RESUMEN
The determination of an optimal treatment plan for an individual patient with rectal cancer is a complex process. In addition to decisions relating to the intent of rectal cancer surgery (ie, curative or palliative), consideration must also be given to the likely functional results of treatment, including the probability of maintaining or restoring normal bowel function/anal continence and preserving genitourinary functions. Particularly for patients with distal rectal cancer, finding a balance between curative-intent therapy while having minimal impact on quality of life can be challenging. Furthermore, the risk of pelvic recurrence is higher in patients with rectal cancer compared with those with colon cancer, and locally recurrent rectal cancer is associated with a poor prognosis. Careful patient selection and the use of sequenced multimodality therapy following a multidisciplinary approach is recommended. These NCCN Guidelines Insights detail recent updates to the NCCN Guidelines for Rectal Cancer, including the addition of endoscopic submucosal dissection as an option for early-stage rectal cancer, updates to the total neoadjuvant therapy approach based on the results of recent clinical trials, and the addition of a "watch-and-wait" nonoperative management approach for clinical complete responders to neoadjuvant therapy.
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Neoplasias del Recto , Humanos , Neoplasias del Recto/terapia , Neoplasias del Recto/diagnóstico , Neoplasias del Recto/patología , Terapia Neoadyuvante/métodos , Terapia Neoadyuvante/normas , Terapia Combinada/métodos , Estadificación de Neoplasias , Oncología Médica/normas , Oncología Médica/métodosRESUMEN
Colorectal cancer (CRC) is the fourth most frequently diagnosed cancer and the second leading cause of cancer death in the United States. Management of disseminated metastatic CRC involves various active drugs, either in combination or as single agents. The choice of therapy is based on consideration of the goals of therapy, the type and timing of prior therapy, the mutational profile of the tumor, and the differing toxicity profiles of the constituent drugs. This manuscript summarizes the data supporting the systemic therapy options recommended for metastatic CRC in the NCCN Guidelines for Colon Cancer.
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Neoplasias del Colon , Humanos , Neoplasias del Colon/diagnóstico , Neoplasias del Colon/terapia , Neoplasias del Colon/patología , Neoplasias del Colon/tratamiento farmacológico , Oncología Médica/normas , Oncología Médica/métodos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Estados UnidosRESUMEN
PURPOSE: To assess whether yttrium-90 transarterial radioembolization (TARE) is safe and effective in the treatment of primary lung cancer metastases to the liver (LCML). METHODS AND METHODS: This retrospective study included 57 patients with LCML who were treated with 79 TARE treatments. Histology included non-small cell lung cancer (NSCLC) (n = 27), small cell lung cancer (SCLC) (n = 17), and lung carcinoid (LC) (n = 13). Survival was calculated using Kaplan-Meier method; differences between groups were estimated using log rank test. Cox proportional hazards model was used to determine factors influencing survival. Adverse events were graded using the Society of Interventional Radiology Adverse Events Classification. RESULTS: Median overall survival (OS) was as follows: NSCLC, 8.3 months (95% confidence interval [CI], 6.3-16.4 months); SCLC, 4.1 months (95% CI, 1.9-6.6 months); and LC, 43.5 months (95% CI, 7.8-61.4 months). For NSCLC, presence of bilobar vs unilobar disease (hazard ratio [HR], 5.24; 95% CI, 1.64-16.79; P = .002); more tumors, 2-5 vs 1 (HR, 4.88; 95% CI, 1.17-20.37; P = .003) and >5 vs 1 (HR, 3.75; 95% CI, 0.95-6.92; P = .05); and lobar vs segmental treatment (HR, 2.56; 95% CI, 0-NA; P = .002) were negative predictors of OS. For SCLC, receipt of >2 lines of chemotherapy vs ≤2 lines (HR, 3.16; 95% CI, 0.95-10.47; P = .05) was a negative predictor of OS. For LC, tumor involvement of >50% was a negative predictor of OS (HR, 3.77 × 1015; 95% CI, 0-NA; P = .002). There were 11 of 79 severe or life-threatening adverse events within 30 days (abdominal pain, altered mental status, nausea/vomiting, acalculous/aseptic cholecystitis, hyponatremia, pancreatitis, renal failure, and death from pneumonia). CONCLUSIONS: TARE has an acceptable safety profile for the treatment of LCML, with survival benefits best seen in LC tumors.
