Jessica G. Zarzour

Adjuvant stereotactic body radiotherapy following transarterial chemoembolization in patients with non-resectable hepatocellular carcinoma tumours of ≥3 cm

OBJECTIVES The optimal locoregional treatment for non-resectable hepatocellular carcinoma (HCC) of ≥ 3 cm in diameter is unclear. Transarterial chemoembolization (TACE) is the initial intervention most commonly performed, but it rarely eradicates HCC. The purpose of this study was to measure survival in HCC patients treated with adjuvant stereotactic body radiotherapy (SBRT) following TACE. METHODS A retrospective study of patients with HCC of ≥ 3 cm was conducted. Outcomes in patients treated with TACE alone (n = 124) were compared with outcomes in those treated with TACE + SBRT (n = 37). RESULTS There were no significant baseline differences between the two groups. The pre-TACE mean number of tumours (P = 0.57), largest tumour size (P = 0.09) and total tumour diameter (P = 0.21) did not differ significantly between the groups. Necrosis of the HCC tumour, measured after the first TACE, did not differ between the groups (P = 0.69). Local recurrence was significantly decreased in the TACE + SBRT group (10.8%) in comparison with the TACE-only group (25.8%) (P = 0.04). After censoring for liver transplantation, overall survival was found to be significantly increased in the TACE + SBRT group compared with the TACE-only group (33 months and 20 months, respectively; P = 0.02). CONCLUSIONS This retrospective study suggests that in patients with HCC tumours of ≥ 3 cm, treatment with TACE + SBRT provides a survival advantage over treatment with only TACE. Confirmation of this observation requires that the concept be tested in a prospective, randomized clinical trial.

Postoperative doppler evaluation of liver transplants

Doppler ultrasound plays an important role in the postoperative management of hepatic transplantation, by enabling early detection and treatment of various vascular complications. This article describes the normal Doppler findings following liver transplantation and reviews the imaging appearances of various vascular complications associated with it. The article also discusses transient waveform abnormalities, often seen on a post-transplant Doppler examination, and the importance of differentiating them from findings suggestive of ominous vascular complications.

Computed tomography predictors of hepatocellular carcinoma tumour necrosis after chemoembolization

BACKGROUND Radiographical features associated with a favourable response to trans-arterial chemoembolization (TACE) are poorly defined for patients with hepatocellular carcinoma (HCC). METHODS From 2008 to 2012, all first TACE interventions for HCC performed at the University of Alabama at Birmingham (UAB) were retrospectively reviewed. Only patients with a pre-TACE and a post-TACE computed tomography (CT) scan were included in the analyses (n = 115). HCC tumour response to TACE was quantified via the the modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria. Univariate and multivariable analyses were constructed. RESULTS The index HCC tumours experienced a > 90% or complete tumour necrosis in 59/115 (51%) of patients after the first TACE intervention. On univariate analysis, smaller tumour size, peripheral tumour location and arterial enhancement were associated with a > 90% or complete tumour necrosis, whereas, only smaller tumour size [odds ratio (OR) 0.62; 95% confidence interval (CI) 0.48, 0.81] and peripheral location (OR 6.91; 95% CI 1.75, 27.29) were significant on multivariable analysis. There was a trend towards improved survival in the patients that experienced a > 90% or complete tumour necrosis (P = 0.08). CONCLUSIONS Peripherally located smaller HCC tumours are most likely to experience a > 90% or complete tumour necrosis after TACE. Surprisingly, arterial-phase enhancement and portal venous-phase washout were not significantly predictive of TACE-induced tumour necrosis. The TACE response was not statistically associated with improved survival.

Acrokeratosis paraneoplastica (Bazex syndrome): Report of a case associated with small cell lung carcinoma and review of the literature

Acrokeratosis paraneoplastic (Bazex syndrome) is a rare, but distinctive paraneoplastic dermatosis characterized by erythematosquamous lesions located at the acral sites and is most commonly associated with carcinomas of the upper aerodigestive tract. We report a 58-year-old female with a history of a pigmented rash on her extremities, thick keratotic plaques on her hands, and brittle nails. Chest imaging revealed a right upper lobe mass that was proven to be small cell lung carcinoma. While Bazex syndrome has been described in the dermatology literature, it is also important for the radiologist to be aware of this entity and its common presentations.

Predictors of repeat transarterial chemoembolization in the treatment of hepatocellular carcinoma

OBJECTIVES Repeat transarterial chemoembolization (TACE) is a common intervention performed for hepatocellular carcinoma (HCC). The aim of this study was to identify predictors of the need for repeat TACE. METHODS Between 2008 and 2012, data on patient and tumour variables were collected for 262 patients treated with a first TACE procedure for HCC. The decision to perform repeat TACE procedures was made at the completion of the first TACE or after follow-up imaging demonstrated the subtotal treatment of HCC tumours. RESULTS Repeat TACE was performed in 67 of 262 (25.6%) patients. Necrosis of HCC, measured after the first TACE, was lower in patients who subsequently received repeat TACE (P = 0.042). On multivariable analysis, total tumour diameter of >5 cm [odds ratio (OR) 2.76, 95% confidence interval (CI) 1.45-5.25; P = 0.002] and increasing age (OR 1.04/year, 95% CI 1.00-1.07; P = 0.030) were predictive of the need for repeat TACE. Measures of liver function and TACE approach (selective versus non-selective) were not predictive of repeat TACE. Median survival did not differ significantly between patients who did (median survival: 21.1 months) and did not (median survival: 26.1 months) receive a repeat TACE procedure (P = 0.574). CONCLUSIONS The requirement for repeat TACE is associated with older age, increased HCC tumour burden and subtotal TACE-induced HCC necrosis. Importantly, repeat TACE was not associated with reduced survival.

