Gastroenteropancreatic Neuroendocrine Tumors-Current Status and Advances in Diagnostic Imaging.

Gastroenteropancreatic neuroendocrine neoplasia (GEP-NEN) is a heterogeneous and complex group of tumors that are often difficult to classify due to their heterogeneity and varying locations. As standard radiological methods, ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography-computed tomography (PET/CT) are available for both localization and staging of NEN. Nuclear medical imaging methods with somatostatin analogs are of great importance since radioactively labeled receptor ligands make tumors visible with high sensitivity. CT and MRI have high detection rates for GEP-NEN and have been further improved by developments such as diffusion-weighted imaging. However, nuclear medical imaging methods are superior in detection, especially in gastrointestinal NEN. It is important for radiologists to be familiar with NEN, as it can occur ubiquitously in the abdomen and should be identified as such. Since GEP-NEN is predominantly hypervascularized, a biphasic examination technique is mandatory for contrast-enhanced cross-sectional imaging. PET/CT with somatostatin analogs should be used as the subsequent method.

Transvascular therapy of Hepatocellular Carcinoma (HCC), status and developments.

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide. Only 30-40% of patients diagnosed with HCC are candidates for curative treatment options. The remaining majority of patients undergo local, regional or systemic palliative therapies. Transvascular therapy of HCC takes advantage of the fact that hypervascularized HCCs receive their main perfusion from the hepatic artery. In this context transvascular therapy describes different therapies: bland embolization (transarterial embolization, TAE), cTACE (conventional transarterial chemoembolization), DEB-TACE (TACE with drug-eluting beads, DEB) and SIRT (selective internal radiation therapy, radioembolization). cTACE is the most common type of transvascular treatment and represents a combination of the intra-arterial use of a chemotherapeutic agent and embolization. There is no standardized regimen for cTACE. It remains unclear whether the intra-arterial application of a chemotherapeutic agent is definitely required, because bland embolization alone using very small spherical particles shows tumor necrosis comparable to cTACE. For DEB-TACE microparticles loaded with a chemotherapeutic drug combine the advantages of cTACE and bland embolization.

Occlusion of a Long-Term Transpleural Biliary Drainage Tract Using a Gelatin Pledget (Hep-Plug™).

This case describes a technique used to close a long-term 14F transpleural biliary drainage catheter tract to prevent biliopleural fistula and further complications. We deployed a compressed gelatin foam pledget provided in a pre-loaded delivery device (Hep-Plug™) along the intrahepatic tissue tract for sealing it against the pleural cavity. The device used is easy to handle and gives the Interventional Radiologist the possibility to safely manage and prevent complications after percutaneous transhepatic interventions.

Retrospective study in 23 patients of the self-expanding sinus-XL stent for treatment of malignant superior vena cava obstruction caused by non-small cell lung cancer.

PURPOSE: To evaluate retrospectively the self-expanding nitinol Sinus-XL stent (OptiMed, Ettlingen, Germany) for the treatment of superior vena cava (SVC) obstruction caused by non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: Between October 2009 and December 2012, 23 patients (7 women and 16 men; age, 62.5 y ± 8.5) with stage IIIA (1 patient), IIIB (4 patients) or IV (18 patients) NSCLC and acute SVC obstruction were scheduled for urgent stent implantation. The primary study endpoints were technical success (defined as accurate stent placement with complete coverage of the obstructed SVC), residual stenosis < 30%, and clinical efficacy. Complications were assessed as a secondary study endpoint. RESULTS: There were 26 stents implanted in 23 patients. The technical success was 100%. Stent dilation was performed after deployment in 18 cases (78%). Stent migration into the right atrium occurred immediately after deployment in one patient; however, this stent was successfully repositioned and stabilized by a second stent. The clinical symptoms improved at least one category according to the International Consensus Committee on Chronic Venous Disease after stent implantation in all but one patient. The mean clinical follow-up was 66 days ± 83 (range, 1-305 d). Three minor complications (13%) and one major complication (4%) occurred. CONCLUSIONS: Implantation of the self-expanding Sinus-XL stent for treatment of SVC obstruction caused by NSCLC is a safe and effective urgent treatment in this palliative setting.

Evaluation of the plasmatic and parenchymal elution kinetics of two different irinotecan-loaded drug-eluting embolics in a pig model.

