A global evaluation of advanced dosimetry in transarterial radioembolization of hepatocellular carcinoma with Yttrium-90: the TARGET study.

PURPOSE: To investigate the relationships between tumor absorbed dose (TAD) or normal tissue absorbed dose (NTAD) and clinical outcomes in hepatocellular carcinoma (HCC) treated with yttrium-90 glass microspheres. METHODS: TARGET was a retrospective investigation in 13 centers across eight countries. Key inclusion criteria: liver-dominant HCC with or without portal vein thrombosis, < 10 tumors per lobe (at least one ≥ 3 cm), Child-Pugh stage A/B7, BCLC stages A-C, and no prior intra-arterial treatment. Multi-compartment pre-treatment dosimetry was performed retrospectively. Primary endpoint was the relationship between ≥ grade 3 hyperbilirubinemia (such that > 15% of patients experienced an event) without disease progression and NTAD. Secondary endpoints included relationships between (1) objective response (OR) and TAD, (2) overall survival (OS) and TAD, and (3) alpha fetoprotein (AFP) and TAD. RESULTS: No relationship was found between NTAD and ≥ grade 3 hyperbilirubinemia, which occurred in 4.8% of the 209 patients. The mRECIST OR rate over all lesions was 61.7%; for the target (largest) lesion, 70.8%. Responders and non-responders had geometric mean total perfused TADs of 225.5 Gy and 188.3 Gy (p = 0.048). Probability of OR was higher with increasing TAD (p = 0.044). Higher TAD was associated with longer OS (HR per 100 Gy increase = 0.83, 95% CI: 0.71-0.95; p = 0.009). Increased TAD was associated with higher probability of AFP response (p = 0.046 for baseline AFP ≥ 200 ng/mL). CONCLUSION: Real-world data confirmed a significant association between TAD and OR, TAD and OS, and TAD and AFP response. No association was found between ≥ grade 3 hyperbilirubinemia and NTAD. TRIAL REGISTRATION NUMBER: NCT03295006.

Bronchial artery enlargement may be the cause of recurrent haemoptysis in Behçet's syndrome patients with pulmonary artery involvement during follow-up.

OBJECTIVES: Haemoptysis occurring in a Behçet's syndrome (BS) patient with pulmonary artery involvement (PAI) during follow-up is usually regarded as PAI relapse. However, bronchial artery enlargement (BAE) may be the source of haemoptysis in some patients. METHODS: A chart review at the end of December 2014 revealed 118 patients with PAI in our centre since 1979. Nine (all men) had recurrent haemoptysis during follow-up which could not be explained with relapse of PAI. RESULTS: Haemoptysis recurred a median of 1.5 years (IQR: 9 months-5 years) during follow-up. Thorax CT scans did not show relapse of PAI or emergence of BAE. The patients were treated empirically but continued to complain of occasional haemoptysis thereafter. BAE was detected in 8 patients after a median follow-up of 9 years (IQR: 5-12 years). Six patients underwent bronchial artery embolisation that was repeated in 3. One patient with severe pulmonary hypertension died 3 weeks later. The remaining 5 are under follow-up for between 5 months-9 years. Pulmonary infarction and mild hemiparesis occurred in 2 patients after embolisation. One patient died with haemoptysis before undergoing embolisation. Another one with small BAE is under follow-up for 8 years without embolisation. The source of bleeding could not be determined in 1 patient who is now haemoptysis free for 5 years. CONCLUSIONS: BAE may be the source of recurring and fatal haemoptysis in BS patients with PAI during follow-up. Embolisation appears to be a life-saving procedure.

A Post-International Gastrointestinal Cancers' Conference (IGICC) Position Statements.

Hepatocellular carcinoma (HCC), the most prevalent liver tumor, is usually linked with chronic liver diseases, particularly cirrhosis. As per the 2020 statistics, this cancer ranks 6th in the list of most common cancers worldwide and is the third primary source of cancer-related deaths. Asia holds the record for the highest occurrence of HCC. HCC is found three times more frequently in men than in women. The primary risk factors for HCC include chronic viral infections, excessive alcohol intake, steatotic liver disease conditions, as well as genetic and family predispositions. Roughly 40-50% of patients are identified in the late stages of the disease. Recently, there have been significant advancements in the treatment methods for advanced HCC. The selection of treatment for HCC hinges on the stage of the disease and the patient's medical status. Factors such as pre-existing liver conditions, etiology, portal hypertension, and portal vein thrombosis need critical evaluation, monitoring, and appropriate treatment. Depending on the patient and the characteristics of the disease, liver resection, ablation, or transplantation may be deemed potentially curative. For inoperable lesions, arterially directed therapy might be an option, or systemic treatment might be deemed more suitable. In specific cases, the recommendation might extend to external beam radiation therapy. For all individuals, a comprehensive, multidisciplinary approach should be adopted when considering HCC treatment options. The main treatment strategies for advanced HCC patients are typically combination treatments such as immunotherapy and anti-VEGFR inhibitor, or a combination of immunotherapy and immunotherapy where appropriate, as a first-line treatment. Furthermore, some TKIs and immune checkpoint inhibitors may be used as single agents in cases where patients are not fit for the combination therapies. As second-line treatments, some treatment agents have been reported and can be considered.

