Alicia S. Borggreve

Radioembolization: Is Prophylactic Embolization of Hepaticoenteric Arteries Necessary? A Systematic Review

PurposeTo study the effectiveness of prophylactic embolization of hepaticoenteric arteries to prevent gastrointestinal complications during radioembolization.MethodsA PubMed, Embase and Cochrane literature search was performed. We included studies assessing both a group of patients with and without embolization.ResultsOur search revealed 1401 articles of which title and abstract were screened. Finally, eight studies were included investigating 1237 patients. Of these patients, 456 received embolization of one or more arteries. No difference was seen in the incidence of gastrointestinal complications in patients with prophylactic embolization of the gastroduodenal artery (GDA), right gastric artery (RGA), cystic artery (CA) or hepatic falciform artery (HFA) compared to patients without embolization. Few complications were reported when microspheres were injected distal to the origin of these arteries or when reversed flow of the GDA was present. A high risk of confounding by indication was present because of the non-randomized nature of the included studies.ConclusionIt is advisable to restrict embolization to those hepaticoenteric arteries that originate distally or close to the injection site of microspheres. There is no conclusive evidence that embolization of hepaticoenteric arteries influences the risk of complications.

Simulation-based trauma education for medical students: A review of literature

Abstract Background: Medical students often do not feel prepared to manage emergency situations after graduation. They experience a lack of practical skills and show significant deficits in cognitive performance to assess and stabilize trauma patients. Most reports in the literature about simulation-based education pertain to postgraduate training. Simulation-based trauma education (SBTE) in undergraduate medical education could improve confidence and performance of recently graduated doctors in trauma resuscitation. We reviewed the literature in search of SBTE effectiveness for medical students. Methods: A PubMed, Embase and CINAHL literature search was performed to identify all studies that reported on the effectiveness of SBTE for medical students, on student perception on SBTE or on the effectiveness of different simulation modalities. Results: Eight studies were included. Three out of four studies reporting on the effectiveness of SBTE demonstrated an increase in performance of students after SBTE. SBTE is generally highly appreciated by medical students. Only one study directly compared two modalities of SBTE and reported favorable results for the mechanical model rather than the standardized live patient model. Conclusion: SBTE appears to be an effective method to prepare medical students for trauma resuscitation. Furthermore, students enjoy SBTE and they perceive SBTE as a very useful learning method.

Quantification of variations in intra-fraction motion of esophageal tumors over the course of neoadjuvant chemoradiotherapy based on cine-MRI

To noninvasively quantify variation in intra-fraction motion of esophageal tumors over the course of neoadjuvant chemoradiotherapy (nCRT) using 2D cine-magnetic resonance imaging (MRI) series. Patients treated with nCRT for esophageal cancer underwent six MRI scans. Scans were acquired prior to the start of nCRT, followed by weekly MRI scans during nCRT. Cine-MRI series were acquired in the coronal and sagittal plane (≈1.6 Hz). To be able to quantify intra-fraction motion over a longer time period, a second cine-MRI series was performed after 10u2009min. Tumor motion was assessed in cranio-caudal (CC), anterior-posterior (AP) and left-right (LR) direction. Motion patterns were analyzed for the presence of deep inhales and tumor drift. A total of 232 cine-MRI series of 20 patients were analyzed. The largest tumor motion was found in CC direction, with a mean peak-to-peak motion of 12.7u2009mm (standard deviation [SD] 5.6), followed by a mean peak-to peak motion in AP direction of 3.8u2009mm (SD 2.0) and in LR direction of 2.7u2009mm (SD 1.3). The CC intra-fraction tumor motion can differ extensively between and within patients. Deep inhales were present in six of 232 scans (3%). After exclusion of these scans, mean CC peak-to-peak motion was12.3u2009mm (SD 5.2). Correction for tumor drift showed a further reduction to 11.0u2009mm (SD 4.6). Despite correction for tumor drift, a large variation in tumor motion occurred within patients during treatment. Mean tumor drift during the 10u2009min interval between the two series was 1.5u2009mm (SD 1.8), with a maximum of 11.6u2009mm. Intra-fraction tumor motion was found to be highly variable between and within patients with esophageal cancer over the course of nCRT. Correction for deep inhales and tumor drift reduced peak-to-peak motion. The stochastic nature of both deep inhales and tumor drift indicates that real-time tumor motion management during radiotherapy is a prerequisite to safely reduce treatment margins.

