CIRSE Standards of Practice on Hepatic Transarterial Chemoembolisation

This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing transarterial chemoembolisation. It has been developed by an expert writing group under the guidance of the CIRSE Standards of Practice Committee. It will encompass all technical details reflecting European practice of different TACE procedures (Lp-TACE, DEM-TACE, DSM-TACE, b-TACE) as well as revising the existing literature on the various clinical indications (HCC, mCRC, ICC, NET). Finally, new frontiers of development will also be discussed

Accuracy of unenhanced magnetic resonance angiography for the assessment of renal artery stenosis

Purpose: To evaluate the accuracy of unenhanced magnetic resonance angiography (U-MRA) using balanced steady-state free precession (SSFP) sequences with inversion recovery (IR) pulses for the evaluation of renal artery stenosis. Materials and methods: U-MRA was performed in 24 patients with suspected main renal artery stenosis. Two radiologists evaluated the quality of the imaging studies and the ability of U-MRA to identify hemodynamically significant main renal artery stenosis (RAS) defined as a stenosis ≥50% when compared to gold standard tests: contrast-enhanced magnetic resonance angiography (CE-MRA) (18 patients) or digital subtraction arteriography (DSA) (6 patients). Results: A total of 44 main renal arteries were evaluated. Of them, 32 renal arteries could be assessed with U-MRA. When CE-MRA or DSA was used as the reference standard, nine renal arteries had hemodynamically significant RAS. U-MRA correctly identified eight out of nine arteries as having ≥50% RAS, and correctly identified 22 out of 23 arteries as not having significant RAS, with a sensitivity of 88.8%, a specificity of 95.65%, positive and negative predictive value of 88.8% and 95.65%, respectively, and an accuracy of 93.75%. Renal artery fibromuscular dysplasia (FMD) was observed in the two misclassified arteries. Conclusion: U-MRA is a reliable diagnostic method to depict normal and stenotic main renal arteries. U-MRA can be used as an alternative to contrast-enhanced magnetic resonance angiography or computer tomography angiography in patients with renal insufficiency unless FMD is suspected. Keywords: Unenhanced magnetic resonance angiography (U-MRA), Renal artery stenosis (RAS), Contrast-enhanced magnetic resonance angiography (CE-MRA), Fibromuscular dysplasia (FMD), Hypertension (HTA

New Challenges in the Management of Cholangiocarcinoma: The Role of Liver Transplantation, Locoregional Therapies, and Systemic Therapy

Cholangiocarcinoma (CCA) is a neoplasm with high mortality that represents 15% of all primary liver tumors. Its worldwide incidence is on the rise, and despite important advances in the knowledge of molecular mechanisms, diagnosis, and treatment, overall survival has not substantially improved in the last decade. Surgical resection remains the cornerstone therapy for CCA. Unfortunately, complete resection is only possible in less than 15–35% of cases, with a risk of recurrence greater than 60%. Liver transplantation (LT) has been postulated as an effective therapeutic strategy in those intrahepatic CCA (iCCA) smaller than 3 cm. However, the low rate of early diagnosis in non-resectable patients justifies the low applicability in clinical practice. The evidence regarding LT in locally advanced iCCA is scarce and based on small, retrospective, and, in most cases, single-center case series. In this setting, the response to neoadjuvant chemotherapy could be useful in identifying a subgroup of patients with biologically less aggressive tumors in whom LT may be successful. The results of LT in pCCA are promising, however, we need a very careful selection of patients and adequate experience in the transplant center. Locoregional therapies may be relevant in unresectable, liver-only CCA. In iCCA smaller than 2 cm, particularly those arising in patients with advanced chronic liver disease in whom resection or LT may not be feasible, thermal ablation may become a reliable alternative. The greatest advances in the management of CCA occur in systemic treatment. Immunotherapy associated with chemotherapy has emerged as the gold standard in the first-line treatment. Likewise, the most encouraging results have been obtained with targeted therapies, where the use of personalized treatments has shown high rates of objective and durable tumor response, with clear signs of survival benefit. In conclusion, the future of CCA treatment seems to be marked by the development of new treatment strategies but high-quality, prospective studies that shed light on their use and applicability are mandatory

Transcatheter Treatment of Hepatocellular Carcinoma with Doxorubicin-loaded DC Bead (DEBDOX): Technical Recommendations

Tranarterial chemoembolization (TACE) has been established by a meta-analysis of randomized controlled trials as the standard of care for nonsurgical patients with large or multinodular noninvasive hepatocellular carcinoma (HCC) isolated to the liver and with preserved liver function. Although conventional TACE with administration of an anticancer-in-oil emulsion followed by embolic agents has been the most popular technique, the introduction of embolic drug-eluting beads has provided an alternative to lipiodol-based regimens. Experimental studies have shown that TACE with drug-eluting beads has a safe pharmacokinetic profile and results in effective tumor killing in animal models. Early clinical experiences have confirmed that drug-eluting beads provide a combined ischemic and cytotoxic effect locally with low systemic toxic exposure. Recently, the clinical value of a TACE protocol performed by using the embolic microsphere DC Bead loaded with doxorubicin (DEBDOX; drug-eluting bead doxorubicin) has been shown by randomized controlled trials. An important limitation of conventional TACE has been the inconsistency in the technique and the treatment schedules. This limitation has hampered the acceptance of TACE as a standard oncology treatment. Doxorubicin-loaded DC Bead provides levels of consistency and repeatability not available with conventional TACE and offers the opportunity to implement a standardized approach to HCC treatment. With this in mind, a panel of physicians took part in a consensus meeting held during the European Conference on Interventional Oncology in Florence, Italy, to develop a set of technical recommendations for the use of DEBDOX in HCC treatment. The conclusions of the expert panel are summarized

BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update

There have been major advances in the armamentarium for hepatocellular carcinoma (HCC) since the last official update of the Barcelona Clinic Liver Cancer prognosis and treatment strategy published in 2018. Whilst there have been advances in all areas, we will focus on those that have led to a change in strategy and we will discuss why, despite being encouraging, data for select interventions are still too immature for them to be incorporated into an evidence-based model for clinicians and researchers. Finally, we describe the critical insight and expert knowledge that are required to make clinical decisions for individual patients, considering all of the parameters that must be considered to deliver personalised clinical management