Radioembolisation of hepatocellular carcinoma: a primer.

Transarterial radioembolisation (TARE) has gained increasing acceptance as an additional/alternative locoregional treatment option for hepatocellular carcinoma, and colorectal hepatic metastases that present beyond potentially curative options. This is a catheter-based transarterial selective internal brachytherapy that involves injection of radioactive microspheres (usually Y-90) that are delivered selectively to the liver tumours. Owing to the combined radioactive and microembolic effect, the findings at follow-up imaging are significantly different from that seen with other transarterial treatment options. Considering increasing confidence among clinicians, refinement in techniques and increasing number of ongoing trials, TARE is expected to gain further acceptance and become an important tool in the armamentarium for the treatment of liver malignancies. So it is imperative that all radiologists involved in the management of liver malignancies are well versed with TARE to facilitate appropriate discussion at multidisciplinary meetings to direct further management. In this article, we provide a comprehensive review on various aspects of radioembolisation with Y-90 for hepatocellular carcinoma including the patient selection, treatment planning, radiation dosimetry and treatment, side effects, follow-up imaging and future direction.

Pilot study evaluating catheter-directed contrast-enhanced ultrasound compared to catheter-directed computed tomography arteriography as adjuncts to digital subtraction angiography to guide transarterial chemoembolization.

AIM: To investigate the feasibility and procedural value of catheter-directed contrast-enhanced ultrasound (CCEUS) compared with catheter-directed computed tomography arteriography (CCTA) in patients undergoing transarterial chemoembolization (TACE) guided by digital subtraction angiography (DSA). MATERIALS AND METHODS: From December 2010 to December 2011, a pilot study was conducted including nine patients (mean age 66.6 years; SD 8.3 years; seven men) undergoing TACE with drug-eluting beads for unresectable hepatocellular carcinoma (HCC). Both CCEUS and CCTA were performed in addition to DSA. Alterations of treatment plan based on CCEUS were recorded and compared with CCTA. RESULTS: CCEUS provided additional information to DSA altering the treatment plan in four out of nine patients (44.4%). In these four patients, CCEUS helped to identify additional tumour feeders (n = 2) or led to a change in catheter position (n = 2). The information provided by CCEUS was similar to that provided by CCTA. CONCLUSION: CCEUS is a potentially valuable imaging tool in adjunction to DSA when performing TACE and may provide similar information to CCTA.

Adjuvant hepatic intra-arterial iodine-131-lipiodol following curative resection of hepatocellular carcinoma: a prospective randomized trial.

BACKGROUND: The purpose of the present study was to determine whether intrahepatic injection of (131)I-lipiodol (Lipiodol) is effective against recurrence of surgically resected hepatocellular carcinoma (HCC). METHODS: From June 2001 through March 2007, this nationwide multi-center prospective randomized controlled trial enrolled 103 patients 4-6 weeks after curative resection of HCC with complete recovery (52: Lipiodol, 51: Control). Follow-up was every 3 months for 1 year, then every 6 months. Primary and secondary endpoints were recurrence-free survival (RFS) and overall survival (OS), respectively, both of which were evaluated by the Kaplan-Meier technique and summarized by the hazard ratio (HR). The design was based on information obtained from a similar trial that had been conducted in Hong Kong. RESULTS: The Lipiodol group showed a small, and nonsignificant, improvement over control in RFS (HR = 0.75; 95 % confidence interval [95 % CI] 0.46-1.23; p = 0.25) and OS (HR = 0.88; 95 % CI 0.51-1.51; p = 0.64). Only two serious adverse events were reported, both with hypothyroidism caused by (131)I-lipiodol and hepatic artery dissection during angiography. CONCLUSIONS: The randomized trial provides insufficient evidence to recommend the routine use of (131)I-lipiodol in these patients.

Computed tomography hepatic arteriography has a hepatic falciform artery detection rate that is much higher than that of digital subtraction angiography and 99mTc-MAA SPECT/CT: implications for planning 90Y radioembolization?

PURPOSE: To compare the hepatic falciform artery (HFA) detection rates of digital subtraction angiography (DSA), computed tomography hepatic arteriography (CTHA) and 99mTc-macroaggregated albumin (99mTc-MAA) single photon emission computed tomography with integrated CT (SPECT/CT) and to correlate HFA patency with complication rates of yttrium-90 (90Y) radioembolization. MATERIAL AND METHODS: From August 2008 to November 2010, 79 patients (range 23-83 years, mean 62.3 years; 67 male) underwent pre-treatment DSA, CTHA and 99mTc-MAA scintigraphy (planar/SPECT/CT) to assess suitability for radioembolization with 90Y resin microspheres. Thirty-seven patients were excluded from the study, because CTHA was performed with a catheter position that did not result in opacification of the liver parenchyma adjacent to the falciform ligament. DSA, CTHA and 99mTc-MAA SPECT/CT images and medical records were retrospectively reviewed. RESULTS: A patent HFA was detected in 22 of 42 patients (52.3%). The HFA detection rates of DSA, CTHA and 99mTc-MAA SPECT/CT were 11.9%, 52.3% and 13.3%, respectively (p<0.0001). An origin from the segment 4 artery was seen in 51.7% of HFAs. Prophylactic HFA coil-embolization prior to 90Y microspheres infusion was performed in 2 patients. Of the patients who underwent radioembolization with a patent HFA, none developed supra-umbilical radiation dermatitis. One patient experienced epigastric pain attributed to post-embolization syndrome and was managed conservatively. CONCLUSION: The HFA detection rate of CTHA is superior to that of DSA and 99mTc-MAA SPECT/CT. Complications related to non-target radiation of the HFA vascular territory rarely occur, even in patients undergoing radioembolization with a patent HFA.

