Roman Kloeckner

MDCT Versus MRI Assessment of Tumor Response After Transarterial Chemoembolization for the Treatment of Hepatocellular Carcinoma

The purpose of this study was to compare the ability of multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) to evaluate treatment results after transarterial chemoembolization (TACE), with a special focus on the influence of Lipiodol on calculation of tumor necrosis according to EASL criteria. A total of 115 nodules in 20 patients (17 males, 3 females; 69.5xa0±xa09.35xa0years) with biopsy-proven hepatocellular carcinoma were treated with TACE. Embolization was performed using a doxorubicin-Lipiodol emulsion (group I) or DC Beads loaded with doxorubicin (group II). Follow-up included triphasic contrast-enhanced 64-row MDCT (collimation, 0.625xa0mm; slice, 3xa0mm; contrast bolus, 120xa0ml iomeprol; delay by bolus trigger) and contrast-enhanced MRI (T1 native, T2 native; five dynamic contrast-enhanced phases; 0.1xa0mmol/kg body weight gadolinium-DTPA; slice thickness, 4xa0mm). Residual tumor and the extent of tumor necrosis were evaluated according to EASL. Contrast enhancement within tumor lesions was suspected to represent vital tumor. In the Lipiodol-based TACE protocol, MDCT underestimated residual viable tumor compared to MRI, due to Lipiodol artifacts (23.2% vs 47.7% after first, 11.9% vs 31.2% after second, and 11.4% vs 23.7% after third TACE; pxa0=xa00.0014, pxa0<xa00.001, and pxa0<xa00.001, respectively). In contrast to MDCT, MRI was completely free of any artifacts caused by Lipiodol. In the DC Bead-based Lipiodol-free TACE protocol, MRI and CT showed similar residual tumor and rating of treatment results (46.4% vs 41.2%, 31.9 vs 26.8%, and 26.0% vs 25.6%; n.s.). In conclusion, MRI is superior to MDCT for detection of viable tumor residuals after Lipiodol-based TACE. Since viable tumor tissue is superimposed by Lipiodol artifacts in MDCT, MRI is mandatory for reliable decision-making during follow-up after Lipiodol-based TACE protocols.

Visceral artery aneurysms: Incidence, management, and outcome analysis in a tertiary care center over one decade

ObjectivesTo evaluate the incidence, management, and outcome of visceral artery aneurysms (VAA) over one decade.Methods233 patients with 253 VAA were analyzed according to location, diameter, aneurysm type, aetiology, rupture, management, and outcome.ResultsVAA were localized at the splenic artery, coeliac trunk, renal artery, hepatic artery, superior mesenteric artery, and other locations. The aetiology was degenerative, iatrogenic after medical procedures, connective tissue disease, and others. The rate of rupture was much higher in pseudoaneurysms than true aneurysms (76.3xa0% vs.3.1xa0%). Fifty-nine VAA were treated by intervention (nu2009=u200945) or surgery (nu2009=u200914). Interventions included embolization with coils or glue, covered stents, or combinations of these. Thirty-five cases with ruptured VAA were treated on an emergency basis. There was no difference in size between ruptured and non-ruptured VAA. After interventional treatment, the 30-day mortality was 6.7xa0% in ruptured VAA compared to no mortality in non-ruptured cases. Follow-up included CT and/or MRI after a mean period of 18.0u2009±u200926.8xa0months. The current status of the patient was obtained by a structured telephone survey.ConclusionsPseudoaneurysms of visceral arteries have a high risk for rupture. Aneurysm size seems to be no reliable predictor for rupture. Interventional treatment is safe and effective for management of VAA.Key Points• Diagnosis of visceral artery aneurysms is increasing due to CT and MRI.• Diameter of visceral arterial aneurysms is no reliable predictor for rupture.• False aneurysms/pseudoaneurysms and symptomatic cases need emergency treatment.• Interventional treatment is safe and effective.