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Carcinoma de Pulmón de Células no Pequeñas , Neoplasias Hepáticas , Neoplasias Pulmonares , Humanos , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/radioterapia , Resultado del Tratamiento , Neoplasias Pulmonares/diagnóstico por imagen , Neoplasias Pulmonares/radioterapia , Carcinoma de Pulmón de Células no Pequeñas/diagnóstico por imagen , Carcinoma de Pulmón de Células no Pequeñas/radioterapia , Estudios Retrospectivos , Radioisótopos de Itrio/efectos adversosRESUMEN
PURPOSE: To assess compare the efficacy effectiveness and safety of percutaneous microwave ablation (MWA) for subdiaphragmatic versus non-subdiaphragmatic colorectal liver metastasis (CLM). MATERIALS AND METHODS: This is a retrospective analysis of a prospectively created microwave ablation (MWA) database, from two prospective clinical trials for CLM patients treated in a single-tertiary center from 2012-2023. Subdiaphragmatic CLM was defined as a tumor located <1 cm from the diaphragm. Minimal Ablation Margin (MM) was calculated with 3D software using the post-ablation contrast enhanced CT. Adverse events were assessed with SIR classification for 6 months. RESULTS: 209 CLMs underwent 191 MWA sessions in 143 patients. Mean tumor diameter was 1.52±0.53 cm. 83/209(39.7%) CLMs were subdiaphragmatic. There was no difference in local tumor progression-free survival (LTPFS) between subdiaphragmatic and non-subdiaphragmatic CLMs (HR:0.65,95%CI:0.37-1.16, p=0.15). MM of 5-10 mm, and >10 mm was documented in 49.3% vs 46.8%, (p=0.83) and in 21.6% vs12.6% (p=0.16) for subdiaphragmatic and non-subdiaphragmatic CLMs.12-month LTPFS was similar between groups (HR:0.65,95%CI:0.37-1.16, p=0.15) without LTP for MM >10mm. There were 3 grade IV adverse events: one diaphragmatic perforation, one liver abscess and one biloma. Pneumothorax was associated with subdiaphragmatic location (p<0.001) and transpulmonary approach (p<0.001). Median hospital stay was 2 days (IQR: 1-3) for patients necessitating thoracostomy (n=20, 9.6%) compared to 1 day for those that did not (IQR: 1-8) without long-term sequelae. CONCLUSION: MWA of subdiaphragmatic CLM is effective and safe, without difference in success and 12-month LTPFS. Pneumothorax was associated with subdiaphragmatic location and thoracostomy that resulted in longer hospitalization without long-term sequelae.
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PURPOSE: To evaluate the histopathologic changes and potential correlations of tumor absorbed dose (TAD) after yttrium-90 transarterial radioembolization (TARE) for colorectal liver metastases (CLMs). MATERIALS AND METHODS: This prospective pilot study assessed 12 patients with 13 CLMs through positron emission tomography (PET)/computed tomography (CT)-guided biopsies before, immediately after TARE (T0), and 3 weeks after TARE (T3). Subsequent sampling from the same location was enabled by fiducial placement. Biopsy samples were evaluated with hematoxylin and eosin, TUNEL, Ki67, OxPhos, caspase-3 (CC3), and pH2AX antibodies. Proliferation changes (Ki67) and double-strand DNA breaks (DSBs) were evaluated quantitatively. TAD was calculated on post-TARE PET/CT scan of the biopsy needle location at T0 and T3. RESULTS: Median TAD at 3 weeks after TARE was 162 Gy (interquartile range (IQR), 92-211 Gy). DSBs decreased significantly from T0 (median, 77%; IQR, 75%-100%) to T3 (median, 14%; IQR, 0%-54%; P = .028). A decrease in Ki67 was also documented (median, 73%; IQR, 70%-80% at T0 vs median, 41%; IQR, 0%-66% at T3; P = .046). There was a strong positive correlation between TAD and DSBs at T0 (r[9] = 0.68) and a strong negative correlation at T3 (r[10] = -0.855; P = .042 and P = .002, respectively). There was a strong negative correlation between TAD and Ki67 at both T0 (r[9] = -0.733; P = .025) and T3 (r[10] = -0.681; P = .030). Tumors that exhibited caspase-3 activation (8/13, 62%) at either T0 or T3 time point were more likely to develop progression (7/8 [88%] vs 1/5 [20%]; P = .015). CONCLUSIONS: Post-TARE biopsy can be used to assess TAD and histopathologic changes. Significant decreases in DSBs and proliferation index were noted after TARE. Post-TARE CC3 activation deserves further exploration.
