Percutaneous Irreversible Electroporation for the Treatment of Colorectal Cancer Liver Metastases with a Proposal for a New Response Evaluation System

PurposeTo describe an initial experience with irreversible electroporation (IRE) in patients with colorectal liver metastasis (CLM).Materials and MethodsA retrospective analysis of patients undergoing IRE for the management of CLM was performed. Procedures were done percutaneously under general anesthesia. Patients were then followed for adverse events, tumor response, and survival.ResultsBetween March 2010 and February 2013, 29 patients underwent percutaneous ablation of 58 tumors in 36 IRE sessions. Most patients (89%) had an absolute or relative contraindication to thermal ablation. The median age was 62 years, and the median time from diagnosis to IRE was 28 months. The median number of lesions treated per patient was two, and the median tumor size was 2.7 cm. Patients had received previous chemotherapy regimens (range, 1–5 per patient). A new Metabolic Imaging And Marker Integration response evaluation criteria was used for response assessment, and was a predictor of progression-free and overall survival. The 2-year progression-free survival rate was 18% (95% confidence interval, 0%–35%), and the 2-year overall survival rate was 62% (95% confidence interval, 37%–87%). Complications included arrhythmias (n = 1) and postprocedure pain (n = 1). Both patients recovered without sequelae.ConclusionsPercutaneous IRE of CLM is feasible and safe. A new response evaluation system for colorectal cancer appears to be prognostic.     

Factors Affecting Periprocedural Morbidity and Mortality and Long-term Patient Survival after Arterial Embolization of Hepatic Neuroendocrine Metastases

PurposeTo identify factors affecting periprocedural morbidity and mortality and long-term survival following hepatic artery embolization (HAE) of hepatic neuroendocrine tumor (NET) metastases.Materials and MethodsThis single-center, institutional review board–approved retrospective review included 320 consecutive HAEs for NET metastases performed in 137 patients between September 1996 and September 2007. Forty-seven HAEs (15%) were performed urgently to manage refractory symptoms in inpatients (urgent group), and 273 HAEs (85%) were elective (elective group). Overall survival (OS) was estimated by Kaplan–Meier methodology. Complications were categorized per Common Terminology Criteria for Adverse Events, version 4.0. Univariate and multivariate analyses were performed to determine independent predictors for OS, complications, and 30-day mortality. The independent factors were combined to develop clinical risk score groups.ResultsUrgent HAE (P = .007), greater than 50% liver replacement by tumor (P < .0001), and extrahepatic metastasis (P = .007) were independent predictors for shorter OS. Patients with all three risk factors had decreased OS versus those with none (median, 8.5 vs 86 mo; P < .001). Thirty-day mortality was significantly lower in the elective (1%) versus the urgent group (8.5%; P = .0009). There were eight complications (3%) in the elective group and five (10.6%) in the urgent group (P = .03). Male sex and urgent group were independent factors for higher 30-day mortality rate (P = .023 and P =.016, respectively) and complications (P = .012 and P =.001, respectively).ConclusionsUrgent HAE, replacement of more than 50% of liver by tumor, and extrahepatic metastasis are strong independent predictors of shorter OS. Male sex and urgent HAE carry higher 30-day mortality and periprocedural morbidity risks.     

Early Treatment Response Evaluation after Yttrium-90 Radioembolization of Liver Malignancy with CT Perfusion

