Stereotactic body radiation therapy vs. radiofrequency ablation in Asian patients with hepatocellular carcinoma.

BACKGROUND & AIMS: Few studies have been conducted to compare the efficacies of stereotactic body radiation therapy (SBRT) and radiofrequency ablation (RFA). Thus, in this multinational study, we compared the effectiveness of SBRT and RFA in patients with unresectable HCC. METHODS: The retrospective study cohort included 2,064 patients treated in 7 hospitals: 1,568 and 496 in the RFA and SBRT groups, respectively. More than half of the patients (56.5%) developed recurrent tumors, mainly after transarterial chemoembolization (44.8%). Propensity score matching was performed to adjust for clinical factors (n = 313 in each group). RESULTS: At baseline, the SBRT group had unfavorable clinical features compared to the RFA group, including BCLC stage (B-C 65% vs. 16%), tumor size (median 3.0 cm vs. 1.9 cm), and frequent history of liver-directed treatment (81% vs. 49%, all p <0.001). With a median follow-up of 27.7 months, the 3-year cumulative local recurrence rates in the SBRT and RFA groups were 21.2% and 27.9%, respectively (p <0.001). After adjusting for clinical factors, SBRT was related to a significantly lower risk of local recurrence than RFA in both the entire (hazard ratio [HR] 0.45, p <0.001) and matched (HR 0.36, p <0.001) cohorts. In subgroup analysis, SBRT was associated with superior local control in small tumors (≤3 cm) irrespective of location, large tumors located in the subphrenic region, and those that progressed after transarterial chemoembolization. Acute grade ≥3 toxicities occurred in 1.6% and 2.6% of the SBRT and RFA patients, respectively (p = 0.268). CONCLUSIONS: SBRT could be an effective alternative to RFA for unresectable HCC, particularly for larger tumors (>3 cm) in a subphrenic location and tumors that have progressed after transarterial chemoembolization. LAY SUMMARY: It is currently not known what the best treatment option is for patients with unresectable hepatocellular carcinoma. Here, we show that stereotactic body radiation therapy provides better local control than radiofrequency ablation, with comparable toxicities. Stereotactic body radiation therapy appears to be an effective alternative to radiofrequency ablation that should be considered when there is a higher risk of local recurrence or toxicity after radiofrequency ablation.

Development and validation of a prognostic model for patients with hepatocellular carcinoma undergoing radiofrequency ablation.

BACKGROUND: There are large variations in prognosis among hepatocellular carcinoma (HCC) patients undergoing radiofrequency ablation (RFA). However, current staging or scoring systems hardly discriminate the outcome of HCC patients treated with RFA. METHODS: A total of 757 treatment-naïve HCC patients undergoing RFA (derivation cohort) were analyzed to establish a nomogram for disease-free survival (DFS) based on Cox proportional hazard regression model. Accuracy of the nomogram was assessed and compared with conventional staging or scoring systems. Furthermore, external validation was performed in an independent cohort including 208 patients (validation cohort). RESULTS: Tumor size, tumor number, alpha-fetoprotein, prothrombin induced by vitamin K absence-II, lymphocyte count, albumin, and presence of ascites were adopted to construct the prognostic nomogram from the derivation cohort. Calibration curves to predict probability of DFS at 3 and 5 years after RFA showed good agreements between the nomogram and actual observations. The concordance index of the present nomogram was 0.759 (95% confidence interval 0.728-0.790), which was superior to those of conventional staging or scoring systems (range 0.505-0.683, all P < .001). These results were also reproduced in the validation cohort. CONCLUSION: Our simple-to-use nomogram optimized for treatment-naïve HCC patients undergoing RFA provided better prognostic performance than conventional staging or scoring systems.

Management of portal hypertension derived from uncommon causes.

