Tatiana Cabrera

Portal vein embolization stimulates tumour growth in patients with colorectal cancer liver metastases

OBJECTIVESnPortal vein embolization (PVE) can facilitate the resection of previously unresectable colorectal cancer (CRC) liver metastases. Bevacizumab is being used increasingly in the treatment of metastatic CRC, although data regarding its effect on post-embolization liver regeneration and tumour growth are conflicting. The objective of this observational study was to assess the impact of pre-embolization bevacizumab on liver hypertrophy and tumour growth.nnnMETHODSnComputed tomography scans before and 4 weeks after PVE were evaluated in patients who received perioperative chemotherapy with or without bevacizumab. Scans were compared with scans obtained in a control group in which no PVE was administered. Future liver remnant (FLR), total liver volume (TLV) and total tumour volume (TTV) were measured. Bevacizumab was discontinued ≥ 4 weeks before PVE.nnnRESULTSnA total of 109 patients and 11 control patients were included. Portal vein embolization induced a significant increase in TTV: the right lobe increased by 33.4% in PVE subjects but decreased by 34.8% in control subjects (P < 0.001), and the left lobe increased by 49.9% in PVE subjects and decreased by 33.2% in controls (P= 0.022). A total of 52.8% of the study group received bevacizumab and 47.2% did not. There was no statistical difference between the two chemotherapy groups in terms of tumour growth. Median FLR after PVE was similar in both groups (28.8% vs. 28.7%; P= 0.825).nnnCONCLUSIONSnAdequate liver regeneration was achieved in patients who underwent PVE. However, significant tumour progression was also observed post-embolization.

Predictors of response to radio‐embolization (TheraSphere®) treatment of neuroendocrine liver metastasis

BACKGROUNDnNeuroendocrine tumours (NET) frequently metastasize to the liver. NET liver metastasis has been shown to respond to Yttrium-90 microspheres therapy. The aims of the present study were to define factors that predict the response to radio-embolization in patients with NET liver metastases.nnnMETHODSnFrom January 2006 until March 2009, all patients with NET liver metastasis that received radio-embolization using TheraSphere® (glass microspheres) were reviewed. The response was determined by a change in the percentage of necrosis (ΔN%) after the first radio-embolization based on the modified RECIST criteria (mRECIST) criteria. The following confounding variables were measured: age, gender, size of the lesions, liver involvement, World Health Organization (WHO) classification, the presence of extra-hepatic metastasis, octereotide treatment and previous operative [surgery and (RFA)] and non-operative treatments (chemo-embolization and bland-embolization).nnnRESULTSnIn all, 25 patients were identified, with a median follow-up of 21.7 months. The median age was 64.6 years, 28% had extra-hepatic metastasis and 56% were WHO stage 2. Post-treatment, the mean ΔN% was 48.4%. Previous surgical therapy was a significant predictor of the response with a response rate of 66.7 ΔN% vs. 31.5 ΔN% (P= 0.02). Bilateral liver disease, a high percentage of liver involvement and large metastatic lesions were inversely related to the degree of tumour response although did not reach statistical significance.nnnCONCLUSIONnRadio-embolization increased the necrosis of NET liver metastasis mainly in patients with less bulky disease. This may imply that surgical therapy before radio-embolization would increase the response rates.

Successful salvage of kidney allografts threatened by ureteral stricture using pyelovesical bypass.

Ureteral stricture is the most common urologic complication after renal transplantation. When endourologic management fails, open ureteral reconstruction remains the standard treatment. The complexity of some of these procedures makes it necessary to explore other means of repair. This study evaluated the intermediate‐term outcome of subcutaneous pyelovesical bypass graft (SPBG) on renal transplant recipients. We reviewed 8 patients (6 male and 2 female; mean age 52 years) with refractory ureteral strictures postrenal transplantation, who received SPBG as salvage therapy. All patients failed endourologic management and half failed open management of their strictures. After a mean follow‐up of 19.4 months, 7 out of 8 renal grafts have good function with mean GFR of 58.5 mL/min/1.73 m2, without evidence of obstruction or infection. One patient lost his graft due to persistent infection of the SPBG and one patient developed a recurrent urinary tract infection managed with long‐term antibiotics. SPBG offers a last resort in the treatment of ureteral stricture after renal transplantation refractory to conventional therapy.

