Frank A. Morello

Hepatic artery embolization and chemoembolization for treatment of patients with metastatic carcinoid tumors: The M.D. Anderson experience

BACKGROUNDCarcinoid tumors have a predilection for metastasizing to the liver. The presence of liver metastases is associated with poor prognosis and also results in significant deterioration of patients quality of life. Several reports suggest that hepatic artery embolization or chemoembolization can be used for control of liver disease in these patients. We retrospectively reviewed our experience with the use of hepatic arterial embolization or chemoembolization in patients with liver-dominant metastatic carcinoid disease, evaluating the clinical and radiologic response rates, duration of response, and progression-free and overall survival rates of these patients. MATERIALS AND METHODSThe medical records of all patients with carcinoid tumors metastatic to the liver who underwent hepatic artery embolization or chemoembolization between January 1992 and December 2000 were reviewed. For the purposes of this study, we compared the follow-up computed tomography or magnetic resonance imaging with the baseline imaging to determine each patients objective tumor response. The interval between the dates of response and disease progression was considered the response duration. Progression-free survival duration was calculated from the date of initial treatment to the date disease progression was recorded or the date of death. Survival durations were calculated using the Kaplan-Meier method. RESULTSEighty-one patients (48 men and 33 women; age range, 38–79 years) were included in this study. The mean duration of disease from the initial discovery of liver metastases until embolization was 24.5 months. Fifty patients were treated with bland hepatic artery embolization, and 31 underwent chemoembolization. Of the 69 patients in whom radiologic response could be evaluated, partial response was observed in 46 patients (67%), minimal response (MR) in six (8.7%), stable disease in 11 (16%), and progressive disease in six (8.7%). The median duration of response in the 42 patients with partial response was 17 months (range, 4–51 months). Sixty-three percent of patients had a reduction in their tumor-related symptoms. The median progression-free survival duration was 19 months (95% confidence interval, 17–21 months); the probability of progression-free survival was 75%, 35%, and 11% at 1, 2, and 3 years, respectively. The median overall survival time was 31 months (95% confidence interval, 23–38 months); the survival probability was 93% at 1 year, 62% at 2 years, and 24% at 5 years. CONCLUSIONSHepatic arterial occlusive therapy using hepatic artery embolization or chemoembolization results in symptomatic and radiologic response in most patients with carcinoid metastases in the liver. The progression-free survival of 19 months achieved with embolization in our study is encouraging, given that most patients had extensive liver involvement and had shown disease progression while receiving systemic treatment.

Transhepatic Ipsilateral Right Portal Vein Embolization Extended to Segment IV: Improving Hypertrophy and Resection Outcomes with Spherical Particles and Coils

PURPOSE To analyze outcomes after right portal vein embolization extended to segment IV (right PVE + IV) before extended right hepatectomy, including liver hypertrophy, resection rates, and complications after embolization and resection, and to assess differences in outcomes with two different particulate embolic agents. MATERIALS AND METHODS Between 1998 and 2004, transhepatic ipsilateral right PVE + IV with particles and coils was performed in 44 patients with malignant hepatobiliary disease, including metastases (n = 24), biliary cancer (n = 14), and hepatocellular carcinoma (n = 6). Right PVE + IV was considered if the future liver remnant (FLR; segments II/III with or without I) was less than 25% of the total estimated liver volume (TELV). Tris-acryl microspheres (100-700 microm; n = 21) or polyvinyl alcohol (PVA) particles (355-1,000 microm; n = 23) were administered in a stepwise fashion. Smaller particles were used to occlude distal branches, followed by larger particles to occlude proximal branches until near-complete stasis. Coils were then placed in secondary portal branches. Computed tomographic volumetry was performed before and 3-4 weeks after right PVE + IV to assess FLR hypertrophy. Liver volumes and postembolization and postoperative outcomes were measured. RESULTS After right PVE + IV with PVA particles, FLR volume increased 45.5% +/- 40.9% and FLR/TELV ratio increased 6.9% +/- 5.6%. After right PVE + IV with tris-acryl microspheres, FLR volume increased 69.0% +/- 30.7% and FLR/TELV ratio increased 9.7% +/- 3.3%. Differences in FLR volume (P = .0011), FLR/TELV ratio (P = .027), and resection rates (P = .02) were statistically significant. Seventy-one percent of patients underwent extended right hepatectomy (86% after receiving tris-acryl microspheres, 57% after receiving PVA). Thirteen patients (29%) did not undergo resection (extrahepatic spread [n = 9], inadequate hypertrophy [n = 3], other reasons [n = 1]). No patient developed postembolization syndrome or progressive liver insufficiency after embolization or resection. One death after resection occurred as a result of sepsis and hemorrhage. Median hospital stays were 1 day after right PVE + IV and 7 days after resection. CONCLUSION Transhepatic ipsilateral right PVE + IV with use of particles and coils is a safe, effective method for inducing contralateral hypertrophy before extended right hepatectomy. Embolization with small spherical particles provides improved hypertrophy and resection rates compared with larger, nonspherical particles.

