Utility of 'dual phase' cone beam computed tomography during radioembolisation in patients with hepatocellular carcinoma : what is really changing in flow dynamics before and after 90Y delivery?

Purpose: The aims of the study were: 1) to compare two phases of dual-phase cone beam computed tomography (DPCBCT) achieved before and after Yttrium-90 (90Y) administration and to evaluate additional benefits during radioembolisation (RE) procedures; and 2) to compare DP-CBCT with pre-procedure contrast enhanced cross-sectional images in terms of tumour detection. Material and methods: Twenty-three hepatocellular carcinoma patients undergoing RE treatment were scanned with DPCBCT consisting of early arterial (EA) and late arterial (LA) phases before and after 90Y administration. The CT-like datasets were compared according to embolisation effect, enhancement patterns, lesion detectability, image quality, and artifacts by two interventional radiologists blinded to each other. The compatibility of the two radiologists was evaluated with kappa statistical analysis, and the difference between EA and LA phases was evaluated with marginal homogeneity test. Also, DP-CBCT images were compared with preprocedural cross-sectional images (CT/MRI). Results: For 23 patients 92 data were acquired. Thirteen patients showed a decrease on post-embolisation images both visually and on Hounsfield unit (HU) measurements. No statistical difference was found for tumour detection between EA and LA phases (p = 1.0). Tumour enhancement was visually superior at LA phases whereas EA phases were better for arterial mapping for selective catheterisation. DP-CBCT images were not inferior to preprocedural cross-sectional imaging findings. Conclusions: DP-CBCT is a promising tool for predicting tumour response to therapy and is not inferior to preprocedural cross-sectional imaging in terms of tumour detection. It allows better assessment during RE procedures because early phases provide good mapping for superselective catheterisation whereas late phases are better for visualisation of tumour enhancement

How to Reduce the Risk for Complications?

Interventional oncology represents a relatively new clinical discipline based upon minimally invasive therapies applicable to almost every human organ and disease. Over the last several decades, rapidly evolving research developments have introduced a newer generation of treatment devices, reagents, and image-guidance systems to expand the armamentarium of interventional oncology across a wide spectrum of disease sites, offering potential cure, control, or palliative care for many types of cancer patients. Due to the widespread use of locoregional procedures, a comprehensive review of the methodologic and technical considerations to optimize patient selection with the aim of performing a safe procedure is mandatory. This article summarizes the expert discussion and report from the Mediterranean Interventional Oncology Live Congress (MIOLive 2020) held in Rome, Italy, integrating evidence-reported literature and experience-based perceptions as a means for providing guidance on prudent ways to reduce complications. The aim of the paper is to provide an updated guiding tool not only to residents and fellows but also to colleagues approaching locoregional treatments.publishersversionpublishe

Gadoxetic acid uptake as a molecular imaging biomarker for sorafenib resistance in patients with hepatocellular carcinoma: a post hoc analysis of the SORAMIC trial

PURPOSE Gadoxetic acid uptake on hepatobiliary phase MRI has been shown to correlate with ß-catenin mutation in patients with HCC, which is associated with resistance to certain therapies. This study aimed to evaluate the prognostic value of gadoxetic acid uptake on hepatobiliary phase MRI in patients with advanced HCC receiving sorafenib. METHODS 312 patients with available baseline hepatobiliary phase MRI images received sorafenib alone or following selective internal radiation therapy (SIRT) within SORAMIC trial. The signal intensity of index tumor and normal liver parenchyma were measured on the native and hepatobiliary phase MRI images, and relative tumor enhancement higher than relative liver enhancement were accepted as high gadoxetic acid uptake, and its prognostic value was assessed using univariate and multivariate Cox proportional hazard models. RESULTS The median OS of the study population was 13.4 (11.8-14.5) months. High gadoxetic acid uptake was seen in 51 (16.3%) patients, and none of the baseline characteristics was associated with high uptake. In univariate analysis, high gadoxetic acid uptake was significantly associated with shorter overall survival (10.7 vs. 14.0~months, p = 0.005). Multivariate analysis confirmed independent prognostic value of high gadoxetic acid uptake (HR, 1.7 1.21-2.3, p = 0.002), as well as Child-Pugh class (p = 0.033), tumor diameter (p = 0.002), and ALBI grade (p = 0.015). CONCLUSION In advanced HCC patients receiving sorafenib (alone or combined with SIRT), high gadoxetic acid uptake of the tumor on pretreatment MRI, a surrogate of ß-catenin mutation, correlates with shorter survival. Gadoxetic acid uptake status might serve in treatment decision-making process