PurposeTo evaluate computed tomography (CT) perfusion for assessment of early treatment response after transarterial radioembolization of patients with liver malignancy.Materials and MethodsDynamic contrast-enhanced CT liver perfusion was performed before and 4 weeks after transarterial radioembolization in 40 patients (25 men and 15 women; mean age, 64 y ± 11; range, 35–80 y) with liver metastases (n = 27) or hepatocellular carcinoma (HCC) (n = 13). Arterial perfusion (AP) of tumors derived from CT perfusion and tumor diameters were measured on CT perfusion before and after transarterial radioembolization. Success of transarterial radioembolization was evaluated on morphologic follow-up imaging (median follow-up time, 4 mo) based on Response Evaluation Criteria in Solid Tumors (Version 1.1). CT perfusion parameters before and after transarterial radioembolization for different response groups were compared. Kaplan-Meier curves were plotted to illustrate overall 1-year survival rates.ResultsLiver metastases showed significant differences in AP before and after transarterial radioembolization in responders (P < .05) but not in nonresponders (P = .164). In HCC, AP values before and after transarterial radioembolization were not significantly different in responders and nonresponders (P = .180 and P = .052). Tumor diameters were not significantly different on CT perfusion before and after transarterial radioembolization in responders and nonresponders with liver metastases and HCC (P = .654, P = .968, P = .148, P = .164). In patients with significant decrease of AP in liver metastases after transarterial radioembolization, 1-year overall survival was significantly higher than in patients showing no reduction of AP.ConclusionsCT perfusion showed early reduction of AP in liver metastases responding to transarterial radioembolization; tumor diameter remained unchanged early after treatment. No significant early treatment response to transarterial radioembolization was found in patients with HCC. In patients with liver metastases, a decrease of AP after transarterial radioembolization was associated with a higher 1-year overall survival rate.     

Intra-arterial Infusion Chemotherapy for Advanced Non–Small-Cell Lung Cancer: Preliminary Experience on the Safety,Efficacy, and Clinical Outcomes

PurposeTo investigate the effectiveness and toxicity of intra-arterial infusion chemotherapy as a therapeutic modality for advanced non–small-cell lung cancer (NSCLC).Materials and MethodsIn a retrospective study, 40 patients with stage III NSCLC received intra-arterial infusion chemotherapy with gemcitabine and cisplatin. Tumor staining was graded based on angiography, and the number of NSCLC feeding arteries detected was recorded. Toxicity was assessed according to National Cancer Institute Common Toxicity Criteria for Adverse Events. The response to treatment was evaluated per Response Evaluation Criteria In Solid Tumors (RECIST). Efficacy was assessed based on time to tumor progression (TTP), and survival was estimated by Kaplan–Meier analysis. Prognostic factors influencing TTP and overall survival rate were evaluated by Cox regression analysis.ResultsThe most frequent drug-related adverse events were cough (n = 17; 42.5%), anorexia (n = 14; 35%), and pain (n = 9; 22.5%). Evaluated per RECIST, a total of 47.5% of patients (n = 19) exhibited response to therapy after completion of the first three cycles of intra-arterial infusion chemotherapy. The median TTP was 5 months. Patients had a median life expectancy of 9 months. By Cox regression analysis, tumor staining was shown to be an independent prognostic factor for TTP (relative risk, 0.405; 95% confidence interval, 0.216–0.760) and overall survival (relative risk, 0.348; 95% confidence interval, 0.185–0.656).ConclusionsIntra-arterial infusion chemotherapy for advanced lung cancer has the potential to reduce the size of tumors and has no severe adverse effects.     

Transcatheter Arterial Chemoembolization for Advanced Hepatocellular Carcinoma with Portal Vein Invasion: Safety,Efficacy, and Prognostic Factors

PurposeTo evaluate the safety and efficacy of transarterial chemoembolization and to identify the prognostic factors associated with survival in patients with hepatocellular carcinoma (HCC) and portal vein (PV) invasion.Materials and MethodsFrom January 2006 to March 2012, 50 patients with HCC invading into the PV (Barcelona Clinic Liver Cancer stage C) were treated with transarterial chemoembolization. The parenchymal tumor and PV tumor were confirmed by multidetector computed tomography (CT) and angiography. There were 14 patients with right PV tumor, 12 patients with left PV tumor, and 24 patients with main PV tumor. The response was evaluated by multidetector CT using Response Evaluation Criteria in Solid Tumors. Patients with residual tumors received repeated transarterial chemoembolization every 6–8 weeks unless the patients achieved complete remission or developed contraindications.ResultsThe median survival period of the entire group was 6.2 months (range, 1.7–50.9 mo), and the overall response rate was 42% (21 of 50 patients). The 6-month, 12-month, 24-month, and 36-month survival rates were 54%, 22%, 10%, and 8%. There were no instances of 30-day mortality or acute liver failure related to transarterial chemoembolization. The median survival of the 21 responders was 10.5 months, and the median survival of the 29 nonresponders was 5.5 months (P < .001). In both univariate and multivariate analyses, only the response to transarterial chemoembolization (hazard ratio = 0.25, P < .001) and the absence of ascites (hazard ratio = 0.24, P = .01) were significant prognostic factors.ConclusionsTransarterial chemoembolization is a safe and effective treatment for HCC with major PV invasion. The response to transarterial chemoembolization and the ascites status were the most significant predictive factors for prolonged survival.     