Percutaneous radiofrequency ablation of lung tumors in a large animal model.

PURPOSE Percutaneous radiofrequency ablation (RFA) is accepted therapy for liver tumors in the appropriate clinical setting, but its use in lung neoplasms remains investigational. We undertook this study to evaluate the feasibility and immediate effectiveness of RFA for treatment of both solitary pulmonary nodules and clusters of lung tumors in a large animal model. MATERIALS AND METHODS Percutaneous RFA of 14 lung tumors in five dogs was performed under CT guidance. Animals were euthanatized 8-48 hours after the procedure. The lungs and adjacent structures were harvested for gross and histopathologic evaluation. RESULTS Five solitary pulmonary nodules (range, 17-26 mm) and three clusters of three nodules each (range, 7-17 mm per nodule) were treated with RFA. All ablations were technically successful. Perilesional ground-glass opacity and small asymptomatic pneumothoraces (n = 4) were visualized during the RFA sessions. One dog developed a large pneumothorax treated with tube thoracostomy but was euthanatized 8 hours post-RFA for persistent pneumothorax and continued breathing difficulty. Follow-up CT 48 hours post-RFA revealed opacification of the whole lung segment. Gross and histopathologic evaluation showed complete thermal coagulation necrosis of all treated lesions without evidence of any viable tumor. The region of thermal coagulation necrosis typically extended to the lung surface. Small regions of pulmonary hemorrhage and congestion often surrounded the areas of coagulation necrosis. CONCLUSIONS RFA can be used to treat both solitary pulmonary nodules and clusters of tumor nodules in the canine lung tumor model. This model may be useful for development of specific RFA protocols for human lung tumors.

Percutaneous ultrasound-guided biopsy in the definitive diagnosis of osteosarcoma.

Thirty-three patients with 35 bone lesions suspicious for osteosarcoma underwent image-guided biopsy. Of those 35 biopsies, 12 were performed with use of fluoroscopy or computed tomography (CT) guidance to target the osseous abnormality. Diagnostic magnetic resonance imaging revealed a soft tissue component in 23 cases; in these cases, biopsies were performed with use of ultrasonography (US) to target the soft tissue component of the tumor. Of the 35 tumors in which biopsy was performed, 33 (94%) were definitively diagnosed as osteosarcoma by image-guided biopsy. All 23 US-guided biopsies resulted in definitive diagnosis. Two of the 12 fluoroscopy- or CT-guided biopsies (17%) were inconclusive.

CT-Guided Needle Biopsy of Deep Pelvic Lesions by Extraperitoneal Approach Through Iliopsoas Muscle

We report our experience with computed tomography (CT)-guided coaxial needle biopsy of deep pelvic lesions by an extraperitoneal approach through the iliopsoas muscle, using a curved needle for difficult-to-reach lesions. We reviewed the records of all patients with pelvic masses who underwent CT-guided percutaneous biopsy via iliopsoas muscle between January 1999 and December 2001. Direct anterior or posterior approach to the lesion was obstructed by bowel, bladder, vessels, or bones in all patients. An 18-gauge guide needle was advanced through the iliopsoas muscle and a 22-gauge Chiba needle was used to perform the biopsy. A custom-tailored curved 22-g needle was used in 17 procedures when the location of the iliac vessels and the slope of the iliac wing obstructed a straight path to the lesion. Fifty-three patients underwent 57 CT-guided needle biopsies during the study period. The lesions comprised obturator (n = 25), internal iliac (n = 11), anterior external iliac (n = 4), and common iliac nodes (n = 4); soft tissue masses along pelvic side-wall (n = 6); adnexal lesions (n = 5); a loculated fluid collection, and a perirectal node. All lesions were safely accessed, and major vessels and viscera were avoided in all cases. Of the 57 biopsies, 53 (93%) yielded diagnostic specimens. No major complications were encountered. CT-guided coaxial needle biopsy by an anterolateral approach through the iliopsoas muscle, with the use of a curved needle in selected cases is safe and effective for obtaining samples from deep pelvic lesions.