Ralf-Thorsten Hoffmann

Pilot randomized trial of selective internal radiation therapy vs. chemoembolization in unresectable hepatocellular carcinoma.

To compare selective internal radiation therapy (SIRT) with transarterial chemoembolization (TACE), the standard‐of‐care for intermediate‐stage unresectable, hepatocellular carcinoma (HCC), as first‐line treatment.

Immunogenic cell death biomarkers HMGB1, RAGE, and DNAse indicate response to radioembolization therapy and prognosis in colorectal cancer patients

Radioembolization therapy (RE) is an efficient locoregional treatment for liver metastases from colorectal cancer. Serum biomarkers involved in immunogenic cell death are potentially valuable for early predicting therapy response and estimating prognosis. In a prospective observation study, blood samples were taken from 49 consecutive colorectal cancer patients with extensive hepatic metastases before, 24 and 48 hr after RE. Serum levels of high mobility group box 1 (HMGB1), receptor of glycation end products (RAGE) and activity of desoxyribonuclease were compared with response to therapy regularly determined radiologically 3 months after therapy and with overall survival. Serum levels of HMGB1 were increased already 24 hr after RE, while RAGE levels were decreased and DNAse remained unchanged. In radiological staging, 35 patients demonstrated disease progression while 14 patients had stable disease or remission. Serum HMGB1 levels 24 hr after RE were significantly higher in progressive than in nonprogressive patients while for RAGE and DNAse no difference was observed between the response groups. Concerning overall survival, high pretherapeutic (0 hr) and 24 hr levels of HMGB1 were associated with poor outcome. Multivariate analysis including HMGB1, tumor, liver and inflammation markers revealed HMGB1 and CRP as independent prognostic parameters. HMGB1 is a valuable serum biomarker for early estimation of therapy response and prognosis in colorectal cancer patients with liver metastases undergoing RE therapy.

Cirse Quality Assurance Document and Standards for Classification of Complications: The Cirse Classification System

Interventional radiology provides a wide variety of vascular, nonvascular, musculoskeletal, and oncologic minimally invasive techniques aimed at therapy or palliation of a broad spectrum of pathologic conditions. Outcome data for these techniques are globally evaluated by hospitals, insurance companies, and government agencies targeting in a high-quality health care policy, including reimbursement strategies. To analyze effectively the outcome of a technique, accurate reporting of complications is necessary. Throughout the literature, numerous classification systems for complications grading and classification have been reported. Until now, there has been no method for uniform reporting of complications both in terms of definition and grading. The purpose of this CIRSE guideline is to provide a classification system of complications based on combining outcome and severity of sequelae. The ultimate challenge will be the adoption of this system by practitioners in different countries and health economies within the European Union and beyond.

Transapical endovascular stenting of penetrating atherosclerotic ulcer of ascending aorta.

A 71-year-old woman presented with acute chest pain and was admitted at our institution. Computed tomography revealed a penetrating atherosclerotic ulcer in the ascending aorta with extensive intramural hematoma. A transapical endovascular stenting was successfully performed. Computed tomography at a 6-month follow-up visit revealed a type I endoleak, which was restented through the same approach. Despite initial satisfactory results, follow-up revealed a persistent endoleak, so that a high-risk open surgical repair was required. Surgical replacement of the ascending aorta was successfully performed without postoperative neurologic deficit.

114 SIRTACE: A RANDOMISED MULTICENTRE PILOT TRIAL OF SELECTIVE INTERNAL RADIOEMBOLISATION (SIRT) WITH YTTRIUM-90 MICROSPHERES VERSUS TRANSARTERIAL CHEMO-EMBOLISATION (TACE) IN PATIENTS WITH UNRESECTABLE HEPATOCELLULAR CARCINOMA (HCC)

114 SIRTACE: A RANDOMISED MULTICENTRE PILOT TRIAL OF SELECTIVE INTERNAL RADIOEMBOLISATION (SIRT) WITH YTTRIUM-90 MICROSPHERES VERSUS TRANSARTERIAL CHEMO-EMBOLISATION (TACE) IN PATIENTS WITH UNRESECTABLE HEPATOCELLULAR CARCINOMA (HCC) F.T. Kolligs, J.I. Bilbao, T. Jakobs, M. Inarrairaegui, J. Nagel, M. Rodriguez, A. Haug, D. D’Avola, M. op den Winkel, A. Martinez-Cuesta, C. Trumm, A. Benito, K. Tatsch, C. Zech, R.-T. Hoffmann, B. Sangro. Department of Internal Medicine II, University of Munich (LMU), Munich, Germany; Interventional Radiology, Clinica Universidad de Navarra, Pamplona, Spain; Institute of Radiology, Krankenhaus Barmherzige Bruder, Munich, Germany; Liver Unit, Clinica Universidad de Navarra and CIBEREHD, Nuclear Medicine, Clinica Universidad de Navarra, Pamplona, Spain; Department of Nuclear Medicine, University of Munich (LMU), Munich, Germany; Interventional Radiology, Hospital de Navarra, Pamplona, Spain; Institute of Radiology, University of Munich (LMU), Munich, Germany; Radiology, Clinica Universidad de Navarra, Pamplona, Spain; Institute of Nuclear Medicine, Klinikum Karlsruhe, Karlsruhe, Germany; Institute of Radiology, University of Basel, Basel, Switzerland; Institute of Radiology, University of Dresden, Dresden, Germany E-mail: fkolligs@med.uni-muenchen.de

Diagnose und multimodale Therapie des hepatozellulären Karzinoms

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related death in the world. The majority of HCCs develops on the basis of a chronic liver disease. This often complicates diagnosis and therapy. Non-invasive diagnostic criteria are based on dynamic imaging techniques and the serum level of AFP (alpha-fetoprotein). When evaluating HCC patients for therapy, besides tumor burden and localisation, the therapeutic evaluation must also consider the general condition of the patient and his/her liver function. For this purpose, the BCLC algorithm of the Barcelona Clinic for Liver Disease has proven helpful. Only one-third of the patients can be cured by resection, transplantation or local tumour ablation. In locally advanced cases transarterial procedures including transarterial chemoembolisation and radioembolisation are applied. HCC is a chemo-resistant tumour and chemotherapy is not accepted as standard of care in HCC. Sorafenib is the first systemic treatment with proven efficacy approved for the treatment of advanced and metastatic HCC. Interdisciplinary management of HCC patients is essential in order to provide every patient with the optimal therapy at his specific stage of disease.

