Body Composition Predictors of Complicated Crohn's Disease.

BACKGROUND: High visceral adipose tissue (VAT) and creeping fat (CrF) in Crohn's disease (CD) have been widely recognized. The VAT to subcutaneous adipose tissue (SAT) ratio and sarcopenia have been associated with CD complications. Studies regarding the influence of body composition predictors on CD complications assessed with magnetic resonance enterography (MRE) are scarce. AIM: The aim of this study was to assess body composition parameters and CrF in opportunistic MRE as predictors of complicated CD. METHODS: This was a retrospective study of 114 patients with inflammatory (n = 54) and complicated (n = 60) CD. The semiautomated assessment of body composition and the qualitative evaluation of CrF were performed. RESULTS: Body composition parameters did not differ between both groups regarding the body mass index (p = 0.50), total adipose tissue index (TATI) (p = 0.14), subcutaneous adipose tissue index (SATI) (p = 0.17), visceral adipose tissue index (VATI) (p = 0.33), VAT/SAT ratio (p = 0.77), intramuscular adipose tissue (p = 0.64), skeletal muscle index (p = 0.22), and sarcopenia (p = 0.50). 47 strictures, 18 fistulae, and seven abscesses were identified. Fistulae were more likely to occur in patients with CrF (odds ratio [OR] 5.07, 95% confidence interval [CI] 1.76-14.56; p=<0.001) and high VAT/SAT ratio (OR: 3.82, 95% CI 1.34-10.85; p = 0.01). CONCLUSION: Body composition measurements in CD patients displayed no statistically significant difference between the groups of inflammatory and complicated disease. Nonetheless, CD patients stratified in the group of high VAT/SAT ratio and the presence of CrF should be recognized as risk groups for the occurrence of fistulae.

Interstitial Brachytherapy for Hepatocellular Carcinoma: Analysis of Prognostic Factors for Overall Survival and Progression-Free Survival and Application of a Risk Stratification Model.

INTRODUCTION: Interstitial brachytherapy (iBT) is an effective treatment for hepatocellular carcinoma (HCC). Identification of prognostic factors is pivotal for patient selection and treatment efficacy. This study aimed to assess the impact of low skeletal muscle mass (LSMM) on overall survival (OS) and progression-free survival (PFS) of iBT in patients with HCC. METHODS: For this single-center study, we retrospectively identified 77 patients with HCC who underwent iBT between 2011 and 2018. Follow-up visits were recorded until 2020. The psoas muscle area, psoas muscle index, psoas muscle density (MD), and the skeletal muscle gauge were assessed on the L3 level on pre-treatment cross-sectional CT scans. RESULTS: Median OS was 37 months. 42 patients (54.5%) had LSMM. An AFP level of >400 ng/ml (hazard ratio [HR] 5.705, 95% confidence interval [CI]: 2.228-14.606, p = 0.001), BCLC stage (HR 3.230, 95% CI: 0.972-10.735, p = 0.026), and LSMM (HR 3.365, 95% CI: 1.490-7.596, p = 0.002) showed a relevant association with OS. Weighted hazard ratios were used to form a predictive risk stratification model with three groups: patients with low risk (median OS 62 months), intermediate risk (median OS 31 months), and high risk (median OS 9 months). The model showed a good prediction of 1-year mortality, with an AUC of 0.71. Higher MD was associated with better PFS (HR 0.920, 95% CI: 0.881-0.962, p < 0.001). CONCLUSION: In patients undergoing iBT for HCC, LSMM is associated with worse OS. A risk stratification model based on LSMM, AFP >400 ng/mL, and BCLC stage successfully predicted patient mortality. The model may support and enhance patient selection.

Local ablation of hepatocellular carcinoma by interstitial brachytherapy: prediction of outcome by diffusion-weighted imaging.

