Prospective Series of Transarterial Chemoembolization of Metastatic Colorectal Cancer to the Liver with 30-60 µm Microspheres Loaded with Irinotecan.

PURPOSE: To describe safety and clinical outcomes among patients with metastatic colorectal cancer (mCRC) to the liver treated with transarterial chemoembolization with HepaSphere™ Microspheres 30-60 µm loaded with irinotecan (ΙRI-HEP-TACE). MATERIAL AND METHODS: In this prospective study (NCT04866290), 100 adults with confirmed mCRC to the liver who were ineligible for resection were enrolled and followed up to 24 months or death. Study outcomes among Salvage (patients not tolerating more cycles of chemotherapy) and Non-salvage patients included overall survival (OS), progression-free survival (PFS), objective response (OR), objective response rate (ORR), best tumor response (BTR), adverse events (AEs), and pharmacokinetics of irinotecan and its active metabolite, 7-ethyl-10-hydroxy-camptothecin (SN38). RESULTS: The median age was 66 years (range: 31-89). Median OS was 15.08 months (95% confidence interval [CI]: 12.33-17.25). PFS was 8.52 months (95% CI: 6.0-9.0; p < 0.001). ORR was 42.2% (95% CI: 31.57-53.50) and 35.9% (95% CI: 25.57-47.62) based on modified RECIST (Response Evaluation Criteria in Solid Tumors) and RECIST 1.1 criteria. BTR was not significantly different between mRECIST and RECIST (p = 0.745). The Non-salvage group had a statistically significant difference in median OS relative to the Salvage group (15.3 vs. 3 months; p < 0.001). Pharmacokinetic analyses demonstrated no correlation of OS with plasma concentration of irinotecan and SN38 (all p > 0.05). Most AEs were Grade 2 (257/279), the most common AE was right upper abdominal pain (180/279). One major AE (tumor rupture) was reported. CONCLUSION: IRI-HEP-TACE is an alternative treatment for patients with Non-salvage mCRC to the liver.

Five-Years Outcome Analysis of 142 Consecutive Hepatocellular Carcinoma Patients Treated with Doxorubicin Eluting Microspheres 30-60 µm: Results from a Single-Centre Prospective Phase II Trial.

PURPOSE: To assess prospectively long-term results of doxorubicin-loaded HepaSphere 30-60 µm in consecutive patients with hepatocellular carcinoma (HCC) not amenable to curative treatments. PATIENTS AND METHODS: Single-center study from June 2011 to December 2015 in 151 patients treated with 75 mg of doxorubicin per HepaSphere vial. Baseline: Barcelona Clinic Liver Cancer BCLC A/B was 49.3%/50.7%, and median diameter 6.1 cm (mean 6.7 ± 2.0). Liver function, local response (mRECIST), liver time to progression (LTTP), progression-free survival (PFS), overall survival (OS) and adverse events (AEs) were recorded. RESULTS: Final analysis included 142 patients with median follow-up of 46.8 months (range 4-72) without grade 4/5 AEs, and 30-day mortality was 0%. Mean number of scheduled treatments was 2.6 (range 1-3) and on demand 3 (range 1-8). Complete response for single tumor ≤ 5 cm was 75.0% and 66.7% for Child A and Child B, while for > 5 cm was 28.6% and 11.8%, respectively. OS was 31.0 months (mean 33.3 ± 15.2; range 8-69), notably for BCLC A 41 months (mean 41.1 ± 15.3; range 13-69) and for BCLC B 26.0 (mean 26.0 ± 10.5; range 8-51). OS at 1, 3 and 5 years: 95.8%, 75.7% and 21.4% for BCLC A, and 94.4%, 36.1% and 2.7% for BCLC B. Median LTTP for BCLC A was 11 months (mean 11.9 ± 4.7; range 3-24) and 7.5 for BCLC B (mean 7.9 ± 2.9). Local response was significant for OS and LTTP (p < 0.0001), while size and lesion number affected LPFS and OS (p < 0.001). CONCLUSIONS: HepaSphere 30-60 µm loaded with doxorubicin provides a safe and effective treatment option for patients with HCC.

