Elevated Angiogenic Factor Levels After Transarterial Radioembolization for Colorectal Cancer Liver Metastases May Predict a Poor Prognosis.

Objectives: To analyze the change in circulating angiogenic factor levels after transarterial radioembolization (TARE) for colorectal cancer liver metastases (CRCLMs) and its prognostic significance. Methods: Blood samples immediately before TARE and on 1 day, 1 week and 6 weeks after were collected for angiogenic factor analysis in 23 patients. Results: Patients with elevated serum basic fibroblast growth factor and platelet-derived growth factor levels in the 1st week and vascular endothelial growth factor (VEGF) levels in the 6th week after TARE had significantly shorter median overall survival (OS) times. Conclusion: Some early increases in serum angiogenic factor levels and in serum VEGF in the 6th week after TARE for CRCLMs are related to short OS and progression-free survival.

An imaging-based artificial intelligence model for non-invasive grading of hepatic venous pressure gradient in cirrhotic portal hypertension.

The hepatic venous pressure gradient (HVPG) is the gold standard for cirrhotic portal hypertension (PHT), but it is invasive and specialized. Alternative non-invasive techniques are needed to assess the hepatic venous pressure gradient (HVPG). Here, we develop an auto-machine-learning CT radiomics HVPG quantitative model (aHVPG), and then we validate the model in internal and external test datasets by the area under the receiver operating characteristic curves (AUCs) for HVPG stages (≥10, ≥12, ≥16, and ≥20 mm Hg) and compare the model with imaging- and serum-based tools. The final aHVPG model achieves AUCs over 0.80 and outperforms other non-invasive tools for assessing HVPG. The model shows performance improvement in identifying the severity of PHT, which may help non-invasive HVPG primary prophylaxis when transjugular HVPG measurements are not available.

PATIENT AND STAFF DOSES FOR VARIOUS INTERVENTIONAL RADIOLOGY AND CARDIOLOGY EXAMINATIONS IN TURKEY.

This study aims to determine the radiation doses of patients and staff during different interventional radiology and cardiology examinations. Dose measurements for interventional radiology examinations were performed in Ibn-i Sina Hospital of Ankara University using Siemens Artis-Zee medical imaging system. Patient dose measurement was carried out for interventional cardiology examinations in Cardiology Department of TOBB-ETU University, Medical Faculty Hospital using Philips Allura Centron interventional X-ray system. Patient doses were obtained in terms of kerma area product (KAP) and cumulative air kerma (CAK) from KAP meter attached to the angiography system. Performance tests of the angiography system were performed before patient dose measurements. Staff dose measurements were carried out with thermoluminescence dosimeters (TLD-100) placed in certain areas on the staff. Patient dose measurements were performed for 15 different interventional radiology examinations on a total of 431 patients and for four different cardiology examinations on a total of 299 patients. Monte Carlo based PCXMC 2.0 program was used to calculate patient effective doses. Lower extremity arteriography was the most common examination with a mean KAP value of 30 Gy cm2 and mean effective dose value of 1.2 mSv for total number of 194 patients. Mean KAP values calculated for coronary angiography, percutaneous coronary intervention, electrophysiological procedures and radiofrequency cardiac ablation examinations were 62.8, 162.8, 16.7 and 70.6 Gy cm2, respectively. Radiologist, nurse and technician effective dose normalised to the unit KAP of patient dose were 0.15, 0.11 and 0.14 µSv Gy-1 cm-2. Similarly, cardiologist, nurse and technician effective dose normalised to the unit KAP of patient dose were 0.22, 0.15 and 0.09 µSv Gy-1 cm-2. Measured KAP and CAK values vary depending on the type and complexity of the examination. The measured staff doses during cardiac examinations were higher when compared with that measured for interventional radiology as expected.

Noncontrast-enhanced MRI-based Noninvasive Score for Portal Hypertension (CHESS1802): An International Multicenter Study.