Cardiac embolization of an implanted fiducial marker for hepatic stereotactic body radiotherapy: a case report

IntroductionIn liver stereotactic body radiotherapy, reduction of normal tissue irradiation requires daily image guidance. This is typically accomplished by imaging a surrogate to the tumor. The surrogate is often an implanted metal fiducial marker. There are few reports addressing the specific risks of hepatic fiducial marker implantation. These risks are assumed to be similar to percutaneous liver biopsies which are associated with a 1-4% complication rate - almost always pain or bleeding. To the best of our knowledge, we present the first case of such a fiducial marker migrating to the heart.Case presentationAn 81-year-old Caucasian man (5 years post-gastrectomy for a gastric adenocarcinoma) was referred post-second line palliative chemotherapy for radiotherapy of an isolated liver metastasis. It was decided to proceed with treatment and platinum fiducials were chosen for radiation targeting. Under local anesthesia, three Nester embolization coils (Cook Medical Inc., Bloomington, IN, USA) were implanted under computed tomography guidance. Before the placement of each coil, the location of the tip of the delivery needle was confirmed by computed tomography imaging. During the procedure, the third coil unexpectedly migrated through the hepatic vein to the inferior vena cava and lodged at the junction of the vena cava and the right atrium. The patient remained asymptomatic. He was immediately referred to angiography for extraction of the coil. Using fluoroscopic guidance, an EN Snare Retrieval System (Hatch Medical L.L.C., Snellville, GA, USA) was introduced through a jugular catheter; it successfully grasped the coil and the coil was removed. The patient was kept overnight for observation and no immediate or delayed complications were encountered due to the migration or retrieval of the coil. He subsequently went on to be treated using the remaining fiducials.ConclusionImplanted fiducial markers are increasingly used for stereotactic radiotherapy. There is sparse literature on the risks of such procedures. Although uncommon, the risk of migration does exist and therefore physicians (surgeons, oncologists and radiologists) and patients should be aware of this possibility.

A rare case of obstructive uropathy in renal transplantation: ipsilateral indirect inguinal herniation of a transplant ureter.

Case Presentation A 76-year-old man with end-stage renal disease secondary to membranous nephropathy had a successful renal transplant 20 years ago. He presented with vague abdominal pain and a right inguinal hernia. His baseline creatinine increased from 50 to 110 mol/L.AbdominalultrasoundandCT scan demonstrated a moderate hydroureteronephrosis with right-sided inguinal hernia containing a loop of ureter (Fig. 1a). An urgent percutaneous nephrostomy tube confirmed the presence of stenosis (Fig. 1b). Subsequently, he had angiographic balloon dilatation followed by an antegrade ureteral stent placement; this reduced the ureter out of the hernia sac. The patient’s creatinine dropped to 65 mol/L. Repair of the hernia was performed electively, and the stent was removed 2 months later with no impact on renal function with a 1 year follow-up. Significant morbidity can result from posttransplant urologic complications (2). Most cases of late ureteral obstruction posttransplantation result from obstruction in the lower ureter or ureterovesical junction (1, 4, 18, 19) and are secondary to technical factors or ischemia (9–13). Although native ureteral and bladder herniation in an inguinal hernia have been previously described (20, 21), only a few cases of transplant ureteral herniation are reported: one in the obturator canal occurring in a woman (22) and four inguinal (14–17). Of these four inguinal ureteral herniations, all occurred in men and three were older than 70 years of age, as in our case. This reflects the increased preponderance of inguinal hernias in men and the increased prevalence with age. In all cases, the diagnosis was made by imaging studies. In addition to the general risk factors for inguinal herniation, the following two factors may have contributed to this case: (i) stricture at the uretrovesical junction, which may have led to tortuosity and kinking of the ureter into the existing inguinal hernia, and (ii) the existence of a redundant long ureter. Other reported factors include placement of the donor ureter over the spermatic cord (15) or accidental ligation of the ureter at the time of an elective hernia repair (1). The definitive treatment is operative herniorrhaphy usually without the need for ureteral re-implantation (14–17, 22). In a report of inguinal herniation from a pediatric en bloc donor, transection and reimplantation of an extremely redundant ureter was necessary (15). However, similar to our case, the surgeons for the remaining reported cases did not manipulate the ureter owing to its tenuous vascularization and healing potential, as transection or re-anastomosis may predispose to ureteric strictures or leaks. Before elective repair, immediate attention to the herniated ureter is important. By the use of interventional radiology, we demonstrate the early reversal of obstructive uropathy until the patient underwent elective hernia repair. The stented ureter may also be protected from damage during the hernia repair.