The ten commandments of liver ablation: expert discussion and report from Mediterranean Interventional Oncology (MIOLive) congress 2017.

Percutaneous liver ablation has become a cornerstone of the recently developed subspecialty of radiology - that is, interventional oncology. Thermal ablation technology has evolved rapidly during the past decades, with substantial technical and procedural improvements that can help obtain better clinical outcomes and safety profiles. Due to the widespread use of percutaneous ablation, a comprehensive review of the methodologic and technical considerations seems to be mandatory. This article summarizes the expert discussion and report from Mediterranean Interventional Oncology Live Congress (MIOLive 2017) that was held in Rome, Italy, integrating evidence-reported literature and experience-based perceptions, to assist not only residents and fellows who are training in interventional radiology but also practicing colleagues who are approaching to this locoregional treatment.

The ten commandments of chemoembolization: expert discussion and report from Mediterranean Interventional Oncology (MIOLive) congress 2017.

Transarterial therapies in the setting of primary and secondary liver malignancies are becoming an essential part of the oncology landscape. The mechanism of action of c-TACE is the induction of tumor necrosis due to the high concentration of the chemotherapeutic that is delivered only locally and to the embolic effect that causes ischemia and increased dwell time of the chemotherapeutic in the tumor. Recently, DEB-TACE has emerged as a variation of c-TACE with the potential for the selective delivery of large amounts of drugs to the tumor for a prolonged period, thereby decreasing plasma levels of the chemotherapeutic agent and related systemic effects. There is an increasing consensus that compared with conventional lipiodol-based regimen, DEB-TACE offers standardized methodology, is more reproducible and is associated with improved response and significantly better safety profile. Using an easy to access point by point format, this manuscript summarizes the expert discussion from the Mediterranean Interventional Oncology Live Congress (MIOLive 2017) about the role of TACE in the treatment of liver tumors.

The ten commandments of hepatic radioembolization: expert discussion and report from Mediterranean Interventional Oncology (MIOLive) congress 2017.

Microsphere and particle technology represent the next-generation agents that have formed the basis of interventional oncology, an evolving subspecialty of interventional radiology. One of these platforms, yttrium-90 microspheres, is increasingly being used as a treatment modality for primary and secondary liver tumors. Due to the widespread use of radioembolization, a comprehensive review of the methodologic and technical considerations seems to be mandatory. This article summarizes the expert discussion and report from Mediterranean Interventional Oncology Live Congress (MIOLive 2017) that was held in Rome, Italy, integrating evidence-reported literature and experience-based perceptions, to assist not only residents and fellows who are training in interventional radiologists but also practicing colleagues who are approaching to this intra-arterial treatment.

Transcatheter arterial embolization as therapy of renal angiomyolipomas: the evolution in 15 years of experience.

OBJECTIVE: This study aims at presenting the evolution of the embolization technique in treating renal angiomyolipomas (AMLs) either diagnosed in patients with acute bleeding or discovered accidentally. METHODS: Ten patients with renal AMLs have been through thirteen selective transcatheter arterial embolizations for 15 years. Two patients had tuberous sclerosis complex (TSC) with bilateral tumors and were embolized twice. Four embolic materials were employed: PVA particles, Gianturco coils, microspheres and microcoils. Catheterization was achieved by means of 5F Cobra 2 catheters and coaxial microcatheter systems. RESULTS: On an emergency basis, embolization was a first-line treatment. In one case, surgery was necessary; in two patients, a second embolization was performed. When treatment was preventive, a single embolization proved to be sufficient, as well. There was no significant deterioration of the serum creatinine levels in the post-embolization period. CONCLUSION: Selective arterial embolization is a rather safe and effective technique to treat AMLs both urgently and preventively. Different embolic materials can be employed. Microspheres and microcatheters stand for new promising materials.

Transarterial embolization of giant liver hemangiomas associated with Kasabach-Merritt syndrome: a case report.

