Clinical outcomes and future fertility after uterine artery embolization for postpartum and post-abortion hemorrhage.

BACKGROUND: Postpartum hemorrhage (PPH) and post-abortion hemorrhage (PAH) are life-threatening conditions. PURPOSE: To evaluate the efficacy and safety of uterine arterial embolization (UAE) for PPH and PAH and to investigate future fertility after UAE. MATERIAL AND METHODS: This study included 57 consecutive patients (mean age = 34 years) who underwent UAE for PPH (n = 46) and PAH (n = 11) at our institution between January 2011 and December 2022. Technical success, non-visualization of the peripheral portion of bilateral uterine arteries on angiography, and clinical success, complete hemostasis after UAE, were assessed. UAE-associated complications and factors related to clinical success were analyzed. Pregnancy outcomes after UAE and complications during subsequent pregnancy were investigated in 16 patients who desired fertility and were followed up for >1 year. RESULTS: The technical and clinical success rates were 100% and 84.2%, respectively. Sepsis (n = 1) and uterine empyema (n = 1) were observed as severe complications. Placental disorder, bleeding within 24 h after delivery or abortion, ≥1.5 shock index, ≥6 units of transfusion erythrocytes, and ≥8 obstetrical disseminated intravascular coagulation score were significantly associated with unfavorable clinical outcomes. In total, 16 pregnancies were observed in 12 patients after UAE, three of which were miscarriages and 13 were successful live births. During pregnancy, uterine rupture (n = 1) and accreta (n = 1) were observed. CONCLUSION: UAE is an effective treatment for PPH and PAH. Although UAE could preserve future fertility, careful attention should be paid to perinatal management for unusual complications.

Treatment of hepatocellular carcinoma with a portal vein tumor thrombus and pulmonary metastases of rectal cancer with microsatellite stability using atezolizumab plus bevacizumab.

Herein, we report the successful treatment using atezolizumab plus bevacizumab of a patient with hepatocellular carcinoma (HCC) with a portal vein tumor thrombus and multiple pulmonary metastases from rectal cancer with microsatellite stability. This patient developed rectal cancer with synchronous pulmonary metastases and HCC. After resecting the primary lesion of the rectal cancer, transcatheter arterial chemoembolization was performed for the HCC. Drug therapy was planned for multiple pulmonary metastases of rectal cancer; however, the early development of recurrent HCC with portal vein tumor thrombus had to be highly prioritized, and atezolizumab plus bevacizumab was introduced. Following the disappearance of the recurrent HCC lesion, the metastatic pulmonary nodules shrunk into scar-like spots. The treatment for both HCC and pulmonary metastases of rectal cancer were considered to result in clinical complete response.

Clinical Outcomes of Radiofrequency Ablation Combined with Transarterial Chemoembolization Using Degradable Starch Microsphere Mixed with Mitomycin C for the Treatment of Non-hepatocellular Carcinoma Malignant Liver Tumors.

Purpose: To retrospectively evaluate the outcomes of radiofrequency ablation combined with transarterial chemoembolization using degradable starch microspheres for non-hepatocellular carcinoma malignant liver tumors. Material and Methods: A total of 15 patients (13 men, 2 women; median age, 67 years) who underwent radiofrequency ablation immediately after transarterial chemoembolization using degradable starch microspheres for liver tumors between July 2011 and September 2020 were included in this study. Thirteen patients had liver metastases from colorectal cancer (n = 6), esophageal cancer (n = 2), lung cancer (n = 2), and other tumors (n = 3), and 2 patients had primary liver tumor of cholangiocellular carcinoma (n = 1) and gastrinoma (n = 1). Twenty tumors (median size, 16 mm) were treated in 17 sessions. Technical success, safety, local tumor progression, and overall survival were evaluated. Safety was assessed according to the clinical practice guideline of the Society of Interventional Radiology. Results: All treatment procedures were successfully completed. There were no major complications. Grade-B complications of self-limiting pneumothorax (n = 1), vomiting (n = 1), and fever (n = 1) occurred in 1 session each. Local tumor progression developed in two tumors (local tumor progression rate, 10%, 2/20). The local tumor progression rates were 5% and 11% at 1 year and at 3 and 5 years, respectively. Tumor size of more than 20 mm (P = 0.0003) and contact with major vessels (P = 0.03) were significant risk factors for local tumor progression. The patients were treated with repeat radiofrequency ablation combined with transarterial chemoembolization using degradable starch microspheres. During median follow-up of 48 months (range, 4-77 months), 5 patients died (33%, 5/15). The overall survival rates were 100%, 85%, and 57% at 1, 3, and 5 years, respectively. The median overall survival time was 69 months. Conclusions: Radiofrequency ablation combined with transarterial chemoembolization using degradable starch microspheres was safe and showed favorable local control for non-hepatocellular carcinoma malignant liver tumors.

