Higher osimertinib introduction rate achieved by multiple repeated rebiopsy after acquired resistance to first/second generation EGFR-TKIs.

BACKGROUND: Indication for treatment with osimertinib after first/second generation (1/2G) epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) resistance depends on T790M mutation detected by rebiopsy. The aim of our study was to analyze the data on clinical practice at our hospital where histological rebiopsy is actively carried out multiple times. METHODS: We retrospectively reviewed our electronic medical records of EGFR-mutant non-small cell lung cancer (NSCLC) patients to examine clinical rebiopsy situation, T790M detection rate, osimertinib introduction rate and associated outcomes. RESULTS: Among 95 patients with EGFR-mutant NSCLC, 72 patients received 1/2G EGFR-TKIs. Of 60 with progressive disease on 1/2G EGFR-TKIs, 50 (83%) underwent rebiopsy. T790M was detected in 40 (80%) of 50, resulting in a 79% osimertinib introduction rate, as one patient refused osimertinib. T790M was detected by first rebiopsy in 18 (36%) of 50 patients, and by second or subsequent rebiopsy in 22 (44%). Median time to treatment failure of T790M-positive patients at first rebiopsy was 22.6 (95% confidence interval [CI]: 10.2-32.8) months, and those at multiple repeated rebiopsy was 20.9 (95% CI: 8.6-not reached) months (p = 0.64). Median overall survival (OS) in osimertinib introduced group was 92.5 (95% CI: 62.9-not reached), while in nonosimertinib median OS was 39.0 months (95% CI: 22.2-not reached) (p = 0.04). CONCLUSIONS: T790M detection rate was increased by multiple repeated rebiopsy, achieving a higher osimertinib introduction rate. This higher introduction rate could contribute to better prognosis of EGFR-mutant NSCLC patients.

Bridging stent placement through the superior vena cava to the inferior vena cava in a patient with malignant superior vena cava syndrome and an iodinated contrast material allergy.

Positioning is critical during the placement of superior vena cava (SVC) stents in patients with malignant SVC syndrome. Although SVC stents effectively relieve various symptoms of SVC syndrome, improper stent positioning may cause life-threatening complications such as migration that result in fatal cardiac failure. Here we describe a patient with an allergy to iodinated contrast material (ICM) who presented with SVC syndrome owing to mediastinal lymph node metastases from hepatocellular carcinoma, which was successfully treated with an SVC stent. Secure stent placement was achieved by bridging the stent through the SVC to the inferior vena cava with venography using carbon dioxide instead of ICM.

Percutaneous Catheter and Port Placement for Hepatic Arterial Infusion Chemotherapy: Catheter Placement from Subclavian Artery.

Hepatic arterial infusion chemotherapy (HAIC) has been performed for patients with life-threatening liver tumors resistant to standard therapies for more than 30 years. Placement of the port and catheter system for HAIC is performed by surgeons or interventional radiologists. Surgical placement requires laparotomy, whereas the interventional radiologic approach places a port and a catheter percutaneously. The interventional radiologic technique of implanting a port and catheter was originally developed in Japan in the 1980s. The procedure consists of arterial redistribution, catheter and port placement, and evaluation and management of the drug distribution. For the catheter and port placement, the subclavian artery, femoral artery, or inferior epigastric artery is used as an access route. We have used a subclavian artery for HAIC to have the stability of the system at the anterior chest wall and the ease to advance a catheter into hepatic arteries at the time of the placement; however, there are some risks, such as cerebral infarction, and the specific skills of a cutdown procedure are required to access the subclavian artery. No procedure can be perfectly appropriate for all patients, and we should consider what we choose on a case-by-case basis. With this video (available online at www.jvir.org), we hope many interventional radiologists will be aware that this could be within their scope of practice with training.

Lateropulsion due to a lesion of the dorsal spinocerebellar tract.

We report three cases showing body lateropulsion as the sole or predominant symptom of caudal lateral medullary infarction. All of them presented a small infarction on the lateral surface of the caudal medulla corresponding to the dorsal spinocerebellar tract (DSCT). Disturbed unconscious proprioception of the lower trunk and the lower limb conveyed by the DSCT might have been responsible for the isolated lateropulsion. Although lateropulsion itself improved within two weeks, one patient's condition progressed to typical lateral medullary infarction. Lateropulsion caused by DSCT infarction could be a prodromal symptom of perfusion failure of a vertebral artery or the posterior inferior cerebellar artery.