BACKGROUND AND AIMS: This study aimed to determine the performance of the non-invasive score using noncontrast-enhanced MRI (CHESS-DIS score) for detecting portal hypertension in cirrhosis. METHODS: In this international multicenter, diagnostic study (ClinicalTrials.gov, NCT03766880), patients with cirrhosis who had hepatic venous pressure gradient (HVPG) measurement and noncontrast-enhanced MRI were prospectively recruited from four university hospitals in China (n=4) and Turkey (n=1) between December 2018 and April 2019. A cohort of patients was retrospectively recruited from a university hospital in Italy between March 2015 and November 2017. After segmentation of the liver on fat-suppressed T1-weighted MRI maps, CHESS-DIS score was calculated automatically by an in-house developed code based on the quantification of liver surface nodularity. RESULTS: A total of 149 patients were included, of which 124 were from four Chinese hospitals (training cohort) and 25 were from two international hospitals (validation cohort). A positive correlation between CHESS-DIS score and HVPG was found with the correlation coefficients of 0.36 (p<0.0001) and 0.55 (p<0.01) for the training and validation cohorts, respectively. The area under the receiver operating characteristic curve of CHESS-DIS score in detection of clinically significant portal hypertension (CSPH) was 0.81 and 0.9 in the training and validation cohorts, respectively. The intraclass correlation coefficients for assessing the inter- and intra-observer agreement were 0.846 and 0.841, respectively. CONCLUSIONS: A non-invasive score using noncontrast-enhanced MRI was developed and proved to be significantly correlated with invasive HVPG. Besides, this score could be used to detect CSPH in patients with cirrhosis.

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.

Scheduling surgery after transarterial embolization: does timing make any difference to intraoperative blood loss for renal cell carcinoma bone metastases?

PURPOSE: Our purpose is to clarify the optimal timing of surgery after transarterial embolization (TAE) for renal cell carcinoma (RCC) bone metastases. METHODS: This retrospective study included 41 patients with RCC bone metastases embolized between 2013 and 2019. Different-sized particulate and/or liquid embolic agents were used for TAE. Embolizations were categorized into groups 1-3 according to the interval between TAE and surgery (group 1: <1 day, group 2: 1-3 days, group 3: >3 days). Degree of embolization after TAE was graded visually based on angiographic images (<50%, 50%-75%, 75%-90%, >90%). The relationship between the TAE-surgery interval and intraoperative blood loss (IBL) and the correlation between IBL and embolization grade were examined. Lesion sizes and the relationships among lesion localizations and contrast media usage, intervention time, and IBL were also analyzed. RESULTS: Forty-six pre-operative TAEs (single lesion at each session) were performed in this study (26 in group 1, 13 in group 2, 7 in group 3). Lesion sizes and distributions were similar between groups (p = 0.897); >75% devascularization was achieved in 40 (TAEs 86.96%), but the IBL showed no correlation with the embolization rate (r=0.032, p = 0.831). The TAE-surgery interval was 1-7 days. The median IBL in group 1 (750 mL; range, 150-3000 mL) was significantly lower than those in the other groups (p = 0.002). Contrast media usage (p = 0.482) and intervention times (p = 0.261) were similar for metastases at different localizations. IBL values after TAE were lower for extremity metastases (p = 0.003). CONCLUSION: Bone metastases of RCC are well-vascularized, and to achieve lowest IBL values, surgery should preferably be performed <1 day after TAE.

Deep Convolutional Neural Network-Aided Detection of Portal Hypertension in Patients With Cirrhosis.

BACKGROUND & AIMS: Noninvasive and accurate methods are needed to identify patients with clinically significant portal hypertension (CSPH). We investigated the ability of deep convolutional neural network (CNN) analysis of computed tomography (CT) or magnetic resonance (MR) to identify patients with CSPH. METHODS: We collected liver and spleen images from patients who underwent contrast-enhanced CT or MR analysis within 14 days of transjugular catheterization for hepatic venous pressure gradient measurement. The CT cohort comprised participants with cirrhosis in the CHESS1701 study, performed at 4 university hospitals in China from August 2016 through September 2017. The MR cohort comprised participants with cirrhosis in the CHESS1802 study, performed at 8 university hospitals in China and 1 in Turkey from December 2018 through April 2019. Patients with CSPH were identified as those with a hepatic venous pressure gradient of 10 mm Hg or higher. In total, we analyzed 10,014 liver images and 899 spleen images collected from 679 participants who underwent CT analysis, and 45,554 liver and spleen images from 271 participants who underwent MR analysis. For each cohort, participants were shuffled and then sampled randomly and equiprobably for 6 times into training, validation, and test data sets (ratio, 3:1:1). Therefore, a total of 6 deep CNN models for each cohort were developed for identification of CSPH. RESULTS: The CT-based CNN analysis identified patients with CSPH with an area under the receiver operating characteristic curve (AUC) value of 0.998 in the training set (95% CI, 0.996-1.000), an AUC of 0.912 in the validation set (95% CI, 0.854-0.971), and an AUC of 0.933 (95% CI, 0.883-0.984) in the test data sets. The MR-based CNN analysis identified patients with CSPH with an AUC of 1.000 in the training set (95% CI, 0.999-1.000), an AUC of 0.924 in the validation set (95% CI, 0.833-1.000), and an AUC of 0.940 in the test data set (95% CI, 0.880-0.999). When the model development procedures were repeated 6 times, AUC values for all CNN analyses were 0.888 or greater, with no significant differences between rounds (P > .05). CONCLUSIONS: We developed a deep CNN to analyze CT or MR images of liver and spleen from patients with cirrhosis that identifies patients with CSPH with an AUC value of 0.9. This provides a noninvasive and rapid method for detection of CSPH (ClincialTrials.gov numbers: NCT03138915 and NCT03766880).