Difficult removal of totally implantable venous access devices in adult patients: Incidence, risk factors, and management.

BACKGROUND: Totally implantable venous access devices (TIVADs) have played an important role of medical oncology practice. However, operators sometimes encounter considerable difficulty when removing TIVADs. This study aimed to investigate the incidence of difficult TIVAD removal, determine associated risk factors, and investigate interventional radiology (IR) approaches to difficult removal. METHODS: A total of 514 TIVAD removal procedures performed in a single-center between January 2014 and May 2021 were retrospectively analyzed to determine incidence of difficult removal and associated risk factors. IR approaches applied in difficult removal cases were also reviewed. RESULTS: The incidence of difficult removal was 7.4% (38/514). In univariable analysis, indwelling duration, silicone catheter, and subcutaneous leakage of fluid were identified as significant risk factors for difficult removal. Multivariable analysis showed that indwelling duration per year (odds ratio (OR), 1.46; 95% confidence interval (CI), 1.28-1.67; p < 0.01) and subcutaneous leakage of fluid (OR, 6.04; 95% CI, 2.45-14.91; p < 0.01) were significantly associated with difficult removal. In the 38 difficult removal cases, 32 TIVADs could be removed using more dissection and traction than the standard removal method. In the other 6, TIVADs were successfully removed by using several IR techniques, including insertion of a guide wire (n = 1), dissection using an introducer sheath (n = 2), pushing with a dilator (n = 1), and pulling with a snare (n = 2). CONCLUSION: Difficult TIVAD removal is uncommon. However, operators should expect it when removing long indwelling TIVADs and those with subcutaneous leakage. IR approaches to difficult removal are minimally invasive and can be useful.

Bleeding anorectal varices treated by a direct puncture approach through the greater sciatic foramen: The utility of a steerable microcatheter for reverse catheterization.

Bleeding is less common from anorectal varices than from esophageal varices, but it is potentially life-threatening. Here, we present a case of a woman in her 70s with critical hemorrhage from anorectal varices. The endoscopic approach could not be performed due to the huge variceal formation and the transhepatic approach was also unsuitable due to the presence of portal vein thrombosis and ascites. A direct puncture to the right superior rectal vein was performed through the greater sciatic foramen under computed tomography fluoroscopic guidance. Using a steerable microcatheter, superior rectal veins were bilaterally embolized with a mixture of n-butyl cyanoacrylate and ethiodized oil, and microcoils. Endoscopy and contrast-enhanced computed tomography performed after the procedure confirmed a marked shrinkage of anorectal varices. When endoscopic or any other approaches are difficult, this technique can be a useful alternative therapeutic option.

Clinical usefulness of Somatostatin Receptor Scintigraphy in the Diagnosis of Neuroendocrine Neoplasms.