Yttrium-90 Radioembolization Stops Progression of Targeted Breast Cancer Liver Metastases after Failed Chemotherapy

PurposeTo determine, in an open-label, retrospective report, the safety and effectiveness of locoregional therapy with yttrium-90 (⁹⁰Y) radioembolization for patients with progressing breast cancer liver metastases (BCLMs) despite multi-agent chemotherapy.Materials and MethodsSeventy-five patients with progressing BCLMs and stable extrahepatic disease were treated with radioembolization at a single institution. Retrospective review of a prospectively collected database was performed to evaluate clinical and biochemical toxicities, tumor response, overall survival (OS), and time to progression. Radiologic response assessments included Response Evaluation Criteria In Solid Tumors in primary index lesions and metabolic activity on positron emission tomography (PET). Univariate and multivariate analyses were performed.ResultsThe mortality rate at 30 days was 4% (n = 3). Clinical toxicity and hyperbilirubinemia of grade 3 or worse occurred in 7.6% (n = 5) and 5.9% of patients (n = 4), respectively. Partial response (PR) was seen in 35.3% of patients (n = 24), stable disease (SD) in 63.2% (n = 43), and progressive disease in 1.5% (n = 1). PET imaging was available in 25 patients, and 21 (84%) had a complete response, PR, or SD. The median OS was 6.6 months (95% confidence interval [CI], 5.0–9.2 mo). The hazard ratio (HR) for OS on multivariate analysis was 0.39 (95% CI, 0.23–0.66) for tumor burden less than 25% compared with greater burden. Elevated bilirubin levels were shown to reduce OS. The HR for hepatic progression was 0.22 (95% CI, 0.05–0.98) for solitary versus multifocal disease.ConclusionsLocoregional therapy with ⁹⁰Y radioembolization is safe and stops or delays the progression of targeted chemorefractory BCLMs. Adverse prognosticators were identified.     

A Single-Institution Experience in Image-Guided Thermal Ablation of Adrenal Gland Metastases

PurposeTo assess safety, technical success, local control, and survival associated with percutaneous image-guided adrenal ablation.Materials and MethodsAdult patients with adrenal metastases who underwent percutaneous image-guided adrenal ablation during the years 2003–2012 were identified. There were 32 patients with 37 adrenal tumors identified. Technical success, safety, local control, and survival were analyzed according to standard criteria.ResultsIn 32 patients (25 men and 7 women; mean age, 66 y; age range, 44–88 y) with 37 adrenal tumors, 35 ablation procedures were performed. One patient with an 8.2-cm tumor underwent planned cryoablation debulking fully anticipating untreated margins owing to close proximity of the pancreas (ie, the intent was to diminish tumor burden rather than a curative intervention). Of the 36 patients treated with curative intent, technical success was achieved in 35 (97%) tumors. Follow-up imaging was performed on 34 of 37 tumors (excluding patients with intentional debulking [n = 1], technical failure [n = 1], and absence of follow-up [n = 1]). Local recurrence developed in 3 (8.8%) of 34 tumors. Local tumor control was achieved in 31 lesions at a mean of 22.7 months of follow-up. Recurrence-free survival and overall survival at 36 months were 88% and 52%, respectively, with a median survival of 34.5 months. A Common Terminology Criteria for Adverse Events version 4 grade 3 or 4 complication was observed in three (8.6%) ablation procedures.ConclusionsImage-guided ablation is safe and effective for local control of metastatic adrenal tumors and provides a minimally invasive alternative to surgical resection in appropriately selected patients.     