BACKGROUND: Interstitial brachytherapy (iBT) has become a viable treatment option in the therapy of early and intermediate stage hepatocellular carcinoma (HCC). Prognostic imaging tools to predict patient outcome are missing. PURPOSE: To assess the predictive value of baseline diffusion-weighted imaging in HCC before iBT with regard to local tumor control and overall survival (OS). MATERIAL AND METHODS: We retrospectively identified 107 patients who underwent iBT for HCC from 2011 to 2018 from our database. Apparent diffusion coefficient (ADC) values for each treated lesion were analyzed in region of interest measurements. Additionally, explorative combined ratios adjusting total measured lesion area and mean measured lesion area per patient by ADC values were calculated. Measurements underwent a univariate and multivariate Cox regression analysis. The log rank test was then used to verify prognostic cutoff levels for median survival time. RESULTS: A total of 189 lesions in 81 patients were measured. Median survival of patients was 46.0 months. Neither ADC parameter was indicative of local tumor control. Lesion size >5 cm was associated with lower local tumor control (hazard ratio [HR]=4.292, 95% confidence interval [CI]=1.285-14.331; P = 0.018). Average measured lesion area divided by ADCmin (ADCarea mean, min) was identified to independently predict OS (HR=1.994, 95% CI=1.172-3.392; P = 0.011). A cutoff based on the variable's median (0.29 × 10-4 AU) identified patients with poor outcome (OS 36 vs. 61 months) for lower ADCarea mean, min values as verified by the log-rank test (P = 0.040). CONCLUSION: Pre-treatment ADCarea mean, min may serve as an independent predictor of OS in patients with HCC undergoing iBT.

Cholecystitis induced by Yttrium-90 radioembolization of advanced liver tumors: prospective evaluation of a management algorithm in 197 consecutive patients.

BACKGROUND: Cholecystitis is a rare but dolorous complication after Y90-radioembolization of liver malignancies. PURPOSE: To decide the occlusion of the cystic artery (CA) to prevent cholecystitis after Y90 radioembolization using an algorithm. MATERIAL AND METHODS: In 130 patients, the gallbladder was at risk of embolization as the right liver lobe was targeted. Precautionary measures (e.g. coil occlusion of the cystic artery) were decided by enhancement of the gallbladder in pre-treatment Tc99m-MAA SPECT/CT and performed directly before Y90 radioembolization. In non-enhancing cases, the CA was left open. The outcome was determined by clinical symptoms of acute or chronic cholecystitis as well as imaging and laboratory parameters. Findings were additionally classified according to the Tokyo Guidelines of acute cholecystitis. RESULTS: Only 16 patients demonstrated enhancement of the gallbladder in Tc99m-MAA SPECT/CT. Including additional indications from angiographic findings, prophylactic measures were scheduled in 22 patients (standard of care). Thus, 121 patients were at risk of non-target embolization to the gallbladder during Y90 microsphere administration (investigative arm). Four cases (3.0%) of cholecystitis occurred by clinical presentation: two patients with onset of acute symptoms within 48 h after Y90 radioembolization ("embolic cholecystitis") and two patients with late onset of symptoms ("radiogenic cholecystitis"). The incidence of cholecystitis was not significantly more frequent without indication of precautionary measures (investigative cohort 2.9% vs. standard of care 4.7%; P = 0.53). CONCLUSION: The overall incidence of cholecystitis after Y90 radioembolization is low. Determination of cystic artery intervention using Tc99m-MAA SPECT/CT successfully balances the incidence of symptomatic cholecystitis with unnecessary vessel occlusion.

Low skeletal muscle mass and post-operative complications after surgery for liver malignancies: a meta-analysis.

PURPOSE: To assess the influence of low skeletal muscle mass (LSMM) on post-operative complications in patients with hepatic malignancies grade (Clavien Dindo ≥ 3) undergoing resection. METHODS: MEDLINE, Cochrane, and SCOPUS databases were screened for associations between sarcopenia and major post-operative complications (≥ grade 3 according to Clavien-Dindo classification) after resection of different malignant liver tumors. RevMan 5.3 software was used to perform the meta-analysis. The methodological quality of the included studies was assessed according to the QUIPS instrument. RESULTS: The analysis included 17 studies comprising 3157 patients. Subgroup analyses were performed for cholangiocarcinoma (CCC), colorectal cancer (CRC) liver metastases, and hepatocellular carcinoma (HCC). LSMM as identified on CT was present in 1260 patients (39.9%). Analysis of the overall sample showed that LSMM was associated with higher post-operative complications grade Clavien Dindo ≥ 3 (OR 1.56, 95% CI 1.25-1.95, p < 0.001). In the subgroup analysis, LSMM was associated with post-operative complications in CRC metastases (OR 1.60, 95% CI 1.11-2.32, p = 0.01). In HCC and CCC sub-analyses, LSMM was not associated with post-operative complications in simple regression analysis. CONCLUSION: LSMM is associated with major post-operative complications in patients undergoing surgery for hepatic metastases and it does not influence major post-operative complications in patients with HCC and CCC.