Prognostic value of baseline imaging and clinical features in patients with advanced hepatocellular carcinoma

AIMS To investigate the prognostic value of baseline imaging features for overall survival (OS) and liver decompensation (LD) in patients with hepatocellular carcinoma (HCC). DESIGN Patients with advanced HCC from the SORAMIC trial were evaluated in this post hoc analysis. Several radiological imaging features were collected from baseline computed tomography (CT) and magnetic resonance imaging (MRI) imaging, besides clinical values. The prognostic value of these features for OS and LD (grade 2 bilirubin increase) was quantified with univariate Cox proportional hazard models and multivariate Least Absolute Shrinkage and Selection Operator (LASSO) regression. RESULTS Three hundred and seventy-six patients were included in this study. The treatment arm was not correlated with OS. LASSO showed satellite lesions, atypical HCC, peritumoral arterial enhancement, larger tumour size, higher albumin-bilirubin (ALBI) score, liver-spleen ratio <1.5, ascites, pleural effusion and higher bilirubin values were predictors of worse OS, and higher relative liver enhancement, smooth margin and capsule were associated with better OS. LASSO analysis for LD showed satellite lesions, peritumoral hypointensity in hepatobiliary phase, high ALBI score, higher bilirubin values and ascites were predictors of LD, while randomisation to sorafenib arm was associated with lower LD. CONCLUSIONS Imaging features showing aggressive tumour biology and poor liver function, in addition to clinical parameters, can serve as imaging biomarkers for OS and LD in patients receiving sorafenib and selective internal radiation therapy for HCC

The Impact of Warmed Intravenous Contrast Material on the Bolus Geometry of Coronary CT Angiography Applications

Objective This study was designed to investigate the effect of administration of warmed contrast material (CM) on the bolus geometry and enhancement as depicted on coronary CT angiography. Materials and Methods A total of 64 patients (42 men, 22 women; mean age, 56 years) were randomly divided into two groups. Group 1 included 32 patients administered CM (Omnipaque [Iohexol] 350 mg I/ mL; Nycomed, Princeton, NJ) saline solutions kept in an incubator at a constant temperature (37℃). Group 2 included 32 patients administered the CM saline solutions kept at constant room temperature (24℃). Cardiac CT scans were performed with a dual source computed tomography (DSCT) scanner. For each group, region of interest curves were plotted inside the ascending aorta, main pulmonary artery and descending aorta on test bolus images. Using enhancement values, time/enhancement diagrams were produced for each vessel. On diagrams, basal Hounsfield unit (HU) values were subtracted from sequentially obtained values. A value of 100 HU was accepted as a cut-off value for the beginning of opacification. The time to peak, the time required to reach 100 HU opacification, maximum enhancement and duration of enhancement above 100 HU were noted. DSCT angiography studies were evaluated for coronary vessel enhancement. Results Maximum enhancement values in the ascending aorta, descending aorta and main pulmonary artery were significantly higher in group 1 subjects. In the ascending aorta, the median time required to reach 100 HU opacification during the test bolus analysis was significantly shorter for group 2 subjects than for group 1 subjects. In the ascending aorta, the descending aorta and main pulmonary artery, for group 1 subjects, the bolus geometry curve shifted to the left and upwards as compared with the bolus geometry curve for group 2 subjects. Conclusion The use of warmed CM yields higher enhancement values and a shorter time to reach maximum enhancement duration, resulting in a shift of the bolus geometry curve to the left that may provide optimized image quality.PubMedWoSScopu