Portal hypertension can arise from any condition interfering with normal blood flow at any level within the portal system. Herein, we presented two uncommon cases of the portal hypertension and its treatment with brief literature review. A 71-year-old man who underwent right hemihepatectomy revealed a tumor recurrence adjacent to the inferior vena cava (IVC). After radiofrequency ablation (RFA) with lymph node dissection, he was referred for abdominal distension. The abdomen computed tomography scan showed severe ascites with a narrowing middle hepatic vein (MHV) and IVC around the RFA site. After insertion of two stents at the IVC and MHV, the ascites disappeared. Another 73-year-old man underwent right trisectionectomy of liver and segmental resection of the portal vein (PV). After operation, he underwent conservative management due to continuous abdominal ascites. The abdomen computed tomography scan showed severe ascites with obliteration of the left PV. After insertion of stent, the ascites disappeared. A decrease of the pressure gradient between the PV and IVC is one of the important treatment strategies for portal hypertension. Vascular stent is useful in the reduction of pressure gradient and thus, can be a treatment option for portal hypertension.

Uterine artery embolization for symptomatic fibroids in postmenopausal women.

PURPOSE: The aim of the current study was to evaluate the efficacy of uterine artery embolization (UAE) for symptomatic fibroids in postmenopausal women. MATERIALS AND METHODS: Among 900 cases who underwent UAE between 2007 and 2013, a total of 9 postmenopausal women with symptomatic fibroids (n=6) and fibroid with adenomyosis (n=3) were included in this retrospective study. Ages ranged from 49 to 55years (median of 52). The embolic agent was nonspherical polyvinyl alcohol particles. We evaluated 18 uterine arteries in nine patients and compared the size of the uterine artery relative to inferior mesenteric artery (IMA) in preprocedural magnetic resonance (MR) angiography. Magnetic resonance imaging (MRI) was performed before and 3months after UAE. Predominant fibroid and uterine volumes were calculated from MR images. RESULTS: Urinary frequency was the most common symptom, observed in seven patients (77.8%). Of two patients (22.2%) with vaginal bleeding from submucosal myomas, one patient had been on hormone replacement therapy (HRT). One patient underwent UAE due to growing leiomyoma after HRT. All of the 18 uterine arteries were bigger than the corresponding IMAs in MR angiography. Contrast-enhanced MRI revealed complete necrosis of the predominant fibroid in all patients. Eight (88.9%) of the nine participants demonstrated resolution of symptoms. The mean predominant fibroid and uterine volume reduction rates were 39.7% and 36.9%, respectively. CONCLUSIONS: In postmenopausal women, UAE was effective to treat symptomatic fibroids, and it could be considered as an alternative treatment to hysterectomy.

Complete response at first chemoembolization is still the most robust predictor for favorable outcome in hepatocellular carcinoma.

BACKGROUNDS & AIMS: The aim of this study is to evaluate the prognostic significances of not only the initial and the best response during repeated transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC), but if eligible, also the time point of achieving treatment responses. METHODS: Three hundred and fourteen treatment-naïve patients with well-preserved liver function undergoing TACE were recruited. Treatment responses were assessed using modified Response Evaluation Criteria in Solid Tumors. Overall survival (OS) was analyzed using Kaplan-Meier methods, and Cox regression analysis was performed for multivariate analysis. RESULTS: After adjusting other variables, objective response (complete response [CR] and partial response [PR]) as the initial response (adjusted hazard ratio [HR] 0.410) and the best response (adjusted HR 0.335) had independent prognostic significances for OS, respectively (both p < 0.001). Objective responders as the initial response had the longest OS, followed by patients who subsequently achieved objective response after at least two sessions and those who did not achieve objective response during treatment course eventually (52.6, 27.0, and 10.8 months, respectively; log-rank test, p < 0.001). Likewise, patients with CR as the initial response had the longest OS, followed by those who subsequently achieved CR after at least two sessions and those who achieved PR as the best response (70.2, 40.6, and 23.0 months, respectively; log-rank test, p < 0.001). Large (>5 cm) and multiple (⩾ 4) tumors were independently associated with failure to achieve CR after the initial TACE (both p < 0.05). CONCLUSION: Both the initial and the best response predicts OS effectively. However, achievement of treatment response at an early time point is still the most robust predictor for favorable outcomes.