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Neoplasias Colorrectales , Embolización Terapéutica , Estudios de Factibilidad , Neoplasias Hepáticas , Tomografía Computarizada por Tomografía de Emisión de Positrones , Radiofármacos , Radioisótopos de Itrio , Humanos , Radioisótopos de Itrio/administración & dosificación , Proyectos Piloto , Neoplasias Hepáticas/radioterapia , Neoplasias Hepáticas/secundario , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/patología , Masculino , Femenino , Neoplasias Colorrectales/patología , Persona de Mediana Edad , Estudios Prospectivos , Anciano , Radiofármacos/administración & dosificación , Resultado del Tratamiento , Factores de Tiempo , Biopsia Guiada por Imagen , Proliferación Celular , Antígeno Ki-67/metabolismo , Roturas del ADN de Doble Cadena , Biomarcadores de Tumor/metabolismoRESUMEN
PURPOSE: To evaluate the prognostic accuracy of intraprocedural and 4-8-week (current standard) post-microwave ablation zone (AZ) and margin assessments for prediction of local tumor progression (LTP) using 3-dimensional (3D) software. MATERIALS AND METHODS: Data regarding 100 colorectal liver metastases (CLMs) in 75 patients were collected from 2 prospective fluorodeoxyglucose positron emission tomography (PET)/computed tomography (CT)-guided microwave ablation (MWA) trials. The target CLMs and theoretical 5- and 10-mm margins were segmented and registered intraprocedurally and at 4-8 weeks after MWA contrast-enhanced CT (or magnetic resonance [MR] imaging) using the same methodology and 3D software. Tumor and 5- and 10-mm minimal margin (MM) volumes not covered by the AZ were defined as volumes of insufficient coverage (VICs). The intraprocedural and 4-8-week post-MWA VICs were compared as predictors of LTP using receiver operating characteristic curve analysis. RESULTS: The median follow-up time was 19.6 months (interquartile range, 7.97-36.5 months). VICs for 5- and 10-mm MMs were predictive of LTP at both time assessments. The highest accuracy for the prediction of LTP was documented with the intra-ablation 5-mm VIC (area under the curve [AUC], 0.78; 95% confidence interval, 0.66-0.89). LTP for a VIC of 6-10-mm margin category was 11.4% compared with 4.3% for >10-mm margin category (P < .001). CONCLUSIONS: A 3D 5-mm MM is a critical endpoint of thermal ablation, whereas optimal local tumor control is noted with a 10-mm MM. Higher AUCs for prediction of LTP were achieved for intraprocedural evaluation than for the 4-8-week postablation 3D evaluation of the AZ.
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Ablación por Catéter , Neoplasias Hepáticas , Humanos , Resultado del Tratamiento , Estudios Prospectivos , Microondas/efectos adversos , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodos , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/cirugía , Neoplasias Hepáticas/secundario , Estudios RetrospectivosRESUMEN
This discussion summarizes the NCCN Clinical Practice Guidelines for managing squamous cell anal carcinoma, which represents the most common histologic form of the disease. A multidisciplinary approach including physicians from gastroenterology, medical oncology, surgical oncology, radiation oncology, and radiology is necessary. Primary treatment of perianal cancer and anal canal cancer are similar and include chemoradiation in most cases. Follow-up clinical evaluations are recommended for all patients with anal carcinoma because additional curative-intent treatment is possible. Biopsy-proven evidence of locally recurrent or persistent disease after primary treatment may require surgical treatment. Systemic therapy is generally recommended for extrapelvic metastatic disease. Recent updates to the NCCN Guidelines for Anal Carcinoma include staging classification updates based on the 9th edition of the AJCC Staging System and updates to the systemic therapy recommendations based on new data that better define optimal treatment of patients with metastatic anal carcinoma.
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Neoplasias del Ano , Carcinoma de Células Escamosas , Humanos , Biopsia , Oncología MédicaRESUMEN
PURPOSE: To evaluate the yttrium-90 (90Y) activity distribution in biopsy tissue samples of the treated liver to quantify the dose with higher spatial resolution than positron emission tomography (PET) for accurate investigation of correlations with microscopic biological effects and to evaluate the radiation safety of this procedure. MATERIALS AND METHODS: Eighty-six core biopsy specimens were obtained from 18 colorectal liver metastases (CLMs) immediately after 90Y transarterial radioembolization (TARE) with either resin or glass microspheres using real-time 90Y PET/CT guidance in 17 patients. A high-resolution micro-computed tomography (micro-CT) scanner was used to image the microspheres in part of the specimens and allow quantification of 90Y activity directly or by calibrating autoradiography (ARG) images. The mean doses to the specimens were derived from the measured specimens' activity concentrations and from the PET/CT scan at the location of the biopsy needle tip for all cases. Staff exposures were monitored. RESULTS: The mean measured 90Y activity concentration in the CLM specimens at time of infusion was 2.4 ± 4.0 MBq/mL. The biopsies revealed higher activity heterogeneity than PET. Radiation exposure to the interventional radiologists during post-TARE biopsy procedures was minimal. CONCLUSIONS: Counting the microspheres and measuring the activity in biopsy specimens obtained after TARE are safe and feasible and can be used to determine the administered activity and its distribution in the treated and biopsied liver tissue with high spatial resolution. Complementing 90Y PET/CT imaging with this approach promises to yield more accurate direct correlation of histopathological changes and absorbed dose in the examined specimens.