Correlation of liver enhancement in gadoxetic acid-enhanced MRI with liver functions: a multicenter-multivendor analysis of hepatocellular carcinoma patients from SORAMIC trial

OBJECTIVES To evaluate the correlation between liver enhancement on hepatobiliary phase and liver function parameters in a multicenter, multivendor study. METHODS A total of 359 patients who underwent gadoxetic acid-enhanced MRI using a standardized protocol with various scanners within a prospective multicenter phase II trial (SORAMIC) were evaluated. The correlation between liver enhancement on hepatobiliary phase normalized to the spleen (liver-to-spleen ratio, LSR) and biochemical laboratory parameters, clinical findings related to liver functions, liver function grading systems (Child-Pugh and Albumin-Bilirubin ALBI), and scanner characteristics were analyzed using uni- and multivariate analyses. RESULTS There was a significant positive correlation between LSR and albumin (rho = 0.193; p < 0.001), platelet counts (rho = 0.148; p = 0.004), and sodium (rho = 0.161; p = 0.002); and a negative correlation between LSR and total bilirubin (rho = -0.215; p < 0.001) and AST (rho = -0.191; p < 0.001). Multivariate analysis confirmed independent significance for each of albumin (p = 0.022), total bilirubin (p = 0.045), AST (p = 0.031), platelet counts (p = 0.012), and sodium (p = 0.006). The presence of ascites (1.47 vs. 1.69, p < 0.001) and varices (1.55 vs. 1.69, p = 0.006) was related to significantly lower LSR. Similarly, patients with ALBI grade 1 had significantly higher LSR than patients with grade 2 (1.74 ± 0.447 vs. 1.56 ± 0.408, p < 0.001); and Child-Pugh A patients had a significantly higher LSR than Child-Pugh B (1.67 ± 0.44 vs. 1.49 ± 0.33, p = 0.021). Also, LSR was negatively correlated with MELD-Na scores (rho = -0.137; p = 0.013). However, one scanner brand was significantly associated with lower LSR (p < 0.001). CONCLUSIONS The liver enhancement on the hepatobiliary phase of gadoxetic acid-enhanced MRI is correlated with biomarkers of liver functions in a multicenter cohort. However, this correlation shows variations between scanner brands. KEY POINTS • The correlation between liver enhancement on the hepatobiliary phase of gadoxetic acid-enhanced MRI and liver function is consistent in a multicenter-multivendor cohort. • Signal intensity-based indices (liver-to-spleen ratio) can be used as an imaging biomarker of liver function. • However, absolute values might change between vendors

Clinical Application of Radioembolization in Hepatic Malignancies: Protocol for a Prospective Multicenter Observational Study

Background: Radioembolization, also known as transarterial radioembolization or selective internal radiation therapy with yttrium-90 (90Y) resin microspheres, is an established treatment modality for patients with primary and secondary liver tumors. However, large-scale prospective observational data on the application of this treatment in a real-life clinical setting is lacking. Objective: The main objective is to collect data on the clinical application of radioembolization with 90Y resin microspheres to improve the understanding of the impact of this treatment modality in its routine practice setting. Methods: Eligible patients are 18 years or older and receiving radioembolization for primary and secondary liver tumors as part of routine practice, as well as have signed informed consent. Data is collected at baseline, directly after treatment, and at every 3-month follow-up until 24 months or study exit. The primary objective of the Cardiovascular and Interventional Radiological Society of Europe Registry for SIR-Spheres Therapy (CIRT) is to observe the clinical application of radioembolization. Secondary objectives include safety, effectiveness in terms of overall survival, progression-free survival (PFS), liver-specific PFS, imaging response, and change in quality of life. Results: Between January 2015 and December 2017, 1047 patients were included in the study. The 24-month follow-up period ended in December 2019. The first results are expected in the third quarter of 2020. Conclusions: The CIRT is the largest observational study on radioembolization to date and will provide valuable insights to the clinical application of this treatment modality and its real-life outcomes

