Transarterial chemoembolisation for advanced hepatocellular carcinoma: results from a North American cancer centre.

AIMS: In Asian countries, transarterial chemoembolisation (TACE) has long been used for palliation of unresectable hepatocellular carcinoma (HCC) without strong evidence of improved survival or quality of life. In 2002, a survival benefi of TACE was shown in two randomised controlled trials in Europe and Hong Kong. The effectiveness of interventions fo HCC is influenced by geographical factors related to diverse patient characteristics and protocols. Therefore, the validation of TACE as palliative modality for unresectable HCC requires confirmation in diverse patient populations. The aim of the present study was to assess the effectiveness of TACE for HCC in a North American population. MATERIALS AND METHODS: This was a single centre prospective cohort study. Child-Pugh A cirrhosis or better patients wit unresectable HCC and without radiological evidence of metastatic disease or segmental portal vein thrombosis wer assessed between November 2001 and May 2004. Of 54 patients who satisfied the inclusion criteria, 47 underwent 80 TACE sessions. Chemoembolisation was carried out using selective hepatic artery injection of 75 mg/m(2) doxorubicin and lipiodol followed by an injection of embolic particles when necessary. Repeat treatments were carried out at 2-3 month intervals for recurrent disease. The primary outcome was overall survival; secondary outcomes were morbidity and tumour response. RESULTS: The survival probabilities at 1, 2 and 3 years were 76.6, 55.5 and 50%, respectively. At 6 months after the first intervention, 31% of patients had a partial response and 60% had stable disease by RECIST criteria. Minor adverse events occurred after 39% of TACEs and major adverse events after 20% of sessions, including two treatment-related deaths (4% of patients). One patient had complete cancer remission after undergoing three TACE treatments. Further progression of tumour growth was prevented in 91% of tumours at the 6 month point after the first TACE. At 3 months, serum levels of the tumour marker alpha-feto protein were significantly reduced in patients with elevated levels before TACE. CONCLUSIONS: The survival probabilities at 1 and 2 years after TACE were comparable with results in randomised studies from Europe and Asia. Most patients tolerated TACE well, but clinicians need to be aware that moderately severe sideeffects require close monitoring and prompt intervention.

Development of a radiofrequency based thermal therapy technique in an in vivo porcine model for the treatment of small renal masses.

PURPOSE: Incidentally detected small renal tumors appear to grow slowly and be localized to the kidney. Minimally invasive therapies are being investigated as alternatives to standard surgical techniques. Radiofrequency ablation has been reported for the treatment of small renal cell carcinomas. We developed a radiofrequency technique and established its efficacy and safety in a large animal model. METHODS AND METHODS: A total of 22 lesions were created in normal kidneys of 7 pigs. Radiofrequency energy was administered during open exposure of the kidneys or percutaneously under ultrasound guidance. Lesion development was monitored with gray-scale and power Doppler ultrasound. To avoid heating surrounding tissues new hydro-dissection and gas-dissection techniques were developed. Lesion sizes and characteristics were assessed by ultrasound and pathological examination. RESULTS: No complications were observed due to probe insertion and removal. Perirenal structures were thermally damaged before the development and application of the dissection techniques. Lesion size was accurately predicted by gray-scale ultrasound on day 7. Loss of perfusion in the ablated volume was confirmed by power Doppler ultrasound. Lesions were wedge-shaped, presumably due to the effects of heating on segmental blood flow distribution. Pathological examination revealed changes consistent with thermal injury and ischemic type infarction. CONCLUSIONS: Radiofrequency thermal therapy is an effective and efficient method for ablating normal renal tissue in the pig. It may be applied percutaneously under ultrasound guidance with minimal complications provided that vital adjacent structures are protected from thermal damage. Further studies are required in humans before adopting this technique as definitive treatment for small renal cell carcinoma.

Venous access: options, approaches and issues.

The placement and management of venous access devices has become a routine and large part of the vascular and interventional radiologic practice. Compared with surgical series, our technical success is better and our complication rates are lower. A dedicated team approach with patient follow-up and management is required to create and maintain a successful line service.

Clinical experience with the antecubital Simon nitinol IVC filter.