Cross-sectional area of the labrum: role in the diagnosis of anterior acetabular labral tears.

OBJECTIVE: To investigate the utility of ultrasound cross-sectional area (CSA) measurements for diagnosing acetabular labral (AL) tears. METHODS: The study included qualitative/quantitative ultrasound examinations of 55 hips in 52 patients with a presumed diagnosis of AL tear and 56 hips in 28 healthy volunteers. MR arthrography examinations were available only for the patients and were reviewed for the presence of AL thickening and tear. RESULTS: The CSA of the anterior labrum was significantly larger in patients with an AL tear on MR arthrography than those in healthy volunteers (P < 0.01). The CSA cut-off value in determining labral thickening that maximises accuracy was 34.7 mm(2), and sensitivity, specificity and accuracy were 86.7%, 74.1% and 77.5%. Direct signs of AL tear on ultrasound had sensitivity, specificity and accuracy of 34.9%, 91.7% and 47.3%. The CSA cut-off value that maximises the accuracy of the AL tear was 40.6 mm(2), and sensitivity, specificity and accuracy were 58.1%, 91.2% and 78.4%. CONCLUSIONS: Ultrasound detects the thickened labrum frequently observed in MR arthrography studies, especially in patients with dysplastic hips. Although specificity of the method of detecting AL tears is high, sensitivity is low, with an overlap between subjects with AL tear and controls. KEY POINTS: • Labral degeneration is frequent in dysplastic hips • Thickened labra are frequently observed on MR arthrograms • Labral thickening can be depicted by quantitative ultrasound measurements • The sensitivity is low with overlap between subjects with AL tear and controls.

The use of Onyx for embolization of peripheral vascular malformations in pediatric patients.

PURPOSE: The management of congenital peripheral vascular malformations (VMs) can present a difficult therapeutic challenge. Endovascular transcatheter embolization of peripheral VMs is widely accepted as a first therapeutic option for many VMs. However, data describing the use of Onyx are limited in children with peripheral VMs. Our aim is to retrospectively evaluate the results of transcatheter arterial embolization with Onyx for peripheral VMs in children. MATERIALS AND METHODS: We analyzed clinical and imaging records of 16 patients who underwent 25 embolization procedures by using Onyx for peripheral VMs. In eight cases, embolization procedures were performed once; in seven cases, twice; and in one case, thrice. RESULTS: Embolization was technically complete in 4 patients and incomplete in 12 patients. Clinically, complete success was achieved in nine patients, and partial success was achieved in six patients. In one patient, reflux to the anterior and posterior tibial arteries caused peripheral ischemia, and the patient was referred to undergo plastic surgery. There were no complications in the other 15 patients. CONCLUSION: With future studies to better characterize the safety profile of this agent in peripheral vasculature, embolization with Onyx may become a valuable treatment option for peripheral VMs in pediatric patients.

Posttraumatic high-flow priapism in children treated with autologous blood clot embolization: long-term results and review of the literature.

BACKGROUND: Usually high-flow priapism is caused by perineal or penile blunt trauma with direct cavernosal artery injury and formation of an arterial-lacunar fistula. Rarely, cavernosal artery injury may result from penetrating trauma. Treatment of high-flow priapism is not considered an emergency because patients are at low risk for permanent complications. For this type of priapism there are several options for treatment including embolization or surgical ligation. OBJECTIVE: To describe the technique of superselective transcatheter embolization with the use of autologous blood clot and to discuss the long-term results. MATERIALS AND METHODS: Seven children with a mean age of 10 years suffering from high-flow priapism were treated with superselective transcatheter embolization with autologous blood clot. In all cases, colour Doppler US was performed to demonstrate increased cavernous blood flow with definitive diagnosis established by superselective arteriography. After the angiographic diagnosis, superselective transcatheter embolization of the fistula with autologous blood clot was performed during the same session. The children were followed up on a monthly basis up to 1 year with clinical findings and penile colour Doppler US examinations. After 1 year, they were followed up annually with clinical assessment only. The mean follow-up period was 6.0 years. RESULTS: Following embolization complete detumescence was achieved in all but one child, who was treated with a second embolization 3 d after the initial session. In addition, for one child a second session of embolization was performed due to the recurrence of partial erection during the 1 week period after the initital embolization. In both cases, complete detumescence was achieved after the second embolization, and no recurrence of priapism was observed in the follow-up period. CONCLUSION: Selective arterial embolization with autologous clot achieved treatment for high-flow priapism in this study with 100% occlusion rate with a maximum of two sessions and no signs of erectile dysfunction were observed in any of the children during long-term follow-up.