Irreversible Electroporation for Nonthermal Tumor Ablation in the Clinical Setting: A Systematic Review of Safety and Efficacy

PurposeTo provide an overview of current clinical results of irreversible electroporation (IRE), a novel, nonthermal tumor ablation technique that uses electric pulses to induce cell death, while preserving structural integrity of bile ducts and vessels.MethodsAll in-human literature on IRE reporting safety or efficacy or both was included. All adverse events were recorded. Tumor response on follow-up imaging from 3 months onward was evaluated.ResultsIn 16 studies, 221 patients had 325 tumors treated in liver (n = 129), pancreas (n = 69), kidney (n = 14), lung (n = 6), lesser pelvis (n = 1), and lymph node (n = 2). No major adverse events during IRE were reported. IRE caused only minor complications in the liver; however, three major complications were reported in the pancreas (bile leak [n = 2], portal vein thrombosis [n = 1]). Complete response at 3 months was 67%–100% for hepatic tumors (93%–100% for tumors < 3 cm). Pancreatic IRE combined with surgery led to prolonged survival compared with control patients (20 mo vs 13 mo) and significant pain reduction.ConclusionsIn cases where other techniques are unsuitable, IRE is a promising modality for the ablation of tumors near bile ducts and blood vessels. This articles gives an extensive overview of the available evidence, which is limited in terms of quality and quantity. With the limitations of the evidence in mind, IRE of central liver tumors seems relatively safe without major complications, whereas complications after pancreatic IRE appear more severe. The available limited results for tumor control are generally good. Overall, the future of IRE for difficult-to-reach tumors appears promising.     

Transcatheter CT Arterial Portography and CT Hepatic Arteriography for Liver Tumor Visualization during Percutaneous Ablation

PurposeTo evaluate the feasibility of combining transcatheter computed tomography (CT) arterial portography or transcatheter CT hepatic arteriography with percutaneous liver ablation for optimized and repeated tumor exposure.Materials and MethodsStudy participants were 20 patients (13 men and 7 women; mean age, 59.4 y; range, 40–76 y) with unresectable liver-only malignancies—14 with colorectal liver metastases (29 lesions), 5 with hepatocellular carcinoma (7 lesions), and 1 with intrahepatic cholangiocarcinoma (2 lesions)—that were obscure on nonenhanced CT. A catheter was placed within the superior mesenteric artery (CT arterial portography) or in the hepatic artery (CT hepatic arteriography). CT arterial portography or CT hepatic arteriography was repeatedly performed after injecting 30–60 mL 1:2 diluted contrast material to plan, guide, and evaluate ablation. The operator confidence levels and the liver-to-lesion attenuation differences were assessed as well as needle-to-target mismatch distance, technical success, and technique effectiveness after 3 months.ResultsTechnical success rate was 100%; there were no major complications. Compared with conventional unenhanced CT, operator confidence increased significantly for CT arterial portography or CT hepatic arteriography cases (P < .001). The liver-to-lesion attenuation differences between unenhanced CT, contrast-enhanced CT, and CT arterial portography or CT hepatic arteriography were statistically significant (mean attenuation difference, 5 HU vs 28 HU vs 70 HU; P < .001). Mean needle-to-target mismatch distance was 2.4 mm ± 1.2 (range, 0–12.0 mm). Primary technique effectiveness at 3 months was 87% (33 of 38 lesions).ConclusionsIn patients with technically unresectable liver-only malignancies, single-session CT arterial portography–guided or CT hepatic arteriography–guided percutaneous tumor ablation enables repeated contrast-enhanced imaging and real-time contrast-enhanced CT fluoroscopy and improves lesion conspicuity.     