PURPOSE: To evaluate the Simon nitinol vena cava filter (SNF) placed via the antecubital vein in a series of patients. Issues examined by the authors included insertion site variables, filter efficacy, and complications. The authors also explored the option of placement of a peripherally inserted central catheter (PICC) via the same access site. MATERIALS AND METHODS: This was a prospective study that included all patients who had undergone antecubital attempt at insertion of the SNF. Seventy-four consecutive patients were enrolled during a 29-month period. A PICC was inserted concomitantly in 23 of these patients. The series included 38 men and 36 women, with a mean age of 62.5 years (range, 17-88 years). The clinical indications for filter placement included contraindication to anticoagulation (81.1%), complication of anticoagulation (9.4%), failure of anticoagulation (8.1%), and prophylactic placement (1.4%). Concomitant PICCs were inserted for chemotherapy (56.5%), venous access (39.1%), and total parenteral nutrition (4.4%). Clinical follow-up was available in 61 patients. Mean follow-up was 124 days (range, 0-884 days). RESULTS: The SNF was successfully placed via the antecubital vein in 98.6% of the patients. In one patient, access was via the right common femoral vein because of failed right arm access. There was a question of pulmonary embolism (PE) after filter placement in two patients. Otherwise, there were no complications related to placement of either the filter or PICC. CONCLUSION: Antecubital venous insertion of the SNF is a safe and effective method for the prevention of PE in patients who cannot be managed with traditional anticoagulation, and offers the option of inserting a PICC with no added complications.

Radiologic placement of metallic esophageal stents: preliminary experience.

OBJECTIVE: To assess the usefulness of covered, self-expanding metallic stents for alleviating stricture associated with malignant esophageal lesions. PATIENTS AND METHODS: Self-expanding metallic stents were placed in 10 patients with dysphagia related to stricture caused by malignant esophageal lesions. The stents were placed fluoroscopically with local anesthesia, and patency of the esophageal lumen was assessed by barium study after the procedure. The patients were then followed clinically. RESULTS: In all 10 cases patency of the lumen was renewed after stent placement. After the procedure 9 of the patients could tolerate a normal or near-normal diet; in the other patient esophageal perforation occurred, and clinical deterioration prevented oral intake of food. In one patient, 2 stents were needed because of the length of the stricture. Two patients experienced reflux after placement of the stent across the gastro-esophageal junction. Another patient had asymptomatic aspiration after stent placement in the proximal esophagus. In 2 patients, symptoms associated with tracheoesophageal fistula were relieved after placement of the stents. Six of the 10 patients died; mean survival after the procedure was 12 (range 1 to 56) weeks. The other 4 patients were alive at the time of writing, having survived for a mean of 7.5 (range 2 to 13) weeks; all of these patients tolerated a near-normal diet. CONCLUSIONS: The placement of covered, self-expanding metallic stents is a quick, effective method of palliating dysphagia related to stricture caused by malignant esophageal lesions.

Misdiagnosis of renal cell carcinoma by computed tomography with angiography: a potential pitfall.

The introduction of helical computed tomography (CT) has led to an increase in the number and complexity of CT protocols. This situation has resulted in a new source of error in the interpretation of CT scans. The authors report a case in which a hyperattenuating cyst discovered incidentally at the time of CT with angiography could have been misdiagnosed as renal cell carcinoma.

Antegrade placement of a ureteric stent by a pull-through technique.

Internal double-J ureteric stents are valuable in the treatment of ureteric obstruction, obviating the need for an external drainage catheter. Retrograde placement of these stents is often performed by the urologist, or, if such placement fails, antegrade placement is performed by the interventional radiology service. In cases of high-grade obstruction it may be possible to pass a guide wire through the stricture but impossible to do so with a catheter. The authors describe a pull-through technique, which was used to place a ureteric stent in a 65-year-old man with bilateral hydronephrosis. The method consists of gaining control of the distal end of the guide wire by retrieving it through the penile urethra to allow the stenosis to be crossed with a catheter.

Expandable metallic bronchial endoprosthesis.

The authors report the successful insertion, under fluoroscopic guidance, of an expandable metallic endoprosthesis in a 60-year-old woman with recurrent obstructive pneumonia secondary to metastasis. This procedure allowed 93 days of palliation for the patient, who had previously required multiple endoscopic treatments for the recurrent bronchial obstruction.

Prognosis in a patient with an initial normal pulmonary angiogram.

A 58-year-old man with pleuritic chest pain and an indeterminate lung scan had normal results of Duplex ultrasound studies of the lower limbs and a normal pulmonary angiogram. Recurrent symptoms led to repeated pulmonary angiography and a diagnosis of pulmonary embolism. This case emphasizes the possibility of missing an initial, or developing a subsequent, pulmonary embolism despite a normal angiogram and reinforces the need for serial studies if a noninvasive strategy for the diagnosis of pulmonary embolism is to be employed.