OBJECTIVES: We investigated the detectability of somatostatin receptor scintigraphy (SRS) for neuroendocrine neoplasms (NEN). METHODS: From January 2016 to October 2020, 125 SRS examinations using indium-111 pentetreotide performed for patients with NEN lesions were retrospectively evaluated. The detection rate of NEN lesions was determined according to histopathological classification by primary site and by organ. RESULTS: At least one NEN lesion was detected in 73% (91/125) with a positive Krenning score of ≥2 in SRS. The detection of abdominal NENs (gastrointestinal tract, 38; pancreas, 62; and others, 14) was 89% (49/55) for neuroendocrine tumor (NET)-grade (G) 1, 78% (32/41) for NET-G2, 66% (2/3) for NET-G3, 31% (4/13) for neuroendocrine carcinoma (NEC), 100% (1/1) for mixed neuroendocrine-non-neuroendocrine neoplasm, and 0% (0/1) for non-classified NEN. That of thoracic NENs was 33% (2/6) for typical carcinoid tumor and 40% (2/5) for atypical carcinoid tumor. For a total of 226 organ lesions, hepatic lesions were 76% (58/76); pancreatic lesions, 61% (31/51); lymph node lesions, 77% (27/35); bone lesions, 83% (20/24); duodenal lesions, 82% (9/11); and other lesions, 41% (11/27). CONCLUSION: The detectability of SRS for NEN in Japan was verified at a center, and its usefulness was confirmed.

Safety, feasibility, and comfort of hepatic angiography and transarterial intervention with radial access for hepatocellular carcinoma.

BACKGROUND AND AIM: Hepatic angiography procedures such as transarterial chemoembolization (TACE) are essential procedures for managing patients with hepatocellular carcinoma (HCC), and are usually performed with femoral access. However, femoral access causes patient discomfort and may be associated with the risk of hematoma or pseudoaneurysm at puncture site. We evaluated the safety, feasibility, and patient comfort of hepatic angiography procedures performed with radial access. METHODS: In this single-institution, retrospective, time-frame study, a total of 206 patients who underwent hepatic angiography procedures with radial access, which were first used on October 2017 at our institution, were compared with 240 patients who underwent the same procedures with femoral access before this period. Several measures were assessed, including procedure time and safety. In addition, a questionnaire was used to compare the access types regarding procedure-associated discomfort. RESULTS: Hepatic angiography procedures performed with radial access, including TACE, were completed in all patients without complications. The procedure time was comparable between radial access and femoral access. Most patients preferred radial to femoral access. Patients taking anticoagulants were able to complete the procedures without discontinuing these drugs. CONCLUSIONS: Hepatic angiography procedures with radial access resulted in less discomfort than those with femoral access, and the two approaches showed similar feasibility and safety. Radial access can be introduced as a routine technique for hepatic angiography procedures.

Preoperative Embolization of Spinal Metastatic Tumor: The Use of Selective Computed Tomography Angiography for the Detection of Radiculomedullary Arteries.

INTRODUCTION: Preoperative embolization for metastatic spinal cord compression (MSCC) has a risk of spinal ischemia. This study aimed to assess the efficacy and safety of preoperative embolization in patients with MSCC and evaluate the use of computed tomography (CT) angiography for the detection of the radiculomedullary arteries (RMA). METHODS: This retrospective study included 20 patients (12 men and 8 women; median age, 66 years), who underwent preoperative embolization before a decompression surgery, which corresponded to 22 embolization procedures. The detection ability of RMA was evaluated using angiography and selective CT angiography. Surgical data including intraoperative blood loss and transfusion were also evaluated. RESULTS: Six RMAs were identified at the levels of affected vertebrae and one level above and below in the diagnostic spinal angiography. In addition to spinal angiography, adjunctive selective CT angiography allowed visualization of another five RMAs. Overall, 11 RMAs were identified in 9 patients. Preoperative embolization was successfully achieved in all patients. As regards complications related to embolization procedure, palsy exacerbated in one patient (4.5%), which improved postoperatively. During the surgical procedure, the mean intraoperative blood loss was 353.4±254.2 mL without intraoperative transfusion in all patients. CONCLUSIONS: The present study showed small amounts of intraoperative blood loss without any severe complications related to preoperative embolization. Selective CT angiography was a useful technique to detect RMAs and contributed to the safety of preoperative embolization.

Novel strategy to treat lung metastases: Hybrid therapy involving surgery and radiofrequency ablation.

