Assessment of automated cone-beam CT vessel identification software during transarterial hepatic embolisation: radiation dose, contrast medium volume, processing time, and operator perspectives compared to digital subtraction angiography.

AIM: To evaluate arterial cone-beam computed tomography (A-CBCT) automated analysis software for identification of vessels supplying tumours during transarterial hepatic embolisation (TAE). MATERIALS AND METHODS: This study was approved by the institutional review board, with waiver of consent. Consecutive TAE procedures using arterial mapping software (AMS), and performed between February 2014 and August 2014, were reviewed. Hepatic arteries were imaged using digital subtraction angiography (DSA) as well as A-CBCT processed with AMS. Interventional radiologists reported1 potential embolisation target vessels computed using AMS versus DSA alone,2 modification of the embolisation plan based on AMS, and3 operator confidence related to technical success. Imaging set-up, processing time, radiation dose, and contrast media volume were recorded. RESULTS: Thirty of 34 consecutive procedures were evaluated retrospectively. At least one additional embolisation target vessel was identified using AMS in 13 procedures (43%, 95% confidence interval [CI]: 26-61%) and embolisation plan modified in 11 (37%, 95% CI: 19-54%). Radiologists reported AMS increased operator confidence and reduced the number of DSA acquisitions in 25 (83%, 95% CI: 70-97%) and 15 cases (50%, 95% CI: 32-68%), respectively. The average A-CBCT acquisition and processing time was 4 minutes 53 seconds and 3 minutes 45 seconds, respectively. A-CBCT contributed to 11% of the radiation dose and 18% of the contrast media volume. CONCLUSION: Physicians report increased tumour supplying vessel detection and intraprocedural confidence using AMS during TAE without substantial impact on radiation dose, contrast media volume, and procedure time.

90Y Resin Microspheres Radioembolization for Colon Cancer Liver Metastases Using Full-Strength Contrast Material.

OBJECTIVES: To assess safety and efficacy of 90Y resin microspheres administration using undiluted non-ionic contrast material (UDCM) {100% Omnipaque-300 (Iohexol)} in both the "B" and "D" lines. MATERIALS AND METHODS: We reviewed all colorectal cancer liver metastases patients treated with 90Y resin microspheres radioembolization (RAE) from 2009 to 2017. As of April 2013, two experienced operators started using UDCM (study group) instead of standard sandwich infusion (control group). Occurrence of myelosuppression (leukopenia, neutropenia, erythrocytopenia or/and thrombocytopenia), stasis, nontarget delivery (NTD), median fluoroscopy radiation dose (FRD), median infusion time (IT), liver progression-free (LPFS) and overall survivals (OS) was evaluated. Complications within 6 months post-RAE were reported according to CTCAE v3.0 criteria. RESULTS: Study and control groups comprised 23(28%) and 58(72%) patients, respectively. Median follow-up was 9.1 months. There was no statistically significant difference in myelosuppression incidence within 6 months post-RAE between groups. Median FRD and IT for study and control groups were 44.6 vs. 97.35 Gy/cm2 (p = 0.048) and 31 vs. 39 min (p = 0.006), respectively. A 38% lower stasis incidence in study group was not significant (p = 0.34). NTD occurred in 1/27(4%) study vs. 5/73(7%) control group procedures (p = 1). Grade 1-2 and grade 3-4 toxicities between study and control group patients were 36%(8/22) vs. 45%(26/58), p = 0.61 and 9%(2/22) vs. 16%(9/58), p = 0.72, respectively. There was no difference in LPFS and OS between groups. CONCLUSION: Administration of 90Y resin microspheres using UDCM in both lines is safe and effective, resulting in lower fluoroscopy radiation dose and shorter infusion time, without evidence of myelosuppression or increased stasis incidence.

Prospective study of outcomes after percutaneous biliary drainage for malignant biliary obstruction.

