , Neoplasias Hepáticas , Humanos , Carcinoma Hepatocelular/terapia , Carcinoma Hepatocelular/patologia , Neoplasias Hepáticas/terapia , Neoplasias Hepáticas/patologiaRESUMO
Transarterial radioembolization (TARE) with Yttrium-90 (Y90) is a growing area of study due to its benefits in early-, intermediate-, and late-stage hepatocellular carcinoma. Treatment intent, including curative therapy, bridging to transplant, and downstaging disease, informs treatment approach and dosimetry goals. Radiation lobectomy (RL) and radiation segmentectomy (RS) are the 2 main forms of Y90 administration which have shown improved survival outcomes with the development of personalized dosimetry. RS aims to achieve complete pathological necrosis with dose escalation and RL aims for local disease control as well as induction of contralateral lobe hypertrophy to improve hepatic reserve. Furthermore, TARE has been validated in head-to-head comparison to other locoregional and systemic therapies. Lastly, early potential exists for combination therapy between TARE and immune checkpoint inhibitors for advanced stage disease.
Assuntos
Carcinoma Hepatocelular , Embolização Terapêutica , Neoplasias Hepáticas , Humanos , Carcinoma Hepatocelular/radioterapia , Carcinoma Hepatocelular/patologia , Neoplasias Hepáticas/radioterapia , Neoplasias Hepáticas/patologia , Radioisótopos de Ítrio/uso terapêuticoRESUMO
OBJECTIVES: To assess the cost-effectiveness of transarterial radioembolization (TARE) versus conventional transarterial chemoembolization (cTACE) and drug-eluting beads chemoembolization (DEE-TACE) for patients with unresectable early- to intermediate-stage hepatocellular carcinoma (HCC). DESIGN: A cohort-based Markov model with a five-year time horizon was developed to evaluate the cost-effectiveness of the three embolization treatments. Upon entering the model, patients with HCC received either TARE or one of the two other embolization treatments. Patients remained in a "watch and wait" state for tumor downstaging that allowed them to move to health states such as liver transplant, resection, systemic therapies, or cure. Clinical input parameters were retrieved from the published literature, and where values could not be sourced, assumptions were made and validated by clinical experts. Health benefits were quantified using quality-adjusted life years (QALYs). Cost input parameters were obtained from various sources, including the Medicare Cost Report, IBM® Micromedex RED BOOK, and published literature. RESULTS: At five years, TARE was found to be cost-saving (saving $15,779 per person compared to cTACE) and produced 0.33 more QALYs per person than cTACE. TARE cost $13,696 more but produced 0.33 more QALYs than DEE-TACE, with an incremental cost-effectiveness ratio of $41,474 per QALY gained at five years. After accounting for parameter uncertainty, the likelihood of TARE being cost-effective was at least 90% against all comparators at a cost-effectiveness threshold of $100,000 per QALY gained. CONCLUSIONS: TARE produces more QALYs than cTACE and DEE-TACE, with a high probability of being cost-effective against both comparators.
The Barcelona Clinic Liver Cancer guideline recommends the use of transarterial radioembolization (TARE), conventional (cTACE), or drug-eluting bead transarterial chemoembolization (DEE-TACE) for treating hepatocellular carcinoma (HCC). This study evaluated the cost-effectiveness of TARE versus two alternative embolization treatments (cTACE and DEE-TACE) in treating patients with unresectable early- to intermediate-stage HCC.A cohort-based Markov model was developed to analyze the costs and benefits of these treatments from a US healthcare perspective within a 5-year time horizon. A 20-year time horizon was assessed as a scenario. In the model, patients were assigned to receive TARE, cTACE, or DEE-TACE and remained in the "watch and wait" stage for tumor downstaging. Data used in the model was taken from previous studies and in consultation with clinical experts. The benefits of the treatments were measured by considering the impact on the patient's quality of life. The costs associated with the treatments were obtained from various sources, including reports, publicly available databases, and published literature.The findings show that TARE is not only cost-saving compared to cTACE but also results in a higher number of quality-adjusted life years (QALYs) per person. While TARE was more expensive than DEE-TACE, it produced more QALYs, further indicating more favorable patient outcomes and overall treatment effectiveness. These findings could potentially impact resource allocation and decision-making for the treatment of HCC.