BACKGROUND: This study was performed to evaluate the clinical outcomes of hybrid treatment involving surgical resection and percutaneous radiofrequency ablation for patients with multiple lung metastases. METHODS: Seventeen patients (6 men, 11 women; median age, 52 years; range, 16-78 years) underwent hybrid treatment involving surgery and radiofrequency ablation to treat multiple lung metastases (median number, 4; range, 2-26) between May 2014 and February 2020. The primary lesions were colorectal carcinoma (n = 9), uterine endometrial carcinoma (n = 3), osteosarcoma (n = 2), renal cell carcinoma (n = 1), glottic carcinoma (n = 1), and fibrolamellar hepatocellular carcinoma (n = 1). Twenty-four sessions each of surgery and radiofrequency ablation were performed. Safety, disease-free survival, and overall survival were evaluated. Safety was assessed according to the Clavien-Dindo Classification. RESULTS: A grade IVa adverse event of empyema developed in one patient (4%, 1/24) after surgery. A grade IIIa adverse event of pneumothorax and a grade II adverse event of lung abscess occurred in four (17%, 4/24) and one session (4%, 1/24) after radiofrequency ablation, respectively. During the median follow up of 34 months (range, 8-67 months), 10 patients (59%, 10/17) developed new metastases. The 5-year disease-free survival rate was 32%. Four or fewer lung metastases (p = 0.008) and metastases from colorectal carcinoma (p = 0.02) were factors significantly associated with longer disease-free survival. One patient (6%, 1/17) died of tumor progression 29 months after initial treatment. The 5-year overall survival rate was 88%. CONCLUSIONS: The strategy of hybrid treatment involving surgery and radiofrequency ablation may offer good outcomes for patients with multiple lung metastases.

Transarterial Embolization for Bleeding in Patients with Head and Neck Cancer: Who Benefits?

OBJECTIVES/HYPOTHESIS: The present study aimed to investigate the efficacy of transarterial embolization (TAE) for bleeding in patients with head and neck cancer (HNC) and to evaluate the prognostic factors after TAE. STUDY DESIGN: Outcome study. METHODS: This retrospective study included 31 consecutive patients (27 men and 4 women; median age, 61 years) who presented uncontrollable hemorrhage associated with HNC and underwent emergency TAE at our institution during a 10-year period (January 2011-December 2020). This corresponded to 40 TAE procedures, including 27 cases with an unstable status (circulatory and/or respiratory insufficiency) and 10 cases with carotid blowout syndrome. The technical success rate and adverse events were analyzed on a per-procedure basis. The rebleeding and overall survival (OS) rates were analyzed on a per-patient basis, and the factors related to OS were evaluated. RESULTS: The technical success rate was 100%. As an adverse event, cerebral infarction was found in three cases with carotid blowout syndrome. The rebleeding rate at 30 days after TAE and in the follow-up period (range, 9-3,004 days) was 17.2% and 35.5%, respectively. The median survival time was 263 days (95% confidence interval: 124.0-402.0 days). In the log-rank test, complete remission (CR) of the primary cancer at the time of the first TAE was identified as a significant influencing factor of survival. CONCLUSION: TAE is effective for the treatment of hemorrhage associated with HNC even in patients with an unstable status. Patients with CR can gain a long life span. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2777-E2783, 2021.

Percutaneous Image-guided Needle Biopsy of Musculoskeletal Tumors: Technical Tips.

With recent advances in imaging technology, the frequency of detecting musculoskeletal lesions has also increased. Percutaneous image-guided needle biopsy is occasionally required for the diagnosis of such lesions. Moreover, in the era of personalized cancer care, chances in histopathological diagnosis and the importance of histopathological diagnosis by percutaneous needle biopsy are increasing. However, as percutaneous needle biopsy is not a common procedure for musculoskeletal lesions, careful planning and the application of adequate techniques such as hydrodissection and the trans-osseous approach are occasionally required. In this review, we have summarized the indications and techniques for percutaneous image-guided needle biopsy for musculoskeletal lesions, including lymphatic lesions.

Comparison of radiopaque dye materials for localization of pulmonary nodules before video-assisted thoracic surgery.

