BestFLR Trial: Liver Regeneration at CT before Major Hepatectomies for Liver Cancer-A Randomized Controlled Trial Comparing Portal Vein Embolization with N-Butyl-Cyanoacrylate Plus Iodized Oil versus Polyvinyl Alcohol Particles Plus Coils.

Background In patients with liver cancer, portal vein embolization (PVE) is recommended to promote liver growth before major hepatectomies. However, the optimal embolization strategy has not been established. Purpose To compare liver regeneration as seen at CT in participants with liver cancer, before major hepatectomies, with N-butyl-cyanoacrylate (NBCA) plus iodized oil versus standard polyvinyl alcohol (PVA) particles plus coils, for PVE. Materials and Methods In this single-center, prospective, randomized controlled trial (Best Future Liver Remnant, or BestFLR, trial; International Standard Randomized Controlled Trial Number 16062796), PVE with NBCA plus iodized oil was compared with standard PVE with PVA particles plus coils in participants with liver cancer. Participant recruitment started in November 2017 and ended in March 2020. Participants were randomly assigned to undergo PVE with PVA particles plus coils or PVE with NBCA plus iodized oil. The primary end point was liver growth assessed with CT 14 days and 28 days after PVE. Secondary outcomes included posthepatectomy liver failure, surgical complications, and length of intensive care treatment and hospital stay. The Mann-Whitney U test was used to compare continuous outcomes according to PVE material, whereas the Χ2 test or Fisher exact test was used for categoric variables. Results Sixty participants (mean age, 61 years ± 11 [standard deviation]; 32 men) were assigned to the PVA particles plus coils group (n = 30) or to the NBCA plus iodized oil group (n = 30). Interim analysis revealed faster and superior liver hypertrophy for the NBCA plus iodized oil group versus the PVA particles plus coils group 14 days and 28 days after PVE (absolute hypertrophy of 46% vs 30% [P < .001] and 57% vs 37% [P < .001], respectively). Liver growth for the proposed hepatectomy was achieved in 87% of participants (26 of 30) in the NBCA plus iodized oil group versus 53% of participants (16 of 30) in the PVA particles plus coils group (P = .008) 14 days after PVE. Liver failure occurred in 13% of participants (three of 24) in the NBCA plus iodized oil group and in 27% of participants (six of 22) in the PVA particles plus coils group (P = .27). Conclusion Portal vein embolization with N-butyl-cyanoacrylate plus iodized oil produced greater and faster liver growth as seen at CT in participants with liver cancer, compared with portal vein embolization with polyvinyl alcohol particles plus coils, allowing for earlier surgical intervention. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Arellano in this issue.

Portal vein embolization with n-butyl-cyanoacrylate through an ipsilateral approach before major hepatectomy: single center analysis of 50 consecutive patients.

PURPOSE: To evaluate the efficacy of portal vein embolization (PVE) with n-Butyl-cyanoacrylate (NBCA) through an ipsilateral approach before major hepatectomy. Secondary end-points were PVE safety, liver resection and patient outcome. METHODS: Over a 5-year period 50 non-cirrhotic consecutive patients were included with primary or secondary liver cancer treatable by hepatectomy with a liver remnant (FLR) volume less than 25% or less than 40% in diseased livers. RESULTS: There were 37 men and 13 women with a mean age of 57 years. Colorectal liver metastases were the most frequent tumor and patients were previously exposed to chemotherapy. FLR increased from 422 ml to 629 ml (P < 0.001) after PVE, corresponding to anincrease of 52%. The FLR ratio increased from 29.6% to 42.3% (P < 0.001). Kinetic growth rate was 2.98%/week. A negative association was observed between increase in the FLR and FLR ratio and FLR volume before PVE (P = 0.002). In 31 patients hepatectomy was accomplished and only one patient presented with liver insufficiency within 30 days after surgery. CONCLUSIONS: PVE with NBCA through an ipsilateral puncture is effective before major hepatectomy. Meticulous attention is needed especially near the end of the embolization procedure to avoid complications. TRIAL REGISTRATION: Clinical Study ISRCTN registration number: ISRCTN39855523 . Registered March 13th 2017.

DEB TACE for Intermediate and advanced HCC - Initial Experience in a Brazilian Cancer Center.

