Joshua Weintraub

Gastroduodenal Ulceration Associated with Radioembolization for the Treatment of Hepatic Tumors: An Institutional Experience and Review of the Literature

BackgroundMicrosphere radioembolization is a method of delivering radiation therapy directly to tumors, thereby minimizing toxicity to adjacent structures. Despite the relatively high precision of this modality, numerous adverse effects have been recognized. One particularly untoward complication is the development of severe gastroduodenal ulceration.MethodsIn order to further characterize gastroduodenal ulceration associated with radioembolization, our institutional experience as well as the reported literature were reviewed.ResultsThe current evidence suggests that radioembolization-associated gastroduodenal ulceration results from inadvertent delivery of microspheres to the microvasculature of the gastrointestinal tract, leading to direct radiation toxicity. The reported incidence of this entity ranges between 2.9% and 4.8%. Most patients with this complication present with abdominal pain, often associated with nausea, vomiting, and anorexia. Symptoms can arise from hours to months after radioembolization treatment; diagnosis is made by endoscopic biopsy and histopathologic evaluation of the ulcer specimen. Radiation-induced ulcers have proven to be extremely difficult to treat. Current therapy based on acid suppression has had limited success, and the evidence for the addition of antioxidants and anti-inflammatory agents is still sparse.ConclusionsThe increasing utilization of radioembolization will lead to adverse events including gastroduodenal ulceration. This entity must be considered in any patient treated with radioactive microspheres presenting with symptoms of dyspepsia. Accurate diagnosis and aggressive treatment are necessary to improve patient outcomes.

Radiologic Monitoring of Hepatocellular Carcinoma Tumor Viability after Transhepatic Arterial Chemoembolization: Estimating the Accuracy of Contrast-enhanced Cross-sectional Imaging with Histopathologic Correlation

PURPOSE Cross-sectional diagnostic imaging studies such as contrast-enhanced quadruple-phase helical computed tomography (CT) and contrast-enhanced magnetic resonance (MR) imaging are routinely performed to evaluate tumor response to transhepatic arterial chemoembolization. However, the true correlation between imaging characteristics and histopathologic tumor viability is not known. The aim of the present retrospective study was to determine the sensitivity and specificity of contrast-enhanced CT and contrast-enhanced MR imaging with use of histopathologic analysis. MATERIALS AND METHODS Between February 2002 and October 2005, a total of 31 patients (age, 51-74 years; mean, 60 y) who had undergone chemoembolization underwent follow-up diagnostic cross-sectional imaging before transplantation. The mean time interval between the imaging study and transplantation was 32 days (range, 1-117 d). Imaging studies were assessed for residual or recurrent tumor and were then correlated to the findings of histopathologic analysis performed on the surgical specimens at the time of transplantation. RESULTS The overall sensitivity and specificity rates of cross-sectional imaging studies were 35% and 64%, respectively. The overall accuracy rate of CT was 43%, with 36% sensitivity and 57% specificity. The overall accuracy rate of MR imaging was 55%, with 43% sensitivity and 75% specificity. Gross macroscopic disease was missed in one patient (9%) who underwent MR imaging and four patients (19%) who underwent CT. CONCLUSIONS Contrast-enhanced CT and MR imaging after chemoembolization are associated with high error rates. Between the two modalities, MR has higher sensitivity and specificity and may be a preferable imaging tool for patients who have undergone chemoembolization.

Time-resolved MR angiography for the classification of endoleaks after endovascular aneurysm repair.

To evaluate the utility of time‐resolved MR angiography (TR‐MRA), compared with digital subtraction angiography (DSA), in the classification of endoleaks in patients who have undergone endovascular aneurysm repair (EVAR).