BACKGROUND: Although a mixture of pigments and radiopaque materials was reported to be useful material for lung nodule localization, the optimal combination has not been well investigated. The purpose of this study is to evaluate the characteristics of various combinations of pigments and radiopaque materials for localization of pulmonary nodules prior to video-assisted thoracic surgery (VATS). METHODS: We compared stability, viscosity, and visibility of 6 radiopaque dye materials of (I) mixture of indigo carmine and lipiodol; (II) mixture of indigo carmine, lipiodol, and lidocaine gel; (III) mixture of indocyanine green in water solution (w-ICG) and lipiodol; (IV) mixture of w-ICG, lipiodol, and lidocaine gel; (V) ICG in contrast medium solution (cm-ICG); and (VI) mixture of cm-ICG and lidocaine gel. Stability was evaluated by observing changes in the mixtures in the test tube with time visually and radiographically. Viscosities were measured by rotational viscometer. Materials were injected into an expanded pig-lung phantom, and area on CT and visibility on thoracoscopy camera were evaluated. RESULTS: Separation could be seen 15 min after preparation in (I) and (III), and 1 h after preparation in (II), both visually and radiographically. In (IV), separation could be seen on the photographs but not on the X-ray images from 3 h after preparation. (V) and (VI) showed no changes within the 2-day observation period. The viscosities of the materials were (I) 0.2±0.1, (II) 2.9±0.1, (III) 0.2±0.1, (IV) 2.6±0.1, (V) 0.2±0.1, and (VI) 1.2±0.1 dPa·s. The area on CT showed very strong negative correlation with viscosity (r=-0.97). The injection point of each material was easily detected on thoracoscopy camera. CONCLUSIONS: Radiopaque dye materials appear useful for localizing pulmonary nodules before VATS; their diffusion in the lung parenchyma can be suppressed by using materials of high viscosity.

Image-guided core needle biopsy in the diagnosis of malignant lymphoma: comparison with surgical excision biopsy.

PURPOSE: This study aimed to compare the efficacy and safety of image-guided core needle biopsy (CNB) with those of surgical excision biopsy (SEB) for the diagnosis of lymphoma, and to clarify the indication of CNB in clinical practice. METHOD: This retrospective study included 263 image-guided CNB cases and 108 SEB cases that were performed at our institution between January 2014 and December 2018. The rate of patients with performance status of grade 1-4 was higher in the CNB group than in the SEB group (43.7% vs. 24.1%, P <  0.01). Waiting time to biopsy and diagnosis was shorter for CNB group than for SEB group (4 days vs. 7 days, 13 days vs. 15 days, P <  0.01). The rate of biopsy at the deep sites was higher in the CNB group than in the SEB group (53.2% vs. 8.3%, P <  0.01). Successful biopsy and complication rates were compared between the 2 groups. RESULTS: There were no significant differences between the CNB and SEB groups in successful biopsy rates (89.0% vs. 93.5%, P =  0.25). The grade 3 complication rate was significantly lower for CNB group than for SEB group (0% vs. 4.6%, P <  0.01), although there was no significant difference in overall complication rates (4.9% vs. 6.5%, respectively, P =  0.61). CONCLUSIONS: CNB showed high diagnostic yield comparable to SEB for suspected lymphoma. CNB was especially recommended to the cases with low-PS, lesions in the deep sites, and requiring early pathological diagnosis.

Clinical Outcomes and Techniques for Radiofrequency Ablation of Lung Tumors Smaller than 1 cm.

Purpose: To evaluate the outcomes of radiofrequency ablation (RFA) on lung tumors < 1 cm in maximum diameter. Materials and Methods: Twenty-eight patients (12 male, 16 female; median age, 59 years; mean age, 58 ± 16 years; range, 16-78 years) who underwent RFA for lung tumors < 1 cm in diameter between November 2009 and September 2018 were included in this study. Thirty-five tumors (median size, 8.4 mm; mean size, 7.7 ± 1.9 mm; range, 3.6-9.9 mm) were treated with 33 sessions of RFA. Technique efficacy and safety were subsequently evaluated. Initial and secondary technique efficacy were defined as complete ablation without residual tumor or local tumor progression after initial and repeat RFA, respectively. Safety was evaluated according to the Common Terminology Criteria for Adverse Events, version 5.0. Results: Residual tumor remained for 1 tumor (3%, 1/35) and local tumor progression was found in 2 tumors (6%, 2/35). Initial technique efficacy rate was therefore 91% (32/35). The remaining 3 tumors were treated by repeat RFA (secondary technique efficacy rate: 100%, 35/35). Initial technique efficacy rate was significantly lower for tumors treated with starting energy ≥ 20 W (P = 0.02) and showing a quick increase in tissue impedance (P = 0.01). There were 4 grade 2 adverse events (12%, 4/33) comprising pneumothorax requiring chest tube placement, and 14 grade 1 adverse events comprising self-limiting pneumothorax (36%, 12/33) and pulmonary parenchymal hemorrhage (6%, 2/33). Conclusion: To achieve good outcomes for lung tumors < 1 cm, radiofrequency energy should be started at < 20 W. Application of manual mode ablation might be considered when delivery of power cannot be continued due to a quick increase in tissue impedance.

