Alexios Kelekis

Post embolization syndrome in doxorubicin eluting chemoembolization with DC bead.

BACKGROUND/AIMS The investigation of post embolization syndrome (PES) in patients with hepatocellular carcinoma (HCC) after treatment with doxorubicin loaded DC Bead (DEB-DOX). METHODOLOGY The study included 237 patients treated with sequential DEB-TACE performed at set time intervals every two months until 3 sessions/6 month f-u. Patients were ECOG 0-1, Child-Stage-A (n=116, 48.9%) and B (n=121, 51%). Embolizations were as selective as possible with DC Bead of 100-300µm in diameter followed by 300-500µm loaded with doxorubicin at 37.5mg/mL of hydrated bead (max:150mg). RESULTS PES regardless of severity was observed in up to 86.5%. However grade 2 PES ranged between 25% and 42.19% across treatments. Temperatures above 38°C were seen in 22.7% to 38.3% across treatments. No statistically significant increase of PES was seen in beads of 100-300µm in diameter; incidence of fever and pain presented correlation with the extent of embolization (p=0.0001-0.006 across treatments). Baseline tumor diameter was associated with incidence of fever (p=0.0001-0.001). Duration of fever correlated with the extent of embolization (p=0.008). PES was not associated with elevation of liver enzymes and was correlated with degree of necrosis (p<0.001). CONCLUSIONS PES after DEB-DOX represents tumor response to treatment and does not represent collateral healthy liver damage.

Percutaneous Augmented Osteoplasty of the Humeral Bone Using a Combination of MicroNeedles Mesh and Cement

Editor: We report a case of percutaneous augmented osteoplasty in a large, solitary, lytic metastatic lesion of the humeral head by means of a metallic mesh consisting of 25–50 stainless steel microneedles combined with polymethyl methacrylate (PMMA) cement injection. Our hospital’s institutional review board did not require approval for this case report. A 40-year-old man with esthesioneuroblastoma and complaints of significant pain and mobility impairment (score of 10 of 10 on a numeric visual scale [NVS]) secondary to a large, solitary, lytic metastatic lesion in the humeral head was referred to our department. Standard x-rays and computed tomography scan showed the lesion covering the humeral head and extending up to the surgical and anatomic neck of the proximal humerus (Fig, a). The patient had undergone a series of radiotherapy sessions within the last 3 months and was taking opioid analgesics (fentanyl transdermal system delivering 75 μg/h; Janssen-Cilag Pty Limited, North Ryde, New South Wales, Australia) with neither significant pain reduction nor improvement in mobility. Because the patientʼs pain was not reduced after radiotherapy, he was referred to our department for therapy with interventional radiology palliative techniques. A percutaneous augmented osteoplasty was chosen as first-line therapy. Blood count and coagulation laboratory tests were performed 24 hours before the percutaneous augmented osteoplasty session. Under local sterile conditions, following antibiotic prophylaxis (according to the our hospital’s infectious diseases protocol, we administered a single intravenous dose of piperacillin/tazobactam) and administration of anesthesia (the technique was performed under local anesthesia and brachial plexus block) and using cardiovascular monitoring and fluoroscopic guidance, a direct access

Long term recurrence analysis post drug eluting bead (deb) chemoembolization for hepatocellular carcinoma (hcc).

UNLABELLED BACKROUND-AIMS: To determine long term outcomes, regarding recurrence and survival, in patients with HCC that achieved complete response after initial treatment with drug eluting beads (DEB) using DC Bead loaded with doxorubicin (DEB-DOX). METHODOLOGY Forty-five patients with HCC, not suitable for curative treatments that exhibited complete response (EASL criteria) to initial DEB-DOX treatment were retrospectively analyzed after a median follow up period of 63 months. Child-Pugh class was A/B (62.2/37.8%) and mean lesion diameter 5.36 ± 1.1 cm. Lesion morphology was one dominant ≤5cm (53.3%), one dominant >5cm (31.1%) and multifocal (15.6%). RESULTS At 5 years, overall survival was 62.2% and recurrence-free survival 8.9%. All deaths that occurred were related to tumor progression (31.1%) or complications of underlying liver disease (28.9%). Median time of initial recurrence from baseline treatment was 18 months (range 8-52). When recurrence occurred, a mean time interval between additional DEB-DOX procedures less than 9 months was correlated to a poorer prognosis (p=0.025). Multivariate analysis identified Child-Pugh class at baseline (p=0.048), combined therapy of recurrences with local ablation (p=0.03) and number of DEB-DOX procedures (p=0.037) as significant prognostic factors of 5-year survival. Lesion morphology displayed significance for recurrence-free survival (p=0.014). Child-Pugh class at baseline, additional local ablation, pattern of initial recurrence and initial sum of recurrent tumor diameters all displayed statistical significance for post-recurrence survival (median 40 months), with the first two variables maintaining statistical significance in multivariate analysis (p=0.015 and p=0.014 respectively). CONCLUSION Initial complete response to DEB-DOX ensures a favorable prognosis. However, management of recurrent tumors, which occur frequently mostly as new lesions, and preservation of underlying liver function appear to play a key role in prolonging survival.

