Maciej Powerski

Clinical Long-term Outcome after Uterine Artery Embolization: Sustained Symptom Control and Improvement of Quality of Life

PURPOSE To evaluate long-term clinical efficacy of uterine artery embolization (UAE) for uterine fibroids with respect to symptom control and improvement in quality of life. MATERIALS AND METHODS Between October 2000 and October 2007, 380 consecutive women underwent UAE. To determine long-term efficacy, the rate of reinterventions (ie, repeat UAE, hysterectomy, myomectomy) and the clinical response regarding symptoms related to bleeding and bulk were documented. Persistence, worsening, or recurrence of symptoms and reinterventions were classified as treatment failure (TF). The cumulative rate of freedom from TF was determined by Kaplan-Meier analysis. Cox regression was used to identify possible clinical or morphologic predictors of outcome. Secondary outcome measures were changes in disease-specific quality of life and onset of menopause. RESULTS Follow-up was available for a median of 5.7 years (range, 3.1-10.1 y) after treatment in 304 of 380 (80%) patients. There were 54 TFs with subsequent reintervention in 46 women. Kaplan-Meier analysis revealed a cumulative TF rate of 23.3% after 10 years. Cox regression demonstrated a significantly higher likelihood of TF in patients<40 years old compared with patients>45 years old (hazard ratio, 2.28; P = .049). Women without TF showed sustained normalization of disease-specific quality of life (P <.001). Cessation of menstruation at a median age of 51 years was reported by 57 (22.8%) of 250 women. CONCLUSIONS UAE leads to long-term control of fibroid-related symptoms and normalization of quality of life in approximately 75% of patients. Younger women seem to have a higher risk of TF than older women closer to menopause.

Computed-tomography-guided high-dose-rate brachytherapy (CT-HDRBT) ablation of metastases adjacent to the liver hilum

PURPOSE To evaluate technical feasibility and clinical outcome of computed tomography-guided high-dose-rate-brachytherapy (CT-HDRBT) ablation of metastases adjacent to the liver hilum. MATERIALS AND METHODS Between November 2007 and May 2012, 32 consecutive patients with 34 metastases adjacent to the liver hilum (common bile duct or hepatic bifurcation ≤5 mm distance) were treated with CT-HDRBT. Treatment was performed by CT-guided applicator placement and high-dose-rate brachytherapy with an iridium-192 source. MRI follow-up was performed 6 weeks and every 3 months post intervention. The primary endpoint was local tumor control (LTC); secondary endpoints included time to progression (TTP) and overall survival (OS). RESULTS Patients were available for MRI evaluation for a mean follow-up time of 18.75 months (range: 3-56 months). Mean tumor diameter was 4.3 cm (range: 1.3-10.7 cm). One major complication was observed. Four (11.8%) local recurrences were observed after a local tumor control of 5, 8, 9 and 10 months, respectively. Twenty-two patients (68.75%) experienced a systemic tumor progression during the follow up period. Mean TTP was 12.9 months (range: 2-56 months). Nine patients died during the follow-up period. Median OS was 20.24 months. CONCLUSION Minimally invasive CT-HDRBT is a safe and effective option also for unresectable liver metastases adjacent to the liver hilum that would have been untreatable by thermal ablation.

Clinical practice in radioembolization of hepatic malignancies: A survey among interventional centers in Europe

OBJECTIVES A survey was conducted to give an overview about the practice of radioembolization in malignant liver tumors by European centers. METHODS A questionnaire of 23 questions about the interventional center, preinterventional patient evaluation, the radioembolization procedure and aftercare were sent to 45 European centers. RESULTS The response rate was 62.2% (28/45). The centers performed 1000 (median = 26) radioembolizations in 2009 and 1292 (median = 40) in 2010. Most centers perform preinterventional evaluation and radioembolization on an inpatient basis. An arterioportal shunt not amendable to preinterventional embolization is considered a contraindication. During preinterventional angiography, the gastroduodenal artery is embolized by 71%, the right gastric artery by 59%, and the cystic artery by 41%. In case of bilobar disease, yttrium-90 microspheres are infused into the common hepatic artery (14%) or separately into left and right hepatic artery (86%). 33% prefer a time interval between right and left liver lobe radioembolization to prevent radiation induced liver disease. 43% of the respondents do not prescribe prophylactic medication after radioembolization. In case of iatrogenic manipulation to the biliary duct system most centers perform radioembolization with prophylactic antibiotics. CONCLUSIONS Despite standardization of the procedure, there are some differences in how radioembolization of liver tumors is performed in Europe.