Percutaneous sclerotherapy of peripheral venous malformations in pediatric patients.

PURPOSE: To report the efficacy of percutaneous puncture and sclerosis using polidocanol in the treatment of venous malformations (VMs) in pediatric patients. PATIENTS/METHODS: Between March 2007 and February 2011, a series of 19 patients with VMs on the upper and lower extremities had undergone a total of 89 sessions of intralesional sclerotherapy using polidocanol. All the procedures were performed in an angiographic suite under general anesthesia in order to maintain sedation for facilitating the procedure. For each injection, approximately 1 ml of 2% polidocanol was injected for each centimeter of the diameter of the lesion, with a maximum of 6 ml. Injection of the sclerosant was guided by real-time sonography and fluoroscopy. RESULTS: After the treatment, the symptoms completely resolved in four patients (21%). Clinical symptoms, such as bulging and pain were improved in 12 out of 19 patients (63%). They remained unchanged in three patients (16%). During the procedures, no major complications were encountered. The minor complications (65%) encountered were swelling and pain after treatment which were resolved by taking NSAID within a few days. CONCLUSION: In pediatric patients, sonographically guided percutaneous puncture and fluoroscopically guided sclerosis using 2% polidocanol is effective, less invasive and safe for the treatment of VMs, with a high success rate and minimal complications.

The position of transarterial chemoembolization with drug-eluting beads and yttrium-90 transarterial radioembolization in patients with hepatocellular carcinoma: Consensus statements from a Delphi-method expert panel in Turkey.

PURPOSE: Clinical studies conducted in different geographic regions using different methods to compare transarterial chemoembolization (TACE) and transarterial radioembolization (TARE) have demonstrated discordant results. Meta-analyses in this field indicate comparable overall survival (OS) with TACE and TARE, while reporting a longer time to progression and a higher downstaging effect with TARE treatment. In terms of isolated procedure costs, treatment with TARE is 2 to 3 times more, and in some countries even more, expensive than TACE. However, relevant literature indicates that TARE is more advantageous compared to TACE regarding the need for repeat procedures, costs of complication management, total hospital stay and quality of life. Heterogeneity of hepatocellular carcinoma (HCC) patients as well as the shortcomings of clinical classifications, randomized clinical trials and cost-effectiveness studies make it difficult to choose between treatment alternatives in this field. As in other countries, these challenges lead to differences in treatment choice across different centers in Turkey. METHODS: The present expert panel used two round modified Delphi method to investigate the resources and clinical parameters referenced while selecting patients for drug-eluting beads (DEB)-TACE and TARE treatment modalities in Turkish clinical practice. The cost-effectiveness parameters and comparisons of these treatments have also been evaluated at a prediction level. RESULTS: The panelists stated that they most commonly use the BCLC staging system for the management of HCC patients in Turkey. However, they did not find any of the staging systems or treatment guidelines sufficient enough for their clinical practice in terms of covering the down-staging intent of treatments. Since living donor transplant preference is higher in Turkey than the rest of the Western countries, down-staging treatments are thought to be more prioritized in Turkey than that in other Western countries. The panelists reached a consensus that TARE may provide improved OS and reduce the number of repeat procedures compared to DEB-TACE in intermediate-stage patients with a single tumor spanning a diameter above 5 cm who experience recurrence after previous treatment with TACE and most TACE-naïve patient groups in intermediate stage. CONCLUSION: Based on the consensus on OS and the number of procedures, the panelists assumed that TARE would be more cost-effective than DEB-TACE in most groups of TACE-naïve patients in intermediate stage and in those with a single tumor spanning a diameter above 5 cm. It was also stated that the predicted cost-effectiveness advantage of TARE could be more pronounced in patients with a tumor diameter greater than 7 cm.

Oxidized LDL and anti-oxLDL antibody levels in peripheral atherosclerotic disease.