PURPOSE: To evaluate and compare irinotecan elution kinetics of two drug-eluting embolic agents in a porcine model. MATERIALS AND METHODS: Embolization of the left liver lobe was performed in 16 domestic pigs, with groups of two receiving 1 mL of DC Bead M1 (70-150 µm) or Embozene TANDEM (75 µm) loaded with 50 mg irinotecan. Irinotecan plasma levels were measured at 0, 10, 20, 30, 60, 120, 180, and 240 minutes after completed embolization and at the time of euthanasia (24 h, 48 h, 72 h, or 7 d). Liver tissue samples were taken to measure irinotecan tissue concentrations. RESULTS: The highest irinotecan plasma concentrations of both embolic agents were measured 10 and 20 minutes after embolization, and concentrations were significantly higher for DC Bead M1 versus Embozene TANDEM (P = .0019 and P = .0379, respectively). At 48 hours and later follow-up, no irinotecan was measurable in the plasma. For both embolic agents, the highest irinotecan tissue concentration was found after 24 hours and decreased in a time-dependent manner at later follow-up intervals. Additionally, SN-38 tissue levels for both agents were therapeutic at 24 hours, with therapeutic levels of SN-38 at 48 hours in one liver embolized with TANDEM particles. Histopathologic analysis revealed ischemic, inflammatory, and fibrotic tissue reactions. CONCLUSIONS: Irinotecan is measurable in plasma and hepatic tissue after liver embolization with both types of irinotecan-eluting embolic agents. DC Bead M1 shows early burst elution kinetics, whereas Embozene TANDEM has a lower and slower release profile. The initial burst is significantly greater after embolization with DC Bead M1 than with Embozene TANDEM.

Hepatic artery stent-grafts for the emergency treatment of acute bleeding.

PURPOSE: We evaluated the technical success and clinical efficacy of stent-graft implantation for the emergency management of acute hepatic artery bleeding. METHODS: Between January 2010 and July 2013, 24 patients with hemorrhage from the hepatic artery were scheduled for emergency implantation of balloon expandable stent-grafts. The primary study endpoints were technical and clinical success, which were defined as successful stent-graft implantation with sealing of the bleeding site at the end of the procedure, and cessation of clinical signs of hemorrhage. The secondary study endpoints were complications during the procedure or at follow-up and 30-day mortality rate. RESULTS: In 23 patients, hemorrhage occurred after surgery, and in one patient hemorrhage occurred after trauma. Eight patients had sentinel bleeding. In most patients (n=16), one stent-graft was implanted. In six patients, two overlapping stent-grafts were implanted. The stent-grafts had a target diameter between 4mm and 7 mm. Overall technical success was 88%. The bleeding ceased after stent-graft implantation in 21 patients (88%). The mean follow-up was 137 ± 383 days. In two patients, re-bleeding from the hepatic artery occurred during follow-up after 4 and 29 days, respectively, which could be successfully treated by endovascular therapy. The complication rate was 21% (minor complication rate 4%, major complication rate 17%). The 30-day mortality rate was 21%. CONCLUSIONS: Implantation of stent-grafts in the hepatic artery is an effective emergency therapy and has a good technical success rate for patients with acute arterial hemorrhage.

Emergency embolization for the treatment of acute hemorrhage from intercostal arteries.

To evaluate embolotherapy for the emergency management of acute bleeding from intercostal arteries. Between October 2003 and August 2012, 19 consecutive patients with hemorrhage from intercostal arteries were scheduled for emergency embolization. The primary study endpoints were technical and clinical success, which were defined as angiographic cessation of bleeding, and cessation of clinical signs of hemorrhage. The secondary study endpoints were periprocedural complications and 30-day mortality rate. In most patients (74 %), hemorrhage was caused by iatrogenic procedures with subsequent intercostal artery laceration. One of the patients was treated twice for recurrent hemothorax caused by a new intercostal artery pseudoaneurysm 7.5 years after the initial procedure. Thus, 20 procedures were performed in these 19 patients. Overall technical success was 85 %. In six patients, no embolization of the "backdoor" was feasible, and in two of these patients additional embolization of other intercostal arteries was necessary to prevent hemorrhage via collateral vessels. Clinical signs of hemorrhage ceased after embolotherapy in 16 of 20 procedures (clinical success 80 %). The mean follow-up was 358.7 ± 637.1 days. One minor procedure-related complication occurred. The 30-day mortality rate was 21 %, however, this was unrelated to intercostal artery hemorrhage. Embolotherapy is an effective emergency therapy for patients with acute hemorrhage from intercostal arteries. Especially if embolization of the backdoor is not feasible, collateral supply via other intercostal arteries should be either ruled out or embolized to prevent ongoing hemorrhage. Despite successful embolotherapy, a majority of patients underwent surgery during follow-up to remove the symptomatic hematoma.

Specific CT 3D rendering of the treatment zone after Irreversible Electroporation (IRE) in a pig liver model: the "Chebyshev Center Concept" to define the maximum treatable tumor size.