Of 22 patients with symptomatic giant liver hemangiomas referred for embolization, two females (52 and 74 years) had Kasabach-Merritt syndrome (KMS). Hematocrit values were observed to be 33% and 29%, platelets 4000 and 5400/mm(3), and fibrinogen 98 and 77 mg/dl, respectively. Lesion diameters were 7 and 14 cm, respectively. Hepatic angiography revealed excessive vascular lakes typical of cavernous hemangiomas. Microspheres of 40-300 microm were superselectively injected under fluoroscopic guidance until cessation of flow. Coil packing of the feeding hepatic artery was additionally used in one patient. The procedure was uneventful in both. Partial restoration of platelet count was observed immediately; fibrinogen levels and platelets were restored completely in one patient and partially in the other, without remissions at 2-year follow-up.

Infliximab therapy in pulmonary fibrosis associated with collagen vascular disease.

OBJECTIVE: To study the potential effectiveness of tumor necrosis factor a (TNF-alpha) inhibitor treatment for pulmonary fibrosis associated with a collagen vascular disease, CVD (rheumatoid arthritis, RA and systemic sclerosis, SSc) refractory to conventional treatment. METHODS: Four patients (three men with RA, one woman with SSc) were treated with infliximab. All patients received 3mg/kgr of infliximab at intervals 0, 2 and 6 weeks, and then maintenance infusions every 8 weeks afterwards for at least a 12-month period. Patients had active disease despite treatment with corticosteroids and other immunomodulatory agents. RESULTS: Treatment was well-tolerated from all patients. Pulmonary fibrosis remained stable during treatment in terms of symptoms, pulmonary function tests (PFTs) and High resolution computed tomography (HRCT) appearance. As expected, a clinical response was observed in joint symptoms in patients with RA as evaluated by the DAS28 (Disease Activity Score, the 28 joint version). CONCLUSION: This study suggests that inhibition of TNF-alpha with infliximab may stabilize the progression of pulmonary fibrosis associated with CVD. Prospective, controlled trials are necessary to determine the efficacy of infliximab in pulmonary fibrosis associated CVD.

Percutaneous radiofrequency ablation of lung tumors with expandable needle electrodes: current status.

Percutaneous radiofrequency thermal ablation (RFA) has been used to treat primary and secondary liver tumors under ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI) guidance for the past decade [Park et al., Radiol Clin North Am 38:545-561, 2000; Siperstein and Gotomirski, Cancer J 6:S293-S301, 2000; Kelekis et al., Eur Radiol 13:1100-1105, 2003]. RFA is a low-cost, minimally invasive treatment that has recently attracted attention for treating tumors in different solid organs with promising results [Dupuy and Goldberg, J Vasc Interv Radiol 12:1135-1148, 2001; Friedman et al., Cardiovasc Intervent Radiol 27:427-434, 2004]. It can be provided with minimal hospitalization, and experienced practitioners have reported low complication rates [Dupuy and Goldberg, J Vasc Interv Radiol 12:1135-1148, 2001; Livraghi et al., Radiology 226:441-451, 2003]. Patients with lung malignancies (primary lung cancer or pulmonary metastases), who cannot be operated, might be candidates for RFA treatment. It can also be used in association with other treatments (i.e., chemotherapy, radiotherapy) for better disease control. Combination of the above with RFA may help reduce morbidity and mortality. Many ways to apply energy to the tumor exist (monopolar and bipolar RFA, microwave, laser, brachytherapy). In this review we will focus on expandable monopolar systems, which despite their deficiencies are the most popular in the interventional radiology sector.