Analysis of prognostic factors in patients receiving transarterial radioembolization for unresectable hepatocellular carcinoma.

AIM: This study aimed to analyze the prognostic factors of patients receiving transarterial radioembolization for unresectable hepatocellular carcinoma. MATERIAL AND METHOD: Eighty-six (73 M and 13F; mean age: 64.3 ± 9.8 years) patients who received transarterial radioembolization for unresectable hepatocellular carcinoma were included. Relationship between serum alpha-fetoprotein and international normalization ratio level, albumin-bilirubin grade, neutrophil-lymphocyte ratio, presence of portal venous thrombosis and extrahepatic metastases, the dimension of index lesion and OS were analyzed. RESULTS: Neutrophil lymphocyte ratio was ≤ 5 in 76 (88%) and >5 in 10 (12%) of patients. Sixty-two (72%) patients died during a mean of 25.6± 9.7 months follow-up. Mean OS for all patients was calculated as 12.9 ± 14.6 months. In univariate analysis, albumin-bilirubin grade (22.3 ± 3.8 vs. 11.6 ± 4.2; P = 0.03), neutrophil-lymphocyte ratio (21.8 ± 3.6 vs. 7.3 ± 2.6; P =0.04), presence of extrahepatic metastases (30.1 ± 5.4 vs. 7.4 ± 2.0; P = 0.001) and portal venous thrombosis (26.5± 4.8 vs. 10.5 ± 2.1; P = 0.01) had significant effect on OS. In multivariate analysis, serum international normalization ratio (P = 0.005) and alpha-fetoprotein level (P = 0.004), albumin-bilirubin grade (P = 0.05), neutrophil-lymphocyte ratio (P = 0.007), Child-Pugh score (0.006) and presence of ascites (P = 0.005) were significantly correlated with OS. CONCLUSION: Patients with low basal albumin-bilirubin grade and neutrophil-lymphocyte ratio survive longer after transarterial radioembolization for unresectable hepatocellular carcinoma. Presence of extrahepatic metastases and portal venous thrombosis seems to have a prognostic value.

Extended left hepatectomy for intrahepatic cholangiocarcinoma: hepatic vein reconstruction with in-situ hypothermic perfusion and extracorporeal membrane oxygenation.

BACKGROUND: Liver resection for intrahepatic cholangiocarcinoma (ICC) with invasion of the inferior vena cava (IVC) and hepatic veins (HV) is a challenging procedure. CASE PRESENTATION: We report a case of a 63-year-old woman with a 6-cm, centrally located liver mass. Her biochemistry results were normal except for a Ca19-9 level of 1199 U/ml. The liver biopsy was consistent with ICC and 60% macrosteatosis. Abdominal CT scans revealed a large central mass invading the left HV, middle HV and right HV, infringing on their junction with the vena cava. An operation was planned using a 3-dimensional (3D) computer simulation model using dedicated software. We also describe a novel veno-portal-venous extracorporeal membrane oxygenation (VPV-ECMO) support with in-situ hypothermic perfusion (IHP) during this procedure. We aimed to perform an extended left hepatectomy and reconstruct 3 right HV orifices with an interposition jump graft to the IVC with total vascular exclusion (TVE) and IHP A supplemental video describing the preoperative planning, the operative procedure with the postoperative follow-up in detail is presented. After the patient was discharged, she developed a hepatic venous outflow obstruction 3 months postoperatively, which was effectively managed with hepatic venous stenting by interventional radiology. She is currently symptom free and without tumour recurrence at the 1-year follow-up. CONCLUSIONS: This report demonstrates that extended left hepatectomy for IHC with IHP and VPV-ECMO is safe and feasible under the supervision of a highly experienced team.

