Shunichi Sadaoka

Phase II study of gemcitabine in combination with regional arterial infusion of nafamostat mesilate for advanced pancreatic cancer.

Purpose:To evaluate the efficacy of regional arterial infusion of the synthetic serine protease inhibitor nafamostat mesilate combined with gemcitabine for the treatment of patients with unresectable locally advanced or metastatic pancreatic cancer. Materials and Methods:A single-arm, single center, institutional review board-approved phase II trial was conducted. Thirty-five of 38 consecutive patients were included in the study. Patients received nafamostat mesilate (4.8 mg/kg continuous regional arterial infusion) with gemcitabine (1000 mg/m2 intravenously) on days 1, 8, and 15. This treatment was repeated at 28-day intervals. The primary endpoints were to evaluate overall survival and 1-year survival rate. The secondary endpoints were to assess therapeutic response and clinical benefit response. Overall survival times were estimated by the Kaplan-Meier survival analysis. Results:The median survival time was 10.0 months, and the 1-year survival rate was 40.0%. The response rate and disease control rate were 17.1% and 88.6%, respectively. A fraction of 25% of the patients who required opioids for cancer-related pain could reduce their opioid intake, and 37.1% of the patients showed healthy weight gain. Among the patients with metastatic pancreatic cancer, the median survival time was 9.0 months, and the 1-year survival rate was 32.0%. The proposed regimen offers an economic advantage compared with recent therapy regimens that have shown significant improvements in median survival over standard chemotherapy with gemcitabine. Conclusions:An alternative regimen for unresectable pancreatic cancer, especially for metastatic pancreatic cancer, is proposed based on acceptable survival time, clinical benefit, and cost advantage.

Extended intraarterial cisplatin infusion for treatment of gynecologic cancer after alteration of intrapelvic blood flow and implantation of a vascular access device

Purpose:Twenty-two patients with advanced gynecologic cancer underwent extended intraarterial cisplatin infusion after alteration of the intrapelvic blood flow and implantation of a vascular access device (VAD).Methods:To maximize concentrations of cisplatin at the target lesion, the superior and inferior gluteal arteries were embolized with steel coils. The tip of the catheter was inserted into the internal iliac artery; the opposite end of the catheter was connected to the VAD.Results:Intensive radioisotope accumulation was demonstrated in the anterior division of the pelvis, seen by scientigraphy performed with technetium 99m macroaggregated albumin via the VAD. Local perfusion in the tumor was well seen by ultrasonographic angiography with CO2 microbubbles via the VAD. Continuous consecutive infusion of cisplatin at a rate of 12.5 mg/day via the VAD minimized the toxicity. The overall response rate was 73%. Radical surgery was possible in 16 of the 22 patients after this intraarterial infusion.Conclusion:This method was useful for treating advanced gynecologic cancer without significant toxicity.

Deep vein thrombosis during chemotherapy in a patient with advanced testicular cancer : Successful percutaneous thrombectomy under temporary placement of retrievable inferior vena cava filter

Abstract A 27‐year‐old man with advanced testicular cancer experienced two events of deep vein thrombosis (DVT) during three cycles of cisplatin‐based combination chemotherapy; the first thrombotic event occurred in the inferior vena cava (IVC) following the initial two cycles of chemotherapy and the second thrombotic event occurred in the right iliac vein following the third cycle. For both thrombotic events, he was successfully managed with thrombolytic therapy and percutaneous thrombectomy using a transcatheter hydraulic thrombectomy device under temporary placement of a retrievable IVC filter. Stasis of the IVC due to compression by a retroperitoneal lymphadenopathy of 7 cm in diameter, which was demonstrated on computed tomographic scans at presentation, was considered a major cause of DVT during chemotherapy. Patients with bulky retroperitoneal disease causing stasis of major veins are at high risk of DVT associated with chemotherapy and thromboprophylaxis should be strongly considered during their chemotherapy.

Phase I/II Multicenter Study of Transarterial Chemoembolization with a Cisplatin Fine Powder and Porous Gelatin Particles for Unresectable Hepatocellular Carcinoma: Japan Interventional Radiology in Oncology Study Group Study 0401

PURPOSE A multicenter phase I/II study of transarterial chemoembolization with a fine cisplatin powder and gelatin particles (GPs) for multifocal hepatocellular carcinoma (HCC) was conducted. Primary endpoints were dose-limiting toxicity (DLT) and recommended dose (RD). Secondary endpoints were the incidence and severity of adverse events and tumor response. MATERIALS AND METHODS Nonselective transarterial chemoembolization was performed until all tumor enhancement disappeared. Lipiodol was not used. In the phase I study, the cisplatin dose was escalated from 35 mg/m(2) to 65 mg/m(2) in 15-mg/m(2) increments to determine DLT and RD. In the phase II study, 40 patients were treated with the RD. Toxicity was assessed by Common Toxicity Criteria for Adverse Effects (version 3.0), and tumor response was evaluated by Response Evaluation Criteria in Solid Tumors (RECIST; version 1.0) and European Association for the Study of the Liver (EASL) criteria. RESULTS A total of 46 patients were enrolled. As no DLT occurred at any dose level in the phase I study, RD was determined as 65 mg/m(2). In the phase II study, the treatment was discontinued in one patient as a result of vasovagal response. Toxicities of grade 3 or higher included nausea (2.2%), pancreatitis (2.2%), cholecystitis (2.2%), thrombocytopenia (8.7%), hyperbilirubinemia (2.2%), and increased aspartate aminotransferase (28.3%) and alanine aminotransferase (21.7%) levels. Tumor response rates under RD were 25.6% and 64.1% by RECIST and EASL criteria, respectively. CONCLUSIONS Nonselective transarterial chemoembolization with fine cisplatin powder and GPs was well tolerated and effective in patients with multifocal HCC at the RD of 65 mg/m(2).