Inter- and intraobserver reliabilities and critical analysis of the osteoporotic fracture classification of osteoporotic vertebral body fractures.

PURPOSE: The Osteoporotic Fracture Working Group (Spine Division of the German Orthopaedic and Trauma Society) has developed a classification system for osteoporotic thoracolumbar fractures, namely the osteoporotic fracture (OF) classification system. The purpose of this study was to determine the inter- and intraobserver reliabilities of the OF classification system for osteoporotic vertebral body fractures (VFs) at a level-one trauma centre. METHODS: Conventional radiography, magnetic resonance imaging (MRI), and computed tomography (CT) scans of 54 consecutive women who sustained an osteoporotic VF were analysed by six orthopaedic traumatologists with varying levels of experience. The inter- and intraobserver reliabilities of the OF classification system were determined using intraclass correlation coefficients (ICCs) and Cohen's kappa. RESULTS: The overall interobserver reliability of the OF classification system was good (ICC, 0.62 [0.51, 0.72]). The intraobserver reliability was found to be substantial (overall weighted Cohen's kappa estimate [95% confidence interval {CI}] = 0.74 [0.67, 0.80]) and better when the radiography, MRI, and CT scans were assessed together than when only the radiography and MRI scans were evaluated, although the difference was not significant. CONCLUSION: The OF classification system is easy to use. It shows good interobserver reliability and substantial intraobserver reliability if diagnostic prerequisites (conventional radiography, MRI, and CT scans) are met.

Biliary duct stenosis after image-guided high-dose-rate interstitial brachytherapy of central and hilar liver tumors : A systematic analysis of 102 cases.

OBJECTIVE: Image-guided high-dose-rate interstitial brachytherapy (iBT) with iridium-192 is an effective treatment option for patients with liver malignancies. Little is known about long-term radiation effects on the bile duct system when central hepatic structures are exposed to iBT. This retrospective analysis investigates the occurrence of posthepatic cholestasis (PHC) and associated complications in patients undergoing iBT. MATERIALS AND METHODS: We identified patients who underwent iBT of hepatic malignancies and had point doses of ≥1 Gy to central bile duct structures. Patients with known bile duct-related diseases or prior bile duct manipulation were excluded. RESULTS: 102 patients were retrospectively included. Twenty-two patients (22%) developed morphologic PHC after a median of 17 (3-54) months; 18 of them were treated using percutaneous transhepatic cholangiopancreatography drainage or endoscopic retrograde cholangiopancreatography. The median point dose was 24.8 (4.4-80) Gy in patients with PHC versus 14.2 (1.8-61.7) Gy in those without PHC (p = 0.028). A dose of 20.8 Gy (biological effective dose, BED3/10 = 165/64.1 Gy) was identified to be the optimal cutoff dose (p = 0.028; 59% sensitivity, 24% specificity). Abscess/cholangitis was more common in patients with PHC compared to those without (4 of 22 vs. 2 of 80; p = 0.029). Median survival did not differ between patients with and without PHC (43 vs. 36 months; p = 0.571). CONCLUSION: iBT of liver malignancies located near the hilum can cause PHC when the central bile ducts are exposed to high point doses. Given the long latency and absence of impact of iBT-induced PHC on median survival, the rate of cholestasis and complications seen in our patients appears to be acceptable.

Transarterial embolisation for the treatment of acute gynecological cancer bleeding.

PURPOSE: Acute bleeding in patients with gynecological cancer may result in serious life-threatening complications. In these situations, immediate diagnostic and appropriate treatment is a challenge for attending physicians. Accordingly, transarterial embolisation (TAE) has been described as an increasing and effective treatment alternative to surgery and radiotherapy. METHODS: In the present retrospective study, 25 patients were included who underwent a TAE in the period from January 2006 to June 2013 due to acute gynecological cancer bleeding. The objective of this study was to assess the efficiency and outcome of TAE. RESULTS: The primary technical success rate was 92.0% (n = 23). 21 patients were analyzed in the 30-day follow-up. The clinical success rate was achieved in 90.5% (n = 19). A clinical failure due to rebleeding was observed in 9.5% (n = 2). No associations were revealed between rebleeding and technical/clinical factors. Within 30 days after the last TAE, the complication and mortality rates were 0.0% and 5.0% (n = 1), respectively. CONCLUSION: TAE was found as an effective and safe treatment in the clinical setting of acute gynecological cancer bleeding. An important component of efficient management is an early and interdisciplinary care. Optimal treatment can be achieved by close cooperation between gynecologists, radiotherapists and interventional radiologists.