Real-Life Report on Chemoembolization Using DEBIRI for Liver Metastases from Colorectal Cancer.

Background. Transarterial chemoembolization (TACE) has been investigated in patients with liver metastases from colorectal cancer (LMCRC). Limited experience and available data suggest that TACE can achieve disease stabilization or improvement, even in heavily pretreated patients. Methods. Patients with LMCRC, ECOG 0–2, who failed at least 1 line of systemic chemotherapy, received embolizations with 2u2009mL of microspheres preloaded with 100u2009mg of irinotecan. Beads were delivered selectively into hepatic arteries. Primary endpoint was overall survival (OS), analyzed using the Kaplan-Meier method. Secondary endpoint was safety, assessed using CTCAE version 4.0. Results. 27 patients were treated using DEBIRI. Patient median age was 57 years (range was 45–82 years). The median number of total embolizations was 1.3 (range 1–3). The median OS was 5.4 months (95% CI; 1.1–22.7 months). The most reported postembolization events were nausea (8/27), vomiting (6/27), right upper quadrant pain (16/27), fatigue (9/27), and the development of ascites (6/27). 5/26 patients required hospitalization after TACE for severe pain. Hospitalization was also required for 1 case of allergic reaction and 1 case of infection. Conclusion. Our data suggest that TACE with DEBIRI could be efficacious in a palliative setting for patients with LMCRC, but they do not necessarily support routine use in clinical practice.

Magnitude of change in alpha-fetoprotein in response to transarterial chemoembolization predicts survival in patients undergoing liver transplantation for hepatocellular carcinoma

BACKGROUNDnDownsizing strategies are often attempted for patients with hepatocellular carcinoma (hcc) before liver transplantation (lt). The objective of the present study was to determine clinical predictors of favourable survival outcomes after transarterial chemoembolization (tace) before lt for hcc outside the Milan criteria, so as to better select candidates for this strategy.nnnMETHODSnIn this retrospective study, patients with hcc tumours either beyond Milan criteria (single lesion > 5 cm, 3 lesions with 1 or more > 3 cm) or at the upper limit of Milan criteria (single lesions between 4.1 cm and 5.0 cm), with a predicted waiting time of more than 3 months, received carboplatin-based tace treatments. Exclusion criteria for tace included Child-Pugh C cirrhosis or the presence of portal vein invasion or extrahepatic disease on imaging. Only patients without tumour progression after tace underwent lt.nnnRESULTSnOf 160 hcc patients who received liver grafts between 1997 and 2010, 35 were treated with tace preoperatively. The median of the sum of tumour diameters was 6.7 cm (range: 4.8-8.5 cm), which decreased with tace to 5.0 cm (range: 3.3-7.0 cm) at transplantation (p < 0.0004). The percentage drop in alpha-fetoprotein (αfp) was a positive predictor (p = 0.0051) and the time from last tace treatment to transplantation was a negative predictor (p < 0.0001) for overall survival.nnnCONCLUSIONSnThe percentage drop in αfp and a shorter time from the final tace treatment to transplantation significantly predicted improved overall survival after lt for hcc downsized with tace. As a serum marker, αfp should be followed when tace is used as a strategy to stabilize or downsize hcc lesions before lt.

