Vittorio Pedicini

Usefulness of alpha-fetoprotein response in patients treated with sorafenib for advanced hepatocellular carcinoma

BACKGROUND & AIMS Tumor shrinkage has been considered a fundamental surrogate efficacy measure for new cancer treatments. However, in patients treated with sorafenib for advanced hepatocellular carcinoma (HCC), tumor shrinkage rarely accompanies increased survival, thereby questioning the prognostic value of imaging-based Response Evaluation Criteria in Solid Tumors (RECIST). We investigated the prognostic usefulness of a decrease in serum alpha-fetoprotein (AFP) and compared it to RECIST. METHODS In HCC patients treated with sorafenib with baseline AFP >20 ng/ml, AFP response was defined as a >20% decrease in AFP during 8weeks of treatment. Patients were also assessed by RECIST and were categorized as having radiologically proven progressive disease or disease control (consisting of complete or partial responses and stable disease). Comparisons of survival by RECIST and AFP response were corrected for guarantee-time bias by the landmark method. RESULTS We evaluated 85 patients for AFP response, among them, 82 were also evaluated by RECIST. In the analysis of AFP response, 32 out of 85 patients (37.6%) were responders, whereas 58 out of 82 patients (70.7%) achieved disease control. In landmark analysis, the hazard ratios (HR) for survival according to AFP response and disease control were 0.59 (p=0.040) and 1.03 (p=0.913), respectively. In multivariate analysis, only AFP response (HR=0.52; p=0.009) and Cancer of the Liver Italian Program dichotomized stage (HR=0.42; p=0.002) were prognostic factors of survival. CONCLUSIONS Assessment of AFP response may be considered as an alternative to RECIST to capture sorafenib activity in HCC.

Minidose Warfarin Prophylaxis for Catheter-Associated Thrombosis in Cancer Patients: Can It Be Safely Associated With Fluorouracil-Based Chemotherapy?

PURPOSE The use of prophylactic low-dose oral warfarin in cancer patients with a central venous catheter (CVC) in place has an established role in the prevention of thrombotic complications and is associated with a low hemorrhagic risk. Despite the literature indicating an adverse interaction between warfarin and fluorouracil (FU), the frequency of this interaction and whether it occurs when minidose warfarin is used is unknown. We analyzed the incidence of alterations in the International Normalized Ratio (INR) and bleeding in cancer patients given minidose warfarin during treatment with continuous-infusion FU-based regimens. PATIENTS AND METHODS Between July 1999 and August 2001, 95 cancer patients were evaluated. Forty-one patients (43%) had liver metastases. Seventy-nine patients (83%) had a Groshong CVC (Bard Access System, Salt Lake City, UT), and 16 (17%) had a Port-a-Cath device (Bard Access System). All patients received oral warfarin at a dose of 1 mg/daily as prophylaxis beginning the day after the catheter was positioned. An INR of more than 1.5 was considered significantly elevated. RESULTS INR elevation occurred in 31 patients (33%), with 18 patients (19%) having an INR more than 3.0. Twelve (39%) of the 31 patients had liver metastases. Bleeding was observed in eight patients (8%); seven of these patients had elevated INR levels. We observed INR elevations in 12 of 21 patients treated with a FU, folinic acid, and oxaliplatin (FOLFOX) regimen, 11 of 40 treated with a de Gramont regimen (FU and folinic acid), and five of 19 treated with a FU, folinic acid, and irinotecan (FOLFIRI) regimen. CONCLUSION A high incidence of INR abnormalities was observed in our cohort of patients, especially those treated with FOLFOX regimen. Clinicians should be aware of this interaction and should regularly monitor the prothrombin time in patients receiving warfarin and FU.

Percutaneous Image-Guided Cryoablation of Breast Cancer: A Systematic Review.

A systematic review of the clinical safety and efficacy of percutaneous breast cancer cryoablation was performed. Of 202 papers screened, seven matched the inclusion criteria. Cryoablation was mainly performed under ultrasound guidance, and on average two cryoprobes were used. Complete local tumor control was noted in 73% of patients (mean follow-up, 8 mo). No major complications were noted. The cosmetic outcome was satisfactory. Breast cancer cryoablation is safe, although local tumor control is suboptimal. The best results are achieved with small (<15 mm) ductal tumors treated by application of multiple cryoprobes.

Transarterial Therapies for Hepatocellular Carcinoma

Background: The treatment of hepatocellular carcinoma (HCC) is still a major health issue because of its increasing incidence and because of the complexity of its management. Transarterial embolization (TAE) and transarterial chemoembolization (TACE) are two widely used locoregional therapies in the treatment of HCC, especially for unresectable intermediate and advanced HCCs. Summary: The modern use of TAE and TACE opens new scenarios for the treatment of unresectable HCC and has yielded interesting results. The present work describes the role of transarterial therapies for HCC and focuses on the different Western and Eastern approaches to the study of response predictors. Key Messages: Recent refinements in interventional radiology techniques and in HCC patient selection have facilitated better local control of the disease. The molecular profiling of HCC to predict the response to TACE and TAE will greatly help clinicians identify the optimum therapy.

Role of interventional radiology in the management of complications after pancreatic surgery: a pictorial review.