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Neoplasias Colorrectales , Embolización Terapéutica , Neoplasias Hepáticas , Humanos , Tomografía Computarizada por Tomografía de Emisión de Positrones , Microtomografía por Rayos X , Autorradiografía , Tomografía de Emisión de Positrones/métodos , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/radioterapia , Neoplasias Hepáticas/tratamiento farmacológico , Radioisótopos de Itrio/efectos adversos , Embolización Terapéutica/efectos adversos , Embolización Terapéutica/métodos , Biopsia Guiada por Imagen , MicroesferasRESUMEN
This selection from the NCCN Guidelines for Rectal Cancer focuses on management of malignant polyps and resectable nonmetastatic rectal cancer because important updates have been made to these guidelines. These recent updates include redrawing the algorithms for stage II and III disease to reflect new data supporting the increasingly prominent role of total neoadjuvant therapy, expanded recommendations for short-course radiation therapy techniques, and new recommendations for a "watch-and-wait" nonoperative management technique for patients with cancer that shows a complete response to neoadjuvant therapy. The complete version of the NCCN Guidelines for Rectal Cancer, available online at NCCN.org, covers additional topics including risk assessment, pathology and staging, management of metastatic disease, posttreatment surveillance, treatment of recurrent disease, and survivorship.
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Neoplasias del Recto , Humanos , Oncología Médica , Terapia Neoadyuvante , Neoplasias del Recto/diagnóstico , Neoplasias del Recto/patología , Neoplasias del Recto/terapiaRESUMEN
PURPOSE: To validate an immunofluorescence assay (IFA) detecting residual viable tumor (VT) as intraprocedural thermal ablation (TA) zone assessment and demonstrate its prognostic value for local tumor progression (LTP) after colorectal liver metastasis (CLM) TA. MATERIALS AND METHODS: This prospective study, approved by the institutional review board, included 99 patients with 155 CLMs ablated between November 2009 and January 2019. Tissue samples from the ablation zone (AZ) center and minimal margin underwent immunofluorescent microscopic examination interrogating cellular morphology and mitochondrial viability (IFA) within 30 minutes after ablation. The same tissue samples were subsequently evaluated with standard morphologic and immunohistochemical methods. The sensitivity, specificity, and overall accuracy of IFA versus standard morphologic and immunohistochemical examination were calculated. The LTP-free survival rates were evaluated for the 12-month follow-up period. RESULTS: Of the 311 tissue samples stained, 304 (98%) were deemed evaluable. Of these specimens, 27% (81/304) were considered positive for the presence of VT. The accuracy of IFA was 94% (286/304). The sensitivity and specificity were 100% (63/63) and 93% (223/241), respectively. The 18 false-positive IFA assessments corresponded to samples that included viable cholangiocytes. The 12-month LTP-free survival was 59% versus 78% for IFA positive versus negative for VT AZs, respectively (P < .001). There was no difference in LTP between margin positive only and central AZ-positive tumors (25% vs 31%, P = 1). CONCLUSIONS: The IFA assessment of the AZ can be completed intraprocedurally and serve as a valid real-time biomarker of complete tumor eradication or detect residual VT after TA. This method could improve tumor control by TA.