OBJECTIVE: Oxidative modification of LDL (oxLDL) is important in atherogenesis and is proposed as a useful marker for identifying patients with coronary artery disease. Antibody to oxLDL (oxLDL Ab) is detected in human sera, although its biological significance is not well established. We aimed to measure oxLDL and oxLDL Ab in peripheral atherosclerotic disease (PAD) patients, and to examine the relation between them in an attempt to understand the role of oxLDL Ab. Total risk of atherosclerosis was estimated using the global risk assessment score (GRAS) calculated on the basis of age, total cholesterol, HDL cholesterol (HDL-Chol), diabetes, hypertension and smoking. MATERIAL AND METHODS: Twenty-one patients aged 63.05+/-9.13 years, diagnosed by peripheric angiography as PAD, and 21 healthy controls aged 47.67+/-13.61 years took part in the study. Total LDL and HDL cholesterol levels were determined by enzymatic methods. Levels of circulating oxLDL were measured by monoclonal antibody 4E6-based competition ELISA. IgG class oxLDL Ab titre was measured by ELISA. RESULTS: Compared to healthy controls, PAD patients had higher levels of oxLDL (p<0.05), oxLDL Ab (p<0.05), LDL cholesterol (LDL-Chol) (p<0.05), total cholesterol (p<0.05) and lower HDL-Chol (p<0.05). OxLDL was found to be positively correlated with total cholesterol (r = 0.471, p<0.05) and LDL-Chol (r = 0.614, p<0.01) and GRAS (r = 0.435, p<0.05) and negatively with HDL-Chol (r = -0.459, p<0.05), but not with oxLDL Ab in PAD patients. CONCLUSIONS: These findings might indicate that high LDL-Chol levels influence the oxidation of LDL and that oxLDL is a possible marker of PAD. However, the role of oxLDL Ab in atherosclerosis remains controversial.

Leiomyosarcoma of the Inferior Vena Cava Confirmed by Aspiration Biopsy With a Catheter During Digital Subtraction Angiography.

Leiomyosarcoma of the vascular origin is a rare malignant tumor. It originates from the smooth muscle cells of the media with intra- or extraluminal growth, and in most cases it arises in the inferior vena cava. The diagnosis is often delayed because the clinical symptoms of this disease are often nonspecific. Accurate diagnosis of inferior vena cava leiomyosarcoma (IVCLMS) needs histologic confirmation. We report a case of IVCLMS histologically confirmed by aspiration biopsy with a catheter during digital subtraction angiography presenting with pulmonary emboli in a 65-year-old man.

Endovascular treatment of inadvertent left internal mammarian artery to great cardiac vein fistula.

Inadvertent left internal mammarian artery to coronary sinus anastomosis is a rare complication of coronary artery by-pass graft surgery. Management of this iatrogenic complication is controversial with conservative, surgical and endovascular options possible. Endovascular treatment offers a minimally invasive approach with a wide variety of embolic agents with different success rates. Herein we present a case of an iatrogenic left internal mammarian artery to coronary sinus anastomosis treated by detachable coil embolization. Use of detachable coil offers more precise deployment that is essential in the treatment of an iatrogenic left internal mammarian artery to coronary sinus anastomosis which can present challenges due to high flow rates and coil migration.

Evaluation of Liver Stiffness After Radioembolization by Real-Time ShearWave™ Elastography: Preliminary Study.

PURPOSE: To evaluate the effect of ShearWave(™) elastography (SWE) for the assessment of liver fibrosis after radioembolization (RE) in patients with liver malignancies. MATERIALS AND METHODS: We prospectively examined the effects of SWE before and after RE in 17 adult patients, from June 2012 to September 2013. All patients underwent SWE within 1 month before and 3 months (96.3 ± 22.9 days) after RE. Measurements were taken in segments III, IV, V, and VI (lateral/medial left lobe and anterior/posterior right lobe, respectively). Liver stiffness was studied in the 39 treated segments. RESULTS: The mean stiffness of liver tissue according to the pre-RE SWE measurements was not different from the post-RE SWE measurements in the segments that did not undergo RE. Conversely, segments treated with RE were significantly stiffer according to the post-RE SWE measurements (mean SWE 17.4 kPa) than according to the baseline measurements (7.0 kPa) (p < 0.001). Patients with hepatocellular carcinoma and preexisting infection with hepatitis B and C viruses had higher pre-embolization stiffness, and the post-embolization stiffness of the treated segments in these patients was higher than that in the remainder of the study population. CONCLUSION: These data suggest that SWE measurements of liver stiffness increase as early as the third month after RE. SWE could be used as a noninvasive complementary imaging method for preliminary assessment of liver fibrosis before and after RE.

Ultrasound-Guided Percutaneous Nephrostomy Performed on Neonates and Infants Using a "14-4" (Trocar and Cannula) Technique.