Radiofrequency Ablation for Ground-Glass Opacity–Dominant Lung Adenocarcinoma

PurposeTo evaluate retrospectively the clinical utility of lung radiofrequency (RF) ablation for the treatment of ground-glass opacity (GGO)–dominant lung adenocarcinoma.Materials and MethodsFrom August 2004 through May 2012, 33 consecutive patients (14 men and 19 women; mean age, 71.1 y; age range, 46–84 y) with 42 lung tumors having ≥ 50% GGO component received lung RF ablation. The mean maximum tumor diameter was 1.6 cm ± 0.9 (range, 0.7–4.0 cm). Feasibility, safety, local tumor progression, and survival were evaluated.ResultsFor the 42 RF sessions, after RF electrodes were placed in each target tumor, planned ablation protocols were completed in all sessions (100%; 42 of 42). No deaths related to the RF procedure occurred. Major and minor complication rates were 4.8% and 23.8%, respectively. Local tumor progression developed in 6 tumors (14.3%; 6 of 42) during a mean follow-up of 42 months ± 23 (range, 5–92 mo). Four of six tumors with local progression were controlled by repeated RF ablation. No evidence of disease was achieved in 31 of 33 patients (93.9%) at the end of the follow-up period. All but one patient (who died of brain hemorrhage) are alive today. Overall and cancer-specific survival rates were 100% and 100% at 1 year, 96.4% (95% confidence interval [CI], 77.5%–99.5%) and 100% at 3 years, and 96.4% (95% CI, 77.5%–99.5%) and 100% at 5 years, respectively.ConclusionsLung RF ablation is a feasible, safe, and useful therapeutic option to control GGO-dominant lung adenocarcinoma.     

High-Frequency Jet Ventilation under General Anesthesia Facilitates CT-Guided Lung Tumor Thermal Ablation Compared with Normal Respiration under Conscious Analgesic Sedation

PurposeTo determine whether technical difficulty of computed tomography (CT)–guided percutaneous lung tumor thermal ablations is altered with the use of high-frequency jet ventilation (HFJV) under general anesthesia (GA) compared with procedures performed with normal respiration (NR) under conscious sedation (CS).Materials and MethodsThermal ablation treatment sessions performed with NR under CS or HFJV under GA with available anesthesia records and CT fluoroscopic images were retrospectively reviewed; 13 and 33 treatment sessions, respectively, were identified. One anesthesiologist determined the choice of anesthesiologic technique independently. Surrogate measures of procedure technical difficulty—time duration, number of CT fluoroscopic acquisitions, and radiation dose required for applicator placement for each tumor—were compared between anesthesiologic techniques. The anesthesiologist time and complications were also compared. Parametric and nonparametric data were compared by Student independent-samples t test and χ² test, respectively.ResultsPatients treated with HFJV under GA had higher American Society of Anesthesiologists classifications (mean, 2.66 vs 2.23; P = .009) and smaller lung tumors (16.09 mm vs 27.38 mm; P = .001). The time duration (220.30 s vs 393.94 s; P = .008), number of CT fluoroscopic acquisitions (10.31 vs 19.13; P = .023), and radiation dose (60.22 mGy·cm vs 127.68 mGy·cm; P = .012) required for applicator placement were significantly lower in treatment sessions performed with HFJV under GA. There was no significant differences in anesthesiologist time (P = .20), rate of pneumothorax (P = .62), or number of pneumothoraces requiring active treatment (P = .19).ConclusionsHFJV under GA appears to reduce technical difficulty of CT-guided percutaneous applicator placement for lung tumor thermal ablations, with similar complication rates compared with treatment sessions performed with NR under CS. The technique is safe and may facilitate treatment of technically challenging tumors.     

Radiofrequency Ablation of T1 Lung Carcinoma: Comparison of Outcomes for First Primary,Metachronous, and Synchronous Lung Tumors

PurposeTo report and compare outcomes after radiofrequency ablation for treatment-naïve first primary, metachronous, and synchronous T1 lung tumors.Materials and MethodsThis institutional review board–approved retrospective study reviewed 29 patients (12 men and 17 women; median age, 73 y; age range, 55–86 y) with treatment-naïve T1 lung tumors treated with radiofrequency ablation. Tumors in the 29 patients included 21 T1a and 8 T1b first primary (n = 11), metachronous (n = 14), or synchronous (n = 4) tumors (adenocarcinoma, n = 25; squamous cell carcinoma, n = 3; unspecified, n = 1). Median tumor diameter was 14 mm (range, 10–26 mm). Surveillance computed tomography or positron emission tomography–computed tomography was performed over a median period of 28 months (range, 12–83 mo). Technical success and effectiveness rates and overall and progression-free 1-year, 3-year, and 5-year survivals were calculated according to stage, first primary, metachronous, and synchronous tumor status.ResultsTechnical success and effectiveness was 97%. Local control occurred in 17 of 21 T1a tumors (81%) and 5 of 8 T1b tumors (62.5%). The local progression rate of first primary tumors (5 of 11; 45%) was higher than that of metachronous (2 of 14; 14%; P = .07) and synchronous (0 of 4; P = .01) tumors. Estimated 1-year, 3-year, and 5-year local tumor progression-free survival was 79%, 75%, and 75%. Estimated 1-year, 3-year, and 5-year overall survival was 100%, 60%, and 14%. Survival outcomes were similar for patients with first primary, metachronous, or synchronous tumors.ConclusionsRadiofrequency ablation results in good local control and progression-free survival in patients with treatment-naïve T1 lung tumors, including patients with metachronous and synchronous tumors.     