BACKGROUND: According to Barcelona Clinic Liver Cancer classification transarterial chemoembolization is indicated in patients with Hepatocellular Carcinoma in the intermediate stage. Drug-eluting microspheres can absorb and release the chemotherapeutic agent slowly for 14 days after its intra-arterial administration. This type of transarterial chemoembolization approach appears to provide at least equivalent effectiveness with less toxicity. METHODS: This is a prospective, single-center study, which evaluated 21 patients with intermediate and advanced hepatocellular carcinoma who underwent transarterial chemoembolization with drug-eluting microspheres. The follow up period was 2 years. Inclusion criteria was Child-Pugh A or B liver disease patients, intermediate or advanced hepatocellular carcinoma and performance status equal or below 2. Transarterial chemoembolization with drug-eluting microspheres was performed at 2-month intervals during the first two sessions. The third and subsequent sessions were performed according to the image findings on follow-up, on a "demand schedule". Tumor response and time to progression were evaluated along the two-year follow up period. RESULTS: Of the 21 patients 90% presented with liver cirrhosis, 62% had Barcelona Clinic Liver Cancer stage B and 38% had Barcelona Clinic Liver Cancer stage C hepatocellular carcinoma. Average tumor size was 6.9 cm. The average number of Transarterial chemoembolization with drug-eluting microspheres procedures was 3 with a total of 64 sessions. The predominant toxicity was mild. Liver function was not significantly affected in most patients. Two deaths occurred within 90 days after Transarterial chemoembolization with drug-eluting microspheres (ischemic hepatitis and hydropic decompensation). Technical success was achieved in 63 of 64 procedures. The mean hospital stay was 1.5 days. The progression free and overall survival at 1 and 2 years were 73.0% and 37.1%, 73.7% and 41.6%, respectively. CONCLUSION: Transarterial chemoembolization with drug-eluting microspheres is able to deliver significant tumor response and progression free survival rate with acceptable toxicity. Larger studies are needed to identify exactly which subset of advanced hepatocellular patients may benefit from this treatment. TRIAL REGISTRATION: study ID ISRCTN16295622. Registered October 14th 2016. Retrospectively registered. Website registration: http://www.isrctn.com/ISRCTN16295622.

Hepatic transarterial chemoembolization and retroperitoneal lymph node radiofrequency ablation in the multidisciplinary approach of an overt metastatic leiomyosarcoma.

Metastatic leiomyosarcoma has a dismal prognosis, and therapy mainly consists of palliative systemic chemotherapy. A selected subgroup of patients with limited metastatic disease may eventually derive benefit from more aggressive strategies, including resection of isolated metastasis. We report here the successful use of hepatic transarterial chemoembolization and retroperitoneal lymph node radiofrequency ablation in a patient with advanced leiomyosarcoma metastatic to the liver and retroperitoneum.

Avaliação das partículas de polímeros superabsorventes (DC-Beads) notratamento do hepatocarcinoma intermediário e avançado

Introdução: O hepatocarcinoma se tornou um dos tumores mais frequentes em todo o mundo com aproximadamente 500.000 novos casos por ano. Os principais fatores de risco são infecções pelos vírus da hepatite B e C e álcool. Na apresentação, a maioria dos pacientes já é excluída dos tratamentos com potencial curativo (ex.: ressecção, transplante ou ablação) devido ao estadiamento avançado. Nesses pacientes, a quimioembolização é o tratamento de escolha. A quimioembolização com as novas partículas superabsorventes (DC-Beads) além de obstruir o fluxo sanguíneo tumoral produz uma liberação de quimioterapia em altas concentrações, na artéria que nutre o tumor, de maneira controlada e sustentada. Esta nova técnica tem o potencial de ser um tratamento com menor toxicidade e uma maior taxa de resposta tumoral. Objetivo: Avaliar, de maneira prospectiva, a quimioembolização com o uso das partículas de polímeros superabsorventes carregadas com quimioterapia no tratamento do hepatocarcinoma intermediário e avançado quanto à resposta tumoral e ao tempo livre de progressão. Metodologia: O estudo proposto é prospectivo, não-randomizado, fase II, onde 21 pacientes portadores de hepatocarcinoma intermediário e avançado matriculados no Instituto Nacional de Câncer foram selecionados e submetidos à quimioembolização com DC-Beads carregadas com doxorrubicina. O resultado foi avaliado através de exames de imagem periódicos (ressonância magnética) e avaliação clínica. Resultados: A quimioembolização com partículas superabsorventes promoveu uma alta taxa de resposta objetiva, [7 pacientes (33%) com resposta completa e 10 pacientes (48%) com resposta parcial], apresentando baixo perfil de toxicidade. Comparando com os resultados da literatura, foi possível tratar pacientes mais graves e com tumores mais avançados (ex.: hepatocarcinoma com estadio C pelos critérios do BCLC) obtendo-se uma alta taxa de resposta tumoral. Conclusão: A quimioembolização com partículas superabsorventes obteve alta taxa de resposta tumoral e toxicidade aceitável. Esta técnica representa uma nova opção de tratamento e possui potencial de se tornar o tratamento padrão para o hepatocarcinoma intermediário e avançado. Porém estudos randomizados serão necessários para melhor avaliação