A successful case of liver biopsy via the right femoral vein using the Quick-Core biopsy needle

A 35-year-old male with ascites and coagulopathy underwent transjugular liver biopsy (TJLB) for severe hepatic dysfunction. However, the acute angle of the inferior vena cava and hepatic veins (HVs) prevented insertion of a 14-gauge inner stiffening metallic cannula into the HV. He then underwent successful liver biopsy by right femoral vein access (transfemoral liver biopsy) using a TJLB device without complications and was pathologically diagnosed with nonalcoholic steatohepatitis.

Successful Treatment by Balloon Angioplasty Under Portography for Late-Onset Stenosis of Portal Vein After Cadaveric Liver Transplantation

A 69-year-old woman, who underwent cadaveric liver transplantation for non-B, non-C liver cirrhosis with hepatocellular carcinoma in April 2009, was admitted to our hospital because of graft dysfunction. Enhanced computed tomography revealed stenosis of the left branch of the portal vein, obstruction of the right branch of the portal vein at porta hepatis, and esophagogastric varices. Balloon angioplasty of the left branch of the portal vein under transsuperior mesenteric venous portography was performed by minilaparotomy. After dilatation of the left branch of the portal vein, the narrow segment of the portal vein was dilated, which resulted in reduction of collateral circulation. At 7 days after balloon angioplasty, esophageal varices were improved. The patient made a satisfactory recovery, was discharged 8 days after balloon angioplasty, and remains well.

Percutaneous cryoablation for stage T1b renal cell carcinoma in a patient with horseshoe kidney

We report the first case of percutaneous cryoablation (PCA) for stage T1b renal cell carcinoma (RCC) in a horseshoe kidney (HK). A 76-year-old man with an HK underwent computed tomography-guided PCA for RCC measuring 42 mm (stage T1b) in diameter. Although transcatheter embolization before the PCA and hydrodissection were required to avoid complication and incomplete ablation, PCA was successfully performed without complication. The complete ablation was confirmed on computed tomography images 1 month after the procedure. There was no recurrence or metastasis during 2 years of follow-up. We believe this is the first report of PCA for stage T1b RCC in a patient with HK. This technique can be performed without regard to tumor size and location and may be considered as a treatment option to avoid complex surgery.

A rare manifestation of clinical T1 renal tumor with parasitic arterial supply from the superior mesenteric artery

A 50-year-old man with von Hippel-Lindau syndrome who had undergone repeated tumor enucleation and transcatheter arterial embolization for multiple renal cell carcinomas (RCC) was referred to our hospital for percutaneous cryoablation (PCA) of an RCC of 42 mm in the midpole region of the right kidney. Transcatheter arterial embolization was planned prior to devascularize the RCC and selective angiography revealed parasitic arterial supply to the tumor by the ileocecal artery. Parasitic arterial supply to RCCs, particularly in patients with history of nephron-sparing treatment, can originate even from an intraperitoneal source and may lead to unexpected embolization.

Percutaneous retrieval of a radiolucent anchoring sleeve embolized in pulmonary artery during pacemaker implantation

An 85-year-old female presented to our institution with symptomatic sick sinus syndrome. During pacemaker implantation, an anchoring sleeve in the right ventricular lead was embolized in the left pulmonary artery. Although the anchoring sleeve was radiolucent, digital subtraction angiography revealed an angiographic filling defect in the lower branch of the left pulmonary artery, and a snare catheter enabled the anchoring sleeve to be grasped and extracted.

Obstructive Jaundice Due to Hilar Bile Duct Compression with Encasement of the Right Hepatic Artery

A 68-year-old woman had a solitary 12.0 cm hepatic cyst with a septum. The cyst was located near the hepatic hilum and she presented with obstructive jaundice caused by compression of the hilar bile duct. Stenosis of the common hepatic duct was detected at the porta hepatis on endoscopic retrograde cholangiography (ERC), and encasement of the right hepatic artery at the same level was revealed by abdominal angiography. Transpapillary cholangioscopy showed compression and mucosal erosions of the hilar bile duct. After transpapillary cholangioscopy, the hepatic cyst became infected, for which emergency percutaneous transhepatic drainage was performed. As a result, the patient’s obstructive jaundice subsided. The mucosal erosions of the bile duct that existed at a site corresponding to the encasement of the right hepatic artery also improved. In conclusion, bile duct stenosis was considered to be caused by compression due to the hepatic cyst and the right hepatic artery.