Downstaging Disease in Patients with Hepatocellular Carcinoma Outside of Milan Criteria: Strategies Using Drug-eluting Bead Chemoembolization

PurposeTo assess downstaging rates in patients with United Network for Organ Sharing stage T3N0M0 hepatocellular carcinoma (HCC) treated with doxorubicin-eluting bead transarterial chemoembolization to meet Milan criteria for transplantation.Materials and MethodsA single-center retrospective review of 239 patients treated with doxorubicin-eluting bead (DEB) chemoembolization between September 2008 and December 2011 was undertaken. Baseline and follow-up computed tomography or magnetic resonance imaging was assessed for response based on the longest enhancing axial dimension of each tumor (ie, modified Response Evaluation Criteria In Solid Tumors measurements), and medical records were reviewed. Fisher exact tests and exact logistic regression were used to test the association of patient and disease characteristics with downstaging.ResultsAfter exclusions, 22 patients remained in the analysis, 17 of whom (77%) had their HCC downstaged to meet Milan criteria. Among those whose disease was downstaged, seven underwent transplantation, one remained listed for transplantation, six had disease progression beyond Milan criteria, two underwent conventional transarterial chemoembolization, and one underwent radiofrequency ablation. The seven patients who received transplants were still living, but recurrent HCC developed in two. Baseline age (P = .25), Model for End-stage Liver Disease score (P = .77), and α-fetoprotein (AFP) level (P = 1.00) were similar between patients with and without downstaged HCC. No associations were observed between the odds of downstaging and sex (P = .21), Child–Pugh class (P = .14), Child–Pugh class controlling for baseline tumor multiplicity (P = .15), Eastern Cooperative Oncology Group performance status (P = 1.00), tumor burden (P = .31), multiple tumors (P = .31), or hepatitis C virus infection (P = 1.00). Fifteen patients who did not receive transplants were alive at 1 year, with two progression-free. Baseline AFP levels differed between those who survived 1 year and those who did not (P = .02), but did not differ by progression-free survival status (P = .62).ConclusionsT3N0M0 HCC treatment with DEB chemoembolization has a high likelihood (77%) of downstaging the disease to meet Milan criteria.     

Cryoablation of Sternal Metastases for Pain Palliation and Local Tumor Control

PurposeTo determine safety and effectiveness of cryoablation of sternal metastases for pain palliation and local tumor control.Materials and MethodsA tumor ablation database was retrospectively reviewed for sternal cryoablation procedures performed between January 2005 and June 2013, which yielded 15 procedures to treat 12 sternal metastases in 12 patients (five men). Median patient age was 57 years (range, 38–80 y). Metastases arose from five primary sites (breast, lung, kidney, ampulla, and thyroid), and median tumor size was 3.8 cm (range, 2.2–7.5 cm). Seven patients (58%) underwent cryoablation for pain palliation, and five (42%) underwent cryoablation for local tumor control of oligometastatic disease. Clinical outcomes (including complications, local tumor control, and pain response) were evaluated retrospectively.ResultsMean pain scores decreased from 7.0 ± 1.9 (median, 7; range, 4–10) at baseline to 1.8 ± 1.2 (median, 1.5; range, 0–4) following cryoablation (P = .00049). Two patients had durable pain palliation, and four had greater than 1 month of pain relief, with a median duration of 5.7 months (range, 1.5–14.7 mo). Two patients in whom recurrent pain developed underwent repeat cryoablation, with durable pain relief. Allowing for a single repeat treatment, local tumor control was achieved in four of five patients (80%) treated for this indication, with median follow-up of 8.4 months (range, 2.6–13.6 mo). In one patient (8%), an infectious complication developed that was successfully treated with antibiotics on an outpatient basis.ConclusionsCryoablation is a safe and potentially effective treatment for patients with painful sternal metastases and can achieve local tumor control in select patients.     