A Retrospective Analysis of Surgical Femoral Artery Closure Techniques: Conventional versus Purse Suture Technique.

BACKGROUND: Different techniques have been reported for the exploration and repair of femoral artery (FA) in patients who undergo minimally invasive cardiac surgery (MICS) and endovascular aortic surgery. We used a modified approach alternative to the conventional technique (group CT) since May 2013, which specifies a shorter groin incision and diamond-shaped hemostatic purse sutures for arteriotomy closure without the requirement of cross-clamping (group PT [purse suture technique]) and evaluated early outcomes and the complication profiles of the 2 techniques for femoral access. METHODS: In our clinic, between May 2011 and December 2015, 503 FA cannulations were performed on 345 patients who underwent MICS (n = 109, mean age 64.1 ± 17.6 years, female/male ratio 71/38), endovascular abdominal aneurysm repair (n = 158, mean age 71.3 ± 10.2 years, female/male ratio 63/95), thoracal endovascular aneurysm repair (n = 50, mean age 65.0 ± 15.3 years, female/male ratio 15/35), and transaortic valve implantation (n = 28, mean age 80.8 ± 5.9 years, female/male ratio 13/15). A total of 295 FAs were exposed via mini incision and were repaired with the PT. We compared the duration of femoral closure (FC), wound infection, and vascular complications including bleeding hematoma, thromboembolic and ischemic events, pseudoaneurysm, seroma, surgical reintervention rates, delayed hospital stay for groin complications, and existence of postoperative local luminal narrowing (LLN) at the intervention site over 25% for both groups. RESULTS: FC time (CT 14.9 ± 3.16 min, PT 6.5 ± 1.12 min, P < 0.0001), bleeding hematoma frequency (CT 6.2%, PT 1.7%, P = 0.01), and prolonged hospital stay for groin complications (CT 14.9%, PT 3.4%, P < 0.0001) were significantly lower in the PT group. Rate of technical success (CT 80.3%, PT 87.4%, P = 0.03) and event-free patient (CT 66.1%, PT 77.5%, P = 0.03) were significantly better in the PT group. There were no differences between groups in terms of ischemic events, wound infection rates, development of pseudoaneurysm and seroma, surgical reintervention rates, and LLN of FA over 25% at 6-month duplex evaluation. CONCLUSIONS: The comparison of the 2 approaches revealed the advantages of the PT in terms of bleeding hematoma and shortening in FC time and the length of hospital stay. We suggest performing a smaller skin incision for FA access and utilizing purse sutures, which allows completing the procedure without cross-clamping, thus providing a favorable approach and excellent comfort for the surgeon.

Prognostic Importance of the Presence of Early Metabolic Response and Absence of Extrahepatic Metastasis After Selective Internal Radiation Therapy in Colorectal Cancer Liver Metastasis.

AIMS: In this study, the authors aimed to identify prognostic factors after selective internal radiation therapy (SIRT) for colorectal cancer (CRC) liver metastasis. METHODS: Forty-nine (28 male, 21 female; mean age: 64.6 ± 10.8) patients who received SIRT for CRC liver metastasis were studied. Effects of number (<5 vs. ≥5), maximum dimension, and standardized uptake value (SUV) of liver metastases, liver tumor load (<25% vs. 26%-50% vs. 51%-75%), presence of extrahepatic disease, and metabolic early response on overall survival were analyzed. RESULTS: Mean follow-up time was 44.1 ± 27.5 months. Overall survival time was calculated as 10.03 ± 1.61 (95% CI; 6.86-13.20) months. SUV (0.004) of liver metastases, early metabolic response (p = 0.015), and presence of extrahepatic metastasis (p = 0.001) were identified as significant factors influencing overall survival. The hazard ratio was 1:2.3 for the presence of extrahepatic metastasis and 1:2.7 for the absence of early metabolic response. CONCLUSION: These findings suggest that patients with CRC liver metastasis who have lower SUV at presentation and early metabolic response have better outcomes after SIRT.

Comparison of survival, safety, and efficacy after transarterial chemoembolization and radioembolization of Barcelona Clinic Liver Cancer stage B-C hepatocellular cancer patients.

