Gianluca Maria Varano

Treatments for colorectal liver metastases: A new focus on a familiar concept

A major challenge for the management of advanced-colorectal-cancer is the multidisciplinary approach required for the treatment of liver metastases. Reducing the burden of liver metastases with liver-directed therapy has an important impact on both survival and health-related quality of life. This paper debates the rationale and current liver-directed approaches for colorectal liver metastases based on the evidence of literature and new clinical trials. Surgery is the gold standard, when feasible, and its the main treatment goal for patients with potentially-resectable disease as a means of prolonging progression-free survival. Better tumor response rates with modern systemic therapy mean that more unresectable patients are now down-staged for radical resection following conversion therapy but for other patients, additional procedures are needed. In multiple unilobar disease, when the projected remnant liver is <30% of the total liver, portal embolization or selective-internal-radiation-therapy (SIRT) can induce hypertrophy of the healthy liver, leading to resectability. In multiple bilobar disease, in situ destruction of non-resectable lesions by minimally invasive techniques may be associated with liver resection to achieve potential curative intent. Other palliative liver-directed approaches, such as SIRT or intra-hepatic chemotherapy (HAI), which are associated with higher response rates, may also have role in down-staging patients for resection. Until recently, such technologies have not been validated in prospective controlled trials. However in the light of new Phase 3 data for SIRT as well as for HAI combined with modern therapies or radiofrequency ablation in the first- and second-line setting, the clinical value of these treatments needs to be re-appraised.

TAE for HCC: When the Old Way is Better than the New Ones!!!

Transarterial chemoembolization (TACE) is nowadays widely applied as a treatment for hepatocellular carcinomas (HCCs) that are not suitable for percutaneous ablation or surgical resection, as this technique has been demonstrated to improve survival in comparison with best supportive care [1]. However, it is still unclear whether results of this kind of treatment are more related to the ischemic effect of the embolization or to the local effect of the delivered drug. In fact, no evidence of superiority of TACE in comparison with embolization alone (TAE) has been ever demonstrated—even if embolizing materials in conventional TACE were not designed to achieve the best ischemic effect, but only to temporarily stop the blood flow to increase the local effect of the drug [2]. Moreover, up to now, there are no drugs with proven good efficacy over HCC, and doxorubicin, the most widely used agent, has been proven to determine only marginal benefits for the patients in terms of disease control and survival [3]. Conversely, doxorubicin has been shown to determine liver toxicity, with a potential consequent worsening of liver function, which might be particularly relevant in cirrhotic patients [4]. Following the idea that the ischemic effect is the most important one in the transarterial treatment of HCC, some materials with higher embolizing effect have been developed and more precise superselective embolizing techniques have been adopted [5, 6]. In particular, the adoption of very small caliber particles, which could reach smaller peripheral arteries causing permanent ischemia, has been reported with favorable results. One of the main problems in comparing TACE with TAE is the difference in the embolizing materials and techniques adopted for the two methods. TACE is generally delivered through an emulsion of Lipiodized oil and doxorubicin followed by blood flow blockage through gelatin sponge injection, while in TAE, embolizing microspheres of different caliber are employed. Recently, specific small caliber beads able to be loaded with drugs have been developed and introduced into the market. Drugeluting beads have been used with good results in the treatment of unresectable HCC, with favorable but not significant difference in comparison with conventional TACE [7]. However, up to very recent times, no studies investigated the results of embolization with small caliber particles with or without the adjunct of drug in the treatment of unresectable HCC. Very recently, Brown et al. reported the results of their prospective randomized trial (started in 2007) comparing doxorubicin-eluting microspheres with embolization with microspheres alone [8]. In this trial, 101 patients were prospectively enrolled and randomized to treatment with the same technique and embolizing material, with the only variable being the presence or absence of the drug. In this study, no difference regarding adverse events, tumor response, median progression-free survival and overall survival was found in the two groups. This is the first strong evidence that TAE, when performed with dedicated material and selective technique, may achieve the same results as that of TACE, thus challenging the real importance of adding drugs when performing transarterial embolization in patients with HCC. Based on this novel evidence, should we start considering avoiding the addition of drugs when performing & Giovanni Mauri giovanni.mauri@ieo.it