Local ablation or radioembolization of colorectal cancer metastases: comorbidities or older age do not affect overall survival.

BACKGROUND: Local ablative techniques are emerging in patients with oligometastatic disease from colorectal carcinoma, commonly described as less invasive than surgical methods. This single arm cohort seeks to determine whether such methods are suitable in patients with comorbidities or higher age. METHODS: Two hundred sixty-six patients received radiofrequency ablation (RFA), CT-guided high-dose rate brachytherapy (HDR-BT) or Y90-radioembolization (Y90-RE) during treatment of metastatic colorectal cancer (mCRC). This cohort comprised of patients with heterogenous disease stages from single liver lesions to multiple organ systems involvement commonly following multiple chemotherapy lines. Data was reviewed retrospectively for patient demographics, previous therapies, initial or disease stages at first intervention, comorbidities and mortality. Comorbidity was measured using the Charlson Comorbidity Index (CCI) and age-adjusted Charlson Index (CACI) excluding mCRC as the index disease. Kaplan-Meier survival analysis and Cox regression were used for statistical analysis. RESULTS: Overall median survival of 266 patients was 14 months. Age ≥ 70 years did not influence survival after local therapies. Similarly, CCI or CACI did not affect the patients prognoses in multivariate analyses. Moderate or severe renal insufficiency (n = 12; p = 0.005) was the only single comorbidity identified to negatively affect the outcome after local therapy. CONCLUSION: Interventional procedures for mCRC may be performed safely even in elderly and comorbid patients. In severe renal insufficiency, the use of invasive techniques should be limited to selected cases.

Small renal carcinoma: the "when" and "how" of operation, active surveillance, and ablation.

Small, locally restricted renal cell carcinoma less than 4 cm in size should ideally be removed operatively by nephron-sparing tumour enucleation (partial kidney resection). In an increasingly elderly population, there is a growing trend toward parallel incidence of renal cell carcinoma and chronic renal insufficiency, with the latter's associated general comorbidities. Thus, for some patients, the risks of the anaesthesia and operation increase, while the advantage in terms of survival decreases. Transcutaneous radio-frequency ablation under local anaesthesia, transcutaneous afterloading high-dose-rate brachytherapy under local anaesthesia, and percutaneous stereotactic ablative radiotherapy may offer a less invasive alternative therapy. Active surveillance is to be regarded as no more than a controlled bridging up to definitive treatment (operation or ablation), while watchful waiting, on account of the lack of prognostic relevance and the symptomatology of renal cell carcinoma, with its comorbidity-related, clearly reduced life expectancy, does not involve any further diagnostic or therapeutic measures.

Radioablation of liver malignancies with interstitial high-dose-rate brachytherapy : Complications and risk factors.

BACKGROUND: To evaluate complications and identify risk factors for adverse events in patients undergoing high-dose-rate interstitial brachytherapy (iBT). MATERIAL AND METHODS: Data from 192 patients treated in 343 CT- or MRI-guided interventions from 2006-2009 at our institution were analyzed. In 41 %, the largest tumor treated was ≥ 5 cm, 6 % of the patients had tumors ≥ 10 cm. Prior to iBT, 60 % of the patients had chemotherapy, 22 % liver resection, 19 % thermoablation or transarterial chemoembolization (TACE). Safety was the primary endpoint; survival data were obtained as the secondary endpoints. During follow-up, MRI or CT imaging was performed and clinical and laboratory parameters were obtained. RESULTS: The rate of major complications was below 5 %. Five major bleedings (1.5 %) occurred. The frequency of severe bleeding was significantly higher in patients with advanced liver cirrhosis. One patient developed signs of a nonclassic radiation-induced liver disease. In 3 patients, symptomatic gastrointestinal (GI) ulcers were detected. A dose exposure to the GI wall above 14 Gy/ml was a reliable threshold to predict ulcer formation. A combination of C-reactive protein ≥ 165 mg/l and/or leukocyte count ≥ 12.7 Gpt/l on the second day after the intervention predicted infection (sensitivity 90.0 %; specificity 92.8 %.) Two patients (0.6 %) died within 30 days. Median overall survival after the first liver treatment was 20.1 months for all patients and the local recurrence-free surviving proportion was 89 % after 12 months. CONCLUSIONS: Image-guided iBT yields a low rate of major complications and is effective.