Assuntos
Carcinoma Hepatocelular , Quimioembolização Terapêutica , Neoplasias Hepáticas , Idoso , Estados Unidos , Humanos , Carcinoma Hepatocelular/terapia , Carcinoma Hepatocelular/patologia , Neoplasias Hepáticas/terapia , Neoplasias Hepáticas/patologia , Análise de Custo-Efetividade , Medicare , Resultado do TratamentoRESUMO
Radiation segmentectomy with a dose of >190 Gy using yttrium-90 (90Y) glass microspheres for intrahepatic cholangiocarcinoma (iCCA) has been shown to be safe and effective. The present study further increased the dose to >400 Gy for treatment of iCCA as complete pathologic necrosis has been shown in hepatocellular carcinoma using this ablative approach. A total of 10 patients with 13 tumors (median size, 5.3 cm; range, 1.5-13.6 cm) at a single institution underwent >400-Gy segmental radioembolization. Objective response was achieved in all tumors (13 of 13, 100%). One patient developed a Grade 3 or greater major adverse event (stroke and hepatic decompensation). One patient was bridged to transplant (>95% pathologic necrosis), whereas another underwent resection (>99% necrosis). Contralateral hypertrophy was observed in 6 out of 6 patients treated with modified lobectomy dosing, with a functional liver reserve increase from a median of 31.5% to 57.1%. The present report suggests that segmental transarterial radioembolization with >400 Gy is feasible in terms of safety and effectiveness for treating iCCA.
Assuntos
Neoplasias dos Ductos Biliares , Carcinoma Hepatocelular , Colangiocarcinoma , Embolização Terapêutica , Neoplasias Hepáticas , Humanos , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/radioterapia , Neoplasias Hepáticas/tratamento farmacológico , Microesferas , Carcinoma Hepatocelular/patologia , Radioisótopos de Ítrio/efeitos adversos , Embolização Terapêutica/efeitos adversos , Colangiocarcinoma/diagnóstico por imagem , Colangiocarcinoma/radioterapia , Necrose/induzido quimicamente , Necrose/tratamento farmacológico , Ductos Biliares Intra-Hepáticos , Neoplasias dos Ductos Biliares/diagnóstico por imagem , Neoplasias dos Ductos Biliares/radioterapia , Resultado do Tratamento , Estudos RetrospectivosRESUMO
PURPOSE: To investigate risk factors associated with post-microwave ablation (MWA) abscess development. MATERIALS AND METHODS: A retrospective case-control analysis was conducted to identify hepatic MWA performed at a single tertiary medical center between January 2010 and January 2022. Case and control patients were defined as those who did or did not develop intrahepatic abscess within 3 months following MWA, respectively. Correlations between risk factors and post-MWA abscess development were assessed by Fisher's exact test. RESULTS: Between 2010 and 2022, 253 patients underwent 376 MWA sessions with post-ablation abscess complication rate of 1.1% (4/376). Complications associated with intrahepatic abscess included bacteremia, empyema, pleural abscess, subcutaneous abscess, cholangitis, bile leak, biliocutaneous and arterio-biliary fistulae, and pseudoaneurysm. One patient expired from septic shock 5 days post-ablation. All abscesses were treated by percutaneous drainage and antibiotics. One patient required concomitant placement of a biliary stent and embolization of a biliocutaneous tract. History of Sphincter of Oddi manipulation (p < 0.01), cholangiocarcinoma (p < 0.05), transarterial radioembolization (TARE) to the index lesion (p < 0.05), and abnormal serum alkaline phosphatase levels (p < 0.05) were significantly correlated with post-MWA abscess. The risk of developing post-MWA abscesses for patients with a history of cholangiocarcinoma or a history of Sphincter of Oddi manipulation were 20.0% and 27.2%, respectively. CONCLUSION: Patients with prior Sphincter of Oddi manipulation, cholangiocarcinoma, or TARE are at greater risk of developing post-MWA abscess.