Hepatopulmonary shunting in patients with primary and secondary liver tumors scheduled for radioembolization

PURPOSE In patients undergoing transarterial radioembolization (RE) of malignant liver tumors, hepatopulmonary shunts (HPS) can lead to nontarget irradiation of the lungs. This study aims at analyzing the HPS fraction in relation to liver volume, tumor volume, tumor-to-liver volume ratio, tumor vascularity, type of tumor, and portal vein occlusion. MATERIALS AND METHODS In the presented retrospective study the percentage HPS fraction was calculated from SPECT/CT after infusion of Tc-99m macroaggregated albumin (Tc-99m MAA) into the proper hepatic artery of 233 patients evaluated for RE. RESULTS HPS fractions correlate very weakly with liver volume (r=0.303), tumor volume (r=0.345), and tumor-to-liver volume ratio (r=0.340). Tumors with strong contrast enhancement (HPSmedian(range)=11.7%(46.3%); n=73) have significantly larger shunt fractions than tumors with little enhancement (HPS=8.3%(16.4%); n=61; p<0.001). Colorectal cancer metastases (HPS=10.6%(28.6%); n=68) and hepatocellular cancers (HPS=11.7%(39.4%); n=63) have significantly larger HPS fractions than metastases from breast cancer (HPS=7.4%(16.7%); n=40; p=0.012 and p=0.001). Patients with compression (HPS=13.9%(43.7%); n=33) or tumor thrombosis (HPS=15.8% (31.2%); n=33) of a major portal vein branch have significantly higher degrees of shunting than patients with normal portal vein perfusion (HPS=8.1% (47.0%); n=167; both p<0.001). The shunt fraction is largest in patients with HCC and thrombosis or occlusion of a major portal vein branch (HPS=16.6% (31.0%); n=32). CONCLUSION The degree of hepatopulmonary shunting depends on the type of liver tumor, tumor vascularity, and portal vein perfusion. There is little to no correlation of HPS with liver volume, tumor volume, or tumor-to-liver volume ratio.

Prophylactic Embolization of the Cystic Artery Prior to Radioembolization of Liver Malignancies—An Evaluation of Necessity

PurposePrior to radioembolization (RE) of hepatic tumors, many centers prophylactically occlude the cystic artery (CA) during evaluation angiography (EVA) to prevent radiation-induced cholecystitis. There is no conclusive evidence for the protective effect of CA embolization and it bears the risk of inducing ischemic cholecystitis. The aim of this study is to evaluate the justification for CA embolization by comparing clinical and morphologic imaging parameters between patients undergoing coil occlusion of the cystic artery (COCA) and those with uncoiled CA (UCCA).Materials and MethodsRetrospective comparison of 37 patients with UCCA versus 68 patients with COCA in terms of clinical findings (CRP, leukocyte count, body temperature, upper abdominal pain) and morphologic imaging parameters associated with cholecystitis (gallbladder (GB) wall thickness, free fluid in GB bed, bremsstrahlung SPECT) after EVA, after RE, and at 6-week follow-up.ResultsAt none of the 3 time points (EVA, RE, 6-week follow-up) was there any significant difference in CRP, leukocyte count, body temperature, or upper abdominal pain between the UCCA and COCA group. There was also no significant difference between the two groups with regard to GB wall thickness, fluid in the GB bed, and bremsstrahlung in SPECT. One patient of the UCCA group and two patients of the COCA developed cholecystitis requiring treatment.ConclusionComparison of clinical and imaging findings between patients with and without CA embolization prior to RE identified no predictors of radiogenic or ischemic cholecystitis after RE. Our study provides no evidence for a benefit of prophylactic CA embolization before RE.

Renal Denervation for Refractory Hypertension – Technical Aspects, Complications and Radiation Exposure

PURPOSE To analyze procedural details, complications and radiation exposure in renal denervation (RDN) using the Medtronic Symplicity® device in the treatment of refractory hypertension. MATERIALS AND METHODS Fifty three consecutive patients underwent RDN. The number of ablations per artery, peri-procedural complications, procedure time (PT), fluoroscopy time (FT), dose-area product (DAP) and procedure-related complications were documented. Additionally, the radiation dose was compared between obese (body mass index ≥ 30 kg/m(2)) and non-obese patients. RESULTS Bilateral RDN was performed in 50/53 (94 %) cases and with a minimum of 4 ablations per artery in 33/50 (66 %), the mean count being 5.4 (range R: 2 - 13) on the right and 4.3 (R: 1 - 10) on the left. The FT and DAP decreased significantly over the first 12 procedures, reaching a steady state with a median FT of 11.2 min (R: 7.5 - 27) and a median DAP of 4796 cGy × cm(2) (R: 1076 - 21 371), resulting in an effective dose of 15.7 mSv. The median PT was 57 min (R: 40 - 70). Obese patients had a 3.3-fold higher radiation dose (p < 0.001). We observed one severe spasm and one imminent respiratory depression, both resolved without sequelae. CONCLUSION For an experienced interventionalist, RDN has a short learning curve with a low risk profile. The radiation dose does not exceed that of other renal artery interventions, but is explicitly higher in obese patients, who account for a large portion of patients with refractory hypertension.

Uterine artery embolization in single symptomatic leiomyoma: do anatomical imaging criteria predict clinical presentation and long-term outcome?