Y90 Radioembolization in chemo-refractory metastastic, liver dominant colorectal cancer patients: outcome assessment applying a predictive scoring system.

BACKGROUND: In treatment-refractory liver dominant metastatic colorectal cancer, the role of liver directed therapies still is unclear. We sought to determine a prognostic score for Y90 radioembolization in these patients. METHODS: We analyzed 106 patients with refractory liver dominant mCRC who had undergone a total of 178 Y90 radioembolizations with resin microspheres was collected. Potential factors influencing survival were analyzed using a Cox regression. The Log rank test served to establish prognostic factors and to form a clinical score for outcome prediction after Y90 radioembolization. RESULTS: Median survival of all patients was 6.7 months. Neither age nor prior surgical or systemic therapy nor metastatic spread had an effect on survival. In contrast, hepatic tumor load, Karnofsky index as well as CEA and CA19-9 serums level had a significant influence (p < 0.001, p = 0.037, p = 0.023 and p < 0.001, respectively). These three factors formed a score with 1 point each for tumor load >20 %, CEA >130 ng/ml or CA19-9 > 200U/ml and Karnofsky index <80 %. Patients with a score of 0 and 1 displayed a median OS of 10.4 months. Patients with a score of 2 and 3 demonstrated a median OS of 5.1 months only (p < 0.001). CONCLUSION: Overaggressive patient selection for Y90 radioembolization of liver dominant chemorefractory mCRC is of questionable benefit. A scoring system comprising hepatic tumor load, CEA and CA19-9 serum levels and Karnofsky index (TuCK-score) may support an improved patient selection. In our cohort of liver only versus liver dominant disease, extrahepatic lung or lymphatic metastases did not significantly alter the prognosis.

Improvement of Contrast Media Enhancement in CTA Evaluating Pulmonary Embolism by Utilizing 'Delayed' Bolus Tracking in the Descending Aorta.

BACKGROUND: As standard bolus triggering in the pulmonary trunk sometimes fails to achieve sufficient enhancement in the pulmonary arteries, the study investigates an alternative, 'delayed' position of the tracking ROI in the descending aorta. MATERIAL/METHODS: Retrospective analysis of 143 patients suspected of pulmonary embolism investigated with 3 different scanners (16 to 80 rows) in clinical routine. Bolus triggering with 120 hounsfield units (HU) was performed using the pulmonary trunk (n=70) or descending aorta (n=73) after application of 70 to 120 mL of contrast agent, Iomeprol 300. Student's t-test was applied to compare vascular enhancement. Additional factors were analysed by a regression analysis. RESULTS: Positioning of the tracking ROI in the descending aorta achieved a significantly higher contrast enhancement in the pulmonary trunk with a mean increase of 63 HU (p<0.001). CONCLUSIONS: In CTA, delayed acquisition by using the descending aorta for bolus triggering can improve the enhancement of the pulmonary trunk to investigate a pulmonary embolism. Furthermore, the scan protocol simultaneously allows to rule out aortic pathologies as an alternative cause for a similar clinical condition.

Left-liver hypertrophy after therapeutic right-liver radioembolization is substantial but less than after portal vein embolization.