BACKGROUND: Percutaneous biliary drainage (PBD) is used to relieve malignant bile duct obstruction (MBO) when endoscopic drainage is not feasible. Little is known about the effects of PBD on the quality of life (QoL) in patients with MBO. The aim of this study was to evaluate changes in QoL and pruritus after PBD and to explore the variables that impact these changes. MATERIALS AND METHODS: Eligible patients reported their QoL and pruritus before and after PBD using the Functional Assessment of Cancer Therapy-Hepatobiliary instrument (FACT-HS) and the Visual Analog Scale for Pruritus (VASP). Instruments were completed preprocedure and at 1 and 4 weeks following PBD. RESULTS: A total of 109 (60 male/49 female) patients enrolled; 102 (94%) had unresectable disease. PBD was technically successful (hepatic ducts cannulated at the conclusion of procedure) in all patients. There were 2 procedure-related deaths. All-cause mortality was 10% (N = 11) at 4 weeks and 28% (N = 31) at 8 weeks post-PBD with a median survival of 4.74 months. The mean FACT-HS scores declined significantly (P < .01) over time (101.3, 94.8, 94.7 at baseline, 1 week, 4 weeks, respectively). The VASP scores showed significant improvement at 1 week with continued improvement at 4 weeks (P < .01). CONCLUSIONS: PBD improves pruritus but not QoL in patients with MBO and advanced malignancy. There is high early mortality in this population.

Radiofrequency ablation in the management of liver metastases from breast cancer.

OBJECTIVE: Systemic chemotherapy remains the standard treatment for patients with breast cancer hepatic metastases. Resection of metastases has survival advantages in a small percentage of selected patients. Radiofrequency ablation has been used in small numbers of selected patients. This small series was undertaken to review our experience with radiofrequency ablation in the management of patients with breast cancer hepatic metastases. CONCLUSION: Radiofrequency ablation of breast cancer hepatic metastases is safe and may be used to control hepatic deposits in patients with stable or no extrahepatic disease.

Rates and patterns of recurrence for percutaneous radiofrequency ablation and open wedge resection for solitary colorectal liver metastasis.

INTRODUCTION: The purpose of this study was to compare rates and patterns of disease progression following percutaneous, image-guided radiofrequency ablation (RFA) and nonanatomic wedge resection for solitary colorectal liver metastases. METHODS: We identified 30 patients who underwent nonanatomic wedge resection for solitary liver metastases and 22 patients who underwent percutaneous RFA because of prior major hepatectomy (50%), major medical comorbidities (41%), or relative unresectability (9%). Serial imaging studies were retrospectively reviewed for evidence of local tumor progression. RESULTS: Patients in the RFA group were more likely to have undergone prior liver resection, to have a disease-free interval greater than 1 year, and to have had an abnormal carcinoembryonic antigen (CEA) level before treatment. Two-year local tumor progression-free survival (PFS) was 88% in the Wedge group and 41% in the RFA group. Two patients in the RFA group underwent re-ablation, and two patients underwent resection to improve the 2-year local tumor disease-free survival to 55%. Approximately 30% of patients in each group presented with distant metastasis as a component of their first recurrence. Median overall survival from the time of resection was 80 months in the Wedge group vs 31 months in the RFA group. However, overall survival from the time of treatment of the colorectal primary was not significantly different between the two groups. CONCLUSIONS: Local tumor progression is common after percutaneous RFA. Surgical resection remains the gold standard treatment for patients who are candidates for resection. For patients who are poor candidates for resection, RFA may help to manage local disease, but close follow-up and retreatment are necessary to achieve optimal results.

Routine urine culture at the time of percutaneous urinary drainage: does every patient need one?