AIM: This study aimed to compare the overall survival (OS) times, long-term complications, and recurrence rates of chemoembolization and radioembolization for Barcelona Clinic Liver Cancer (BCLC) stage B-C hepatocellular cancer patients. MATERIALS AND METHODS: This retrospective study included 80 BCLC stage B-C hepatocellular cancer patients who received chemoembolization (group 1) or radioembolization (group 2). The OS times, long-term complications, and disease recurrence rates of the two groups were compared. The prognostic role of sex, age, presence of underlying chronic liver disease, BCLC stage, dimension and number of liver lesions, tumor load, and presence of extrahepatic disease were also analyzed for each group. RESULTS: Each group included 40 (67 men, 13 women, mean age: 41.9±21.9 years) patients. During the follow-up period, 22 patients died in group 2 and 30 patients died in group 1. The overall mean survival of the entire patient group was calculated to be 37.31±3.94 months [95% confidence interval (CI), 30.46-44.1 months], with 30.63±3.68 months (95% CI, 23.42-37.84 months) for group 1 and 39.24±4.62 months (95% CI, 30.18-48.29 months) for group 2 (P=0.014). The 1- and 2-year survival rates were 72 versus 74% and 47 versus 59% for groups 2 and 1, respectively. There was no significant difference between the chronic complication (P=0.32) and disease recurrence (P=0.65) rates of the groups. Whereas the dimension of the largest lesion was the most significant predictor (P=0.01) in group 2, female sex (P=0.008), dimension of the largest lesion (P=0.03), and BCLC stage (P=0.01) were significant in group 1. CONCLUSION: Although chemoembolization and radioembolization for BCLC Stage B-C patients have similar levels of safety and efficacy, they differ in OS. In this retrospective study, patients undergoing radioembolization had a longer survival rate.

Radioembolization with (90)Y resin microspheres for intrahepatic cholangiocellular carcinoma: prognostic factors.

AIM: To investigate the prognostic factors that predict overall survival after radioembolization in patients with cholangiocellular carcinoma. METHODS: The study comprised 16 patients who received radioembolization with Y(90) resin microspheres for cholangiocarcinoma. The statistical relationships between overall survival after radioembolization and age, number, dimension and fluorodeoxyglucose (FDG) avidity of liver lesions, liver tumor load, presence of extrahepatic metastases, and radiological response were analyzed. RESULTS: Mean 1.7 ± 0.1 GBq(90)Y microspheres were administered to a total of 16 patients (mean age: 55.37 ± 17.7; 8 males, 8 females). Mean AST, ALT, and total bilirubin levels were calculated as 35 ± 15, 40 ± 37 IU/L, and 0.77 ± 0.37 mG/dL, respectively. In 6 patients, 1 liver lesion was determined, in 2 patients ≤ 5, and in 8 patients >5, with dimensions varying between 12 and 120 mm. The liver lesions of 13 patients were FDG avid (mean SUVmax: 7.4 ± 2.2). Extrahepatic metastases were demonstrated in 5 patients. Tumor load of 4, 8, and 4 patients was calculated as <25, 25-50, and >50%, respectively. Five patients were responsive to treatment. During the follow-up period of 243 (range 98-839) days, 12 patients died. In Cox-regression analysis, FDG avidity (p = 0.02), the dimensions (p = 0.03) of the liver lesion, tumor load (p = 0.02), and radiological response (p = 0.01) were found to be statistically significant parameters predictive of overall survival after radioembolization (p = 0.006). CONCLUSION: FDG avidity and the dimension of the largest liver lesion, tumor load, and radiological response are prognostic factors in patients receiving radioembolization for cholangiocellular carcinoma. Patients with lower tumor load, FDG-negative tumors, and smaller tumors seem to survive longer after radioembolization.

Prognostic factors for prediction of survival of hepatocellular cancer patients after selective internal radiation therapy.