Treatment of Acute Inferior Vena Cava and Iliac Vein Thrombosis With Pharmacomechanical Thrombectomy Using Simultaneously Operating “Kissing” Trellis-8 Thrombolysis Catheters

Purpose To present a new endovascular technique for treating acute large thrombus burden in the iliocaval venous system. Technique This method is demonstrated in a 62-year-old man with end-stage renal disease on hemodialysis who had a nonfunctioning right femoral dialysis catheter that was placed 3 month earlier. After catheter removal, venography demonstrated significant thrombus in the inferior vena cava (IVC) and both iliac veins. The patient was treated successfully using two simultaneously operating Trellis-8 thrombolysis catheters placed side-by-side in the IVC and both iliac veins in a “kissing” configuration. Conclusion This technique was able to effectively debulk acute large thrombus burden in the iliocaval system in a single session and preserve the patients available hemodialysis access. The technique has the potential to minimize morbidity, duration of hospital stay, and overall cost of treatment.

Contrast-Enhanced Ultrasound Classification of Previously Indeterminate Renal Lesions

To determine the utility of contrast‐enhanced ultrasound (US) for characterizing renal lesions that were indeterminate on prior imaging.

Correlating Preoperative Imaging with Histologic Subtypes of Renal Cell Carcinoma and Common Mimickers

Renal cell carcinoma (RCC) consists of distinct subtypes that have unique pathologic and imaging features as well as specific cytogenetic and molecular characteristics. As the prognosis and therapeutic strategies may differ for each subtype, correlation of the preoperative imaging with the pathologic findings is of great clinical relevance. In addition, differentiation of RCC from benign entities is ideal in order to prevent overtreatment. However, a noninvasive diagnosis with imaging alone is not always straightforward due to the overlapping appearance of RCC with benign lesions such as fat-poor angiomyolipoma and oncocytoma. With new imaging modalities, there have been significant improvements in correlating preoperative imaging with pathologic characteristics. These new discoveries are able to aid in a more specific, noninvasive, diagnosis that in turn helps direct patient management.

Clear Cell Papillary Renal Cell Carcinoma: New Clinical and Imaging Characteristics

OBJECTIVE To investigate clear cell papillary (CCP) renal cell carcinoma (RCC), an uncommon tumor of low malignant potential characterized by low-grade, clear cells, showing papillary and tubular architecture. This relatively newly described entity is still being characterized. We present our series of CCP RCC with new clinical and imaging findings. MATERIALS AND METHODS We reviewed the clinical, pathologic, and imaging findings of 28 CCP RCCs in 21 patients identified from our institution between 2010 and 2016. RESULTS Sixteen of 21 (76%) patients were African American with an equal male-to-female ratio. Mean follow-up was 26.1 ± 16.9 months. Mean age at diagnosis was 58.3 ± 10.7 years, and mean preoperative creatinine was 2.7 ± 2.9 mg/dL. End-stage renal disease or chronic kidney disease was present in 10 of 21 (47.6%) patients. Mean tumor size was 2.2 ± 1.5 cm. All cases were stage pT1, and 25 of 28 (89%) tumors were grade 2. No necrosis or sarcomatoid features were identified. Two patients had synchronous clear cell RCC and 1 patient had synchronous papillary RCC. No recurrence or metastases were identified. On imaging, the majority of the lesions were solid, with relatively low-level enhancement, similar to papillary RCC, with regions of heterogeneous hyper-enhancement, similar to clear cell RCC. The rate of growth on serial imaging was comparable with that observed for other low-staged RCCs. CONCLUSION In our series, CCP RCC was seen more commonly in African American patients and associated with end-stage renal disease or chronic kidney disease. Imaging characteristics are similar in both clear cell RCC and papillary RCC. A nephron-sparing approach is recommended when surgically feasible.

Co-registration of MRI and ultrasound: accuracy of targeting based on radiology-pathology correlation

We reviewed the role of multiparametric magnetic resonance imaging (MP-MRI) and methods of MRI guided biopsy including in-bore, cognitive fusion, and software-based fusion. MP-MRI has been developed, optimized, and studied as a means of improving prostate cancer detection beyond the standard evaluation that utilizes digital rectal examinations and serum prostate specific antigen (PSA). MP-MRI has been proven to be an excellent diagnostic imaging modality that improves prostate cancer detection and risk stratification by guiding biopsy samples. The co-registration between MRI and ultrasound has allowed for software-based fusion which enables office-based biopsy procedures while still benefiting from the detailed prostate characterization of MRI. MP-MRI/ultrasound fusion guided biopsy has been studied in detail as this technology has been developed, tested, and validated in the past decade. The imaging to pathology correlation supporting the use of MP-MRI/ultrasound fusion is well documented in the literature. As the indication for the use of prostate MP-MRI becomes more widespread, it is important to continue to evaluate the correlation between imaging and pathologic findings.