Long-term clinical effects of interferon gamma-1b and colchicine in idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF)/usual interstitial pneumonia is a deadly disease with no effective treatment. The purpose of this randomised prospective multicentric study was to characterise the clinical effects of interferon gamma (IFN-gamma) 1b administered subcutaneously thrice weekly versus colchicine for 2 yrs. This study had no pre-specified end-points. Fifty consecutive IPF patients were randomised. Patients with mild-to-moderate IPF were eligible for the study if they had histologically proven IPF, or, in the absence of surgical biopsy, fulfilled the European Respiratory Society/American Thoracic Society criteria. In the intent-to-treat population, five out of 32 (15.6%) IFN-gamma-1b patients and seven out of 18 (38.8%) colchicine patients died after a median follow-up period of 25 months Patients treated with IFN-gamma 1b showed a better outcome after 2 yrs of therapy, and fewer symptoms, as assessed using the St George's Respiratory Questionnaire, after 12 months of therapy. Also, the IFN-gamma-1b group exhibited a higher forced vital capacity (percentage of the predicted value) after 24 months of treatment. No significant differences were detected in resting arterial oxygen tension, total lung capacity (% pred), transfer factor of the lung for carbon monoxide (% pred) and high-resolution computed tomographic scoring between the two treatment groups. These data suggest that long-term treatment with interferon gamma 1b may improve survival and outcome in patients with mild-to-moderate idiopathic pulmonary fibrosis. Further studies are needed to verify these results.

Virtual bronchoscopy versus thin section computed tomography in evaluation of moderate and low grade stenoses: receiver operating characteristic curve analysis.

PURPOSE: To evaluate the impact of virtual bronchoscopy, under proper threshold settings, on observer level of confidence in the assessment of bronchial abnormalities producing stenoses < or = 75% compared to interpretation of thin section computed tomography (CT) images. MATERIAL AND METHODS: Sixty-five patients with fiberoptic bronchoscopy positive for tracheobronchial abnormalities were evaluated in a blinded observer study using a commercially available virtual endoscopy software package. The findings of virtual endoscopy were compared with those of fiberoptic bronchoscopy using receiver operating characteristic curves (ROCs) and other statistical tools. RESULTS: A total of 102 lesions were identified by fiberoptic bronchoscopy, with 44 of these producing bronchial stenoses < or = 75%. Concerning the latter lesions, for virtual bronchoscopy the areas under the ROCs were 0.93 and 0.96 for the two observers, respectively, while for thin section CT the corresponding values were 0.86 and 0.88; the differences observed were statistically significant. Contrary to thin section CT, virtual bronchoscopy did not show statistically significant differences from fiberoptic bronchoscopy regarding estimation of degree of stenosis. CONCLUSION: Virtual bronchoscopy under proper threshold settings has a statistically significant impact on observer performance where moderate and low-grade bronchial stenoses are concerned and gives an estimate of the degree of stenosis more precisely than thin section CT.

Clearance of technetium-99m-DTPA in pulmonary sarcoidosis.

BACKGROUND: The aim of this study was to explore the possible association of the lung clearance of 99mTc-DTPA scan with HRCT lung abnormalities and with the pulmonary function tests [PFTs] in patients with sarcoidosis. METHODS: We studied prospectively 15 patients [5 males, 10 females] of median age 46yr [range 27-67] with histologically proved sarcoidosis. HRCT scoring included the sum of the severity and extent of lymph node enlargement and parenchymal involvement. RESULTS: The mean DTPA clearance half-time [tau 1/ <40 min] was found [mean [SD]] 38.3+/-4.5min. The lymph node enlargement was found 34% and the parenchymal involvement 12%. DTPA clearance was negatively correlated with the parenchymal involvement [r= -0.651, p=0.0091]. The HRCT parenchymal abnormalities were found significantly correlated with PFTs [FVC [r= -0.65, p=0.008] and TLCO [r= -0.76, p=0.02]. CONCLUSIONS: Our data suggest a moderate association between 99mTc-DTPA scan and HRCT in pulmonary sarcoidosis. However, further studies in large scale of sarcoid patients are needed to clarify the role of this novel methodology in the evaluation and follow-up of this disorder.

The role of ThinPrep cytology in the investigation of lung tumors.