Percutaneous Radiofrequency Ablation for Liver Tumors: Technical Tips.

Percutaneous radiofrequency ablation (RFA) has been accepted as a minimally invasive therapeutic treatment for liver malignancies. Although RFA is usually applied for the treatment of small liver tumors (<3 cm), several technical developments have expanded the use of RFA. RFA is now used for the treatment of large liver tumors, and the number of complications associated with this treatment has decreased. These refinements may ultimately lead to better long-term prognosis. Here, we review recent refinements of liver RFA and provide technical tips.

Submucosal Tunnel Formation as a Complication Caused by Long Intestinal Tube Insertion: A Case Report.

We present a case of a 76-year-old man with submucosal tunnel formation caused by long intestinal tube (LIT) insertion. The patient had undergone an LIT insertion to treat bowel obstruction caused by ascending colon cancer. Although intestinal decompression was achieved successfully, a procedural pre-scheduled endoscopy incidentally revealed that the LIT had penetrated the abdominal esophageal mucosa and re-entered the gastric lumen, passing through the submucosal layer at the gastroesophageal junction. Therefore, the LIT was removed under endoscopic observation during ileocecal resection surgery and the patient was treated conservatively. The current case suggests that this unfamiliar complication can occur without any signs or symptoms.

Adenocarcinoma and neuroendocrine tumor arising within presacral teratoma associated with Currarino syndrome: A case report.

We present a case of a 59-year-old woman with a malignant tumor arising within presacral teratoma associated with Currarino syndrome (CS). A characteristic crescent-shaped sacrum was detected on preoperative image examination and the presacral mass was pathologically diagnosed as a malignant tumor associated with CS. To our knowledge, this is the first case report of presacral teratoma associated with CS coexisting with both adenocarcinoma and a neuroendocrine tumor.

Transcatheter Arterial Embolization for Postoperative Bleeding Following Abdominal Surgery.

PURPOSE: We aimed to estimate the usefulness of transcatheter arterial embolization (TAE) in patients with postoperative abdominal hemorrhage and to evaluate the effects of pancreatic fistula on clinical outcomes and angiographic findings. MATERIALS AND METHODS: We enrolled 22 patients (20 males and 2 females; mean age 63 years; range 25-86 years), who underwent transarterial angiography for postoperative hemorrhage after abdominal surgery. This group corresponded to 28 procedures. Technical and clinical success rates were calculated, and clinical findings and outcomes were compared between patients with and without a pancreatic fistula. RESULTS: Pre-interventional CT was performed in all patients before first angiography, and the location of the bleeding was identified in all but one patient. Active arterial bleeding, identified by extravasation of contrast agent (n = 12), pseudoaneurysm formation (n = 12), and arterial wall irregularity (n = 2) were detected in 28 angiographic procedures, and embolization was performed in 26 instances. Various embolization techniques such as isolation, packing, embolization, and stentgraft implantation were performed. The technical and clinical success rates were 96% (25/26 procedures) and 82% (18/22 patients), respectively. In hemodynamically unstable patients (shock index: heart rate/systolic blood pressure > 1), a 92% (12/13 cases) technical success rate was achieved. There were no significant differences in any evaluated parameters between patients with and without pancreatic fistula. CONCLUSION: TAE is a safe and effective for treating postoperative hemorrhage even in patients with hemodynamic instability and pancreatic fistula. Additionally, pre-interventional CT is useful for effective, consecutive interventions.