Percutaneous Liver Fiducial Implants: Techniques, Materials and Complications

Stereotactic body radiation therapy (SBRT) is a radiotherapy technique that utilizes precise targeting to deliver high doses of tumoricidal radiation in the course of a small number of treatment sessions. SBRT is used to treat a variety of primary and metastatic tumours of the lung, liver, pancreas, kidney, spine and prostate. These treatments are already standard for medically inoperable early lung cancer and indications are evolving for other disease sites. In SBRT of liver lesions (Dawood et al., 2009; Lo et al., 2010), tumour-targeting accuracy is crucial given the radiosensitive nature of the liver, frequent proximity of the tumour to the small bowel and significant movement of the liver with breathing. Reduction of normal tissue irradiation requires the radiation to be image-guided (as opposed to relying on skin marks or body casts). This image-guidance is typically accomplished through visualization of a surrogate to the tumour. The surrogate can be the whole liver, the diaphragm or an implanted marker (Wunderink et al., 2010). Implanted markers have the advantage of being visible on planar x-ray images and fluoroscopy loops. If large enough, they can also be seen on images produced with the treatment beam. The details of the implementation of fiducial imaging vary with different radiotherapy devices but typically images of the fiducials are correlated to the position of the chest wall at different points in the breathing cycles. This gives the user knowledge of the displacement of the tumour (assumed to be at a fixed distance from the fiducials). One can then choose to turn on the beam in a specific phase of the breathing cycle or have the radiation delivery device track the movement of the tumour. As an example, the Cyberknife system acquires up to 15 pairs of stereoscopic x-rays just before treatment. Fiducials are automatically detected by the system’s image analysis software. The 3D position of the fiducials is then correlated to the position of chest wall as recorded by the movement of 3 lights on the patient’s chest. The robot on which the radiation source is mounted can then use the model correlating chest wall motion and fiducial motion to mimic the movement of the tumour while the patient breathes (Figure 1). In this process, there is continuous monitoring (via cameras) of the chest wall but only intermittently imaging of the fiducials with stereoscopic x-rays. These additional x-rays are used to verify and update the correlation model.

Superior Hypogastric Nerve Block as Post–Uterine Artery Embolization Analgesia: A Randomized and Double-Blind Clinical Trial

Purpose To evaluate the effectiveness of superior hypogastric nerve block (SHNB) in reducing narcotic use after uterine artery embolization (UAE). Materials and Methods This study was a prospective, randomized, double-blind, parallel clinical trial in patients referred to a tertiary care university teaching hospital for UAE. Forty-four participants were enrolled (mean age, 46 years; range, 32-56 years). No consenting patient was excluded. All participants were randomized 1:1 to undergo either a sham procedure or SHNB. There were 22 participants in each group. One participant was lost to follow-up regarding home survey results. Use of narcotics and antiemetics was recorded in-hospital. Pain scores were recorded at home for 10 days with use of a visual analog scale (range, 1-10). Statistical analysis was performed by using the t test and χ2 test, with P < .05 considered indicative of a statistically significant difference. The full study protocol can be found at www.clinicaltrials.gov (NCT02270255). Results Participant demographic characteristics, fibroid volume, symptoms, and perceived sensitivity to pain were similar in both groups. Immediately after embolization, the pain score was lower in the SHNB group than in the sham group (mean, 1.0 ± 2.1 vs 2.6 ± 2.0, respectively; P = .01). The total need for fentanyl in the postanesthesia care unit was lower in the SHNB group than in the sham group (mean, 56 μg ± 67 vs 124 μg ± 91, respectively; P = .009). The morphine-equivalent dose needed was lower in the SHNB group than in the sham group (mean, 5.1 mg ± 5.8 vs 11.0 mg ± 9.0, respectively; P = .014). Of the 22 participants in the SHNB group, five (23%) needed antiemetics versus 12 of 22 participants (55%) in the sham group (P = .03). No difference in hospital admissions was observed between the two groups, and no major complications occurred from the SHNB. Conclusion Use of superior hypogastric nerve block reduces the amount of pain-related narcotics and antiemetics after uterine artery embolization.