PURPOSE: To determine the clinical variables associated with bacteriuria in patients undergoing primary percutaneous antegrade urinary drainage procedures in order to predict the utility of routinely obtaining urine cultures at the time of the procedure. METHODS: Between October 1995 and March 1998 urine cultures were prospectively obtained in all patients undergoing a primary percutaneous antegrade urinary drainage procedure. One hundred and eighty-seven patients underwent 264 procedures. Results were available in 252 cases. Culture results were correlated with clinical, laboratory, and demographic variables. Anaerobic cultures were not uniformly performed. RESULTS: Urine cultures were positive in 24 of 252 (9.5%) cases. An indwelling or recently removed ipsilateral device (catheter or stent) and a history of previous cystectomy with urinary diversion were significant predictors of a positive culture. Patients without either of these predictors, and without clinical or laboratory evidence of infection, were rarely found to have positive cultures. CONCLUSION: The likelihood of a positive urine culture can be predicted on the basis of the aforementioned clinical variables. In the absence of these clinical indicators routine urine cultures are neither useful nor cost-effective.

Upper urinary tract metastases from adenocarcinoma of the colon.

An unusual presentation of colorectal metastasis to the upper urinary tract is reported. The metastasis manifested as a filling defect seen during antegrade pyelography. Cytologic evaluation of aspirated material demonstrated metastatic colonic adenocarcinoma. A dilated collecting system may be caused by intraluminal material including tumor and blood clots. Whenever fixed filling defects are encountered, urine cytology should be sent even in the absence of renal parenchymal involvement by tumor. The cytological evaluation may allow for prompt diagnosis and treatment.

Portal vein embolization with use of polyvinyl alcohol particles.

Preoperative portal vein embolization has been used as method of inducing compensatory hypertrophy in the future remnant liver since it was first described in the late 1980s. Many different vascular embolic agents have been successfully used for this procedure, and there is no general consensus regarding which is the best agent. Polyvinyl alcohol (PVA) particles commonly used for arterial embolization come in many sizes, are readily available, and are easy to administer via conventional catheters. We describe an easy, safe, and effective method of the use of PVA particles for portal vein embolization.

Particle embolization of hepatic neuroendocrine metastases for control of pain and hormonal symptoms.

PURPOSE: To evaluate treatment outcome with respect to the indication for treatment in patients with neuroendocrine tumors metastatic to the liver undergoing hepatic artery embolization with polyvinyl alcohol (PVA) particles. MATERIALS AND METHODS: Charts and radiographs were reviewed of 35 patients undergoing 63 separate sessions of embolotherapy between January 1993 and July 1997. Patient demographics, tumor type, indication for embolization, and complications were recorded. Symptomatic and morphologic responses to therapy were noted, as well as duration of response. RESULTS: Fourteen men and 21 women underwent embolization of 21 carcinoid and 14 islet cell tumors metastatic to the liver. These patients underwent 63 separate episodes of embolotherapy. Of 48 episodes that could be evaluated, response to treatment was noted following 46 episodes (96%). The duration of response was longest in patients treated for hormonal symptoms with (17.5 months) or without (16 months) pain, and was shortest (6.2 months) when the indication was pain alone. Complications occurred after 11 of the 63 embolizations (17%), including four (6%) deaths. Cumulative 5-year survival following embolotherapy was 54%. CONCLUSION: Hepatic artery embolization with PVA particles is beneficial for patients with neuroendocrine tumors metastatic to the liver and may be used for control of pain as well as hormonal symptoms. This therapy should be used cautiously when more than 75% of the hepatic parenchyma is replaced by tumor.

Particle embolization for hepatocellular carcinoma.

PURPOSE: To evaluate the outcome of all patients undergoing particle embolization for hepatocellular carcinoma at a single institution from January 1, 1993, through December 31, 1995. MATERIALS AND METHODS: The charts and radiographs of all patients undergoing particle embolization during the study period were reviewed. The following information was collected: patient demographics, Child class and Okuda stage, number of embolization treatment sessions, length of hospital stay, complications related to the embolization procedure, including postembolization syndrome, current patient status, and date of death. RESULTS: Forty-six patients underwent 86 embolization sessions during the study period. Postembolization syndrome developed after 70 of the 86 sessions (81%); in four cases (4.6%) this required treatment that extended the patient's hospital stay. Three other complications occurred (3.5%), including a splenic infarct and two episodes of transient hepatic failure, all treated supportively. There was one death within 30 days, but it was not directly attributable to embolotherapy. Follow-up was available for all of the patients who underwent treatment. Thirty-four patients were classified as Child class A, and 12 were classified as Child class B. Thirty patients were classified as Okuda stage I, 14 were classified as Okuda stage II, and two were classified as Okuda stage III. Overall actuarial survival was 50% at 1 year and 33% at 2 years. There was a statistically significant difference in survival between Okuda stage I and stage II patients, but not between Child class A and class B patients. CONCLUSION: Particle embolization for hepatocellular carcinoma is well tolerated and demonstrates actuarial survival of 50% at 1 year and 33% at 2 years.