Radiation exposure in CT-guided interventions

PURPOSEnTo investigate radiation exposure in computed tomography (CT)-guided interventions, to establish reference levels for exposure, and to discuss strategies for dose reduction.nnnMATERIALS AND METHODSnWe analyzed 1576 consecutive CT-guided procedures in 1284 patients performed over 4.5 years, including drainage placements; biopsies of different organs; radiofrequency and microwave ablations (RFA/MWA) of liver, bone, and lung tumors; pain blockages, and vertebroplasties. Data were analyzed with respect to scanner settings, overall radiation doses, and individual doses of planning CT series, CT intervention, and control CT series.nnnRESULTSnEighty-five percent of the total radiation dose was applied during the pre- and post-interventional CT series, leaving only 15% applied by the CT-guided intervention itself. Single slice acquisition was associated with lower doses than continuous CT-fluoroscopy (37 mGy cm vs. 153 mGy cm, p<0.001). The third quartile of radiation doses varied considerably for different interventions. The highest doses were observed in complex interventions like RFA/MWA of the liver, followed by vertebroplasty and RFA/MWA of the lung.nnnCONCLUSIONSnThis paper suggests preliminary reference levels for various intervention types and discusses strategies for dose reduction. A multicenter registry of radiation exposure including a broader spectrum of scanners and intervention types is needed to develop definitive reference levels.

Randomized Comparison of Selective Internal Radiotherapy (SIRT) Versus Drug-Eluting Bead Transarterial Chemoembolization (DEB-TACE) for the Treatment of Hepatocellular Carcinoma

PurposeTo prospectively compare SIRT and DEB-TACE for treating hepatocellular carcinoma (HCC).MethodsFrom 04/2010–07/2012, 24 patients with histologically proven unresectable N0, M0 HCCs were randomized 1:1 to receive SIRT or DEB-TACE. SIRT could be repeated once in case of recurrence; while, TACE was repeated every 6xa0weeks until no viable tumor tissue was detected by MRI or contraindications prohibited further treatment. Patients were followed-up by MRI every 3xa0months; the final evaluation was 05/2013.ResultsBoth groups were comparable in demographics (SIRT: 8males/4females, mean age 72xa0±xa07xa0years; TACE: 10males/2females, mean age 71xa0±xa09xa0years), initial tumor load (1 patient ≥25xa0% in each group), and BCLC (Barcelona Clinic Liver Cancer) stage (SIRT: 12×B; TACE 1×A, 11×B). Median progression-free survival (PFS) was 180xa0days for SIRT versus 216xa0days for TACE patients (pxa0=xa00.6193) with a median TTP of 371xa0days versus 336xa0days, respectively (pxa0=xa00.5764). Median OS was 592xa0days for SIRT versus 788xa0days for TACE patients (pxa0=xa00.9271). Seven patients died in each group. Causes of death were liver failure (nxa0=xa04 SIRT group), tumor progression (nxa0=xa04 TACE group), cardiovascular events, and inconclusive (nxa0=xa01 in each group).ConclusionsNo significant differences were found in median PFS, OS, and TTP. The lower rate of tumor progression in the SIRT group was nullified by a greater incidence of liver failure. This pilot study is the first prospective randomized trial comparing SIRT and TACE for treating HCC, and results can be used for sample size calculations of future studies.

Conventional transarterial chemoembolization versus drug-eluting bead transarterial chemoembolization for the treatment of hepatocellular carcinoma