Management of pyogenic liver abscesses - percutaneous or open drainage?

This pictorial essay aims to review the literature on the management of pyogenic liver abscess, focusing on the choice of drainage. Articles on the treatment of pyogenic liver abscess, accessed through a MEDLINE search using PubMed, were reviewed. A case series of the authors' experience with clinicopathological correlation is presented to highlight the indication and outcome of each modality of drainage. Intravenous antibiotic is the first line, and mainstay, of treatment. Drainage is necessary for large abscesses, equal to or larger than 5 cm in size, to facilitate resolution. While percutaneous drainage is appropriate as first-line surgical treatment in most cases, open surgical drainage is prudent in cases of rupture, multiloculation, associated biliary or intra-abdominal pathology. Percutaneous drainage may help to optimise clinical condition prior to surgery. Laparoscopic drainage is a feasible surgical option with promising results in the future. Liver resection is reserved for concomitant localised intrahepatic disease and tumour, after control of sepsis. The final verdict on the outcome of percutaneous versus open surgical drainage of pyogenic liver abscesses requires further studies in a controlled trial setting. Nevertheless, in current good clinical practices, the choice of therapy needs to be individualised according to patient's clinical status and abscess factors. They are complementary in the management of liver abscesses.

Colorectal hepatic metastases: Role of radiofrequency ablation.

INTRODUCTION: Radiofrequency ablation (RFA) is a new minimally invasive treatment that has been increasingly used in the treatment of liver metastases. This review aims to outline the principles governing the use of RFA and to examine its role when applied to the management of colorectal liver metastases. METHODS: A Medline search of experimental and clinical studies relating to the use of RFA in the management of colorectal hepatic metastasis was carried out. RESULTS: RFA is currently used as an alternative to surgery in patients with unresectable disease, and sometimes as its companion, allowing patients hitherto considered unsuitable for resection to become surgical candidates. RFA has been shown to be safe and well tolerated, with few major complications and minimal patient discomfort. Although its use is unlikely to achieve cure in such patients, it has a definite role in palliation and relief of symptoms. Long-term data, when these become available, may also show improved survival. However, because RFA is a local ablative therapy, it does not address the progressive and systemic nature of colorectal carcinoma. CONCLUSIONS: RFA is an important alternative/complimentary tool in the management of colorectal hepatic metastases. Combining RFA with surgery or chemotherapy may reduce the incidence of local and systemic relapse.

Routine abdominal and pelvic ultrasound examinations: an audit comparing radiographers and radiologists.

An audit of 202 routine abdominal and pelvic ultrasound examinations was carried out to evaluate the clinical performance and interpretation of these scans by radiographers and compare them with radiologists, and to investigate the extended role of radiographers in performing these scans. Each scan was first performed by a radiographer and then repeated by the radiologist. The findings were subsequently compared and any discrepancy resolved by re-scanning the patient with or without the involvement of an independent radiologist, or by follow-up of the patient by other imaging studies. In 158 (78.2%) scans, there was complete agreement between the radiographer's and radiologist's findings. In 44 scans (21.8%), there was incomplete agreement--there were 108 abnormal findings in these scans with incomplete agreement/discrepancy in 53 abnormalities. Overall, the accuracy of radiographers was 92.0% and radiologists was 91.7%; however, the accuracy rates were 94.0% and 96.4%, respectively, when minor abnormal findings without significant influence on the patient's clinical outcome were excluded.

Single centre review of radiologically-guided percutaneous nephrostomies: a report of 273 procedures.

INTRODUCTION: To evaluate the technical success and complications associated with radiologically-guided percutaneous nephrostomies (PCNs) in a single centre. MATERIALS AND METHODS: A total of 273 PCNs performed in 190 patients in our hospital over a 3-year period from January 1997 to December 1999 were retrospectively reviewed. The study population consisted of 97 males and 93 females, ranging in age from 13 to 91 years. The main indications were urinary obstruction (77.7%), pyonephrosis (18.3%) and urinary diversion (4%). Demographic variables, technical and risk factors related to the procedure, complications, effect on urine cultures and body temperature; and subsequent patient management were examined. RESULTS: The technical success rate was 99%. The 30-day mortality was 7.2%, none of which were procedure related. Haemorrhage requiring transfusion occurred in 4.3% while septicaemia affected 3.2% of patients. Drainage catheter complications included catheter dislodgement and blockage which were 11.9% and 4.1%, respectively. Thirty-one per cent of PCNs subsequently underwent ureteric stenting as the definitive treatment modality. CONCLUSION: Radiologically-guided PCN is a safe procedure with a high technical success rate.