MR Imaging–Guided Percutaneous Cryotherapy for Lung Tumors: Initial Experience

PurposeTo evaluate prospectively the initial clinical experience of magnetic resonance (MR) imaging–guided percutaneous cryotherapy of lung tumors.Materials and MethodsMR imaging–guided percutaneous cryotherapy was performed in 21 patients with biopsy-proven lung tumors (12 men, 9 women; age range, 39–79 y). Follow-up consisted of contrast-enhanced chest computed tomography (CT) scan performed at 3-month intervals to assess tumor control; CT scanning was carried out for 12 months or until death.ResultsCryotherapy procedures were successfully completed in all 21 patients. Pneumothorax occurred in 7 (33.3%) of 21 patients. Chest tube placement was required in one (4.8%) case. Hemoptysis was exhibited by 11 (52.4%) patients, and pleural effusion occurred in 6 (28.6%) patients. Other complications were observed in 14 (66.7%) patients. The mean follow-up period was 10.5 months (range, 9–12 mo) in patients who died. At month 12 of follow-up, 7 (33.3%) patients had a complete response to therapy, and 10 (47.6%) patients showed a partial response. In addition, two patients had stable disease, and two patients developed progressive disease; one patient developed a tumor in the liver, and the other developed a tumor in the brain. The 1-year local control rate was 81%, and 1-year survival rate was 90.5%.ConclusionsMR imaging–guided percutaneous cryotherapy appears feasible, effective, and minimally invasive for lung tumors.     

Limitations of Body Surface Area–Based Activity Calculation for Radioembolization of Hepatic Metastases in Colorectal Cancer

PurposeTo calculate absorbed radiation doses in patients treated with resin microspheres prescribed by the body surface area (BSA) method and to analyze dose-response and toxicity relationships.Materials and MethodsA retrospective review was performed of 45 patients with colorectal carcinoma metastases who received single-session whole-liver resin microsphere radioembolization. Prescribed treatment activity was calculated using the BSA method. Liver volumes and whole-liver absorbed doses (D_WL) were calculated. D_WL was correlated with toxicity and radiographic and biochemical response.ResultsThe standard BSA-based administered activity (range, 0.85–2.58 GBq) did not correlate with D_WL (mean, 50.4 Gy; range, 29.8–74.7 Gy; r = −0.037; P = .809) because liver weight was highly variable (mean, 1.89 kg; range, 0.94–3.42 kg) and strongly correlated with D_WL (r = −0.724; P < .001) but was not accounted for in the BSA method. Patients with larger livers were relatively underdosed, and patients with smaller livers were relatively overdosed. Patients who received D_WL > 50 Gy experienced more toxicity and adverse events (> grade 2 liver toxicity, 46% vs 17%; P < .05) but also responded better to the treatment than patients who received D_WL< 50 Gy (disease control, 88% vs 24%; P < .01).ConclusionsUsing the standard BSA formula, the administered activity did not correlate with D_WL. Based on this short-term follow-up after salvage therapy in patients with late stage metastatic colorectal carcinoma, dose-response and dose-toxicity relationships support using a protocol based on liver volume rather than BSA to prescribe the administered activity.     

Prospective,Randomized Study of Coil Embolization versus Surefire Infusion System during Yttrium-90 Radioembolization with Resin Microspheres