Assuntos
Neoplasias dos Ductos Biliares , Ablação por Cateter , Colangiocarcinoma , Abscesso Hepático , Neoplasias Hepáticas , Humanos , Micro-Ondas , Estudos Retrospectivos , Ablação por Cateter/efeitos adversos , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/complicações , Abscesso Hepático/etiologia , Fatores de Risco , Colangiocarcinoma/cirurgia , Ductos Biliares Intra-Hepáticos/cirurgia , Neoplasias dos Ductos Biliares/cirurgiaRESUMO
PURPOSE: To determine the safety and effectiveness of yttrium-90 transarterial radioembolization (TARE) combined with systemic gemcitabine, cisplatin, and capecitabine for the first-line treatment of locally advanced intrahepatic cholangiocarcinoma (iCCA). MATERIALS AND METHODS: Data of 13 patients with treatment-naïve, locally advanced iCCA treated with a downstaging protocol using gemcitabine, cisplatin, TARE, and capecitabine were retrospectively reviewed. Overall survival (OS), local tumor response (modified Response Evaluation Criteria in Solid Tumors), progression-free survival (PFS), technical adverse events, and toxicity were measured. RESULTS: Calculated from the time of diagnosis, the median OS was 29 months (95% confidence interval [CI], 15 to not reached), with a 1-year OS of 84.6% (95% CI, 52.2%-95.9%) and 2-year OS of 52.9% (95% CI, 20.3%-77.5%). The median OS values were 24 months (95% CI, 8 to not reached) and 21 months (95% CI, 5 to not reached) from the time of initial cycle of chemotherapy and TARE, respectively. Patients who were downstaged to surgery (n = 7, 53.8%) had a more favorable OS (median OS, not reached vs 15 months; P = .0221). Complete and partial radiologic responses were achieved in 5 (38.5%) and 6 (46.2%) patients, respectively. The median PFS was 13 months (95% CI, 12 to not reached). Although no serum toxicity with Grade >2 occurred within 3 months after TARE, 1 patient was no longer a surgical candidate given suboptimal nutrition status despite successful downstage on imaging studies. Two patients required a reduced dose or delay of post-TARE chemotherapy. CONCLUSIONS: First-line combination therapy with TARE and systemic gemcitabine, cisplatin, and capecitabine is an effective treatment with an acceptable safety profile for iCCA with a high rate of downstaging to resection.
Assuntos
Neoplasias dos Ductos Biliares , Colangiocarcinoma , Humanos , Gencitabina , Capecitabina/efeitos adversos , Cisplatino/efeitos adversos , Estudos Retrospectivos , Radioisótopos de Ítrio , Colangiocarcinoma/diagnóstico por imagem , Colangiocarcinoma/terapia , Resultado do Tratamento , Ductos Biliares Intra-Hepáticos , Neoplasias dos Ductos Biliares/diagnóstico por imagem , Neoplasias dos Ductos Biliares/terapiaRESUMO
PURPOSE: Factors affecting tumor-to-normal tissue ratio (T:N) have implications for patient selection, dosimetry, and outcomes when considering radioembolization for HCC. This study sought to evaluate patient, disease specific, and technical parameters that predict T:N as measured on planning pre-90Y radioembolization 99mTc-MAA scintigraphy for hepatocellular carcinoma (HCC). METHODS: 99mTc-MAA hepatic angiography procedures with SPECT/CT over a 4-year period were reviewed. Data recorded included patient demographics, details of underlying liver disease, tumor size, history of prior treatments for HCC and technical parameters from angiography. Anatomic-based segmentation was performed in 93 cases for measurement of tumor and perfused liver volumes and SPECT counts. T:N were calculated and correlated with collected variables. RESULTS: Mean calculated T:N was 2.52. History of prior ablation was significantly correlated with higher T:N (mean 3.39 vs 2.24, p = 0.003). Cases in which mapping was being performed for treatment of disease progression was significantly correlated with higher T:N (mean 3.35 vs 2.14, p = 0.001). Larger tumor size trended toward lower T:N (p = 0.052). CONCLUSION: Patients with history of ablation and those undergoing treatment for disease progression have higher T:N and, therefore, could be considered for radioembolization preferentially over alternative treatments.
