Transarterial Chemoembolization for Metastatic Neuroendocrine Tumors With Massive Hepatic Tumor Burden: Is the Benefit Worth the Risk?

BACKGROUND: Neuroendocrine tumors (NETs) have a propensity to metastasize to the liver, often resulting in massive tumor burden and hepatic dysfunction. While transarterial chemoembolization (TACE) is effective in treating patients with NET metastatic to the liver, there are limited data on its utility and benefit in patients with large hepatic involvement. The aim of our study was to determine the clinical benefit and complication rate of TACE in patients with massive hepatic tumor burden. METHODS: Medical records were reviewed in patients with grade 1 or 2 NETs with hepatic metastasis at our institution from January 2000 to September 2014 who underwent TACE. Of 201 total patients, 68 had massive hepatic tumor burden involving >75 % of liver parenchyma. RESULTS: Carcinoid syndrome was present in 40 (59 %) patients, and 57 (84 %) of the 68 patients were symptomatic from their disease. Complications beyond post-TACE syndrome occurred in 21.7 % of patients, with the most common complication being cardiac arrhythmias. The 30-day mortality rate was 7 %. Biochemical response was observed in 78 % of patients, while symptomatic relief and radiographic response was achieved in 85 and 82 % of patients, respectively. Median overall survival following TACE was 28 months, with 1-, 2-, and 5-year overall survival of 76, 54, and 26 %, respectively. CONCLUSIONS: In spite of massive tumor burden, clinical and biochemical improvements were seen in the majority of patients. Morbidity was acceptable and reversible but with a fairly high mortality rate of 7 %. TACE should still be considered in selective patients with massive hepatic tumor burden from metastatic NET for symptom control and palliation.

Institutional Interventional Radiology Symposium Increases Medical Student Interest and Identifies Target Recruitment Candidates.

OBJECTIVES: To assess and raise medical student interest in interventional radiology (IR); and to evaluate student response across gender, level of training, and surgical vs nonsurgical specialty interest. MATERIALS AND METHODS: All Ohio medical students were invited to an IR Symposium held by a large academic medical center in central Ohio. The program encompassed didactic lectures, hands-on simulation models, and a networking luncheon with faculty, trainees, and industry partners. All attendees completed an anonymous, 5-point Likert scaled survey preattending and postattending the event to assess their awareness of IR as a specialty, understanding of the current training pathways, and level of interest. RESULTS: A total of 46 participants (M:F 60%:40%, MS1-53%, MS2-36%, and MS3-11%) attended the symposium. The cohort demonstrated increased interest in pursuing a career in IR following the symposium (4.12 vs 3.70, P < 0.001). Students with an interest in a nonsurgical specialty showed an increased interest in IR (4.20 vs 3.68, P < 0.001), whereas surgically oriented students did not demonstrate a significant increase (4.00 vs 3.71, P = 0.375). No statistically significant differences were noted across gender or level of training. The symposium experience significantly increased understanding of the IR training pathways (4.51 vs 2.94, P < 0.001). Students rated lectures (57%) and endovascular simulators (41%) as the most useful experiences. CONCLUSIONS: This study demonstrated the role of symposia in improving medical student awareness of IR and training pathways. Findings were validated across gender and training level, and identified the subset of students with nonsurgical interests as most responsive to such intervention and potential recruitment.

Elevated Alkaline Phosphatase Prior to Transarterial Chemoembolization for Neuroendocrine Tumors Predicts Worse Outcomes.

INTRODUCTION: We hypothesized that an elevated preoperative alkaline phosphatase (AP) predicted worse outcomes for patients undergoing transarterial chemoembolization (TACE) for neuroendocrine tumor (NET) liver metastases. METHODS: We reviewed all patients who underwent TACE for metastatic NET between 2009 and 2013. Survival was evaluated using preprocedure variables. RESULTS: One hundred and nine patients underwent 210 TACE procedures. The average age was 57.7 years (range 20-78). Primary sites included pancreas (N = 20), other gastrointestinal (N = 52), lung (N = 9), and unknown (N = 28). The tumor was grade 1 in 68 (62 %), grade 2 in 21 (19 %), and grade 3 in 3 (3 %). Extrahepatic disease was present in 54 (50 %) and greater than 50 % hepatic tumor burden by imaging in 63 (58 %). Elevated bilirubin occurred in 8 (7 %), elevated AP in 22 (20 %), elevated ALT in 21 (19 %), and elevated AST in 41 (38 %). Univariate predictors included tumor grade (43 vs 27 vs 21 months, p = 0.015), hepatic tumor burden (59 vs 37 months, p = 0.009), and elevated AP (59 vs 23 months, p < 0.001). On multivariate analysis, only elevated AP (p = 0.001) predicted worse survival. CONCLUSIONS: Elevated AP prior to TACE for metastatic NET portends a worse survival outcome, even more so than tumor grade or extent of hepatic disease.

Endovascular therapy for subclavian artery rupture in von Recklinghausen disease.

Vascular anomalies are extremely rare in patients with von Recklinghausen disease. This report presents a case of an acute spontaneous subclavian artery rupture in a patient with von Recklinghausen disease. A 44-year-old woman with a history of neurofibromatosis type 1, multiple sclerosis, and aortic valve replacement experienced a ''popping sensation'' in her neck. An emergent angiogram via a right brachial artery approach revealed active extravasation of contrast from the proximal part of the right subclavian artery between the vertebral and axillary arteries. An 8 mm × 5 cm endoprosthesis stent graft was placed across the area of extravasation via the brachial sheath. Completion angiography revealed brisk flow through the stent graft with resolution of the area of extravasation and no residual stenosis. Arterial rupture, aneurysm formation, stenosis, and dissection can be fatal in patients with neurofibromatosis. Further research is needed to determine screening guidelines and management algorithms for this patient population.