Clara Lee

Liver, gastrointestinal, and cardiac toxicity in intermediate hepatocellular carcinoma treated with PRECISION TACE with drug-eluting beads: results from the PRECISION V randomized trial.

OBJECTIVE The purpose of our study was to evaluate hepatic, gastrointestinal, and cardiac toxicity after PRECISION transarterial chemoembolization (TACE) with drug-eluting beads (DEB) versus conventional TACE with doxorubicin in the treatment of intermediate-stage hepatocellular carcinoma (HCC). SUBJECTS AND METHODS Two hundred twelve patients (185 men and 27 women; mean age, 67 years) were randomized to TACE with DEB or conventional TACE. The majority of patients (67% in both groups) presented in a more advanced stage. Safety was measured by rate of adverse events (Southwest Oncology Group criteria) and changes in laboratory parameters. Cardiotoxicity was assessed with left ventricular ejection fraction (LVEF) mainly on MRI or echocardiography. RESULTS The mean maximum postchemoembolization alanine transaminase increase in the DEB group was 50% less than in the conventional TACE group (p < 0.001) and 41% less in respect to aspartate transaminase (p < 0.001). End-of-study values returned to approximately baseline levels but with greater variability in conventional TACE patients. Treatment-emergent adverse events in the hepatobiliary system organ class occurred in 16.1% of DEB group patients compared with 25% of conventional TACE patients. There were fewer liver toxicity events in the DEB group. There was a small but statistically significant difference in mean change from baseline in LVEF between the two groups of 4 percentage points for the conventional TACE group (95% CI, 0.71-7.3; p = 0.018). CONCLUSION PRECISION TACE with DEB loaded with doxorubicin offers a safe therapy option for intermediate-stage HCC, even in patients with more advanced liver disease.

Bolus timing in high-pitch CT angiography of the aorta

OBJECTIVE To investigate the bolus geometry in high-pitch CT angiography (CTA) of the aorta without ECG synchronisation in comparison to single-source CT. METHODS Overall 160 consecutive patients underwent CTA either in conventional single-source mode with a pitch of 1.2 (group 1), or in dual-source mode with a pitch of 3.0 (groups 2, 3 and 4) using different contrast media timings with bolus triggering at 140 HU (5s, group 1; 10s, group 2; 12s, group 3; 14s, group 4). Contrast material, saline flush, flow rate and kV/mAs settings were kept equal for optimum comparability. Aortic attenuation was measured along the z-axis of the patient at different anatomic landmarks and subjective image quality was compared. RESULTS The most homogeneous enhancement of the aorta was reached with a delay of 10s after reaching the trigger threshold. The imaging length was not significantly different, but the examination time was significantly (p<0.001) shorter in the high-pitch group (7.7s vs. 1.7s for group 1 vs. 2, 3 and 4). CONCLUSION In high-pitch CT angiography using a start delay of 10s after a trigger threshold of 140 HU in the descending aorta is reached, a homogenous contrast along the z-axis is accomplished.

Evaluation of MRI T1-based treatment monitoring during laser-induced thermotherapy of liver metastases for necrotic size prediction

Abstract Purpose: The aim of this study was to evaluate the accuracy of real-time magnetic resonance imaging (MRI) T1-based treatment monitoring for predicting volume of lesions induced by laser-induced thermotherapy (LITT) of liver metastases. Materials and methods: This prospective study was approved by the institutional review board and informed consent from all included patients was obtained. In 151 patients, 237 liver metastases were ablated during 372 LITT procedures. 1.5T MRI treatment monitoring was performed based on longitudinal relaxation time (T1) using fast low-angle shot (FLASH) sequences. Patients underwent additional contrast-enhanced MRI directly after LITT, 24 h after the procedure and during follow-up at 3, 6 and 12 months. The amount of energy necessary to induce a defined necrotic area was investigated within the various liver segments. Results: The total amount of energy applied during LITT varied from 6.12–225.32 kJ (mean 48.96 kJ). Ablation in liver segments 5 (2.12 kJ/cm3) and 8 (2.16 kJ/cm3) required the highest energy. The overall pre-ablative metastasis volume ranged from 0.5–51.94 cm3 (mean 1.99 cm3, SD 25.49 cm3) while the volume measured in the last available T1 image varied from 0.78–120 cm3 (mean 26.25 cm3, SD 25.66 cm3). Volumes measured via MRI T1-based treatment monitoring showed a stronger correlation with necrosis 24 h after LITT (r = 0.933, p < 0.001) than contrast-enhanced MRI directly after the procedure (r = 0.888, p < 0.001). Conclusions: Real-time MRI T1-based treatment monitoring during LITT of liver metastases allows for precise estimation of the resulting lesion volume and improves control of the energy necessary during ablation.