Assuntos
Carcinoma Hepatocelular , Embolização Terapêutica , Neoplasias Hepáticas , Humanos , Carcinoma Hepatocelular/patologia , Neoplasias Hepáticas/patologia , Agregado de Albumina Marcado com Tecnécio Tc 99m , Estudos Retrospectivos , Progressão da Doença , Embolização Terapêutica/métodos , Radioisótopos de ÍtrioRESUMO
Purpose: The IMbrave150 Phase III trial demonstrated the superiority of atezolizumab and bevacizumab (Atezo/Bev) over sorafenib for unresectable hepatocellular carcinoma (HCC). The present study aims to evaluate the feasibility of TARE in combination with Atezo/Bev for the treatment of intermediate and advanced staged HCC. Methods: A retrospective review at a single institution was performed between May 2021 and December 2022. Patients who received TARE using yttrium-90 (Y90) with concomitant or sequential Atezo/Bev systemic treatment were included. The following outcomes were retrieved: overall survival (OS), radiologic tumor response, progression-free survival, technical adverse events related to TARE, and toxicity based on the National Cancer Institute-Common Terminology Criteria for Adverse Events version 5.0. Results: Ten consecutive patients with intermediate (n â= â4) and advanced stage HCC (n â= â6) were treated with TARE and sequential/concomitant Atezo/Bev. Tumor control was achieved in all TARE-treated target lesions (100%). Overall disease progression occurred in 4 patients with PFS of 78.8% and 66.7% at 6- and 12- months, respectively. Two patients died at follow-up, with 6-month and 12-month OS rates of 90.0% and 77.1%, respectively. Three (75%) patients with intermediate stage disease were downstaged into Milan criteria. One patient developed grade 3 transaminitis and hypoglobulinemia, while Atezo/Bev was switched to Lenvatinib in another patient due to immunotherapy related myositis. Conclusion: This study demonstrates the initial safety and feasibility of combined TARE with Atezo/Bev for intermediate/advanced stage HCC. Further prospective studies with larger sample sizes are warranted.
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PURPOSE: To investigate the utilization of an angiography-CT (Angio-CT) system and its advantages for single patient encounters. METHODS: Interventions utilizing both CT and fluoroscopy to perform multiple procedures in a single encounter or single interventions using both were identified. Cases were stratified by complexity (defined by RVUs). Comparative analyses of room (TRoom) and total encounter (TEncounter) times were performed between non-complex bundled cases and controls. RESULTS: Between June 2018 and August 2019, 1108 procedures were performed via the Angio-CT system; 10% (114/1108) used both fluoroscopy and CT. 21% (24/114) Involved more than one procedure in a single encounter that required a CT-only and fluoroscopy-only bundled procedure. 59% (67/114) were non-complex, and 70% (80/114) were non-oncologic. 82.5% (14/17) of non-complex bundled procedures demonstrated TRoom below the mean of their respective controls; 52.8% (9/17) were 2 standard deviations below the control means. Pleural catheter placement following post-lung biopsy pneumothorax was the most common non-complex bundled case with a significant reduction in TRoom when performed via Angio-CT compared to control (99 vs. 163 min, p < 0.0001). There was a significant reduction in TEncounter for abdominopelvic drain placement procedures bundled with either (1) percutaneous nephrostomy tube evaluation with or without replacement, or (2) central venous catheter placement (211 min vs. 344 min, p < 0.001 and 231 min vs. 347 min, p < 0.05, respectively). CONCLUSION: The primary use for the hybrid Angio-CT system was to perform non-oncologic and non-complex cases with potential reduction in TRoom and TEncounter for specific non-complex bundled cases.