Background Uterine artery embolization (UAE) has proven to be an effective treatment alternative for women suffering from symptomatic uterine leiomyomas. However, long-term clinical evaluation reveals treatment failure in approximately 25% of patients. To cope with the great variability in the extent of leiomyoma disease former studies are based on the simplifying assumption that the largest leiomyoma mainly causes the symptoms. Purpose To evaluate whether anatomical characteristics in women with a single symptomatic leiomyoma influence clinical presentation and outcome after UAE. Material and Methods Ninety-one patients with a single leiomyoma underwent UAE. Age, uterine and fibroid volume, fibroid location, and clinical symptoms (bleeding- and/or bulk-related symptoms) were documented. The need for reinterventions (i.e. repeat UAE, hysterectomy, myomectomy) and unchanged or worsened symptoms after UAE were classified as treatment failure (TF). Contrast-enhanced magnetic resonance imaging (MRI) 48–72 h after UAE was available in 38 women. The rate of fibroid infarction was determined and patients were assigned to one of three groups: complete (100%), almost complete (90–99%), or partial infarction (<90%). Cox regression analysis (CRA) was used to determine the influence of morphological and clinical parameters on outcome. Results Follow-up was available in 79/91 (87%) women (median age, 42 years; range, 33–56 years) at a median of 5 years (range, 3.1–9.2 years) after UAE. Anatomical leiomyoma criteria neither connected to specific clinical presentation nor influenced clinical outcome. Younger women showed a higher risk for TF with every year older lowering the risk by the factor of 0.86 (P = 0.024). Subgroup analysis showed predictive value of fibroid infarction with a cumulative survival free from TF of 91% for complete vs. 0% for partial infarction (P < 0.001). Conclusion Even in women with single leiomyomas, anatomical criteria do not specify clinical presentation or predict clinical outcome. Younger patient age and incomplete fibroid infarction relate to higher rates of TF.

Anatomic variants of arteries often coil-occluded prior to hepatic radioembolization

Background: Prior to radioembolization (RE) treatment of malignant liver lesions, many interventionalists occlude the right gastric artery (RGA), the cystic artery (CA), and the gastroduodenal artery (GDA) to prevent radioactive microspheres from entering non-target vessels. Purpose: To systematically analyze anatomic variants of arteries that are important to know for the interventional radiologist performing RE of the liver. Material and Methods: The computed tomography (CT) angiographies and conventional angiographies of 166 patients evaluated for RE were retrospectively analyzed for the presence of anatomic variants of the RGA, GDA, and CA. Results: The RGA was found to arise from the left hepatic artery in 42% of cases, from the proper hepatic artery in 40%, from the GDA in 10%, from the right hepatic artery in 4%, and from the common hepatic artery in 3% of cases. The GDA originated in the common hepatic artery in 97% of cases, in the left hepatic artery in 2%, and in the celiac trunk in 1% of cases. The CA arose from the right hepatic artery in 96% of cases and from the GDA in 2% of cases; in 2% of our study population, the gallbladder was supplied by small branches from the liver parenchyma. Conclusion: Variant anatomy of the RGA is common, while it is quite rare for the GDA and CA. Knowledge of the variations of liver supplying arteries helps the interventionalist to embolize necessary vessels prior to RE.

Impaired hepatic Gd-EOB-DTPA enhancement after radioembolisation of liver malignancies

To evaluate the uptake of the liver‐specific magnetic resonance imaging (MRI) contrast agent gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd‐EOB‐DTPA) by functional liver parenchyma after radioembolisation (RE) of hepatic malignancies.

Improvement of image quality and dose management in CT fluoroscopy by iterative 3D image reconstruction

AbstractObjectivesThe objective of this study was to assess the influence of an iterative CT reconstruction algorithm (IA), newly available for CT-fluoroscopy (CTF), on image noise, readers’ confidence and effective dose compared to filtered back projection (FBP).MethodsData from 165 patients (FBP/IA = 82/74) with CTF in the thorax, abdomen and pelvis were included. Noise was analysed in a large-diameter vessel. The impact of reconstruction and variables (e.g. X-ray tube current I) influencing noise and effective dose were analysed by ANOVA and a pairwise t-test with Bonferroni–Holm correction. Noise and readers’ confidence were evaluated by three readers.ResultsNoise was significantly influenced by reconstruction, I, body region and circumference (all p ≤ 0.0002). IA reduced the noise significantly compared to FBP (p = 0.02). The effect varied for body regions and circumferences (p ≤ 0.001). The effective dose was influenced by the reconstruction, body region, interventional procedure and I (all p ≤ 0.02). The inter-rater reliability for noise and readers’ confidence was good (W ≥ 0.75, p < 0.0001). Noise and readers’ confidence were significantly better in AIDR-3D compared to FBP (p ≤ 0.03). Generally, IA yielded a significant reduction of the median effective dose.ConclusionThe CTF reconstruction by IA showed a significant reduction in noise and effective dose while readers’ confidence increased.Key Points• CTF is performed for image guidance in interventional radiology. • Patient exposure was estimated from DLP documented by the CT. • Iterative CT reconstruction is appropriate to reduce image noise in CTF. • Using iterative CT reconstruction, the effective dose was significantly reduced in abdominal interventions.