AIM: In this study, it was aimed to explore the prognostic factors in patients who received selective internal radiation therapy for hepatocellular cancer. MATERIALS AND METHODS: A retrospective evaluation was made of 28 (24 male, 4 female, mean age 65.4 ± 6.8 years) hepatocellular cancer patients who received selective internal radiation therapy with Y-90 resin microspheres. Using Cox proportional hazards regression analysis, the relationship between age, gender, MELD score, serum albumin and AFP levels, number of liver lesions, size of the largest lesion, absence of (18)F-FDG uptake, maximum standardized uptake value and overall survival times was analyzed. RESULTS: Treatment was applied to the right lobe in 22 and both in 6 patients. Mean treatment dose was 1.5 ± 0.2 GBq. Number of liver lesions were 1, <5 and multiple in 16, 5 and 7 patients, respectively, and the mean size of the largest lesion was 41.5 mm (min-max 15-160 mm). While (18)F-FDG uptake was seen in 24 patients, liver lesions were hypometabolic in 4 patients. Mean SUVmax of liver lesions was calculated as 5.3 ± 0.3. During the mean 17.8 (min-max 2-39) months follow-up period, 19 patients died. Median survival time was computed as 18 ± 5 months (95% CI 8.1-27.8). Age (p = 0.04), serum AFP level (p = 0.03) and size of the largest lesion (p = 0.02) had a significant negative effect on survival according to the Cox proportional hazards regression analysis. CONCLUSION: Age, serum AFP level and the size of the largest liver lesion have a negative significant effect on survival of hepatocellular cancer patients who received selective internal radiation therapy.

Radioembolization with yttrium-90 resin microspheres for neuroendocrine tumor liver metastases.

PURPOSE: We aimed to evaluate the effectiveness and safety of radioembolization with yttrium-90 (90Y) microspheres in cases with unresectable neuroendocrine tumor liver metastases (NETLMs). METHODS: Thirty patients (mean age, 55 years) underwent resin-based 90Y radioembolization for unresectable NETLM at a single institution between April 2008 and June 2013. Post-treatment tumor response was assessed by cross-sectional imaging using the Response Evaluation Criteria in Solid Tumors (RECIST). Prognostic variables that affected survival were determined. RESULTS: The mean follow-up was 23.0±19.4 months and the median overall survival was 39 months (95% CI, 12.6-65.4 months), with one- and two-year survival rates of 71% and 45%, respectively. Imaging follow-up using RECIST at three-month intervals demonstrated partial response in 43%, complete remission in 3%, stable disease in 37%, and progressive disease in 17% of patients. Extent of tumor involvement was found to have a statistically significant influence on overall survival (P = 0.03). The existence of extrahepatic disease at the time of radioembolization, radiographic response, age, and primary neuroendocrine tumor site were not significant prognostic factors. CONCLUSION: The current study demonstrates the effectiveness and safety of radioembolization for the treatment of unresectable NETLMs. We identified that the extent of tumor involvement has a significant effect on overall survival. The use of imaging methods reflecting metabolic activity or cellularity such as scintigraphy or diffusion-weighted MRI would be more appropriate, for the response evaluation of liver metastases after radioembolization.

Effect of carotid artery stenting on ophthalmic artery flow patterns.

OBJECTIVES: The purpose of this study was to assess the effect of carotid artery stenting on ophthalmic artery blood flow using transorbital color and spectral Doppler sonography and review the changes in relation to cerebral hemodynamics. METHODS: Twenty-eight consecutive patients with severe internal carotid artery stenosis (≥ 70%) who were scheduled for carotid stenting were included. Ophthalmic artery Doppler sonography was performed bilaterally before and after stenting. The flow direction, peak systolic velocity (PSV), end-diastolic velocity (EDV), pulsatility index (PI), and resistive index in the ophthalmic artery were recorded. RESULTS: Twenty male and 8 female patients with 10 right-sided and 18 left-sided stenoses were studied. The mean overall carotid stenosis ratio ± SD was 87.3% ± 9.9%. After stenting in the ophthalmic artery ipsilateral to the stenosis, significant increases in the PSV (-3.87 ± 48.81 to 46.70 ± 25.33 cm/s; P < .001), and EDV (-3.02 ± 16.31 to 11.24 ± 7.37 cm/s; P < .001) were detected, and the increase in the PI approached significance (1.40 ± 0.59 to 1.62 ± 0.52; P = .055). A change in the flow direction from retrograde to antegrade was noted in 11 patients (39%) after stenting, and in 1 patient with no detectable flow, reconstitution of flow was observed. Increases in the PSV and EDV (P= .03 for ΔEDV) were more pronounced in symptomatic patients than asymptomatic patients after stenting. CONCLUSIONS: Substantially decreased ophthalmic artery velocity and retrograde flow are suggestive of high-grade carotid artery stenosis (≳90%). Stenting improves ophthalmic artery perfusion and positively changes cerebral hemodynamics in high-grade carotid artery stenosis, especially in symptomatic patients, which can be monitored with ophthalmic artery Doppler sonography.