Generalized cardiovascular disease on a preoperative CT scan is predictive for anastomotic leakage after esophagectomy

BACKGROUNDnRecent studies demonstrated that calcification of arteries supplying the gastric tube is associated with anastomotic leakage after esophagectomy. However, it remains unclear whether this association only derives from local flow limitations, or generalized vascular disease as well. The purpose of this study was to determine whether calcification throughout the entire cardiovascular system is associated with anastomotic leakage.nnnMETHODSnConsecutive patients who underwent an esophagectomy with gastric tube reconstruction and cervical anastomosis for esophageal cancer were analyzed. Diagnostic CT images were scored for the presence of arterial calcification on 10 locations based on a visual grading system. The association with anastomotic leakage was studied using logistic regression analysis.nnnRESULTSnA total of 406 patients were included for analysis of whom 104 developed anastomotic leakage (25.6%). Presence of calcification in the coronary arteries (minor calcification: 36.5% leakage; no calcification: 18.1%, pxa0=xa0.001), supra-aortic arteries (minor calcification: 30.9% leakage; major calcification: 35.3%; no calcification: 16.1%, pxa0=xa0.007 and pxa0<xa0.001, respectively) and thoracic aorta (major calcification: 33.3% leakage; no calcification: 19.4%, pxa0=xa0.011) was associated with leakage. In multivariable analysis, minor calcification of the coronary arteries (OR 2.29, 95% CI: 1.28-4.12, pxa0=xa0.005) and calcification of the supra-aortic arteries (OR 2.48, 95% CI: 1.30-4.74, pxa0=xa0.006 for minor calcification and OR 2.72, 95% CI: 1.49-4.99, pxa0=xa0.001 for major calcification) remained independently associated with leakage.nnnCONCLUSIONSnCalcification of the coronary and supra-aortic arteries on routine CT are predictive of cervical anastomotic leakage after esophagectomy. These results suggest that generalized cardiovascular disease is a strong indicator for the risk of leakage.

The predictive value of new-onset atrial fibrillation on postoperative morbidity after esophagectomy

New-onset atrial fibrillation (AF) is frequently observed following esophagectomy and may predict other complications. The aim of the current study was to determine the association between, and the possible predictive value of, new-onset AF and infectious complications following esophagectomy. Consecutive patients who underwent elective esophagectomy with curative intent for esophageal cancer between 2004 and 2016 in the University Medical Center Utrecht were included from a prospective database. The date of diagnosis of the complications included in the current analysis was retrospectively collected from the computerized medical record. The association between new-onset AF and infectious complications was studied in univariable and multivariable logistic regression analyses. A total of 455 patients were included. In 93 (20.4%) patients new-onset AF was encountered after esophagectomy. There were no significant differences in patient and treatment-related characteristics between the patients with and without AF. In 9 (9.7%) patients, AF was the only adverse event following surgery. In multivariable analyses, AF was significantly associated with infectious complications in general (OR 3.00, 95% CI: 1.73-5.21). More specifically, AF was associated with pulmonary complications (OR 2.06, 95% CI: 1.29-3.30), pneumonia (OR 2.41, 95% CI: 1.48-3.91) and anastomotic leakage (OR 3.00, 95% CI: 1.80-4.99). In patients who underwent esophagectomy, new-onset AF was highly associated with infectious complications. AF may serve as an early clinical warning sign for anastomotic leakage. Therefore, further evaluation of patients who develop new-onset AF after esophagectomy is warranted.

Patient perspectives on repeated MRI and PET/CT examinations during neoadjuvant treatment of oesophageal cancer