UNLABELLED: In patients with liver malignancies potentially amenable to curative extended right hepatectomy but insufficient size of the future liver remnant (FLR), portal vein embolization (PVE) of the tumor-bearing liver is used to induce contralateral liver hypertrophy but leaves the tumor untreated. Radioembolization (RE) treats the tumor in the embolized lobe along with contralateral hypertrophy induction. We performed a matched-pair analysis to compare the capacity for hypertrophy induction of these two modalities. Patients with right-hepatic secondary liver malignancies with no or negligible left-hepatic tumor involvement who were treated by right-lobar PVE (n = 141) or RE (n = 35) at two centers were matched for criteria known to influence liver regeneration following PVE: 1) baseline FLR/Total liver volume ratio (<25 versus ≥ 25%); 2) prior platinum-containing systemic chemotherapy; 3) embolization of segments 5-8 versus 4-8; and 4) baseline platelet count (<200 versus ≥ 200 Gpt/L).The primary endpoint was relative change in FLR volume from baseline to follow-up. Twenty-six matched pairs were identified. FLR volume increase from baseline to follow-up (median 33 [24-56] days after PVE or 46 [27-79] days after RE) was significant in both groups but PVE produced significantly more FLR hypertrophy than RE (61.5 versus 29%, P < 0.001). Time between treatment and follow-up was not correlated with the degree of contralateral hypertrophy achieved in both groups. Although group differences in patient history and treatment setting were present and some bias cannot be excluded, this was minimized by the matched-pair design, as remaining group differences after matching were found to have no significant influence on contralateral hypertrophy development. CONCLUSION: PVE induces significantly more contralateral hypertrophy than RE with therapeutic (nonlobectomy) doses. However, contralateral hypertrophy induced by RE is substantial and RE minimizes the risk of tumor progression in the treated lobe, possibly making it a suitable modality for selected patients.

Sarcopenia does not limit overall survival in patients with colorectal liver metastases undergoing interstitial brachytherapy.

PURPOSE: Several studies report an association of sarcopenia with survival in oncologic patients. The aim of this study is to assess the influence of sarcopenia on overall survival (OS) in patients with colorectal liver metastases undergoing interstitial brachytherapy (iBT) METHODS: We identified 144 patients with colorectal liver metastases from our database from 2014-2017. Computed tomography (CT) chest scans at the L3 level were retrospectively analyzed. Psoas muscle area (PMA), psoas muscle index (PMI), and skeletal muscle gauge (SMG) were measured on the CT scan before treatment. Parameters were associated with overall survival. RESULTS: 116 patients were included. Median overall survival was 27 months. Median PMA was 13.79 cm2, median PMI 4.51 cm2/m2. Neither PMA (HR 1.036, 95 % CI 0.996-1.078, p = 0.080), PMI (HR 1.068, 95 % CI 0.922-1.238, p = 0.382), nor SMG (HR 1.00, 95 % CI 0.998-1.003, p = 0.955) were significantly associated with overall survival. CONCLUSION: Sarcopenic patients undergoing iBT for colorectal liver metastases did not show decreased overall survival. If confirmed by comparative studies, sarcopenia may serve as a biomarker for treatment decision in patients with CRLM. KEY POINTS: Sarcopenia is not a risk factor for survival in patients with CLRM undergoing iBT. CITATION FORMAT: · Thormann M, Heitmann F, Wrobel V et al. Sarcopenia does not limit overall survival in patients with colorectal liver metastases undergoing interstitial brachytherapy. Fortschr Röntgenstr 2023; 195: 217 - 223.

Parameters of body composition and creeping fat are associated with activity of Crohn's disease.

AIM: This study aimed at assessing body composition parameters, creeping fat (CrF), and Crohn's disease's (CD) activity based on the Magnetic Resonance Index of Activity (MaRIA). METHODS: 114 CD patients who underwent magnetic resonance enterography (MRE) between June 2010 and April 2020 were retrospectively assessed. The semi-automated body composition segmentation, the qualitative evaluation of CrF, and MaRIA were performed. Based on their MaRIA score, patients were divided into two groups: mild-to-moderate disease (MaRIA <11, n = 50) and severe disease (MaRIA ≥11, n = 64). MRE parameters were analyzed between both groups. Patients were dichotomized according to body composition categories and the presence of CrF. Univariate regression analyses were performed to investigate the association between dichotomized variables and severe disease. Significant variables were incorporated into the multivariate logistic regression model. RESULTS: The severe disease group exhibited higher serum C-reactive protein (CRP) levels compared to the mild-to-moderate disease group (p ≤0.001). In the mild-to-moderate disease group, a higher proportion of patients had a body mass index (BMI) ≥ 25 (kg/m2) (32.0%) compared to the severe disease group (16.5%) (p = 0.04). The subcutaneous adipose tissue index (SATI) was significantly higher in the mild-to-moderate disease group (p = 0.04). The visceral to subcutaneous adipose tissue (VAT/SAT) ratio tended to be higher in the severe disease group (p = 0.09). There was no significant difference between both groups regarding total adipose tissue index (TATI) (p = 0.10), visceral adipose tissue index (VATI) (p = 0.51), intramuscular adipose tissue index (IMATI) (p = 0.38), skeletal muscle index (SMI) (p = 0.83), and sarcopenia (p = 0.75). In the multivariate analysis, CrF was significantly associated with severe disease (odds ratio [OR] 11.50, 95% confidence interval [CI] 3.13-42.17; p ≤0.001). Additionally, a BMI ≥ 25 (kg/m2) was protective against severe disease (OR: 0.34, 95% CI 0.12-0.95; p = 0.04). CONCLUSION: CrF is significantly associated with CD activity.