Unusual tumour ablations: report of difficult and interesting cases

Image-guided ablations are nowadays applied in the treatment of a wide group of diseases and in different organs and regions, and every day interventional radiologists have to face more difficult and unusual cases of tumour ablation. In the present case review, we report four difficult and unusual cases, reporting some tips and tricks for a successful image-guided treatment.

Minimal invasive treatments for liver malignancies

Minimal invasive therapies have proved useful in the management of primary and secondary hepatic malignancies. The most relevant aspects of all these therapies are their minimal toxicity profiles and highly effective tumor responses without affecting the normal hepatic parenchyma. These unique characteristics coupled with their minimally invasive nature provide an attractive therapeutic option for patients who previously may have had few alternatives. Combination of these therapies might extend indications to bring curative treatment to a wider selected population. The results of various ongoing combination trials of intraarterial therapies with targeted therapies are awaited to further improve survival in this patient group. This review focuses on the application of ablative and intra-arterial therapies in the management of hepatocellular carcinoma and hepatic colorectal metastasis.

Percutaneous Retrieval of a Guide Wire Fragment with the Use of an Angioplasty Balloon and an Angiographic Catheter: The Sandwich Technique

We describe a case where a guide wire tip was detached and retrieved with the use of a catheter and a small angioplasty balloon, a technique we call the sandwich technique. Foreign body retrieval is now a common procedure in every interventional radiology department. Endovascular procedures and central line insertion sometimes lead to the creation of foreign bodies, which require retrieval, preferably in the same setting. Therefore, a large variety of endovascular retrieval tools, including snares, baskets, and forceps, is currently used [1–5]. However, there are cases where none of the conventional off-the-shelf tools may be suitable for retrieval of a foreign body. In such cases, the skill and the imagination of the operator are necessary to avoid failure and more serious complications. A 73-year-old patient with history of hypertension and smoking was admitted to our hospital with bilateral rest pain. Diagnostic assessment with computed tomography (CT) revealed an area of a 2-cm-long stenosis of the left common iliac artery and complete occlusion of the right common iliac artery (Fig. 1). After discussion at a clinical multidisciplinary meeting, an endovascular approach was decided, and retrograde puncture of the left common femoral artery was performed with a 4F sheath (CheckFlo; Cook Medical, Bjaeverskov, Denmark). The narrowed area was easily crossed with a 0.035-inch hydrophilic guide wire (Radifocus; Terumo Europe, Leuven, Belgium), and a pigtail catheter (Cordis, East Bridgewater, NJ, USA) was advanced in the aortic bifurcation in order to perform a diagnostic angiogram. Angiogram confirmed the CT findings, and 5000 IU of heparin was administered intra-arterially. The 4F sheath was exchanged to a 6F one (CheckFlo, Cook Medical, Bjaeverskov, Denmark), and the stenotic area in the left common iliac artery was initially predilated with an 8 9 40 mm balloon (Sterling; Boston Scientific, Natick, MA, USA), then treated with a 9 9 28 mm balloonexpandable stent (Omnilink; Abbot Vascular, Santa Clara, CA, USA) with satisfactory results (Fig. 2). We chose an initial crossover approach in an attempt to recanalize the right common iliac artery. Therefore, a 5F Sim2 catheter (Cordis) was advanced in the right common iliac artery. Several attempts with a 0.035-inch hydrophilic guide wire (Radifocus; Terumo Europe) to cross the occluded segment were unsuccessful. Therefore, a 0.018inch guide wire (V18; Boston Scientific) was used instead to try and cross the lesion intraluminally, with the catheter over the wire. After several rotational movements under light pressure in the attempt to entirely cross the occluded segment, the floppy tip of the guide wire accidentally detached from the rest of tool and was embedded in the vessel (Fig. 3). The length of the detached fragment was approximately 6 cm. The proximal part of the fragment remained in the catheter; however, it was evident that it was detached from the rest of the guide wire. At this point, we decided to not change the position of the catheter so as to not further dislodge the detached part. Because the right side was occluded, there was no access from the right common femoral artery. The chosen solution was to try to retrieve the fragment by fixing the guide wire within the catheter and then withdrawing the whole system. For this purpose, a 1.5 9 20 mm low-profile cardiologic balloon (Apex; Boston Scientific) was used and advanced M. Rossi M. Citone G. Varano G. Orgera Department of Radiology, S. Andrea Hospital Sapienza Rome University, Rome, Italy