Aggressive Vertebral Hemangioma Treated with Combination of Vertebroplasty and Sclerotherapy Through Transpedicular and Direct Approach

Vertebral hemangiomas are benign tumors constituting 2–3 % of the spinal tumors and *10–12 % of autopsy findings with the vast majority of the lesions being asymptomatic [1, 2]. Minority of hemangiomas (0.9–1.2 %) produce symptoms either due to a pathologic fracture or due to cord compression [1, 2]. Pathologic fracture has to do with collapse of the vertebral body whilst cord compression more often is encountered when the posterior elements of thoracic vertebrae are involved [1, 2]. The proposed therapy modes of symptomatic vertebral hemangiomas include transarterial embolization with liquid agents (reserved nowadays mainly as a presurgical technique to reduce intraoperative bleeding), open surgery (which constitutes of vertebral resection and bracing), percutaneous vertebroplasty, radiotherapy, and direct ethanol injection inside the hemangioma [1–7]. We report a case where a combined therapy for symptomatic vertebral hemangioma was performed and consisted solely of minimally invasive, image-guided techniques, including a transforaminal approach (similar to the one used for infiltrations). Case Report

Recanalization of Dialysis Catheter-Related Subclavian Vein Occlusion Using a Re-Entry Device: Report of Two Patients

Dialysis in patients with end-stage renal disease should be performed using a timely placed permanent access. A structured approach to choosing the type and location of long-term access should help optimize access survival and minimize complications. Good surgical practice mandates that one should always consider the most distal site possible to permit the maximum number of future possibilities for access. A peripheral-to-central sequence of fistulae construction should be envisioned, beginning with the ‘‘snuff box’’ fistula at the base of the thumb, followed by the standard Brescia-Cimino wrist fistula, followed by a forearm cephalic fistula at the dorsal branch, and, finally, a mid-forearm cephalic fistula. If a forearm fistula is not feasible, an antecubital fistula, and, finally, a transposed basilica fistula should be considered. If a graft is constructed, preference should be given to the following sequence: forearm loop; upper arm, straight or curved; then upper-arm loop. All upper-extremity options should be considered before using the thigh. In all situations, a systematic radiologic evaluation of the venous systems should be conducted before placement [1]. However, many patients undergo central vein catheter placement for dialysis purposes before the creation of the shunt. It is estimated that as many as 40% of these patients will develop subclavian vein stenosis or occlusion [2]. If the shunt is created in the arm ipsilateral to the subclavian vein lesion, the patient will experience arm swelling, pain, and increased recirculation because of the sudden increase in venous pressure. Interventional treatment is the mainstay of therapy of these lesions [3]. If standard interventional techniques fail, sharp needle recanalization technique has been used in small numbers of patients with good results [4]. We describe an alternative method in two dialysis patients, in whom difficult-to-cross subclavian vein occlusions were successfully recanalized with the use of a re-entry device.

Percutaneous, Imaging-Guided Biopsy of Bone Metastases

Approximately 70% of cancer patients will eventually develop bone metastases. Spine, due to the abundance of red marrow in the vertebral bodies and the communication of deep thoracic-pelvic veins with valve-less vertebral venous plexuses, is the most common site of osseous metastatic disease. Open biopsies run the risk of destabilizing an already diseased spinal or peripheral skeleton segment. Percutaneous biopsies obviate such issues and provide immediate confirmation of correct needle location in the area of interest. Indications for percutaneous bone biopsy include lesion characterization, optimal treatment and tumor recurrence identification, as well as tumor response and recurrence rate prediction. Predicting recurrence in curative cases could help in treatment stratification, identification, and validation of new targets. The overall accuracy of percutaneous biopsy is 90–95%; higher positive recovery rates govern biopsy of osteolytic lesions. The rate of complications for percutaneous biopsy approaches is <5%. The purpose of this review is to provide information about performing bone biopsy and what to expect from it as well as choosing the appropriate imaging guidance. Additionally, factors governing the appropriate needle trajectory that would likely give the greatest diagnostic yield and choice of the most appropriate biopsy system and type of anesthesia will be addressed.

Computed Tomography and Ultrasounds for the Follow-up of Hepatocellular Carcinoma Ablation: What You Need to Know

Image-guided tumor ablation provides curative treatment in properly selected patients or appropriate therapeutic options whenever surgical techniques are precluded. Tumor response assessment post ablation is important in determining treatment success and future therapy. Accurate interpretation of post-ablation imaging findings is crucial for therapeutic and follow-up strategies. Computed Tomography (CT) and Ultrasound (US) play important roles in patients’ follow-up post liver thermal ablation therapies. Contrast-enhanced ultrasound (CEUS) can provide valuable information on the ablation effects faster and at a lower cost than computed tomography or magnetic resonance imaging. However, a disadvantage is that the technique cannot examine total liver parenchyma for disease progression as CT and Magnetic Resonance (MR) imaging can. Follow-up strategies for assessment of tumor response includes contrast enhanced multiphasic (non-contrast, arterial, portal, delayed phases) imaging with Computed Tomography at three, six, and 12 months post ablation session and annually ever since in order to prove sustained effectiveness of the ablation or detect progression.