OBJECTIVEnThe perceived burden of diagnostic tests by patients during the assessment of esophageal cancer warrants attention with the current increase in repeated imaging for purposes of disease monitoring during and after treatment. The purpose of this prospective study was to evaluate the experienced burden associated with repeated MRI and positron emission tomography with integrated CT (PET/CT) examinations during neoadjuvant treatment for esophageal cancer from the perspective of the patient.nnnMETHODSnIn 27 patients receiving neoadjuvant chemoradiotherapy (nCRT) for esophageal cancer MRI and PET/CT examinations were performed before nCRT, during nCRT and before surgery. The experienced burden during repeated MRI and PET/CT examinations was evaluated with a self-report questionnaire addressing discomfort, pain, anxiety and embarrassment, each measured on a 5-point Likert scale (1 = none; up to 5 = veryu2009much). In addition, a comparative assessment was used to rank MRI, PET/CT and baseline endoscopy.nnnRESULTSnAll scans were performed without the occurrence of an adverse event. Few patients experienced discomfort (mean scorexa0±SD: 1.9 ± 1.0 for MRI vs 2.0 ± 1.0 for PET/CT, p = 0.586), pain (1.1 ± 0.4 for MRI vs 1.3 ± 0.7 for PET/CT, p = 0.059), anxiety (1.0 ± 0.2 for MRI vs 1.0 ± 0.2 for PET/CT, p = 1.000) and embarrassment (1.0 ± 0 for MRI vs 1.0 ± 0.2 for PET/CT, p = 0.317) during both MRI and PET/CT. Patients preferred MRI over PET/CT (67% vs 22%, respectively, p = 0.023), and MRI over endoscopy (59% vs 19%, respectively, p = 0.027). In the comparison between PET/CT and endoscopy, 59% of patients preferred PET/CT and 26% preferred endoscopy (p = 0.093).nnnCONCLUSIONnRepeated imaging with both MRI and PET/CT is generally well-tolerated for the assessment of response to treatment in esophageal cancer patients. Shorter acquisition times and altered body positioning during scanning will likely improve patient experience. ufeffAdvances in knowledge: This paper demonstrates that MRI and PET/CT are generally well-tolerated imaging procedures for the assessment of response to treatment in esophageal cancer patients. When asked to rank different tests, patients preferred MRI over PET/CT and endoscopy.

Preoperative image-guided identification of response to neoadjuvant chemoradiotherapy in esophageal cancer (PRIDE): a multicenter observational study

BackgroundNearly one third of patients undergoing neoadjuvant chemoradiotherapy (nCRT) for locally advanced esophageal cancer have a pathologic complete response (pCR) of the primary tumor upon histopathological evaluation of the resection specimen. The primary aim of this study is to develop a model that predicts the probability of pCR to nCRT in esophageal cancer, based on diffusion-weighted magnetic resonance imaging (DW-MRI), dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and 18F-fluorodeoxyglucose positron emission tomography with computed tomography (18F-FDG PET-CT). Accurate response prediction could lead to a patient-tailored approach with omission of surgery in the future in case of predicted pCR or additional neoadjuvant treatment in case of non-pCR.MethodsThe PRIDE study is a prospective, single arm, observational multicenter study designed to develop a multimodal prediction model for histopathological response to nCRT for esophageal cancer. A total of 200 patients with locally advanced esophageal cancer - of which at least 130 patients with adenocarcinoma and at least 61 patients with squamous cell carcinoma - scheduled to receive nCRT followed by esophagectomy will be included. The primary modalities to be incorporated in the prediction model are quantitative parameters derived from MRI and 18F-FDG PET-CT scans, which will be acquired at fixed intervals before, during and after nCRT. Secondary modalities include blood samples for analysis of the presence of circulating tumor DNA (ctDNA) at 3 time-points (before, during and after nCRT), and an endoscopy with (random) bite-on-bite biopsies of the primary tumor site and other suspected lesions in the esophagus as well as an endoscopic ultrasonography (EUS) with fine needle aspiration of suspected lymph nodes after finishing nCRT. The main study endpoint is the performance of the model for pCR prediction. Secondary endpoints include progression-free and overall survival.DiscussionIf the multimodal PRIDE concept provides high predictive performance for pCR, the results of this study will play an important role in accurate identification of esophageal cancer patients with a pCR to nCRT. These patients might benefit from a patient-tailored approach with omission of surgery in the future. Vice versa, patients with non-pCR might benefit from additional neoadjuvant treatment, or ineffective therapy could be stopped.Trial registrationThe article reports on a health care intervention on human participants and was prospectively registered on March 22, 2018 under ClinicalTrials.gov Identifier: NCT03474341.

Surgical treatment of esophageal cancer in the era of multimodality management

Over the last decades, the treatment of resectable esophageal cancer has evolved into a multidisciplinary process in which all players are essential for treatment to be successful. Medical oncologists and radiation oncologists have been increasingly involved since the implementation of neoadjuvant therapy, which has been shown to improve survival. Although esophagectomy is still considered the cornerstone of curative treatment for locally advanced esophageal cancer, it remains associated with considerable postoperative morbidity, despite promising results of minimally invasive techniques. In this light, both physical status and response to neoadjuvant therapy may be important factors for selecting patients who will benefit from surgery. Furthermore, it is important to optimize the entire perioperative trajectory: from the initial outpatient clinic visit to postoperative discharge. Enhanced recovery after surgery is increasingly recognized for esophagectomy and emphasizes perioperative aspects, such as nutrition, physiotherapy, and pain management. To date, several facets of esophageal cancer treatment remain topics of debate, such as the preferred neoadjuvant treatment, anastomotic technique, extent of lymphadenectomy, organization of postoperative care, and the role of surgery beyond locally advanced disease. Here, we describe the current and future perspectives in the surgical treatment of patients with esophageal cancer in the context of the available literature.