PURPOSE: Percutaneous nephrostomy (PCN) catheters are placed under combined ultrasound and fluoroscopic guidance in the interventional radiology suite and present unique challenges in neonates and infants. The purpose of this study was to demonstrate feasibility of PCN using a "14-4" (trocar and cannula) technique on neonates and infants. MATERIALS AND METHODS: Between September 2009 and June 2014, data for 27 kidneys from consecutive 22 neonates or infants who underwent PCN catheter placement using the "14-4" technique were retrospectively analyzed. The median age at the time of placement of the PCN catheters was 11 days (range 5-300 days). There were 18 males and 4 females. All procedures were performed in the interventional radiology suite but without using fluoroscopy. RESULTS: Unilateral PCN was performed on 17 out of 22 patients, while bilateral drainage was performed on five patients. The technical success rate was 100%. The median duration of PCN catheter was 75 days (range 10-138 days). Minor macroscopic hematuria not requiring blood transfusion was present in two of the patients in which the hematuria lasted in 2 days. CONCLUSION: Placement of PCN catheters using a "14-4" technique with ultrasound as the sole imaging modality is a technically feasible and desirable option for neonates or infants. The technique obviates the need for ionizing radiation and potentially could be performed in the ultrasound room or even at the bedside.

Percutaneous treatment of an infected aneurysmal sac secondary to aortoesophageal fistula with a history of stent-graft treatment for thoracic aortic aneurysm.

A 68-year-old man who was subjected to stent-grafting of a descending thoracic aortic aneurysm (TAA) 4 months previously was admitted to our hospital with constitutional symptoms, including high fever, sweating, nausea, vomiting, weight loss, and backache. An infected aneurysmal sac was suspected based on computed tomography (CT) findings, and an aortoesophageal fistula (AEF) was identified during esophagoscopy. CT-guided aspiration was performed using a 20-G Chiba needle, confirming the presence of infection. For treatment of the infected aneurysmal sac, CT-guided percutaneous catheter drainage in a prone position was performed under general anesthesia with left endobronchial intubation. Drainage catheter insertion was successfully performed using the Seldinger technique, which is not a standard treatment of an infected aneurysmal sac. Improvement in the patient's clinical condition was observed at follow-ups, and CT showed total regression of the collection in the aneurysmal sac.

Posttraumatic nonischemic priapism treated with autologous blood clot embolization.

INTRODUCTION: High-flow arterial priapism is rare and characterized by a prolonged nonpainful erection. Autologous clot embolization allows complete resolution of the problem in most of the cases. AIM: To review our experience with superselective transcatheter embolization in the treatment of nonischemic priapism. MAIN OUTCOME MEASURES: Advances in the understanding of the nonischemic priapism with the aid of newer techniques have altered the current management of nonischemic priapism. MATERIALS AND METHODS: Between 2002 and 2006, 11 patients underwent superselective transcatheter embolization of nonischemic priapism with blunt trauma to the penis or perineum. All patients underwent diagnostic evaluation with color-flow Doppler ultrasound and superselective pudendal arteriography, revealing bilateral arteriocorporal fistula and pseudoaneurysm in two cases, bilateral arteriocorporal fistula in one case, unilateral arteriocorporal fistula in one case, and unilateral arteriocorporal fistula and pseudoaneurysm in seven cases. Autologous blood clot was used as an embolization agent in all cases combined with microcatheter guidance. RESULTS: The procedure was technically successful in all cases. In three (27.2%) cases, a second embolization was required due to recurrence of priapism. In all patients, erectile function was restored within 6 weeks of the procedure. Follow-ups at 6 and 12 months after the last procedure revealed that full erectile capacity was restored in 10 of 11 patients, and these patients did not experience further recurrence of priapism. One patient reported a slight decrease in the quality of his penile erection. CONCLUSIONS: Our experience revealed that superselective transcatheter embolization and transient occlusion of the fistula with autologous blood clot is an effective therapy for the treatment of nonischemic priapism. Furthermore, recovery of erectile function due to recanalization of the occluded vessel occurred weeks after the procedure.

Lumbar and iliac artery aneurysms in Menkes' disease: endovascular cover stent treatment of the lumbar artery aneurysm.

We report lumbar and iliac artery aneurysms in a 3-month-old boy with Menkes' disease. The iliac artery aneurysm thrombosed spontaneously, documented by follow-up colour Doppler sonography. The lumbar artery aneurysm was successfully treated using a cover stent. There was no filling of the lumbar artery aneurysm and no stenosis of the cover stent during the 9-month follow-up.