PurposeTo compare standard coil embolization versus the use of an antireflux microcatheter (ARM) in patients undergoing planning angiography before selective internal radiation therapy (SIRT).Materials and MethodsA prospective, single-center trial was performed in which 30 patients were randomly assigned to undergo SIRT with coil embolization or the use of an ARM. The coil group underwent detachable coil embolization of nontarget vessels, and the ARM group underwent infusion of macroaggregated albumin with use of an ARM system, without coil embolization. Single-photon emission computed tomography (CT)/CT was then performed to assess for nontarget distribution. The primary endpoint was fluoroscopy time during planning angiography. Secondary endpoints included deployment time, total procedure time, radiation dose–area product, contrast agent used, and adverse events. Endpoints were evaluated during planning angiography and SIRT.ResultsOver a 9-month period, 30 consecutive patients were randomized at a 1:1 ratio between coil embolization and ARM groups. Technical success rates were 100% in both groups. Mean fluoroscopy time was significantly reduced in the ARM group versus the coil embolization group (1.8 min [range, 0.4–4.9 min] vs 6.0 min [range, 1.9–15.7 min]; P = .002). The planning procedure time (P < .001), deployment time (P < .001), dose–area product (P = .04), and amount of contrast agent used (P < .001) were also significantly less in the ARM group than in the coil embolization group. No nontarget distribution was detected in either group. There was no difference between groups in dose delivered on the day of SIRT (P = .71). There were no major or minor adverse events at 30 days.ConclusionsThe use of an ARM during planning angiography can significantly reduce fluoroscopy time, procedure time, and radiation dose.     

Thermal Ablation Matches Sublobar Resection Outcomes in Older Patients with Early-stage Non–small Cell Lung Cancer

PurposeTo compare survival outcomes of sublobar resection and thermal ablation for early-stage non–small cell lung cancer (NSCLC) in older patients.Materials and MethodsSEER-Medicare linked data for patients with a diagnosis of lung cancer from 2007–2009 were used. Patients ≥ 65 years old with stage IA or IB NSCLC who were treated with sublobar resection or thermal ablation were identified. Primary outcome was overall survival (OS), and secondary outcome was lung cancer–specific survival (LCSS). Demographic and clinical variables were compared. Unadjusted OS and LCSS curves were estimated using the Kaplan-Meier method, and multivariate analysis was performed using the Cox model. OS and LCSS curves for propensity score matched groups were also compared.ResultsThe final unmatched study population comprised 1,897 patients. Patients who underwent sublobar resection were significantly younger (P = .006) and significantly less likely to have a comorbidity index > 1 (P = .036), a diagnosis of chronic obstructive pulmonary disease (P = .017), or adjuvant radiation therapy (P < .0001) compared with patients treated with thermal ablation. Unadjusted survival curves of unmatched groups demonstrated significantly better OS (P = .028) and LCSS (P = .0006) in the resection group. Multivariate Cox model adjusting for demographic and clinical variables found no significant difference in OS between the treatment groups (P = .555); a difference in LCSS (hazard ratio = 1.185, P = .026) persisted. Survival curves for matched groups found no significant difference in OS (P = .695) or LCSS (P = .819) between treatment groups.ConclusionsAfter controlling for selection bias, this study found no difference in OS between patients treated with sublobar resection and thermal ablation.     

An Economic Analysis of Sublobar Resection versus Thermal Ablation for Early-Stage Non–Small-Cell Lung Cancer

PurposeTo compare medical costs for a matched-pair cohort of Medicare patients with early-stage non–small-cell lung cancer (NSCLC) who underwent treatment with sublobar resection or thermal ablation.Materials and MethodsPatients at least 65 years of age with stage IA/IB NSCLC treated with sublobar resection or thermal ablation from 2007 to 2009 were identified from Surveillance, Epidemiology, and End Results/Medicare–linked data and matched by propensity scores. The primary outcome of interest, cost from the payer’s perspective, was derived from Medicare claims data. A partitioned inverse probability-weighted estimator was used to calculate mean and median treatment-related costs and costs at 1, 3, 12, 18, and 24 months after treatment. Baseline characteristics, Kaplan–Meier survival curves, and calculated cost variables were compared between the two groups.ResultsThe final matched cohort of 128 patients had similar baseline characteristics and overall survival (P = .52). Patients who underwent ablation had significantly lower treatment-related costs than those who underwent sublobar resection (P < .001). The difference in median treatment-related cost was $16,105. At 1 month, 3 months, and 12 months after treatment, cumulative costs remained significantly different (P ≤ .011). Lower cost associated with ablations performed in the outpatient setting was a major contributor to the differences between the two treatment modalities, although inpatient ablations maintained a small cost advantage over sublobar resections.ConclusionsAmong matched Medicare patients with stage I NSCLC, thermal ablation resulted in significantly lower treatment-related costs and cumulative medical costs 1 month, 3 months, and 12 months after treatment compared with sublobar resection.