Percutaneous laser ablation for thyroid benign and malignant diseases

Minimally invasive image-guided thermal ablation is becoming increasingly common as an alternative to surgery for the treatment of benign thyroid nodules. Among the various techniques for thermal ablation, laser ablation (LA) is the least invasive, using the smallest applicators available on the market and enabling extremely precise energy deposition. However, in some cases, multiple laser fibers must be used simultaneously for the treatment of large nodules. In this review, the LA technique is described, and its main clinical applications and results are discussed and illustrated.

Ultrasound and cone beam CT fusion for liver ablation: technical note

Abstract Purpose: To assess the feasibility of fusion imaging between intraprocedural ultrasound (US) and contrast-enhanced cone-beam CT (CBCT) for small (< 2 cm) hepatocellular carcinoma (HCC). Materials and methods: Six patients (five males, one female, age range 58–80, mean 69 years), with small (mean diameter 16.8 mm) HCC poorly visible at US underwent percutaneous microwave ablation under US/CBCT fusion guidance. During general anesthesia with apnea control, a contrast- enhanced CBCT was acquired with an active tracker. Subsequently, real time US images were fused with CBCT images, and treatment performed under fusion imaging guidance. Feasibility of fusion imaging and percutaneous ablation were assessed, correct targeting (distance from center of tumor and center of ablation area <5 mm) and one-month primary technical efficacy were evaluated. Major and minor complications as well as overall procedural time were recorded. Results: US/CBCT fusion was feasible in all cases, allowing for completion of the treatment as previously planned (technical success 100%). Correct targeting was achieved in 4/6 cases (66%), while in two cases, center of tumor and center of ablated area were respectively 7 and 8 mm distant. At 1 month CT scan, all tumors were completely ablated (primary technical efficacy 100%). No major or minor complications occurred. Mean overall procedure time was 127 min. Conclusions: US/CBCT fusion is a feasible technique for liver ablation, and might represent a useful tool to increase the correct targeting of poorly US-visible HCC nodules in the angio suite.

Surgery of Metastases in Stage IV Breast Cancer

Breast cancer is the most common female tumor worldwide. Breast cancer can recur at any time, but most recurrences occur within 5 years from diagnosis, and in such cases, they show a severe prognosis and a broad spectrum of survival (from a few months to years), depending on tumor- and patient-related features. In some selected cases, surgery may improve not only quality of life but also overall survival; the possible outcome is closely related to a good selection of the patients. Currently there are no established criteria or scoring systems, so in order to evaluate a possible indication for surgery, we need to consider dynamic determinants (tumor kinetics, time to progression, and aggressiveness), static determinants (extent of disease, PS, and comorbidity), and biological determinants (mutations and receptors), with a view to obtaining a complete resection of the disease.

Histologically-Proven Efficacy of Bland Embolization in a Patient with Net Liver Metastasis.

We present a case of 57-year-old patient with three liver metastases from a primary neuroendocrine duodenal tumor, who underwent bland embolization with excellent response to therapy, followed by surgical resection. The purpose of our case report is to describe the histological characteristics of tumoral response to therapy after bland embolization focusing on intralesional necrosis and microsphere distribution.