Prognostic importance of 18F-FDG uptake pattern of hepatocellular cancer patients who received SIRT.

PURPOSE: The aim of the study was to evaluate the effect of 18F-FDG uptake pattern of liver lesions to treatment response of patients who received yttrium-90 (Y-90) selective internal radiation therapy (SIRT) for hepatocellular cancer (HCC). PATIENTS AND METHODS: Nineteen patients (5F, 14M, mean age: 64.5 ± 14.7 years old, range: 57-73 years) who received SIRT treatment in our department for HCC between June 2008 and May 2011 were included in the study. All patients underwent 18F-FDG PET/CT before SIRT for evaluation of disease stage and metabolic activity of liver lesions. Patients were divided into 3 groups according to FDG uptake patterns of primary liver lesions (hypoactive, nonhomogenous, and focal intense). Progression-free survival (PFS) times of each group and patients with hepatic only and hepatic with extrahepatic disease were analyzed. Disease progression criteria were increase in tumor volume, progressive elevation of serum alpha-fetoprotein levels, and detection of extrahepatic metastases. Kaplan-Meier analysis was used for comparison of PFS times. RESULTS: The mean treatment dose was calculated as 1.4 ± 1.0 GBq. While liver lesions of 4 patients were hypoactive in pretreatment 18F-FDG PET/CT, liver lesions of 6 and 9 patients had nonhomogenous and intense FDG uptake, respectively. Mean PFS time of patients who had hypoactive liver lesions was 5.25 ± 1.52 months. In patients who had liver lesions with nonhomogenous uptake, mean PFS time was 12.3 ± 2.6 months. Lastly, in patients with intense uptake in liver lesions, PFS time was calculated as 19.8 ± 5.0 months. Difference between each group was statistically significant (P = 0.017). There was no significant difference in the PFS of the patients with limited hepatic disease and patients with extrahepatic involvement. CONCLUSION: In patients with unresectable HCC, higher SUVmax lesions unexpectedly had better PFS rates after SIRT, suggesting SIRT has a treatment advantage over other therapeutic options in these patients.

The prognostic value of quantitative parameters of 18F-FDG PET/CT in the evaluation of response to internal radiation therapy with yttrium-90 in patients with liver metastases of colorectal cancer.

INTRODUCTION: The aim of this study was to evaluate tumor response using fluorine-18-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) in patients who received yttrium-90 selective internal radiation therapy (SIRT) for colorectal liver metastases. The initial and sixth-week tumor lesion glycolysis values were calculated to evaluate the success of the treatment and compare it with patient survival. MATERIALS AND METHODS: Thirty-five patients (15 female, 20 male, mean age: 61.9 ± 9.0 years, range: 33-76 years) who received SIRT treatment for unresectable colorectal cancer liver metastases in our hospital between June 2008 and May 2011 were included in the study. All patients included in the study had liver-only or liver-dominant disease. The treatment response was evaluated by 18F-FDG PET/CT in the sixth week after treatment. Response was evaluated according to the change in total lesion glycolysis (ΔTLG). The ΔTLG was calculated using the following formula: ΔTLG=100 ×[standardized uptake value (SUV) mean1 × total functional tumor volumes (FTVs)1-SUV mean2 × FTV2]/SUV mean1 × FTV1. RESULTS: Mean FTV1 and FTV2 values were calculated to be 235.7 ± 203 and 107.3 ± 67 mm3, respectively (P=0.04). The mean ΔTLG was 43 ± 35 (range: 0-100). Mean overall survival time was 12.7 ± 8.0 months (range: 3-31 months). The cutoff value of ΔTLG was calculated to be 26.5 using receiver operating characteristic analysis (sensitivity 64%; specificity 85%; AUC=0.717 ± 0.087, P=0.034). Patients were allocated into those having values greater than the cutoff value (group 1) and those having values lower than the cutoff value (group 2) in order to calculate the effect of ΔTLG on survival. Survival was 11.32 ± 1.18 (95% CI 9.02-13.62) months in group 2 and 20.76 ± 2.71 (95% CI 15.46-26.06) months in group 1 (P=0.016). ΔTLG was found to be a significant factor in univariate analysis (P=0.01). CONCLUSION: An 18F-FDG PET/CT scan with calculation of ΔSUVmax3, ΔFTV, and ΔTLG before and at the sixth week after SIRT may play an important role in evaluating early tumor response and survival expectancy in these patients and help decide whether these patients should be referred to other treatment modalities or to follow-up.