A rare case of pancreatic endometriosis in a postmenopausal woman and review of the literature

Pancreatic endometriosis is very rare with only a few cases reported in the literature. The imaging features are non-specific and the definitive diagnosis is usually only established after surgery. We report on a 68-year-old woman with left upper quadrant pain who demonstrated a mass in the pancreatic tail on imaging. Laboratory results showed only mildly elevated liver enzymes, tumor markers were within the normal range. A left pancreatectomy was performed, frozen section suggesting a benign lesion, and final histopathology confirmed endometriotic cysts. A research of the literature found only eight reported cases of endometriotic cysts of the pancreas, with the majority affecting premenopausal women. Preoperative diagnosis is challenging and most patients undergo resection because of suspected neoplasm. Thorough diagnostic workup may help in avoiding extensive surgery and reduce postoperative complications.

Circulating Nucleosomes in Cancer Patients with Liver Metastases Undergoing Selective Internal Radiation Therapy Using Yttrium-90 Labelled Microspheres

Selective internal radiation therapy (SIRT) is a new and effective loco-regional anticancer treatment option for advanced cancer patients with liver metastases or liver cancer. In a prospective study, blood samples were taken from 112 patients with extensive hepatic metastases from various primary tumors (49 colorectal, 22 breast, 15 cholangiocellular and pancreatic, 7 carcinoid, 13 others) or with primary hepatic cancer (n = 6) before, and 3, 6, 24 and 48 h after SIRT. Circulating nucleosomes were determined by ELISA and the patterns of nucleosome release in the different groups of primary cancers were compared. Serum nucleosomes showed significant increases already 24 h after SIRT (p < 0.001) and remained high after 48 h (p < 0.001). Those early increases were observed in all patient groups irrespective of the various primary tumors. However, they started from different pre-therapeutic absolute nucleosome levels that may reflect diverse biological properties of the various tumor diseases. Circulating nucleosomes are increased early after application of SIRT. Their relevance for prediction of therapy response and estimation of prognosis has to be shown in prospective studies.

Anastomotic leak after surgical repair of type A aortic dissection – prevalence and consequences in midterm follow-up

BACKGROUND This study reports the mid-term prevalence and therapeutic consequences of anastomotic leaks after surgery for Stanford type A aortic dissections. PATIENTS AND METHODS From July 2007 to July 2013, 93 patients survived surgery for acute type A dissections at our center and underwent a standardized follow-up. The pre-, peri-, and postoperative as well as the midterm results were collected prospectively. Follow-up computed tomography (CT) imaging was performed 7 days, 3, and 12 months after surgery, and yearly thereafter, to assess the presence or progression of anastomotic leaks at the aorto-prosthesis anastomotic sites. RESULTS The mean follow-up was 4 years (1534 ± 724 days). Follow-up CT revealed anastomotic leaks in 4 patients (4.3 %). All leaks developed during midterm follow-up and half of them did not increase with time. Two patients required redo surgery for an increase in periaortic extravasation and compression of neighboring structures. Further analysis was not able to reveal independent risk factors for development or deterioration of leaks. CONCLUSIONS Anastomotic leaks after surgery for Stanford Type A aortic dissection can develop in midterm follow-up, even after initially excellent results. Meticulous follow-up is mandatory to detect possible deterioration and a need for redo surgery.

Management of the left subclavian artery during TEVAR – complications and mid-term follow-up

BACKGROUND Numerous conditions that affect the boundary between the aortic arch and descending aorta are treated with thoracic endovascular aortic repair (TEVAR). In 40 % of cases, coverage of the left subclavian artery (LSA) cannot be prevented. Subsequently, neurological complications such as stroke or ischemia of the left upper extremity may develop. However, the actual risk of these complications is subject to considerable controversy. The optimal treatment approach, specifically the question whether primary revascularization of the LSA should be performed in all cases, is unclear. PATIENTS AND METHODS The present retrospective study analyzed the short- and mid-term results of patients treated with TEVAR with complete coverage of the LSA. The postoperative protocol consisted of clinical and noninvasive examinations as well as morphological imaging. Survival, complication, and reintervention rates were recorded. RESULTS A total of 40 patients, undergoing TEVAR with complete coverage of the LSA between January 2010 and December 2014 were analyzed retrospectively. The 30-day survival rate was 95 %, the survival one year after performed TEVAR was 67.5 %. The average follow-up was 1.5 years. After TEVAR procedure with complete coverage of the LSA, only one patient (2.5 %) developed critical ischemia of the left arm immediately after aortic stent implantation, requiring revascularization by transposition of the LSA. Anterior spinal artery syndrome occurred in another patient (2.5 %) immediately following TEVAR. During follow-up examinations, all patients showed a compensated arterial arm status. None of the patients developed new neurological deficits during the follow-up period. CONCLUSIONS The study shows that performing TEVAR without primary revascularization of the LSA was justifiable in our cohort. An important risk factor of developing cerebral ischemia seems to be insufficient collateralization through the circle of Willis.