Comparison of the efficacy of covered versus uncovered metallic stents in treating inoperable malignant common bile duct obstruction: a randomized trial.

PURPOSE: To compare patency and overall survival achieved with covered versus uncovered metallic stents among patients with inoperable malignant extrahepatic biliary obstruction. MATERIALS AND METHODS: There were 40 patients enrolled in this prospective randomized study between January 2012 and July 2013. Mean age of patients was 62.6 years (range, 43-86 y). The malignancies causing extrahepatic biliary obstruction were pancreatic cancer (n = 18), stomach cancer (n = 13), gallbladder cancer (n = 3), common bile duct cancer (n = 2), and other cancer types (n = 4). Uncovered (n = 20) and covered (n = 20) stents were used. Stent patency, overall survival, and complications were evaluated and statistically compared. RESULTS: Mean patency of uncovered stents (413.3 d ± 63.0) was significantly longer than mean patency of covered ones (207.5 d ± 46.0; P = .041). Mean overall survival was 359.9 days ± 61.5 for uncovered stents, which was statistically similar to survival of 350.5 days ± 43.8 for covered stents (P = .271). Causes of recurrent obstruction included tumor ingrowth (n = 2), tumor overgrowth (n = 5), debris or food material (n = 5), and stent migration (n = 2). One case of acute cholecystitis occurred in covered stent group. CONCLUSIONS: Uncovered metallic stents had superior patency duration than covered stents for patients with malignant extrahepatic biliary obstruction. However, the overall complication and survival rates achieved with covered and uncovered stents were similar.

The effect of uterine artery embolization on premenstrual symptoms in patients with symptomatic fibroids or adenomyosis.

PURPOSE: To evaluate whether uterine artery embolization (UAE) can reduce the premenstrual symptoms in women undergoing UAE for fibroid tumors or adenomyosis. MATERIALS AND METHODS: Among 141 women who underwent UAE for symptomatic fibroid tumors or adenomyosis at a single institution between March 2011 and February 2013, 54 premenstrual symptoms in 39 patients were prospectively analyzed. Premenstrual symptoms were rated by the patient on a scale of 0 to 10, with 0 representing no symptom and 10 representing the baseline severity. The change in premenstrual symptom score was calculated by subtracting the baseline score from the post-UAE score. At 3-6 months after UAE, each woman also completed a symptom severity questionnaire to assess the severity of menstrual bleeding to compare the changes in premenstrual symptoms scores between women with and without menorrhagia. RESULTS: Back pain, headache, and gastrointestinal symptoms (eg, constipation, indigestion, lower abdominal pain) were significantly improved after UAE (P < .05). Muscle pain, fatigue, nervousness, breast tenderness, and systemic edema were also improved, but not significantly so. The mean premenstrual symptom score change in patients with menorrhagia was significantly greater than in those without menorrhagia (-6.4 vs -3.7; P = .044).There was no correlation between the degree of menorrhagia score change and the degree of premenstrual symptom score change (P = .186). CONCLUSIONS: UAE could be a method to alleviate some premenstrual symptoms in patients with uterine fibroid tumors or adenomyosis.

Inferior Mesenteric Artery Collaterals to the Uterus during Uterine Artery Embolization: Prevalence, Risk Factors, and Clinical Outcomes.