Giant arteriovenous malformation located on the chest wall - Diagnosis and endovascular treatment: Report of a case

Peynircioglu, Bora/0000-0002-1457-4721WOS: 000284645600012PubMed: 21110162Congenital arteriovenous malformations are usually found in the lower extremities, but a chest wall location is extremely rare. Extensive vascular malformations present difficulties for patients because of severe unsightliness and life-threatening bleeding. Surgical planning and therapeutic indications in vascular malformations are still a difficult problem. This report describes the case of a 27-year-old woman with a congenital giant arteriovenous malformation of the left chest wall. Preoperative embolization was planned prior to surgical intervention because of the increased risk of massive bleeding, and the malformation was completely embolized with absolute alcohol

Iliac Vascular Complication After Spinal Surgery: Immediate Endovascular Repair Following Ct Angiographic Diagnosis

Iliac arterial injuries are rare but important complications that can develop after spinal surgery. The presentation of these M. injuries is usually late, with symptoms such as leg swelling or cardiac failure. However, acute massive bleeding may be a sign of early presentation as in our patient. Herein, we present a case of life-threatening bleeding with early computed tomography angiographic diagnosis of common iliac artery pseudoaneurysm and iliac arteriovenous fistula secondary to spinal surgery which was successfully managed by endovascular stent graft treatment.WoSScopu

Mesenteric Angiography Of Patients With Gastrointestinal Tract Hemorrhages: A Single Center Study

PURPOSE This retrospective study was designed to investigate the transcatheter mesenteric angiography of patients with gastrointestinal (GI) bleeding and to determine the most important variables that should be monitored in patients with Cl bleeding prior to transcatheter arteriography. MATERIALS AND METHODS In this study, we evaluated the transcatheter mesenteric angiography results of patients with massive GI bleeding (defined as hypotension, tachycardia, and a greater than 4-unit blood transfusion requirement in 24 h) seen between 2005 and 2009. Detailed clinical follow-up and accessible hospital data from 45 procedures were examined from 42 patients (two procedures were performed in three patients) between 24 and 85 years old (mean age, 57.6 years). The present study included 33 males and 9 females. Angiography was performed for lower Cl bleeding in 22 patients, upper Cl bleeding in 15 patients, and upper/lower (multiple origins) GI bleeding in five patients. Imaging work-ups, including endoscopic interventions, and follow-ups with patients after the procedure were evaluated in detail. Several variables recorded prior to the procedure, including the clinical status, etiological cause of the bleeding, bleeding parameters (e.g., international normalized ratio, platelets), imaging workup, gender, season, and angiography time, were examined. RESULTS Embolization was performed in 24 (53%) of the 45 procedures. Overall, the technical success rate of the diagnostic arteriograms was 100%, and no major complications occurred. For the embolizations, coils were used in 17 patients (70%), polyvinyl alcohol particles were used in six patients (25%), and n-butyl cyano-acrylate was used in one patient (4%). The detection rate of mesenteric arteriographies to examine GI bleeding performed outside of normal working hours was significantly greater than the detection rate of the arteriographies performed during normal working hours (P = 0.050). Low platelet levels or a prolonged prothrombin time were not associated with the mesenteric arteriography results (P = 1.00). Interestingly, the intermittent nature of Cl bleeding was the most challenging part of detection, which made management of the bleeding difficult. Blind embolization of the left gastric artery was only helpful in preventing massive bleeding in three out of eight patients with upper Cl bleeding. CONCLUSION Endoscopy for upper gastrointestinal bleeding and scintigraphy for lower gastrointestinal bleeding are important steps in the management and outcome of transcatheter angiography. Computerized tomography angiography is a promising tool for the treatment of both upper and lower GI bleeding, and this procedure has become part of the imaging toolset. In addition, angiography performed outside of working hours had a higher rate of clinical success than the angiographies performed in working hours, most likely secondary to much appropriate timing of arteriogram in terms of critical bleeding intervals.WoSScopu