Intra-arterial treatment with 90yttrium microspheres in treatment-refractory and unresectable liver metastases of neuroendocrine tumors and the use of 111in-octreotide scintigraphy in the evaluation of treatment response.

PURPOSE: The aim of this study was to examine the efficacy of intra-arterial (90)Yttrium treatment in the management of unresectable hepatic neuroendocrine tumors (NET) metastases unresponsive to treatment and the role of (111)In-octreotide scintigraphy in the evaluation of treatment response. METHODS: Thirteen (13) patients with a mean age of 53.3 years not eligible for surgical treatment were included. Before the procedure, routine tests for renal/hepatic functions and bilirubin levels as well as (99m)Tc-macroaggregated albumin test to detect any leakage to the lungs were done. Treatment doses were calculated using body surface area method and all patients received (90)Y resin microspheres through hepatic artery catheter. Abdominopelvic computed tomography (CT) and (111)In-octreotide scintigraphy were done before and after treatment. Patients were divided into two groups based on their treatment response as assessed by either (111)In-octreotide scintigraphy or CT: group 1, responders; group 2, nonresponders. RESULTS: For all patients, 1-year survival rate and overall survival was 84.7% and 20 months, respectively. Based on (111)In-octreotide scintigraphy findings, 1-year survival rate was 90% and 66.7% for responders and nonresponders, respectively, whereas corresponding overall survival was 21.3 months and 15.3 months. Survival data based on CT findings were as follows: 1-year survival rate, responders, 80%; nonresponders, 100%; overall survival, responders, 20.4 months, nonresponders, 18.5 months. CONCLUSIONS: Intra-arterial treatment with (90)Y has survival benefits in treatment-refractory liver metastases from NETs and it could be used in these patients. Since it is a functional imaging method, (111)In-octreotide scintigraphy may be better discriminates patients responding to treatment from patients not responding.

Selective intraarterial radionuclide therapy with Yttrium-90 (Y-90) microspheres for unresectable primary and metastatic liver tumors.

BACKGROUND: The aim of this study was to evaluate the success of selective intraarterial radionuclide therapy (SIRT) with Yttrium-90 (Y-90) microspheres in liver metastases of different tumors. We also interpreted the contribution of SIRT to survival times according to responder- non responder and hepatic- extra hepatic disease. METHODS: The clinical and follow-up data of 124 patients who were referred to our department for SIRT between June 2008 [corrected] and October 2010 were evaluated retrospectively. SIRT has been applied to 78 patients who were suitable for treatment. All the patients had primary liver tumor or unresectable liver metastasis of different malignancies. The treatment was repeated at least one more time in 5 patients to the same or other lobes. Metabolic treatment response evaluated by fluorine-18 fluorodeoxyglucose (F18-FDG) positron emission tomography/computed tomography (PET/CT) in the 6th week after treatment. F18-FDG PET/CT was repeated in per six weeks periods. The response criterion had been described as at least 20% decrease of SUV value. Also in patients with neuroendocrine tumor serial Gallium-68 (Ga-68) PET/CT was used for evaluation of response. Patients were divided into 2 groups according to their treatment response. RESULTS: 68 patients received treatment for the right lobe, seven patients received treatment for the left lobe and 3 patients for both lobes. The mean treatment dose was estimated at 1.62 GBq. In the evaluation of treatment response; 43(55%) patients were responder (R) and 35 (45%) patients were non-responder (NR) in the sixth week F18-FDG PET/CT. Mean pretreatment SUVmax value of R group was 11.6 and NR group was 10.7. While only 11 (31%) out of 35 NR patients had H disease, 30 (69%) out of 43 R patients had H disease (p < 0.05). The mean overall survival time of R group was calculated as 25.63 ± 1.52 months and NR group's 20.45 ± 2.11 (p = 0.04). The mean overall survival time of H group was computed as 25.66 ± 1.52 months and EH group's 20.76 ± 1.97 (p = 0.09). CONCLUSIONS: SIRT is a useful treatment method which can contribute to the lengthening of survival times in patients with primary or metastatic unresectable liver malignancies. Also F18-FDG PET/CT is seen to be a successful imaging method in evaluating treatment response for predicting survival times in this patient group.