ECG-gated Versus Non-ECG-gated High-pitch Dual-source CT for Whole Body CT Angiography (CTA)

RATIONALE AND OBJECTIVES To investigate motion artifacts, image quality, and practical differences in electrocardiographic (ECG)-gated versus non-ECG-gated high-pitch dual-source computed tomography angiography (CTA) of the whole aorta. MATERIALS AND METHODS Two groups, each including 40 patients, underwent either ECG-gated or non-ECG-gated high-pitch dual-source CTA of the whole aorta. The aortic annulus, aortic valve, coronary ostia, and the presence of motion artifacts of the thoracic aorta as well as vascular contrast down to the femoral arteries were independently assessed by two readers. Additional objective parameters including image noise and signal-to-noise ratio were analyzed. RESULTS Subjective and objective scoring revealed no presence of motional artifacts regardless of whether the ECG-gated or the non-ECG-gated protocol was used (P > 0.1). Image acquisition parameters (examination length, examination duration, radiation dose) were comparable between the two groups without significant differences. The aortic annulus, aortic valve, and coronary ostia were reliably evaluable in all patients. Vascular contrast was rated excellent in both groups. CONCLUSIONS High-pitch dual-source CTA of the whole aorta is a robust and dose-efficient examination strategy for the evaluation of aortic pathologies whether or not ECG gating is used.

First Clinical Evaluation of High-Pitch Dual-Source Computed Tomographic Angiography Comparing Automated Tube Potential Selection With Automated Tube Current Modulation.

Objective To investigate and compare the use of automated tube potential selection (ATPS) with automated tube current modulation (ATCM) in high-pitch dual-source computed tomographic angiography (CTA) for imaging the whole aorta without electrocardiogram synchronization. Methods Two groups of 60 patients underwent CTA on a dual-source computed tomographic device in high-pitch mode: ATCM (with 100-kV fixed tube potential) was used in group 1 and ATPS (with the same image quality options) in group 2. For the evaluation of radiation exposure, CT dose index and dose-length product were analyzed. Contrast and image quality were assessed by 2 independent observers. Results The ATPS group received a higher radiation dose than the ATCM group (P < 0.001) because in 80% of patients, the software switched to use of a 120-kV tube potential. In all cases, images of the aorta were of sufficient quality. Conclusions High-pitch dual-source CTA of the aorta using ATPS is feasible in clinical routine, but is associated with higher radiation exposure than the ATCM protocol. This finding contradicts previously evaluations of ATPS based on single-source techniques.

Interventionelle Therapie primärer Lebertumoren

ZusammenfassungDer vorliegende Beitrag befasst sich mit der Vorstellung interventioneller Therapieverfahren wie transarterielle Chemoembolisation (TACE), selektive interne Radiotherapie (SIRT), Radiofrequenzablation (RFA), laserinduzierte Thermotherapie (LITT) und Mikrowellenablation (MWA) für die palliative Therapie von malignen primären Lebertumoren wie dem hepatozellulären Karzinom (HCC) und dem intrahepatischen Cholangiokarzinom (ICC). Da zum Zeitpunkt der Diagnosestellung viele Patienten mit einem HCC oder ICC als inoperabel eingestuft werden, stellen die interventionell-onkologischen Verfahren neben der systemischen Chemotherapie wichtige Therapieformen dar. Erläutert werden die allgemeinen technischen Grundlagen dieser Verfahren sowie die jeweiligen Einsatzbereiche und Voraussetzungen. Neben den Vorteilen und Resultaten wird auch auf die Kontraindikationen, Komplikationen und Nebenwirkungen eingegangen.AbstractThe aim of this article is to present interventional therapy methods, such as transarterial chemoembolization (TACE), selective internal radiation therapy (SIRT), radiofrequency ablation (RFA), laser-induced thermotherapy (LITT) and microwave ablation (MWA) for palliative therapy of primary malignant liver tumors, such as hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). At the time of diagnosis many patients with HCC and ICC do not have resectable tumors and in addition to systematic chemotherapy locoregional therapies become important alternative therapy options in the field of interventional oncology. The basic principles of these interventions, the respective application area and conditions are defined. In addition the advantages of the methods, results and also contraindications, complications and possible side effects are discussed.