Treatment of Hepatocellular Carcinoma Combining Sorafenib and Transarterial Locoregional Therapy: State of the Science

The potential for increased efficacy with combined transarterial chemoembolization and sorafenib is a topic of increased interest to specialists who care for patients with unresectable hepatocellular carcinoma. There is strong scientific rationale for combination therapy: transarterial chemoembolization produces ischemia and stimulates hypoxia-inducible factor-1α, resulting in a local and systemic upregulation of vascular endothelial growth factor (VEGF), which can increase tumor angiogenesis. This upregulation can theoretically be counteracted with the multikinase inhibitor sorafenib, which is thought to act directly on platelet-derived growth factor, Raf kinase, and VEGF receptors. The potential of this approach has not yet been fully realized in clinical trials, and many unanswered questions remain. This review article discusses the state of the science of arterial locoregional therapies and sorafenib.

Balloon Catheter Dilatation of Benign Esophageal Strictures in Children

PURPOSE This retrospective study evaluated the safety and efficacy of fluoroscopically guided balloon dilatation of benign pediatric esophageal strictures. MATERIALS AND METHODS Between 2000 and 2005, 272 esophageal balloon dilatations were performed in 49 children, aged 18 days to 18 years. Chart and primary physician record reviews were used to assess complications, age-appropriate food intake, and dysphagia. Efficacy was calculated by time to recurrent symptoms requiring repeat balloon dilatation. Durability was assessed by the frequency of dilatations. RESULTS Seventy-seven percent of patients required a second dilatation within 9 months. Survival analysis (Kaplan-Meier) demonstrated no significant difference for efficacy in relation to patient age (P = .76) or stricture cause (P = .56). A decrease in the number of dilatations occurred over time to achieve longer symptom-free intervals. Patients underwent an average of 5.6 dilatations with an average total intervention time of 2 years. Patients were able to remain symptom free for a mean of 110 days. The procedure had a success rate of 100%, the only major complication being an esophageal perforation (complication rate, 0.37%) in a patient with a stricture secondary to correction of a tracheoesophageal fistula. CONCLUSIONS Balloon esophageal dilatation in children is an effective and safe first-line therapy. Complications are quite rare and manageable. Although cures are unusual, most children require less than one dilatation every 6 months. It is concluded that fluoroscopically guided balloon dilatation should be the primary method of treating benign esophageal strictures.

Single-Center Experience with Elective Transcatheter Coil Embolization of Splenic Artery Aneurysms: Technique and Midterm Follow-up

PURPOSE To review a single-center experience with elective coil embolization of splenic artery aneurysm (SAA) and analyze efficacy of the technique at midterm follow-up. MATERIALS AND METHODS From 2002 through 2011, 50 patients (28 women, 22 men; age range, 24-89 y; mean age, 53.5 y ± 13.6) underwent transcatheter coil embolization for treatment of SAAs. Pseudoaneurysms and ruptured aneurysms were excluded. A total of 63 SAAs were treated (size, 13-97 mm; mean, 29 mm). Ninety-eight percent of aneurysms were treated with coils alone. Regular follow-up consisted of an office visit and imaging. Patient medical records were reviewed for aneurysm location, procedural approach, and technical and clinical outcomes. RESULTS Ninety-eight percent of procedures were technically successful at thrombosing the aneurysm at the time of procedure. Repeat intervention was performed in four of 47 patients (9%) because of continued aneurysm perfusion at follow-up. Mean time to repeat intervention was 125 days (range, 42-245 d). All repeat interventions were technically successful. Neither aneurysm growth nor aneurysm rupture was observed in any patient during the follow-up period (mean, 78 weeks; range, 9 d to 7.1 y). There were no major adverse events. Major splenic infarction occurred in three of 33 patients (9%) with no underlying liver disease and normal splenic volume and in seven of 14 patients (50%) with portal hypertension. CONCLUSIONS Percutaneous transcatheter coil embolization is a safe, effective, and minimally invasive treatment for SAAs as evidenced by high rates of technical success and freedom from aneurysm rupture.