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Ablación por Catéter , Neoplasias Colorrectales , Neoplasias Hepáticas , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodos , Neoplasias Colorrectales/patología , Progresión de la Enfermedad , Técnica del Anticuerpo Fluorescente , Secciones por Congelación , Humanos , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/cirugía , Estudios Prospectivos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVE: To determine the feasibility and prognostic value of 3D measuring of the ablation margins using a dedicated image registration software. METHODS: This retrospective study included 104 colorectal liver metastases in 68 consecutive patients that underwent microwave ablation between 08/2012 and 08/2019. The minimal ablation margin (MM) was measured in 2D using anatomic landmarks on contrast enhanced CT(CECT) 4-8 weeks post-ablation, and in 3D using an image registration software and immediate post-ablation CECT. Local tumor progression (LTP) was assessed by imaging up to 24 months after ablation. A blinded interventional radiologist provided feedback on the possibility of additional ablation after examining the 3D-margin measurements. RESULTS: The 3D-margin assessment was completed in 79/104 (76%) tumors without the need for target manipulation. In 25/104 (24%) tumors, manipulation was required due to image misregistration. LTP was observed in 40/104 (38.5%) tumors: 92.5% vs 7.5% for those with margin <5mm vs ≥5mm, respectively (p = 0.0001). The 2D and 3D-assessments identified margin <5mm in 17/104 (16%), and in 74/104 (71%) ablated tumors, respectively (p < 0.01). The sensitivity and specificity of the 3D software for predicting LTP was 93% (37/40) and 42% (27/64), respectively. Additional ablation to achieve a MM of 5 mm would have been offered in 26/37 cases if the 3D-margin assessment was available intraoperatively. CONCLUSION: Image registration software can measure ablation margins and detect MM under 5 mm intraoperatively, with significantly higher sensitivity than the 2D technique using landmarks on the post-ablation CECT. The identification of a margin under 5 mm is strongly associated with LTP.
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Ablación por Catéter , Neoplasias Colorrectales , Neoplasias Hepáticas , Ablación por Catéter/métodos , Neoplasias Colorrectales/patología , Humanos , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/patología , Neoplasias Hepáticas/cirugía , Márgenes de Escisión , Estudios Retrospectivos , Tomografía Computarizada por Rayos X/métodos , Resultado del TratamientoRESUMEN
Background Lung chemoembolization is an emerging treatment option for lung tumors, but the optimal embolic, drug, and technique are unknown. Purpose To determine the technical success rate and safety of bronchial or pulmonary artery chemoembolization of lung metastases using ethiodized oil, mitomycin, and microspheres. Materials and Methods Patients with unresectable and unablatable lung, endobronchial, or mediastinal metastases, who failed systemic chemotherapy, were enrolled in this prospective, single-center, single-arm, phase I clinical trial (December 2019-September 2020). Pulmonary and bronchial angiography was performed to determine the blood supply to the lung metastases. Based on the angiographic findings, bronchial or pulmonary artery chemoembolization was performed using an ethiodized oil and mitomycin emulsion, followed by microspheres. The primary objectives were technical success rate and safety, according to the National Cancer Institute Common Terminology Criteria for Adverse Events. CIs of proportions were estimated with the equal-tailed Jeffreys prior interval, and correlations were evaluated with the Spearman test. Results Ten participants (median age, 60 years; interquartile range, 52-70 years; six women) were evaluated. Nine of the 10 participants (90%) had lung metastases supplied by the bronchial artery, and one of the 10 participants (10%) had lung metastases supplied by the pulmonary artery. The technical success rate of intratumoral drug delivery was 10 of 10 (100%) (95% CI: 78, 100). There were no severe adverse events (95% CI: 0, 22). The response rate of treated tumors was one of 10 (10%) according to the Response Evaluation Criteria in Solid Tumors and four of 10 (40%) according to the PET Response Criteria in Solid Tumors. Ethiodized oil retention at 4-6 weeks was correlated with reduced tumor size (ρ = -0.83, P = .003) and metabolic activity (ρ = -0.71, P = .03). Pharmacokinetics showed that 45% of the mitomycin dose underwent burst release in 2 minutes, and 55% of the dose was retained intratumorally with a half-life of more than 5 hours. The initial tumor-to-plasma ratio of mitomycin concentration was 380. Conclusion Lung chemoembolization was technically successful for the treatment of lung, mediastinal, and endobronchial metastases, with no severe adverse events. Clinical trial registration no. NCT04200417 © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Georgiades et al in this issue.
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Arterias Bronquiales , Quimioembolización Terapéutica/métodos , Neoplasias Pulmonares/terapia , Arteria Pulmonar , Anciano , Antibióticos Antineoplásicos/uso terapéutico , Aceite Etiodizado/uso terapéutico , Femenino , Humanos , Neoplasias Pulmonares/patología , Masculino , Microesferas , Persona de Mediana Edad , Mitomicina/uso terapéutico , Estudios Prospectivos , Resultado del TratamientoRESUMEN
This selection from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Colon Cancer focuses on systemic therapy options for the treatment of metastatic colorectal cancer (mCRC), because important updates have recently been made to this section. These updates include recommendations for first-line use of checkpoint inhibitors for mCRC, that is deficient mismatch repair/microsatellite instability-high, recommendations related to the use of biosimilars, and expanded recommendations for biomarker testing. The systemic therapy recommendations now include targeted therapy options for patients with mCRC that is HER2-amplified, or BRAF V600E mutation-positive. Treatment and management of nonmetastatic or resectable/ablatable metastatic disease are discussed in the complete version of the NCCN Guidelines for Colon Cancer available at NCCN.org. Additional topics covered in the complete version include risk assessment, staging, pathology, posttreatment surveillance, and survivorship.