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Radiologia Intervencionista , Tomografia Computadorizada por Raios X , Angiografia , Angiografia por Tomografia Computadorizada , Fluoroscopia/métodos , Humanos , Radiografia Intervencionista/métodos , Tomografia Computadorizada por Raios X/métodosRESUMO
BACKGROUND. Accurate assessment of hepatopulmonary shunting, typically performed by planar scintigraphy, is critical in planning 90Y radioembolization. High lung shunt fractions (LSFs) may alter treatment. OBJECTIVE. The purpose of this study is to compare LSFs calculated from planar scintigraphy versus SPECT/CT in patients with high planar LSFs (> 15%) and to describe the potential clinical and dosimetric implications of SPECT/CT LSF calculations. METHODS. This retrospective study included 36 patients (29 men and seven women; mean age, 62.4 ± 9.8 [SD] years) who underwent 99mTc-macroaggregated albumin (MAA) planar scintigraphy for planning hepatic radioembolization, had a planar LSF greater than 15%, and underwent concurrent SPECT/CT. Clinically reported planar LSFs were recorded. SPECT/CT LSFs were retrospectively calculated using automatically generated volumetric ROIs around the lungs and liver with subsequent manual adjustments. Total lung and perfused liver doses were calculated using a medical internal radiation dose model. Values derived from planar and SPECT/CT data were compared using Mann-Whitney U tests. Multivariable regression analysis was performed of factors associated with the discrepancy in LSF between the techniques. RESULTS. Mean planar LSF was 25.1% ± 11.6%, and mean SPECT/CT LSF was 16.0% ± 9.3% (p < .001). Mean lung dose was 18.8 ± 8.0 Gy for planar LSF versus 12.3 ± 7.2 Gy for SPECT/CT LSF (p < .001). Mean perfused liver dose was 92.9 ± 36.1 Gy using planar LSF versus 102.7 ± 39.1 Gy using SPECT/CT LSF (p < .001). In multivariable analysis, a larger discrepancy in LSF between planar scintigraphy and SPECT/CT was associated with a body mass index (weight in kilograms divided by the square of height in meters) of 26 or higher (p = .02), maximum tumor size of less than 9 cm (p = .05), and left hepatic intraarterial injection (p = .02). Fourteen of 36 patients did not undergo upfront radioembolization due to a planar LSF greater than 20% and instead underwent shunt-reducing embolization with subsequent radioembolization (n = 7), transarterial chemoembolization (n = 5), or no treatment (n = 2). Five of these 14 patients had a SPECT/CT LSF of less than 20% and would have been eligible for upfront radioembolization based on SPECT/CT LSF. Seven of 29 patients treated with radioembolization underwent prescribed dose reductions based on planar LSF; six of these patients would have qualified for standard radioembolization without dose reduction using SPECT/CT LSF. CONCLUSION. Planar scintigraphy yields greater LSFs compared with SPECT/CT, possibly leading to unnecessary shunt-reducing procedures and prescribed dose reductions. CLINICAL IMPACT. SPECT/CT should be considered for clinical LSF calculations before radioembolization in patients with high LSFs.
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Carcinoma Hepatocelular , Quimioembolização Terapêutica , Embolização Terapêutica , Neoplasias Hepáticas , Idoso , Carcinoma Hepatocelular/patologia , Embolização Terapêutica/métodos , Feminino , Humanos , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/radioterapia , Pulmão/patologia , Masculino , Microesferas , Pessoa de Meia-Idade , Cintilografia , Estudos Retrospectivos , Agregado de Albumina Marcado com Tecnécio Tc 99m , Tomografia Computadorizada de Emissão de Fóton Único , Tomografia Computadorizada por Raios X , Radioisótopos de Ítrio/uso terapêuticoRESUMO
PURPOSE: We aimed to assess the association between complication rate and time to feeding in a cohort of patients undergoing radiologically guided placement of gastrostomy tubes. METHODS: A retrospective study was conducted of all patients receiving pull-type and push-type gastrostomy tubes placed by interventional radiologists between January 1st, 2017 and December 31st, 2018 at a single institution. Primary outcomes included procedural and tube-related complications per medical chart review with a follow-up interval of 30 days. Exclusion criteria were enteral nutrition delayed more than 48 hours, no feeding information, and tubes placed for venting (n=20). Overall, 303 gastrostomy tubes (pull-type, n=184; push-type, n=119) were included. The most common indications for placement included head and neck carcinoma for push-type tubes (n=76, 63.9%) and cerebral vascular accident for pull-type tubes (n=78, 42.4%). RESULTS: In a multiple regression analysis, there was no statistically significant association between complications and time to feeding (p = 0.096), age (p = 0.758), gender (p = 0.127), indication for tube placement (p = 0.206), or type of tube placed (p = 0.437). Average time to initiation of enteral nutrition was 12.3 hours for the pull-type and 21.7 hours for the push-type cohort (p < 0.001). Additional multiple regression analyses of pull-type tubes and push-type tubes separately also did not find any significant association between complications and the above factors (p > 0.05). CONCLUSION: There was no statistically significant correlation between time to feed and complications, suggesting that there is no clinical difference between early and late feeding following gastrostomy tube placement.