Intra-arterial Methylprednisolone Infusion in Treatment-Resistant Graft-Versus-Host Disease

Acute graft-versus-host disease (GVHD) is a potentially fatal complication following allogeneic hematopoietic stem cell transplant. Standard primary therapy for acute GVHD includes systemic steroids, often in combination with other agents. Unfortunately, primary treatment failure is common and carries a high mortality. There is no generally accepted secondary therapy for acute GVHD. Although few data on localized therapy for GVHD have been published, intra-arterial injection of high-dose corticosteroids may be a viable option. We treated 11 patients with steroid-resistant GVHD using a single administration of intra-arterial high-dose methylprednisolone. Three patients (27%) died periprocedurally. Four patients (36%) had a partial response to intra-arterial treatment and were discharged on total parenteral nutrition and oral medication. Four patients (36%) had a complete response and were discharged on oral diet and oral medication. No immediate treatment or procedure-related complications were noted. Twenty-seven percent of patients survived long-term. Our preliminary results suggest that regional intra-arterial treatment of steroid-resistant GVHD is a safe and potentially viable secondary therapy in primary treatment-resistant GVHD.

Combined transarterial chemoembolization and radiofrequency ablation for hepatocellular carcinoma

Transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) are both efficacious in treating well-selected patients who have hepatocellular carcinoma (HCC). The sequential combination of these two modalities has a sound theoretical basis and raises the probability of complete local response in tumors that are beyond the size at which the likelihood of failure with RFA alone begins to rise. Cheng et al. have found that when limited to patients with well-compensated liver disease, combined TACE and RFA does not seem to dramatically increase the risk of complications beyond the risk levels associated with the individual procedures. The survival benefit demonstrated in this recent article is, however, an artifact of a rigid study design that did not allow rational selection of treatment on the basis of individual patient and tumor characteristics. This study bolsters the evidence that the combination of TACE with RFA enhances local response, strengthening the status of nonsurgical treatment compared with resection for the treatment of early HCC.

Emergent Embolization of Arterial Bleeding after Vacuum-Assisted Breast Biopsy

Vacuum-assisted core breast biopsy has become important in evaluating patients with suspicious breast lesions. It has proven to be a relatively safe procedure that in rare cases can result in vascular complications. These are the first reported cases of transcatheter embolization of uncontrolled breast hemorrhage after vacuum-assisted breast biopsy. With increased use of biopsy and larger-gauge devices, breast imaging groups may consider embolotherapy as a safe alternative for treatment of hemorrhage in a select group of patients.

Characterization of extrahepatic distribution of Tc-99m macroaggregated albumin in hepatic perfusion imaging studies prior to yttrium-90 microsphere therapy.

Tc-99m macroaggregated albumin (MAA) hepatic perfusion study and hepatic angiography are routinely performed prior to yttrium-90 (Y-90) microsphere therapy for patients with hepatocellular carcinoma (HCC) or metastatic cancers to the liver. The purpose of this study was to examine the incidence of altered Tc-99m MAA distribution in these patients and to identify factors that are associated with these changes. A total of 176 Tc-99m MAA hepatic perfusion studies in 159 patients performed in preparation for Y-90 microsphere therapy were retrospectively reviewed. Abnormal findings were identified and correlated with diagnosis, infusion site, tumor volume, and tumor uptake by using bivariate statistical analysis. Abnormal Tc-99m MAA distribution on the hepatic perfusion imaging studies include excessive hepatopulmonary shunting with an elevated shunting fraction (>10%; n=23, 13%) and abnormal intra-abdominal visceral deposition in the GI tract, pancreas, spleen, and umbilical vein (n=19; 11%). Patients with a diagnosis of HCC showed higher incidence of abnormal hepatopulmonary shunting compared with other types of tumors (p<0.05). The incidence of abnormal intra-abdominal visceral deposition is higher with infusion into the left hepatic artery or proper hepatic artery/common hepatic artery compared with infusion into right hepatic artery (p<0.001). In 9 of 12 cases with abnormal deposition in the stomach, duodenum, or pancreas, the cause was identified upon reviewing angiography retrospectively and was subsequently corrected. In conclusion, the hepatic perfusion imaging study is an important imaging modality in preparation and guidance of Y-90 microsphere treatment.