Prevention of radiation-induced liver toxicity after interstitial HDR brachytherapy by pentoxifylline and ursodeoxycholic acid: patient compliance and outcome in a randomized trial.

AIM: To investigate the impact of pentoxifylline (PTX, 3 × 400 mg per day) and ursodeoxycholic acid (UDCA, 3 × 250 mg per day) administered for 12 weeks on radiation-induced liver toxicity. MATERIALS AND METHODS: Inclusion criteria were liver metastases of extrahepatic malignancies undergoing HDR-BT. 36 patients were prospectively randomized to the medication (N = 18) or control arm (N = 18) and follow-up by hepatobiliary magnetic resonance imaging (MRI) was scheduled 6 and 12 weeks after local ablation by HDR-BT. We determined the threshold doses of fRILI by image fusion of MRI with the dosimetry data. RESULTS: 32 patients completed the study schedule. Per-protocol treatment was limited to 8 patients in the medication group and 16 patients in the control group. 22 adverse events of any grade likely or certainly related to PTX were recorded in 12 patients leading to the discontinuation of the study medication in 7 patients and to a dose reduction of PTX in 2 patients. In the per-protocol population, statistical analysis failed to prove a reduction of fRILI 6 and 12 weeks after HDR-BT. The incidence of adverse effects attributed to PTX (70.6%) was well above the data found in the literature for its approved indication. CONCLUSION: The study endpoint was not met mainly attributed to the low statistical power of the small per-protocol cohort. Independently, PTX cannot be recommended for the reduction of radiation-induced liver toxicity in oncologic patients undergoing HDR-BT of liver metastases. Further studies might focus on a combination of UDCA with other potential drugs to help establish a preventive and tolerable regimen.

Local tumor control of intermediate and advanced stage hepatocellular carcinoma after local ablative treatment with image-guided interstitial high-dose-rate brachytherapy: A subgroup analysis of 286 HCC nodules.

PURPOSE: Image-guided interstitial high-dose-rate brachytherapy (iBT) has been demonstrated to offer high local tumor control rates (LTC) of >90% after local ablation of intermediate and advanced hepatocellular carcinoma (HCC; BCLC B and C). The purpose of this study was to show the efficacy of iBT stratified by subgroups and to identify clinical characteristics associated with superior local tumor control (LTC) based on a highly heterogenous patient population METHODS AND MATERIALS: A cumulative number of 286 HCC nodules in 107 patients were retrospectively analyzed. Clinical and imaging follow-ups were conducted every 3 months after treatment. Analyzed clinical factors were: etiology, presence of liver cirrhosis, radiographic features, lesion size, pretreatment, administered dose, presence of portal hypertension, portal vein thrombosis, and level of alpha-fetoprotein (AFP). RESULTS: LTC rate was 88.8% for a median follow-up of 14.3 months (range 3-81 months; 95% CI: 85-92%). Median minimal enclosing tumor dose (D100) was 16.1 Gy (range 7.1-30.3 Gy; reference dose 15 Gy). Subgroup analysis showed significant fewer local recurrences for alcoholic liver disease (ALD)-related HCCs compared to those related to other causes of liver cirrhosis (nonalcoholic fatty liver disease, virus-related liver cirrhosis and other causes) (p = 0.015). LTC was significantly lower after prior surgical resection (p = 0.046). No significant variance was observed for the applied D100 in each group or for all other clinical factors tested. CONCLUSIONS: IBT achieves high LTC rates across treated subgroups. However, further studies should particularly address the possible impact of underlying etiology on local recurrence with emphasis on a possible higher radiosensitivity of ALD-related HCCs.