Introdução: O hepatocarcinoma se tornou um dos tumores mais frequentes em todo o mundo com aproximadamente 500.000 novos casos por ano. Os principais fatores de risco são infecções pelos vírus da hepatite B e C e álcool. Na apresentação, a maioria dos pacientes já é excluída dos tratamentos com potencial curativo (ex: ressecção, transplante ou ablação) devido ao estadiamento avançado. Nesses pacientes, a quimioembolização é o tratamento de escolha. A quimioembolização com as novas partículas superabsorventes (DC-Beads) além de obstruir o fluxo sanguíneo tumoral produz uma liberação de quimioterapia em altas concentrações, na artéria que nutre o tumor, de maneira controlada e sustentada. Esta nova técnica tem o potencial de ser um tratamento com menor toxicidade e uma maior taxa de resposta tumoral. Objetivo: Avaliar, de maneira prospectiva, a quimioembolização com o uso das partículas de polímeros superabsorventes carregadas com quimioterapia no tratamento do hepatocarcinoma intermediário e avançado quanto à resposta tumoral e ao tempo livre de progressão. Metodologia: O estudo proposto é prospectivo, não-randomizado, fase II, onde 21 pacientes portadores de hepatocarcinoma intermediário e avançado matriculados no Instituto Nacional de Câncer foram selecionados e submetidos à quimioembolização com DC-Beads carregadas com doxorrubicina. O resultado foi avaliado através de exames de imagem periódicos (ressonância magnética) e avaliação clínica. Resultados: A quimioembolização com partículas superabsorventes promoveu uma alta taxa de resposta objetiva, [7 pacientes (33%) com resposta completa e 10 pacientes (48%) com resposta parcial], apresentando baixo perfil de toxicidade. Comparando com os resultados da literatura, foi possível tratar pacientes mais graves e com tumores mais avançados (ex.: hepatocarcinoma com estadio C pelos critérios do BCLC) obtendo-se uma alta taxa de resposta tumoral. Conclusão: A quimioembolização com partículas superabsorventes obteve alta taxa de resposta tumoral e toxicidade aceitável. Esta técnica representa uma nova opção de tratamento e possui potencial de se tornar o tratamento padrão para o hepatocarcinoma intermediário e avançado. Porém estudos randomizados serão necessários para melhor avaliação

Introduction: Hepatocellular carcinoma has become one of the most frequent tumor worldwide with an annual incidence of 500.000 new cases per year. The most important risk factors are the hepatitis B and C, infection and alcohol. At presentation, most of the patients are not able to potentially curative treatments (e.g.: resection, transplantation or ablation) as a result of advanced tumor staging. In these patients, chemoembolization is the treatment of choice. Chemoembolization with the new superabsorbents particles (DC-beads), besides stopping arterial flow to the hepatic tumor, also deliver a high concentration of the chemotherapy agent to the tumor vessel in a controlled and sustained manner. This new technic has the potential to become a treatment with less toxicity and higher tumor response. Purpose: Analyze prospectively the chemoembolization with superabsorbents particles loaded with chemotherapy in the treatment of intermediate and advanced hepatocellular carcinoma as to tumor response and progression free survival. Methods: This is a prospective, phase II, non-randomized study in which we enrolled 21 patients from the National Cancer Institute of Brazil with a diagnosis of intermediate or advanced hepatocellular, whom submitted to chemoembolization with DC-Beads loaded with doxorubicin. The outcome was measured by periodic imaging evaluation (magnetic resonance) and clinical status. Results: Chemoembolization with superabsorbents particles yielded a high objective response rate [7 patients (33%) with complete response and 10 patients (48%) with partial response] with a low toxicity profile. When comparing with the literature, the present study showed that it was possible to treat more severe patients with more advanced tumors (e.g.: BCLC C Hepatocellular carcinoma) with high response rate. Conclusion: Chemoembolization with superabsorbents particles yielded a high objective response rate and low toxicity. This technic represents a new way to perform this procedure and has the potential to become the standardized treatment for hepatocellular carcinoma in this subset of patients. Even thought randomized controlled trial are needed to better establish this outcome

[Anomalous origin of Coronary Artery (ALCAPA) in 64-channel TC scanner].

Multidetector computed tomography (MDCT) with 64 channels provides to clinical practice an excellent method to detect coronary artery anomalies. The diagnosis of coronary anomalies consisting of origin of left coronary artery in the pulmonary trunk in adults with no history of congenital disease has few reports in literature. We report a case in a 30-year old female patient complaining of fatigue on major efforts and positive scintigraphy for ischemia. The diagnosis was made through 64-channel MDCT and thus it appears that the method can be used as baseline.

Origem Anômala da Coronária (ALCAPA) em tomógrafo de 64 canais / Anomalous origin of Coronary Artery (ALCAPA) in 64-channel TC scanner

A tomografia computadorizada multidetector (TCMD) com 64 canais disponibiliza para a prática clínica um excelente método para detecção de anomalias das artérias coronárias. O diagnóstico da anomalia coronariana consistindo da origem da artéria coronária esquerda no tronco pulmonar em adulto sem história prévia de doença congênita apresenta escassa casuística na literatura. Realizamos um relato de caso em uma paciente feminina de 30 anos de idade, com queixas de cansaço aos grandes esforços e cintilografia positiva para isquemia. O diagnóstico foi realizado pela TCMD de 64 canais e com isso verifica-se que o método pode ser utilizado como de primeira linha.

Multidetector computed tomography (MDCT) with 64 channels provides to clinical practice an excellent method to detect coronary artery anomalies. The diagnosis of coronary anomalies consisting of origin of left coronary artery in the pulmonary trunk in adults with no history of congenital disease has few reports in literature. We report a case in a 30-year old female patient complaining of fatigue on major efforts and positive scintigraphy for ischemia. The diagnosis was made through 64-channel MDCT and thus it appears that the method can be used as baseline.