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Gastrostomia , Neoplasias de Cabeça e Pescoço , Cateterismo , Nutrição Enteral/efeitos adversos , Gastrostomia/efeitos adversos , Humanos , Estudos RetrospectivosRESUMO
BACKGROUND: To conduct a meta-analysis to assess the safety and efficacy of prophylactic transcatheter arterial embolization (PTAE) for the treatment of high-risk bleeding peptic ulcers after achieving endoscopic hemostasis. METHODS: PubMed and Cochrane Library were queried for full-text articles published up to December 2019. The following keywords were used: "prophylactic embolization", "supplement embolization", "gastrointestinal bleeding", and "ulcer bleeding". High-risk ulcers were defined based on endoscopic findings (i.e., large ulcers, Forrest class I-IIb) and/or clinical presentation (i.e., hypotension, decreased hemoglobin during endoscopy). Only comparative studies investigating PTAE versus conservative treatment after achieving endoscopic hemostasis were included. Baseline study characteristics, rebleeding rate, need for surgery, mortality, and PTAE-related complication rates were investigated. Quantitative analyses were performed with Stata 15.1. RESULTS: Among the five included original studies, a total of 265 patients received PTAE and 617 were managed conservatively after endoscopy. The rebleeding rate (6.8% vs 14.3%, p = 0.003) and mortality (4.5% vs 8.8%, p = 0.032) of patients from the PTAE group were lower than the control group. PTAE also reduced the cumulative need for future surgical intervention (3.0% vs 14.4%, p = 0.005). The PTAE-related major and minor events were 0.75% and 14.4%, respectively. CONCLUSION: PTAE had therapeutic potentials in reducing rebleeding risk, need for surgical intervention, and morality in high-risk peptic ulcers after achieving endoscopic hemostasis. The embolization-associated adverse events were minimal. Future studies should aim to increase the sample size and resources for performing endovascular interventions.
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Embolização Terapêutica , Hemostase Endoscópica , Úlcera Péptica Hemorrágica/terapia , HumanosRESUMO
The first synthetic cannabinoid receptor agonists (SCRAs) were designed as tool compounds to study the endocannabinoid system's two predominant cannabinoid receptors, CB1R and CB2R. Unfortunately, novel SCRAs now represent the most rapidly proliferating novel psychoactive substances (NPS) of abuse globally. Unlike ∆9-tetrahydrocannabinol, the CB1R and CB2R partial agonist and the intoxicating constituent of Cannabis, many SCRAs characterized to date are full agonists of CB1R. Gaining additional insight into the pharmacological activity of these SCRAs is critical to assess and regulate NPSs as they enter the marketplace. The purpose of this study was to assess select SCRAs recently identified by Canadian police, border service agency, private companies and the illicit market as potential CB1R and CB2R agonists. To this end, fifteen SCRAs were screened for in vitro activity and in silico interactions at CB1R and CB2R. Several SCRAs were identified as being highly biased for cAMP inhibition or ßarrestin2 recruitment and receptor subtype selectivity between CB1R and CB2R. The indazole ring and halogen-substituted butyl or pentyl moieties were identified as two structural features that may direct ßarrestin2 bias. Two highly-biased SCRAs-JWH-018 2'-napthyl-N-(3-methylbutyl) isomer (biased toward cAMP inhibition) and 4-fluoro MDMB-BINACA (biased toward ßarrestin2 recruitment) displayed unique and differential in vivo activity in mice. These data provide initial insight into the correlations between structure, signalling bias, and in vivo activity of the SCRAs.