AIMS OF THE STUDY: The aim of this study was to evaluate the role of liquid-based cytology with the ThinPrep (TP) (Cytyc; Cytyc, Co, Boxborough, MA, USA) technique, using fine-needle aspiration (FNA) for sampling, in the investigation of suspicious pulmonary lesions. METHODS: We performed percutaneous computed tomography (CT)-guided FNA biopsy of focal pulmonary lesions in 80 adult patients. Study subjects were all consecutive patients and potential candidates for surgery. The sample was then examined by both conventional smears (CS) and TP techniques. TP smears of all FNA were prepared from needle rinsing obtained following preparation of CS. All cytological diagnoses were correlated with the CS and/or thoracotomy histological diagnoses in order to evaluate the role of liquid-based cytology with the TP technique. RESULTS: Using TP technique diagnosis was successfully established in 75 patients out of 80, whereas using CS cytology diagnosis was established in 54 patients (p<0.001, z=3899). Inadequate material was observed in 5 cases (6.25%) with the TP technique and in 13 cases (16.25%) with the CS technique (z=-2.77, p<0.05). CONCLUSIONS: We believe that the TP technique has a good overall yield for the diagnosis of suspicious for malignant lung lesions. We found that the accuracy of determining lung cancer was excellent.

Cirrhosis-related intrathoracic disease. Imaging features in 1038 patients.

BACKGROUND/AIMS: To describe imaging features of cirrhosis-related intrathoracic disease. METHODOLOGY: Chest CTs of 1038 cirrhotic patients (mean age 53 yrs; range, 17-79) were evaluated for: bronchoarterial ratio (BAR), arteriovenous malformations, interstitial opacities, emphysema, and pleural effusions. Lymphangiography, pulmonary angiography, cardiac ultrasound and scintigraphy were selectively performed. RESULTS: Mean BAR was 0.83+/-0.19. In two patients with hepatopulmonary syndrome (HPS), mean BAR was 0.55. HRCT detected interstitial lung opacities in 15 patients. Signs of fibrosis were seen in 7 (only two associated to biliary cirrhosis) and interstitial edema in 8. Accurate pattern recognition was achieved in 10/15 cases (66.6%). Of the 93 patients with emphysema only one had documented alpha1-AT deficiency (1.08%). Multiple type 1 vascular dilatations were visualized in two patients with HPS. Hepatic hydrothorax was present in 49 patients (4.72%); right-sided in 34 (69.4%), bilateral in 9 (18.4%) and left-sided in 6 (12.2%). Hepatic chylothorax was confirmed in 3 patients. Lymphangiography demonstrated the site of leakage and the engorged thoracic duct. CONCLUSIONS: CT can identify intrathoracic pathology associated with liver disease. Decreased BAR is highly specific for HPS. However, a multimodality approach is necessary to depict cases of liver origin.

Acute mediastinitis: spectrum of computed tomography findings.

The objective of this study was to describe CT findings and to determine the diagnostic value of CT in diagnosis of acute mediastinitis. CT findings were retrospectively studied in 40 patients with suspected acute mediastinitis, including 28 postoperative patients, five with acute descending necrotizing mediastinitis (ADNM), and seven with suspected post-traumatic perforation of the esophagus. Findings included increased attenuation of mediastinal fat (100%), localized mediastinal fluid collections (55%), free gas bubbles in the mediastinum (57.5%), mediastinal lymph nodes (35%), pericardial effusions (27.5%), pleural effusions (85%), lung infiltrates (35%), sternal dehiscence (40%), and pleuromediastinal fistula (2.5%). The sensitivity and specificity of CT in postoperative patients in the first 17 days was 100% and 33% respectively, and after day 17, 100% and 90%. In patients with ADNM sensitivity was 100% while in patients with suspected esophageal perforation sensitivity and specificity were 100%. CT is a highly sensitive technique for the detection of mediastinitis of various causes. For the postoperative patients there is clear time dependence for CT interpretation and accuracy. In patients with suspected ADNM, and traumatic esophageal perforation CT is highly specific early after clinical presentation.

Fibrosing mediastinitis causing rapidly progressive dyspnea, pulmonary edema and death in a 16 yr old male.

Idiopathic fibrosing mediastinitis is a rare entity involving more severely the more compliant structures within the mediastinum. In this report a rare case of simultaneous involvement of both the superior vena cava (SVC) and pulmonary veins is described in a 16--year old male with progressive dyspnea on exertion, cough and a three months' history of blood--tinged sputum. Physical examination and imaging studies revealed signs of pulmonary venous hypertension (PVH) and SVC stenosis. Fibrosing mediastinitis was confirmed by multiple biopsy samples.