BackgroundTo compare the overall survival of patients with hepatocellular carcinoma (HCC) who were treated with lipiodol-based conventional transarterial chemoembolization (cTACE) with that of patients treated with drug-eluting bead transarterial chemoembolization (DEB-TACE).MethodsBy an electronic search of our radiology information system, we identified 674 patients that received TACE between November 2002 and July 2013. A total of 520 patients received cTACE, and 154 received DEB-TACE. In total, 424 patients were excluded for the following reasons: tumor type other than HCC (nu2009=u200991), liver transplantation after TACE (nu2009=u2009119), lack of histological grading (nu2009=u200958), incomplete laboratory values (nu2009=u200915), other reasons (e.g., previous systemic chemotherapy) (nu2009=u2009114), or were lost to follow-up (nu2009=u200927). Therefore, 250 patients were finally included for comparative analysis (nu2009=u2009174 cTACE; nu2009=u200976 DEB-TACE).ResultsThere were no significant differences between the two groups regarding sex, overall status (Barcelona Clinic Liver Cancer classification), liver function (Child-Pugh), portal invasion, tumor load, or tumor grading (all pu2009>u20090.05). The mean number of treatment sessions was 4u2009±u20093.1 in the cTACE group versus 2.9u2009±u20091.8 in the DEB-TACE group (pu2009=u20090.01). Median survival was 409xa0days (95xa0% CI: 321–488 days) in the cTACE group, compared with 369xa0days (95xa0% CI: 310–589 days) in the DEB-TACE group (pu2009=u20090.76). In the subgroup of Child A patients, the survival was 602xa0days (484–792 days) for cTACE versus 627xa0days (364–788 days) for DEB-TACE (pu2009=u20090.39). In Child B/C patients, the survival was considerably lower: 223xa0days (165–315 days) for cTACE versus 226xa0days (114–335 days) for DEB-TACE (pu2009=u20090.53).ConclusionThe present study showed no significant difference in overall survival between cTACE and DEB-TACE in patients with HCC. However, the significantly lower number of treatments needed in the DEB-TACE group makes it a more appealing treatment option than cTACE for appropriately selected patients with unresectable HCC.

Survival analysis of proposed BCLC-B subgroups in hepatocellular carcinoma patients.

The BCLC‐staging system is used to facilitate treatment decisions in patients with hepatocellular carcinoma (HCC). Owing to the observed clinical heterogeneity of the intermediate stage BCLC‐B, a subclassification was proposed taking Child–Pugh score and extended criteria for transplantation into account. Analysis of the prognostic significance of a proposed subclassification of the BCLC‐B score in a European cohort of HCC patients.

Radiation Exposure in Vascular Angiographic Procedures

PURPOSEnTo evaluate dose reduction in vascular angiographic procedures by using fluoroscopy capture instead of digital subtraction angiography frames for documentation.nnnMATERIALS AND METHODSnA total of 764 consecutive vascular interventional procedures performed over a period of 1 year were retrospectively analyzed with respect to the fluoroscopy time and the resulting dose-area product (DAP), the DAP of the radiographic frames, and the overall DAP.nnnRESULTSnA total of 70% of the total DAP was a result of the acquisition of radiographic frames, leaving only 30% being applied by fluoroscopy.nnnCONCLUSIONSnFluoroscopy capture should be used for documentation whenever possible. A registry of radiation exposure should not only comprise a sufficiently large number of interventions but also different intervention types to allow the development of interventional reference levels.

Radiation Exposure in Nonvascular Fluoroscopy-Guided Interventional Procedures

PurposeTo investigate the radiation exposure in non-vascular fluoroscopy guided interventions and to search strategies for dose reduction.Materials and MethodsDose area product (DAP) of 638 consecutive non-vascular interventional procedures of one year were analyzed with respect to different types of interventions; gastrointestinal tract, biliary interventions, embolizations of tumors and hemorrhage. Data was analyzed with special focus on the fluoroscopy doses and frame doses. The third quartiles (Q3) of fluoroscopy dose values were defined in order to set a reference value for our in-hospital practice.ResultsMean fluoroscopy times of gastrostomy, jejunostomy, right and left sided percutaneous biliary drainage, chemoembolization of the liver and embolization due to various hemorrhages were 5.9, 8.6, 13.5, 16.6, 17.4 and 25.2 min, respectively. The respective Q3 total DAP were 52.9, 73.3, 155.1, 308.4, 428.6 and 529.3 Gy*cm2. Overall, around 66% of the total DAP originated from the radiographic frames with only 34% of the total DAP applied by fluoroscopy (Pxa0<xa00.001). The investigators experience had no significant impact on the total DAP applied, most likely since there was no stratification to intervention-complexity.ConclusionTo establish Diagnostic Reference Levels (DRLs), there is a need to establish a registry of radiation dose data for the most commonly performed procedures. Documentation of interventional procedures by fluoroscopy “grabbing” has the potential to considerably reduce radiation dose applied and should be used instead of radiographic frames whenever possible.