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Neoplasias del Colon , Biosimilares Farmacéuticos , Neoplasias del Colon/diagnóstico , Neoplasias del Colon/genética , Neoplasias del Colon/terapia , Reparación de la Incompatibilidad de ADN , Humanos , Inestabilidad de Microsatélites , MutaciónRESUMEN
PURPOSE: To evaluate the safety and efficacy of 2 locoregional therapies (LRTs) including hepatic artery embolization (HAE) and transarterial radioembolization (TARE) in the treatment of patients with metastatic ovarian cancer to the liver. MATERIAL AND METHODS: From October 2010 to May 2019, the data of 15 consecutive patients (median age, 54 years ± 9.8; range, 35-78 years) with hepatic metastatic ovarian cancer who were treated with either HAE (n = 6; 40%) or TARE (n = 9; 60%) were reviewed. The most common histopathologic type was epithelial ovarian carcinoma (80%). The most common chemotherapy regimens used prior to embolization included carboplatin, paclitaxel, cisplatin, and bevacizumab. Patients received a mean of 4 lines ± 3 (range, 1-9) of chemotherapy. All patients with serous carcinoma were resistant to platinum at the time of embolization. Indications for embolization were progression of disease to the liver while receiving chemotherapy in 14 (93.3%) patients and palliative pain control in 1 patient. RESULTS: The overall response rates at 1, 3, and 6 months were 92.4%, 85.6%, and 70%, respectively. Median overall survival from the time of LRT was 9 (95% confidence interval [CI], 4-14) months. Median local tumor progression was 6.4 months ± 5.03 (95% CI, 3.3-9.5). No grade 3-5 adverse events were detected in either group. CONCLUSIONS: HAE and TARE were well tolerated in patients with metastatic ovarian cancer to the liver and possibly ensured prolonged disease control in heavily treated, predominantly in patients resistant to platinum. Larger numbers are needed to verify these data.
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Resinas Acrílicas/administración & dosificación , Embolización Terapéutica , Gelatina/administración & dosificación , Arteria Hepática , Neoplasias Hepáticas/terapia , Neoplasias Ováricas/terapia , Radiofármacos/administración & dosificación , Resinas Acrílicas/efectos adversos , Adulto , Anciano , Progresión de la Enfermedad , Embolización Terapéutica/efectos adversos , Embolización Terapéutica/mortalidad , Femenino , Gelatina/efectos adversos , Humanos , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/secundario , Persona de Mediana Edad , Ciudad de Nueva York , Neoplasias Ováricas/mortalidad , Neoplasias Ováricas/patología , Tamaño de la Partícula , Supervivencia sin Progresión , Radiofármacos/efectos adversos , Estudios Retrospectivos , Factores de TiempoRESUMEN
During the past 10 years, performing real-time molecular imaging with positron emission tomography (PET) in combination with computed tomography (CT) during interventional procedures has undergone rapid development. Keeping in mind the interest of the nuclear medicine readers, an update is provided of the current workflows using real-time PET/CT in percutaneous biopsies and tumor ablations. The clinical utility of PET/CT guided biopsies in cancer patients with lung, liver, lymphoma, and bone tumors are reviewed. Several technological developments, including the introduction of new PET tracers and robotic arms as well as opportunities provided through acquiring radioactive biopsy specimens are briefly reviewed.
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Fluorodesoxiglucosa F18/química , Tomografía Computarizada por Tomografía de Emisión de Positrones/normas , Radiofármacos/química , Neoplasias Óseas , Relación Dosis-Respuesta en la Radiación , Fluorodesoxiglucosa F18/metabolismo , Humanos , Hígado , Pulmón , Linfoma , Medicina Nuclear , Radiofármacos/metabolismo , Tomografía Computarizada por Rayos XRESUMEN
The NCCN Guidelines for Rectal Cancer provide recommendations for the diagnosis, evaluation, treatment, and follow-up of patients with rectal cancer. These NCCN Guidelines Insights summarize the panel discussion behind recent important updates to the guidelines. These updates include clarifying the definition of rectum and differentiating the rectum from the sigmoid colon; the total neoadjuvant therapy approach for localized rectal cancer; and biomarker-targeted therapy for metastatic colorectal cancer, with a focus on new treatment options for patients with BRAF V600E- or HER2 amplification-positive disease.