BACKGROUND: Size and shape of the treatment zone after Irreversible electroporation (IRE) can be difficult to depict due to the use of multiple applicators with complex spatial configuration. Exact geometrical definition of the treatment zone, however, is mandatory for acute treatment control since incomplete tumor coverage results in limited oncological outcome. In this study, the "Chebyshev Center Concept" was introduced for CT 3d rendering to assess size and position of the maximum treatable tumor at a specific safety margin. METHODS: In seven pig livers, three different IRE protocols were applied to create treatment zones of different size and shape: Protocol 1 (n = 5 IREs), Protocol 2 (n = 5 IREs), and Protocol 3 (n = 5 IREs). Contrast-enhanced CT was used to assess the treatment zones. Technique A consisted of a semi-automated software prototype for CT 3d rendering with the "Chebyshev Center Concept" implemented (the "Chebyshev Center" is the center of the largest inscribed sphere within the treatment zone) with automated definition of parameters for size, shape and position. Technique B consisted of standard CT 3d analysis with manual definition of the same parameters but position. RESULTS: For Protocol 1 and 2, short diameter of the treatment zone and diameter of the largest inscribed sphere within the treatment zone were not significantly different between Technique A and B. For Protocol 3, short diameter of the treatment zone and diameter of the largest inscribed sphere within the treatment zone were significantly smaller for Technique A compared with Technique B (41.1 ± 13.1 mm versus 53.8 ± 1.1 mm and 39.0 ± 8.4 mm versus 53.8 ± 1.1 mm; p < 0.05 and p < 0.01). For Protocol 1, 2 and 3, sphericity of the treatment zone was significantly larger for Technique A compared with B. CONCLUSIONS: Regarding size and shape of the treatment zone after IRE, CT 3d rendering with the "Chebyshev Center Concept" implemented provides significantly different results compared with standard CT 3d analysis. Since the latter overestimates the size of the treatment zone, the "Chebyshev Center Concept" could be used for a more objective acute treatment control.

Irreversible electroporation of the pig kidney with involvement of the renal pelvis: technical aspects, clinical outcome, and three-dimensional CT rendering for assessment of the treatment zone.

PURPOSE: To analyze irreversible electroporation (IRE) of the pig kidney with involvement of the renal pelvis. MATERIALS AND METHODS: IRE of renal tissue including the pelvis was performed in 10 kidneys in five pigs. Three study groups were defined: group I (two applicators with parallel configuration; n = 11), group II (three applicators with triangular configuration; n = 2), and group III (six applicators with complex configuration; n = 3). After IRE and before euthanasia, pigs underwent contrast-enhanced computed tomography (CT). Technical aspects (radial distance of applicators, resulting mean current), clinical outcome (complications, blood samples), and three-dimensional CT rendering for assessment of the treatment zone (short axis, circularity) were assessed. RESULTS: Radial distances of applicators were 14.3 mm ± 2.8 in group I, 12.3 mm ± 1.9 in group II, and 16.4 mm ± 3.5 in group III. Resulting mean currents were 25.7 A ± 6.5 in group I, 27.0 A ± 7.1 in group II, and 39.4 A ± 8.9 in group III. In group III, two perirenal hematomas were identified. There was no damage to the renal pelvis. During IRE, clinical blood parameters and cardiovascular markers did not change significantly. Short axis measurements were 20.6 mm ± 3.6 in group I, 31.9 mm ± 8.2 in group II, and 39.3 mm ± 2.4 in group III (P < .01 between groups). Circularity scores were 0.8 ± 0.2 in group I, 0.7 ± 0.1 in group II, and 0.7 ± 0.1 in group III, with a score of 1 indicating perfect roundness (P value not significant). CONCLUSIONS: IRE of the pig kidney with involvement of the renal pelvis is feasible and safe. Size but not shape of the treatment zone is significantly affected by applicator configuration.

Quantification of tissue shrinkage and dehydration caused by microwave ablation: experimental study in kidneys for the estimation of effective coagulation volume.

PURPOSE: To quantify the extent of tissue shrinkage and dehydration caused by microwave (MW) ablation in kidneys for estimation of effective coagulation volume. MATERIALS AND METHODS: MW ablations were carried out in ex vivo porcine kidneys. Six study groups were defined: groups 1A, 2A, and 3A for MW ablation (90 W for 5 min, 7.5 min, or 10 min), and groups 1B, 2B, and 3B for control (without MW ablation). Pre- and postinterventional volume analyses were performed. Effective coagulation volumes (original tissue included in coagulation) were determined. Postinterventional dehydration analyses were performed with calculation of mean mass fractions of water. RESULTS: Mean deployed energies were 21.6 kJ ± 1.1 for group 1A, 29.9 kJ ± 1.0 for group 2A, and 42.1 kJ ± 0.5 kJ for group 3A, and were significantly different (P < .0001). Differences between pre- and postinterventional volumes were -3.8% ± 0.6 for group 1A, -5.6% ± 0.9 for group 2A, and -7.2% ± 0.4 for group 3A, and -1.1% ± 0.3 for group 1B, -1.8% ± 0.4 for group 2B, and -1.1% ± 0.4 for group 3B. Postinterventional volumes were significantly smaller than preinterventional volumes for all groups (P < .01). Underestimations of effective coagulation volume from visualized coagulation volume were 26.1% ± 3.5 for group 1A, 35.2% ± 11.2 for group 2A, and 42.1% ± 4.9 for group 3A, which were significantly different (P < .01). Mean mass fractions of water were 64.2% ± 1.4 for group 1A, 63.2% ± 1.7 for group 2A, and 62.6% ± 1.8% for group 3A, with significant differences versus corresponding control groups (P < .01). CONCLUSIONS: For MW ablation in kidneys, underestimation of effective coagulation volume based on visualized coagulation volume is significantly greater with greater deployed energy. Therefore, local dehydration with tissue shrinkage is a potential contributor.