Clinical factors associated with positive bile cultures during primary percutaneous biliary drainage.

PURPOSE: To evaluate the utility of routine bile cultures and to determine the risk factors for bacterial colonization of the bile as well as the biliary flora in patients with biliary obstruction undergoing primary percutaneous biliary drainage. MATERIALS AND METHODS: Between October 1995 and January 1997, bile cultures were prospectively obtained in all patients undergoing percutaneous biliary drainage. Seventy-six patients underwent 86 procedures. Culture results were correlated with clinical, laboratory, and demographic variables. The antibiotic sensitivities of cultured organisms were examined. RESULTS: Fever, previous endoscopic or percutaneous biliary instrumentation, and bilioenteric anastomosis were significant predictors of a positive bile culture. In the absence of any of these indicators, bile cultures were unlikely to be positive. Enterococcus species was the organism isolated most commonly. Yeast, gram-negative aerobic bacilli, and Streptococcus viridans followed in frequency. CONCLUSION: Bile cultures provide valuable information that was useful for planning antibiotic prophylaxis and treatment. The likelihood of positive bile cultures can be predicted based on certain clinical variables. Continued investigation is needed to better predict bacterial flora in individual patients. Given the association between previous instrumentation and biliary colonization, noninvasive imaging modalities should be exhausted before invasive procedures are performed for solely diagnostic purposes in patients with biliary obstruction.

Outpatient treatment of iatrogenic pneumothorax after needle biopsy.

PURPOSE: To evaluate prospectively the feasibility of treating iatrogenic pneumothorax after fine-needle aspiration biopsy (FNAB) of the lung with short-term placement of a small-caliber chest tube and to determine whether a 1-hour clamping trial is adequate to identify patients with persistent air leak. MATERIALS AND METHODS: All patients undergoing FNAB of lung masses over a 28-month period were entered into the study. Patients with symptomatic, enlarging, or greater than 30% pneumothorax were treated with an 8-F chest tube. After 2 hours, the chest tube was clamped, and if the lung remained expanded for an additional hour, the chest tube was removed and the patients were discharged after a brief observation period. Patients were followed up by telephone after 24 hours. RESULTS: Three hundred fifteen patients underwent FNAB of the lung. Sixty-eight patients (22%) developed a pneumothorax. Chest tubes were placed in 14 patients (4%): Six patients (2%) required admission to the hospital (four for air leaks), and the other eight patients were treated successfully as outpatients, with removal of the chest tube before discharge the day of FNAB. CONCLUSION: Patients who develop clinically important pneumothorax after FNAB can be safely treated with short-term, small-caliber chest tubes and require hospital admission only if they demonstrate evidence of continued air leak.

The use of MRI in the diagnosis of occult hip fractures in the elderly: a preliminary review.

Establishing the diagnosis of a non-displaced hip fracture in an elderly patient can be a prolonged and costly procedure, involving hospital admission, several days of bed rest, and a bone scan 3 to 5 days later. The authors evaluated 10 hips in 10 patients with a questionable diagnosis of non-displaced hip fracture. Magnetic resonance imaging (MRI) soon after admission revealed four patients with acute hip fractures who were subsequently treated. The other six patients, whose scans were negative for either femoral neck or intertrochanteric fractures, were mobilized. The authors show that, through the use of an immediate MRI study of a questionable hip fracture, the prolonged recumbency and inherent costs associated with awaiting a positive bone scan can be avoided.