Development of an IHE MRRT-compliant open-source web-based reporting platform

AbstractObjectivesTo develop a platform that uses structured reporting templates according to the IHE Management of Radiology Report Templates (MRRT) profile, and to implement this platform into clinical routine.MethodsThe reporting platform uses standard web technologies (HTML / JavaScript and PHP / MySQL) only. Several freely available external libraries were used to simplify the programming. The platform runs on a standard web server, connects with the radiology information system (RIS) and PACS, and is easily accessible via a standard web browser.ResultsA prototype platform that allows structured reporting to be easily incorporated into the clinical routine was developed and successfully tested. To date, 797 reports were generated using IHE MRRT-compliant templates (many of them downloaded from the RSNA’s radreport.org website). Reports are stored in a MySQL database and are easily accessible for further analyses.ConclusionDevelopment of an IHE MRRT-compliant platform for structured reporting is feasible using only standard web technologies. All source code will be made available upon request under a free license, and the participation of other institutions in further development is welcome.Key Points• A platform for structured reporting using IHE MRRT-compliant templates is presented.n • Incorporating structured reporting into clinical routine is feasible.n • Full source code will be provided upon request under a free license.

Selective internal radiotherapy (SIRT) versus transarterial chemoembolization (TACE) for the treatment of intrahepatic cholangiocellular carcinoma (CCC): study protocol for a randomized controlled trial

BackgroundCholangiocellular carcinoma is the second most common primary liver cancer after hepatocellular carcinoma. Over the last 30xa0years, the incidence of intrahepatic cholangiocellular carcinoma has risen continuously worldwide. Meanwhile, the intrahepatic cholangiocellular carcinoma has become more common than the extrahepatic growth type and currently accounts for 10-15% of all primary hepatic malignancies. Intrahepatic cholangiocellular carcinoma is typically diagnosed in advanced stages due to late clinical symptoms and an absence of classic risk factors. A late diagnosis precludes curative surgical resection. There is evidence that transarterial chemoembolization leads to better local tumor control and prolongs survival compared to systemic chemotherapy. New data indicates that selective internal radiotherapy, also referred to as radioembolization, provides promising results for treating intrahepatic cholangiocellular carcinoma.Methods/DesignThis pilot study is a randomized, controlled, single center, phase II trial. Twenty-four patients with intrahepatic cholangiocellular carcinoma will be randomized in a 1:1 ratio to receive either chemoembolization or radioembolization. Randomization will be stratified according to tumor load. Progression-free survival is the primary endpoint; overall survival and time to progression are secondary endpoints. To evaluate treatment success, patients will receive contrast enhanced magnetic resonance imaging every 3xa0months.DiscussionCurrently, chemoembolization is routinely performed in many centers instead of systemic chemotherapy for treating intrahepatic cholangiocellular carcinoma confined to the liver. Recently, radioembolization has been increasingly applied to cholangiocellular carcinoma as second line therapy after TACE failure or even as an alternative first line therapy. Nonetheless, no randomized studies have compared radioembolization and chemoembolization. Considering all this background information, we recognized a strong need for a randomized controlled trial (RCT) to compare the two treatments. Therefore, the present protocol describes the design of a RCT that compares SIRT and TACE as the first line therapy for inoperable CCC confined to the liver.Trial registrationClinicalTrials.gov, Identifier: NCT01798147, registered 16th of February 2013.