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Neoplasias del Colon , Neoplasias del Recto , Neoplasias del Colon/diagnóstico , Neoplasias del Colon/terapia , Humanos , Terapia Neoadyuvante , Guías de Práctica Clínica como Asunto , Neoplasias del Recto/diagnóstico , Neoplasias del Recto/terapiaRESUMEN
PURPOSE: To describe ablation of bone, liver, lung, and soft tissue tumors from oligometastatic breast cancer and to define predictors of local progression and progression-free survival (PFS). MATERIALS AND METHODS: A total of 33 women (mean age 52 ± 12 years old; range, 28-69 years), underwent 46 thermal ablations of liver (n = 35), lung (n = 7), and bone/soft tissue (n = 4) metastases. Mean tumor diameter was 18 ± 15 mm (range, 6-50 mm). Ablations were performed to eradicate all evident sites of disease (n = 24) or to control growing sites in the setting of other stable or responding sites of disease (n = 22). Patient characteristics, ablation margins, imaging responses, and cases of PFS were assessed. Follow-up imaging was performed using contrast-enhanced computed tomography (CT), magnetic resonance (MR) imaging, or positron-emission tomography/ CT. RESULTS: Median PFS was 10 months (95% confidence interval [CI], 6.2 -14.5 months), and time to local progression was 11 months (95% CI, 5-16 months). Eight patients (24%) maintained no evidence of disease during a median follow-up period of 39 months. Ablation margin ≥5 mm was associated with no local tumor progression. Longer PFS was noted in estrogen receptor-positive patients (12 vs 4 months; P = .037) and younger patients (12 vs 4 months; P = .039) treated to eradicate all sites of disease (13 vs 5 months; P = .05). Eighteen patients (55%) developed new metastases during study follow-up. CONCLUSIONS: Thermal ablation of oligometastatic pulmonary, hepatic, bone, and soft tissue tumors can eliminate local tumor progression if margins are ≥5 mm. Longer PFS was observed in patients who were estrogen receptor-positive and patients who were younger and in whom all sites of disease were eradicated.
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Neoplasias Óseas/cirugía , Neoplasias de la Mama/patología , Criocirugía , Neoplasias Hepáticas/cirugía , Neoplasias Pulmonares/cirugía , Metastasectomía/métodos , Ablación por Radiofrecuencia , Neoplasias de los Tejidos Blandos/cirugía , Adulto , Anciano , Neoplasias Óseas/diagnóstico por imagen , Neoplasias Óseas/mortalidad , Neoplasias Óseas/secundario , Neoplasias de la Mama/mortalidad , Criocirugía/efectos adversos , Criocirugía/mortalidad , Bases de Datos Factuales , Progresión de la Enfermedad , Estudios de Factibilidad , Femenino , Humanos , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/secundario , Neoplasias Pulmonares/diagnóstico por imagen , Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/secundario , Márgenes de Escisión , Metastasectomía/efectos adversos , Metastasectomía/mortalidad , Persona de Mediana Edad , Supervivencia sin Progresión , Ablación por Radiofrecuencia/efectos adversos , Ablación por Radiofrecuencia/mortalidad , Estudios Retrospectivos , Factores de Riesgo , Neoplasias de los Tejidos Blandos/diagnóstico por imagen , Neoplasias de los Tejidos Blandos/mortalidad , Neoplasias de los Tejidos Blandos/secundario , Factores de Tiempo , Carga TumoralRESUMEN
Purpose To compare the effect of autologous blood patch injection (ABPI) with that of a hydrogel plug on the rate of pneumothorax at CT-guided percutaneous lung biopsy. Materials and Methods In this prospective randomized controlled trial ( https://ClinicalTrials.gov , NCT02224924), a noninferiority design was used for ABPI, with a 10% noninferiority margin when compared with the hydrogel plug, with the primary outcome of pneumothorax rate within 2 hours of biopsy. A type I error rate of 0.05 and 90% power were specified with a target study population of 552 participants (276 in each arm). From October 2014 to February 2017, all potential study participants referred for CT-guided lung biopsy (n = 2052) were assessed for enrollment. Results The data safety monitoring board recommended the trial be closed to accrual after an interim analysis met prespecified criteria for early stopping based on noninferiority. The final study group consisted of 453 participants who were randomly assigned to the ABPI (n = 226) or hydrogel plug (n = 227) arms. Of these, 407 underwent lung biopsy. Pneumothorax rates within 2 hours of biopsy were 21% (42 of 199) and 29% (60 of 208); chest tube rates were 9% (18 of 199) and 13% (27 of 208); and delayed pneumothorax rates within 2 weeks after biopsy were 1.4% (three of 199) and 1.5% (three of 208) in the ABPI and hydrogel plug arms, respectively. Conclusion Autologous blood patch injection is noninferior to a hydrogel plug regarding the rate of pneumothorax after CT-guided percutaneous lung biopsy. © RSNA, 2018 Online supplemental material is available for this article.