Intervention Planning Using a Laser Navigation System for CT-Guided Interventions: A Phantom and Patient Study

Objective To investigate the accuracy, efficiency and radiation dose of a novel laser navigation system (LNS) compared to those of free-handed punctures on computed tomography (CT). Materials and Methods Sixty punctures were performed using a phantom body to compare accuracy, timely effort, and radiation dose of the conventional free-handed procedure to those of the LNS-guided method. An additional 20 LNS-guided interventions were performed on another phantom to confirm accuracy. Ten patients subsequently underwent LNS-guided punctures. Results The phantom 1-LNS group showed a target point accuracy of 4.0 ± 2.7 mm (freehand, 6.3 ± 3.6 mm; p = 0.008), entrance point accuracy of 0.8 ± 0.6 mm (freehand, 6.1 ± 4.7 mm), needle angulation accuracy of 1.3 ± 0.9° (freehand, 3.4 ± 3.1°; p < 0.001), intervention time of 7.03 ± 5.18 minutes (freehand, 8.38 ± 4.09 minutes; p = 0.006), and 4.2 ± 3.6 CT images (freehand, 7.9 ± 5.1; p < 0.001). These results show significant improvement in 60 punctures compared to freehand. The phantom 2-LNS group showed a target point accuracy of 3.6 ± 2.5 mm, entrance point accuracy of 1.4 ± 2.0 mm, needle angulation accuracy of 1.0 ± 1.2°, intervention time of 1.44 ± 0.22 minutes, and 3.4 ± 1.7 CT images. The LNS group achieved target point accuracy of 5.0 ± 1.2 mm, entrance point accuracy of 2.0 ± 1.5 mm, needle angulation accuracy of 1.5 ± 0.3°, intervention time of 12.08 ± 3.07 minutes, and used 5.7 ± 1.6 CT-images for the first experience with patients. Conclusion Laser navigation system improved accuracy, duration of intervention, and radiation dose of CT-guided interventions.

Energy Limits in Second Generation High- pitch Dual Source CT - Comparison in an Upper Abdominal Phantom

Objectives: The aim of our study was to find out how much energy is applicable in second-generation dual source high-pitch computed tomography (CT) in imaging of the abdomen. Materials and Methods: We examined an upper abdominal phantom using a Somatom Definition Flash CT-Scanner (Siemens, Forchheim, Germany). The study protocol consisted of a scan-series at 100 kV and 120 kV. In each scan series we started with a pitch of 3.2 and reduced it in steps of 0.2, until a pitch of 1.6 was reached. The current was adjusted to the maximum the scanner could achieve. Energy values, image noise, image quality, and radiation exposure were evaluated. Results: For a pitch of 3.2 the maximum applicable current was 142 mAs at 120 kV and in 100 kV the maximum applicable current was 114 mAs. For conventional abdominal imaging, current levels of 200 to 260 mAs are generally used. To achieve similar current levels, we had to decrease the pitch to 1.8 at 100 kV - at this pitch we could perform our imaging at 204 mAs. At a pitch of 2.2 in 120 kV we could apply a current of 206 mAs. Conclusion: We conclude our study by stating that if there is a need for a higher current, we have to reduce the pitch. In a high-pitch dual source CT, we always have to remember where our main focus is, so we can adjust the pitch to the energy we need in the area of the body that has to be imaged, to find answers to the clinical question being raised.

Doxorubicin-eluting beads in the treatment of liver carcinoma

Introduction: Doxorubicin and especially doxorubicin-eluting beads (DEBs) have become an intensive study subject in the locoregional therapy of liver carcinoma over the past 6 years. Since sorafenib has become the new standard in the treatment of advanced liver carcinoma and has been combined with DEB in clinical studies to evaluate safety and efficacy, it has shown promising results. Thus, the authors have investigated the evidence that DEB is a potential drug in the treatment of intermediate liver carcinoma, even in combination with systemic therapies. Areas covered: Evaluation of published articles in English using metadatabase such as PubMed. Expert opinion: Since there is no standard therapy regimen in the locoregional transarterial treatment of intermediate liver carcinoma, DEBs were designed to offer an attempt to homogenize the use of cytostatic and embolic agents. The development of so-called doxorubicin-eluting beads in the past few years is an effort to minimize systemic toxicity and increase local drug concentration. In the therapy of liver carcinoma, doxorubicin should not be systemically administered due to its high toxicity. Clinical trials indicate that the administration of DEB is safe and effective for the treatment of liver carcinoma and can even be combined with systemic drugs such as sorafenib.