PURPOSE: To evaluate the prevalence of inferior mesenteric artery (IMA) collaterals to the uterus found during uterine artery embolization (UAE), associated risk factors, and clinical outcomes. MATERIALS AND METHODS: The records of 559 women who underwent UAE during the period 2008-2011 for uterine fibroids or adenomyosis found on magnetic resonance imaging were retrospectively analyzed. If IMA collaterals to the uterus were suspected on aortography performed after embolization, selective angiography was performed. Risk factors for IMA collaterals to the uterus were analyzed, including the presence of adenomyosis, baseline uterine volume, or prior pelvic surgery. RESULTS: Collaterals to the uterus were found from the ovarian artery (n = 21; 3.8%), IMA (n = 7; 1.3%), round ligament artery (n = 1; 0.2%), and internal pudendal artery (n = 1; 0.2%). IMA collaterals were found in seven patients. Of 185 patients, 6 (3.2%) had adenomyosis, with or without fibroids, which was significantly more frequent than the 1 (0.27%) of 374 patients who had fibroids only (P = .006). On multiple logistic regression analysis, the presence of adenomyosis (odds ratio, 19.556; P = .0168) and uterine volume (odds ratio, 1.003; P = .0069) were independent factors for the presence of IMA collaterals. Of the seven patients with IMA collaterals, embolization was not attempted in six, resulting in clinical failure in four. One patient who underwent IMA embolization with coils experienced clinical improvement. CONCLUSIONS: The IMA was the second most common (1.3%) source of collaterals to the uterus. IMA collaterals were more frequent in patients with adenomyosis than in patients with fibroids only, resulting in high frequency of treatment failure.

Magnetic compression anastomosis is useful in biliary anastomotic strictures after living donor liver transplantation.

BACKGROUND: An anastomotic biliary stricture is a complication of living donor liver transplantation (LDLT) performed using duct-to-duct anastomosis. Despite advances in treating this complication, there is no one established treatment protocol. OBJECTIVE: To investigate the safety, effectiveness, and mid-term outcome of magnetic compression anastomosis (MCA) for treating biliary obstruction after LDLT when the obstruction cannot be resolved by using percutaneous or peroral methods. DESIGN: Retrospective, observational study with standardized treatment and follow-up. SETTING: Tertiary-care academic medical center. PATIENTS: Twelve patients underwent MCA procedures to treat anastomosis site stricture after LDLT. INTERVENTIONS: MCA. MAIN OUTCOME MEASUREMENTS: Bile duct patency, technique performance, and complications were evaluated. RESULTS: We achieved magnet approximation at the anastomotic stricture in 10 of 12 patients (83.3%). The magnets failed to approximate in 2 patients. We achieved recanalization of the stricture site in 10 of 10 patients. We removed an internal catheter in 9 patients. The mean interval from magnet approximation to removal was 74.2 days (range 14-181 days). The mean time from recanalization to removal of the internal catheter was 183 days (range 51-266 days). Patients were examined regularly after removing the internal catheter with a mean follow-up period of 331 days (range 148-581 days). The observed MCA-related complications consisted of 1 case of mild cholangitis and 1 recurrence of the anastomotic stricture. LIMITATIONS: Nonrandomized study design. CONCLUSIONS: MCA safely and effectively resolved post-LDLT biliary duct-to-duct anastomotic strictures that could not be resolved using conventional methods, such as ERCP and percutaneous transhepatic biliary drainage.

Fluoroscopically guided placement of self-expandable metallic stents and stent-grafts in the treatment of acute malignant colorectal obstruction.

PURPOSE: To evaluate the technical feasibility and clinical effectiveness of fluoroscopically guided placement of self-expandable metallic stents and stent-grafts for acute malignant colorectal obstruction. MATERIALS AND METHODS: Radiologic images and clinical reports of 42 patients (22 men, 20 women; age range, 28-93 years; median age, 65.5 years) who underwent fluoroscopically guided colorectal stent insertion without endoscopic assistance for acute malignant obstruction were reviewed retrospectively. Eighteen patients received bare stents as a bridge to surgery. Twenty-four patients received 27 insertions of either a bare stent (n = 15) or a stent-graft (n = 12) for palliation. The obstruction was located in the rectum (n = 8), sigmoid (n = 17), descending colon (n = 8), splenic flexure (n = 3), and transverse colon (n = 6). RESULTS: Clinical success, defined as more than 50% dilatation of the stent with subsequent symptomatic improvement, was achieved in 41 of the 42 patients (98%). No major procedure-related complications occurred. Minor complications occurred in eight of the 45 procedures (18%). No perioperative mortalities occurred within 1 month after surgery. In the palliative group, the median stent patency was 62 days (range, 0-1,014 days). There was no statistically significant difference in stent patency between the bare stents (range, 0-855 days; median, 68 days) and stent-grafts (range, 1-1,014 days; median, 81 days). CONCLUSIONS: Fluoroscopically guided placement of self-expandable metallic stents and stent-grafts for the relief of acute malignant colorectal obstruction was technically feasible without endoscopic assistance-even in lesions proximal to the splenic flexure and transverse colon-and clinically effective in both bridge to surgery and palliative management.