AbstractPancreatic resections are surgical procedures associated with high incidence of complications, with relevant morbidity and mortality even at high volume centres. A multidisciplinary approach is essential in the management of these events and interventional radiology plays a crucial role in the treatment of patients developing post-surgical complications. This paper offers an overview on the interventional radiological procedures that can be performed to treat different type of complications after pancreatic resection. Procedures such as percutaneous drainage of fluid collections, percutaneous transhepatic biliary procedures, arterial embolisation, venous interventions and fistula embolisation are viable treatment options, with fewer complications compared with re-look surgery, shorter hospital stay and faster recovery. A selection of cases of complications following pancreatic surgery managed with interventional radiological procedure are presented and discussed. Teaching Points • Interventional radiology is crucial to treat complications after pancreatic surgery • Percutaneous drainage of collections can be performed under ultrasound or computed tomography guidance • Percutaneous biliary procedures can be used to treat biliary complications • Venous procedures can be performed effectively through transhepatic or transjugular access • Fistulas can be treated effectively by percutaneous embolisation

Endovascular treatment of an anastomotic iliac pseudoaneurysm after surgical aortic repair using a Cardiatis multilayer stent

The Cardiatis multilayer stent (Cardiatis, Isnes, Belgium) is a cobalt, self-expandable bare stent made of two interconnected layers without any covering that allows a pressure decrease and thrombus formation into an aneurysmal sac, while improving laminar flow in the main artery and surrounding vital branches. We report a case of an anastomotic iliac pseudoaneurysm successfully treated with the deployment of a Cardiatis multilayer stent.

Colonic Ischemia, Perforation, and Colectomy after a Complicated Endovascular Embolization for Type II Endoleak with the Use of Cyanoacrylate Glue

one case, postmortem examination revealed a catheter fragment lodged in the valve after the malpositioned catheter had been pulled back at bedside and the tip unknowingly left behind. These events did not result in immediate lethal malfunction; rather, acute alterations in cardiac output eventually progressed to unrecoverable circulatory collapse over the span of 2–5 days. Recognition of catheter or wire entanglement with the artificial valve may allow for immediate retrieval with only transient cardiovascular impairment. It is unclear what the long-term sequelae of such an event would be and whether normal flow dynamics could be restored. This event remains a significant risk that should be mentioned while obtaining informed consent from the patient and during documentation after the procedure. In the right clinical setting, similar transvenous procedures can be offered to patients with a Total Artificial Heart. We chose an A-shaped multipurpose catheter because it is easily torqued and allows directional passage of a wire. This is our standard access catheter for transvenous liver biopsies; however, any similar type of catheter would have sufficed. A stiff exchange wire

Iatrogenic Pulmonary Pseudoaneurysm Treated with Percutaneous Coil and Glue Embolization

A 76-year-old female patient experienced recurrent hemoptysis in the first 48 hours after thoracotomy for mitral valve replacement. On multidetector computed tomography (CT), a large lung pseudoaneurysm of the right middle lobe was detected (Fig 1), which showed contrast enhancement similar to that of the aorta. The patient was, therefore, referred to the interventional radiology service to undergo endovascular embolization. Despite selective angiography of multiple bronchial arteries, no feeding vessels were detected. Pulmonary angiography (Fig 2) ruled out supply from the pulmonary arteries. Therefore, the pseudoaneurysm was directly punctured with a Chiba needle under fluoroscopic guidance, and a small amount (0.5 mL) of n-butyl cyanoacrylate (NBCA; Glubran 2; GEM, Viareggio, Italy) was injected in the pseudoaneurysm sac. However,

Preserving the left subclavian artery patency in challenging proximal neck during thoracic endovascular aortic repair.

Coverage of the left subclavian artery in thoracic endovascular aortic repair is still a controversial procedure. We report a case of 30-year-old patient with a chronic rupture of the aortic isthmus and short proximal lending zone (10 mm) treated by thoracic endovascular aortic repair using a balloon catheter inflated at the origin of the left subclavian artery (and protruding in the aortic arch) to both preserve the arterial branch patency and fully exploit the proximal neck.

Retrospective analysis of central venous catheter-related thrombosis in 427 cancer patients prophylaxed with low-dose warfarin

8102 Background: Cancer patients (pts) develop venous thrombosis more frequently than the general population; central venous catheters (CVC) insertion is a further risk factor. In this retrospective study, we analyzed whether low doses of warfarin are useful and safe in the thrombosis prophylaxis for cancer pts with CVC. METHODS Between July 2000 and May 2003, 427 pts (median age was 57 years; range 19-81) were evaluated. One hundred fifty-six (37%) pts had hematological malignancies. During warfarin prophylaxis, 142 pts received one (33%), 224 (52%) two, and 61 (15%) three or more chemotherapy regimens respectively. One hundred fifty-five pts (36%) underwent high-dose chemotherapy (HDT) followed by peripheral-blood-stem-cell transplantation (PBSCT). Three types of CVC were used throughout the study: 233 patients (54,5%) had an external device such as Vygon catheter, 167 (39%) had an external device such as Groshong Catheter, and 27 (6,5%) had a device completely internalized such as Port-a-cath. All pts received 1 mg/daily of oral warfarin from the day after CVC positioning until its removal. RESULTS The catheters were monitored for a mean of 168 days (range 22-706). There were 9 thrombotic events (1,8%). Of these, six events were observed in pts with haematological malignancies while one patient developed thrombosis during HDT. The median age was 40 years. The median number of days between line insertion and thrombosis was 152 (22-216). A number of potential predictive factors were analyzed for their impact on thrombotic events but no correlation was detected. Overall, International Normalized Ratio (INR) elevation occurred in 55 (12,8%) pts. Bleeding was observed in 15 (3,5%) pts, ten of whom had elevated INR levels. Of these, all were treated with regimens containing continuous-infusion 5-Fluorouracil (5-FU). DISCUSSION This large retrospective study shows that minidose warfarin can protect from clinical thrombosis. However an elevation of INR value associated to hemorrhagic symptoms can occur in pts treated with 5-FU-based regimens, suggesting a strict monitoring of these pts. No significant financial relationships to disclose.