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Terapia Biológica , Hidrogeles , Biopsia Guiada por Imagen , Pulmón , Neumotórax , Adulto , Anciano , Anciano de 80 o más Años , Terapia Biológica/efectos adversos , Terapia Biológica/métodos , Terapia Biológica/estadística & datos numéricos , Femenino , Humanos , Hidrogeles/administración & dosificación , Hidrogeles/uso terapéutico , Biopsia Guiada por Imagen/efectos adversos , Biopsia Guiada por Imagen/métodos , Biopsia Guiada por Imagen/estadística & datos numéricos , Pulmón/diagnóstico por imagen , Pulmón/patología , Pulmón/cirugía , Masculino , Persona de Mediana Edad , Neumotórax/epidemiología , Neumotórax/etiología , Neumotórax/prevención & control , Neumotórax/terapia , Estudios Prospectivos , Tomografía Computarizada por Rayos X , Trasplante Autólogo , Adulto JovenRESUMEN
BACKGROUND: This study aimed to evaluate whether rapid fluorescent tissue examination immediately after colorectal cancer liver metastasis (CLM) ablation correlates with standard pathologic and immunohistochemical (IHC) assessments. METHODS: This prospective, National Institutes of Health-supported study enrolled 34 consecutive patients with 53 CLMs ablated between January 2011 and December 2014. Immediately after ablation, core needle sampling of the ablation zone was performed. Tissue samples were evaluated with fluorescent viability (MitoTracker Red) and nuclear (Hoechst) stains. Confocal microscope imaging was performed within 30 min after ablation. The same samples were subsequently fixed and stained with hematoxylin and eosin (H&E). Identified tumor cells underwent IHC staining for proliferation (Ki67) and viability (OxPhos). The study pathologist, blinded to the H&E and IHC assessment, evaluated the fluorescent images separately to detect viable tumor cells. Sensitivity, specificity, and overall concordance of the fluorescent versus H&E and IHC assessments were calculated. RESULTS: A total of 63 tissue samples were collected and processed. The overall concordance rate between the immediate fluorescent and the subsequent H&E and IHC assessments was 94% (59/63). The fluorescent assessment sensitivity and specificity for the identification of tumor cells were respectively 100% (18/18) and 91% (41/45). CONCLUSIONS: The study showed a high concordance rate between the immediate fluorescent assessment and the standard H&E and IHC assessment of the ablation zone. Given the documented prognostic value of ablation zone tissue characteristics for outcomes after ablation of CLM, the fluorescent assessment offers a potential intra-procedural biomarker of complete tumor ablation.
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Biomarcadores de Tumor/análisis , Ablación por Catéter/métodos , Neoplasias Colorrectales/patología , Fluorescencia , Neoplasias Hepáticas/secundario , Coloración y Etiquetado/métodos , Neoplasias Colorrectales/diagnóstico por imagen , Neoplasias Colorrectales/cirugía , Estudios de Seguimiento , Humanos , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/cirugía , Pronóstico , Estudios Prospectivos , Tomografía Computarizada por Rayos X/métodosRESUMEN
Small bowel adenocarcinoma (SBA) is a rare malignancy of the gastrointestinal tract that has increased in incidence across recent years. Often diagnosed at an advanced stage, outcomes for SBA are worse on average than for other related malignancies, including colorectal cancer. Due to the rarity of this disease, few studies have been done to direct optimal treatment, although recent data have shown that SBA responds to treatment differently than colorectal cancer, necessitating a separate approach to treatment. The NCCN Guidelines for Small Bowel Adenocarcinoma were created to establish an evidence-based standard of care for patients with SBA. These guidelines provide recommendations on the workup of suspected SBA, primary treatment options, adjuvant treatment, surveillance, and systemic therapy for metastatic disease. Additionally, principles of imaging and endoscopy, pathologic review, surgery, radiation therapy, and survivorship are described.