Transcatheter arterial chemoembolization of hepatocellular carcinoma with hepatic arteriovenous shunt after temporary balloon occlusion of hepatic vein.

PURPOSE: Hepatocellular carcinoma with hepatic artery to hepatic vein (AV) shunt has increased risk of pulmonary complications during transcatheter arterial chemoembolization (TACE). The purpose of this study is to assess temporary balloon occlusion as a means of preventing pulmonary complications during TACE of hepatocellular carcinoma with AV shunt. MATERIALS AND METHODS: Eleven hepatocellular carcinoma patients (M: F = 9:2; mean age, 48 years) with angiographically evident AV shunt underwent TACE with occlusion of the shunt-draining hepatic veins using temporary occlusion balloon catheters. All tumors were in the right lobe, and all AV shunts were between the right hepatic artery and right hepatic vein. The occlusion balloon was inserted via femoral (n = 6) or jugular (n = 5) venous access. The balloon diameter ranged from 8.5 to 11.5 mm and time of ballooning was 3 to 15 minutes (mean, 9.5 minutes). TACE was performed using emulsion of iodized oil and doxorubicin, followed by Gelfoam embolization. The balloon was deflated immediately after chemoembolization, and physical examination and chest radiography were performed. Follow-up computed tomography was performed within 2 weeks after TACE to evaluate the result and pulmonary complications. RESULTS: The technical success rate was 100%. There was no symptom, sign, or radiographic evidence of pulmonary complication. Follow-up computed tomography revealed complete iodized oil uptake by the tumor in eight patients and incomplete uptake by the tumor in three patients. There was no iodized oil uptake in the lungs. CONCLUSIONS: Temporary balloon occlusion of the hepatic vein in hepatocellular carcinoma with AV shunt allowed completion of TACE using conventional method while preventing pulmonary complications.

Mechanical thrombectomy of acute iliofemoral deep vein thrombosis with use of an Arrow-Trerotola percutaneous thrombectomy device.

PURPOSE: To evaluate the immediate and 1-year clinical outcomes of mechanical thrombectomy with use of the Arrow-Trerotola percutaneous thrombectomy device (PTD) with or without low-dose urokinase in the treatment of acute iliofemoral deep vein thrombosis (DVT). MATERIALS AND METHODS: Mechanical thrombectomy with the PTD was performed in 25 patients with acute iliofemoral DVT. Thrombolytic therapy with low-dose urokinase was used in all patients without contraindications (n = 20). Other therapies used in combination included inferior vena cava filter insertion (n = 5), sheath aspiration thrombectomy (n = 25), and angioplasty and stent placement (n = 20). RESULTS: Initial technical and clinical success was achieved in all cases. In the 20 patients who had no contraindications to the use of urokinase, the dosage of urokinase did not exceed 1 million IU (range, 360,000-1,000,000 IU; mean, 640,000 IU). The mean time of urokinase infusion was 16 hours (range, 12-20). In five patients who had a contraindication to the use of urokinase, mechanical thrombectomy with the PTD was successful without the use of urokinase. There were no major complications. Primary patency of the stent-implanted common iliac vein segment was achieved at 1 year in 17 of 20 patients (85%). The overall 1-year clinical success rate was 92% (23 of 25 patients). Valvular insufficiency occurred in two patients (8%). CONCLUSION: The PTD is an effective mechanical thrombectomy device in the treatment of acute iliofemoral DVT with or without adjunctive urokinase thrombolysis.

Percutaneous sclerotherapy of renal cysts with a beta-emitting radionuclide, holmium-166-chitosan complex.