DW-MRI and DCE-MRI are of complementary value in predicting pathologic response to neoadjuvant chemoradiotherapy for esophageal cancer

Abstract Purpose: To explore the potential benefit and complementary value of a multiparametric approach using diffusion-weighted (DW-) and dynamic contrast-enhanced (DCE-) magnetic resonance imaging (MRI) for prediction of response to neoadjuvant chemoradiotherapy (nCRT) in esophageal cancer. Material and methods: Forty-five patients underwent both DW-MRI and DCE-MRI prior to nCRT (pre), during nCRT (week 2–3) (per) and after completion of nCRT, but prior to esophagectomy (post). Subsequently, histopathologic tumor regression grade (TRG) was assessed. Tumor apparent diffusion coefficient (ADC) and area-under-the-concentration time curve (AUC) were calculated for DW-MRI and DCE-MRI, respectively. The ability of these parameters to predict pathologic complete response (pCR, TRG1) or good response (GR, TRGu2009≤u20092) to nCRT was assessed. Furthermore the complementary value of DW-MRI and DCE-MRI was investigated. Results: GR was found in 22 (49%) patients, of which 10 (22%) patients showed pCR. For DW-MRI, the 75th percentile (P75) ΔADCpost-pre was most predictive for GR (c-indexu2009=u20090.75). For DCE-MRI, P90 ΔAUCper-pre was most predictive for pCR (c-indexu2009=u20090.79). Multivariable logistic regression analyses showed complementary value when combining DW-MRI and DCE-MRI for pCR prediction (c-indexu2009=u20090.89). Conclusions: Both DW-MRI and DCE-MRI are promising in predicting response to nCRT in esophageal cancer. Combining both modalities provides complementary information, resulting in a higher predictive value.

Accessory Left Gastric Artery from Left Hepatic Artery is a Potential Risk for Radioembolization Complications

While prophylactic embolization of hepaticoenteric arteries may not be necessary in the majority of patients who have been referred for yttrium-90 (Y) radioembolization (RE), it is important to note that some patients have hepaticoenteric arteries that should be coil embolized to prevent gastrointestinal complications due to inadvertent extrahepatic deposition of activity. In general, the rate of gastrointestinal complications after RE is low in both embolized and non-embolized patient cohorts [1]. No evidence in favor of routine performance of prophylactic embolization could be found. However, when microspheres are injected proximal to the origin of a hepaticoenteric artery (with the exception of the cystic artery and hepatic falciform artery), it is advised to embolize this artery during pre-treatment angiography. A left gastric artery originating from the left hepatic artery is one of those distal hepaticoenteric arteries that should be embolized before treatment. Significant extrahepatic deposition of microspheres may otherwise occur. To illustrate the importance of C-arm CT during pretreatment angiography, we have included a patient with a left gastric artery originating from the left hepatic artery (Fig. 1). To prevent gastrointestinal complications and unnecessary extra procedures, it is important to use pre-treatment imaging work-up, including contrast-enhanced arterial phase CT and C-arm CT during angiography, to accurately guide treatment strategy. In a cohort of 118 patients, Ishigami et al. compared pretreatment multiphase contrast-enhanced CT and CT during angiography with intra-arterial injection of contrast as the standard of reference. A left gastric artery from the left hepatic artery was found in 25/118 patients (21 %). The sensitivity, specificity, and accuracy of pre-treatment multiphase contrast-enhanced CT to detect a left gastric artery originating from the left hepatic artery were 72 %, 99 %, and 93 %, respectively. Conventional digital subtraction angiography imaging had a sensitivity, specificity, and accuracy of 88 %, 98 %, and 96 %, respectively [2]. It may be hypothesized that the sensitivity of pre-treatment multiphase contrast-enhanced CT to detect small aberrant arteries may be increased by using a shorter delay than the 45-second delay that was used in this study [3]. In conclusion, a left gastric artery originating from the left hepatic artery is a fairly common variant finding. Pretreatment imaging and imaging during angiography workup may help to prevent unnecessary extra procedures, as well as inadvertent gastrointestinal complications.