Chronic Mesenteric Ischemia: Differential Vascularsurgical Therapy and Its Outcome in a Single-Center Observational Study.

Aim: The aim of this study was to investigate short-/long-term vascularsurgical patency and the outcome in chronic mesenteric ischemia (CMI) depending on the mesenteric revascularization technique and reflecting real-world data. Methods: This retrospective single-center observational study registered all patients who had undergone open vascularsurgical reconstruction because of CMI at a tertiary German university hospital comparing 1-versus (vs.) 2-vessel as well as antegrade versus retrograde reconstructions. Results: In total, 35 patients were enrolled (mean [± SD] age, 64 ± 13 [range, 45-83] years; sex ratio [m:f], 16:19 [46:54]) over 12 years. Three patients with symptoms of mesenteric ischemia because of rare causes (radiation-induced and median arcuate ligament syndrome) have been excluded. While 51% of patients underwent 1-vessel reconstruction, 49% underwent 2-vessel reconstruction. There was a trend of (i) more perioperative complications in the 2-vessel group (88.2% vs. 55.6%, p = 0.06) and (ii) higher morbidity at 1 year in the 2-vessel versus 1-vessel group (57.1% and 42.9%, respectively; p = 0.466), while the morbidity of the 2-vessel versus 1-vessel group at 5 years (100% vs. 33.3%) was significantly different (p = 0.009). The mortality was greater in the 2-vessel versus 1-vessel group as it was significantly different in the early postoperative period (31.3% vs. 0, p = 0.016) and at 1 year (50% vs. 0, p = 0.005) and 5 years (100% vs. 11%, p = 0.003). Regarding overall survival, the 1-vessel group showed a significant superiority above the 2-vessel group (p = 0.004). Actually, there was no significant difference of early postoperative morbidity comparing the retrograde and antegrade group (p = 0.285) as well as at 1 year and 5 years (p = 0.715 and p = 0.620, respectively). In addition, there was no significantly different postoperative mortality in antegrade versus retrograde group at each time. Specific and general complication rates were 62.9% and 57.1%, respectively, resulting in an overall morbidity of 77.1% (mortality, 20%). Conclusion: The vascular surgeon should be prepared to perform various procedures of mesenteric reconstruction to tailor the operative strategy to the specific needs of the individual patient.

Needle track seeding in colorectal carcinoma after local ablation by high-dose-rate brachytherapy: a retrospective study of 1,107 catheter placements.

Purpose: Image-guided brachytherapy with a single-fraction irradiation (high-dose-rate brachytherapy - HDR-BT) is a promising local ablation technique for unresectable liver metastases. The occurrence of needle track seeding after biopsy and microwave ablation (MWA) has been documented primarily in hepatocellular carcinoma (HCC). Comprehensive data on colorectal metastases and treatment with HDR-BT is missing. The aim of this study was to investigate the incidence of extra- and intra-hepatic track seeding after HDR-BT in patients with colorectal metastases of the liver, and the identification of possible risk factors. Material and methods: Patients with at least one treatment of HDR-BT were included. Two readers identified possible track seeding after at least 3 months of follow-up. For verification, we used image fusion of CT/MRI images from 3D irradiation plan and follow-up. Intra- and extra-hepatic seeding were included. As possible risk factors, demographics, tumor grading, and aspects of catheter placement were identified, and generalized linear mixed model for evaluation was applied. Results: On total, 138 patients were included in the study (85 males). We treated 472 liver lesions with 1,107 catheter placements. Sixteen needle track lesions were identified with a catheter-based risk of 1.5% and patient-based risk of 10.9% during a median follow-up of 543 days. Extra-hepatic track seeding (patient-based risk of 1.4%) was found in two patients only. Possible risk factors were tumor grading (p = 0.01) and using MRI-guidance (p = 0.02). There was also a correlation with a high number of interventions per patient (p = 0.009) and number of treated lesions (p = 0.04). Conclusions: Brachytherapy for treatment of colorectal metastases is associated with a similar risk for extra-hepatic track seeding compared to radio-frequency ablation (RFA). Intra-hepatic seeding, which has not been studied extensively before, occurs more often with seeding frequency comparable to biopsy of colorectal metastases. Possible risk factors could be tumor grading and using MRI-guidance.