OBJECTIVE: To evaluate the usefulness of a beta-emitting radionuclide (holmium-166-chitosan complex) as a sclerosing agent for the treatment of renal cysts. MATERIALS AND METHODS: Using 10-30 mCi of holmium-166-chitosan complex, 20 renal cysts in 17 patients (14 male and 3 female patients, ranging in age from 47 to 82 years) were treated by percutaneous sclerotherapy under ultrasonographic guidance. The volume of the cysts before and after the sclerotherapy and the percentage change in volume were calculated in order to evaluate the response to therapy, which was classified as either complete regression (invisible), nearly complete regression (< 15 volume% of initial volume), partial regression (15-50 volume%) or no regression (> 50 volume%). RESULTS: The follow-up period ranged from 6 to 36 months (mean 28 months). Eighteen cysts (90%) regressed completely (n=11, 55%) or near-completely (n=7, 35%). Partial regression was obtained in one patient (5%) and there was no regression in one patient (5%). No significant complications were encountered. CONCLUSION: The holmium-166-chitosan complex seems to be useful as a new painless sclerosing agent for the treatment of renal cysts with no significant complications.

Transcaval transjugular intrahepatic portosystemic shunt: preliminary clinical results.

OBJECTIVE: To determine the feasibility of transcaval transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with unusual anatomy between the hepatic veins and portal bifurcation, and inaccessible or inadequate hepatic veins. MATERIALS AND METHODS: Transcaval TIPS, performed in six patients, was indicated by active variceal bleeding (n=2), recurrent variceal bleeding (n=2), intractable ascites (n=1), and as a bridge to liver transplantation (n=1). The main reasons for transcaval rather than classic TIPS were the presence of an unusually acute angle between the hepatic veins and the level of the portal bifurcation (n=3), hepatic venous occlusion (n=2), and inadequate small hepatic veins (n=1). RESULTS: Technical and functional success was achieved in all patients. The entry site into liver parenchyma from the inferior vena cava was within 2 cm of the atriocaval junction. Procedure-related complications included the death of one patient due to hemoperitoneum despite the absence of contrast media spillage at tractography, and another suffered reversible hepatic encephalopathy. CONCLUSION: In patients with unusual anatomy between the hepatic veins and portal bifurcation, and inaccessible or inadequate hepatic veins, transcaval TIPS creation is feasible.

Extrahepatic collateral supply of hepatocellular carcinoma by the intercostal arteries.

PURPOSE: To evaluate computed tomographic (CT) and angiographic findings of extrahepatic collateral supply of hepatocellular carcinoma (HCC) by the intercostal artery (ICA) and the efficacy of transcatheter arterial chemoembolization (TACE) in the ICA. MATERIALS AND METHODS: The CT and angiographic findings of 30 ICA collateral supplies of HCC in 19 patients were evaluated. TACE of the ICA collaterals was performed in 10 patients. The clinical outcomes and complications were evaluated. RESULTS: ICA collaterals were found at the first to 18th sessions of TACE of HCC. The CT findings were: large HCC (mean diameter, 10.3 cm), subcapsular location (94.7%), defect in iodized oil retention or progression of HCC at subcapsular region (31.6%), HCC abutting the abdominal wall in a broad area with or without abdominal wall invasion (63.2%), hypertrophied ICA (31.6%), and branching collateral vessels coursing from the abdominal wall to the HCC (26.3%). On angiograms, all ICA collaterals originated from the right side at levels of T8 (6.7%), T9 (30.0%), T10 (46.7%), or T11 (16.7%). Twelve sessions of TACE of the ICA collaterals were performed in 10 patients. Follow-up angiography was performed in six patients and showed persistent obliteration in one, recanalization in three, and progression in two. Complications were shoulder pain (n = 2), itching sensation (n = 1), erythema of skin (n = 1), and skin necrosis (n = 1). CONCLUSION: ICA collateral supply of HCC usually occurs in advanced HCC or after multiple sessions of TACE. When there are suggestive CT findings, ICA collaterals should be sought when TACE is performed in the management of HCC.