Prostatic Artery Embolization—Anatomic Predictors of Technical Outcomes

PurposeTo determine if cone-beam CT and digital subtraction angiography analysis of pelvic arterial anatomy has predictive value for radiation exposure and technical success of prostatic artery embolization (PAE).Materials and MethodsThis prospective, nonrandomized, single-center study included 104 consecutive patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia. Cone-beam CT was performed in 160/208 (76.9%) hemipelves to determine prostatic artery (PA) origin. Classification of pelvic arterial tortuosity was possible in 73/104 (70.2%) patients. Learning curves of 2 interventionalists who performed 86.5% of PAEs were analyzed.ResultsTortuosity of pelvic arteries was classified as mild in 25 (34.2%) patients median age 64 years, moderate in 40 (54.8%) patients median age 69 years, and severe in 8 (11.0%) patients median age 70 years (mild vs moderate, P = .002; mild vs severe, P = .019); median fluoroscopy times were 24, 36, and 46 minutes (P = .008, P = .023); median contrast volumes were 105, 122.5, and 142 mL (P = .029, P = .064); and bilateral PAE rates were 84.0%, 77.5%, and 62.5% (P = .437), respectively. PA origin from superior vesical artery was most frequent (27.5%) and showed higher dose area product (median 402.4 vs 218 Gy ∙ cm², P = .033) and fluoroscopy time (median 42.5 vs 27 min, P = .01) compared with PA origin from obturator artery, which was least frequent. Interventionalist experience revealed significant impact on procedure times (median 159 vs 130 min, P = .006).ConclusionsTortuosity of pelvic arteries was more frequent in older patients and predicted worse technical outcomes of PAE. PA origin from obturator artery was associated with lower dose area product and fluoroscopy time, especially compared with PA origin from superior vesical artery. Interventionalist experience showed significant influence on technical outcome.     

A Single-Institutional Comparative Analysis of Advanced Versus Standard Snare Removal of Inferior Vena Cava Filters

PurposeTo investigate differences in procedure time, radiation exposure, and periprocedural complications associated with advanced inferior vena cava (IVC) filter retrieval compared with standard snare retrieval.Materials and MethodsA total of 378 patients underwent standard or advanced IVC filter retrieval over a 5-year period. Technical success, retrieval techniques, fluoroscopy time, radiation dose, and complications were analyzed. All retrieval procedures with techniques other than a “snare-and-sheath” method were categorized as advanced, including failed standard attempts requiring intraprocedural conversion to advanced techniques.ResultsA total of 462 filter retrieval attempts were made in 378 patients (57% female). Success rates for standard and advanced retrieval attempts were 86.8% (317 of 365) and 91.8% (89 of 97), respectively. The rate of periprocedural complications was significantly higher in the advanced retrieval group (P = .006). Complication rates for standard and advanced retrievals were 0.6% (2 of 318; all minor) and 5.2% (5 of 97; 3 minor [3.1%] and 2 major [2.1%]), respectively. The 2 major complications during advanced retrievals included filter fracture and embolization. Average fluoroscopy time for advanced retrievals was significantly higher than for standard retrievals (23.1 min vs 4.3 min; P < .001). Average radiation dose for advanced retrievals was also significantly higher than for standard retrievals (557.2 mGy vs 156.9 mGy; P < .001). Use of general anesthesia was also significantly more common in advanced retrievals compared with standard retrievals (6.2% vs 0.9%; P = .002).ConclusionsAdvanced filter retrieval results in a similarly high rate of technical success compared with standard snare retrieval but is associated with greater fluoroscopy time, anesthesia requirements, and radiation exposure.     

Analyzing Radiation Use during Transjugular Intrahepatic Portosystemic Shunt Creation

Portal vein access during transjugular intrahepatic portosystemic shunt creation was examined in 11 patients. Radiation metrics (kerma area product, reference point air kerma, and fluoroscopy times) during portal vein access were significantly greater for conventional versus intravascular US–guided transjugular intrahepatic portosystemic shunt (54.8 mGy ∙ cm² ± 27.6 vs 8.4 mGy ∙ cm² ± 5.0, P = .009; 210.4 mGy ± 109.1 vs 29.5 mGy ± 18.4, P = .009; 19.1 min ± 8.6 vs 8.9 min ± 4.6, P = .04). Wedged hepatic venography is a major contributor to radiation exposure. Intravascular US guidance is associated with significantly reduced radiation use.     

Percutaneous Gastrostomy Compared with Esophageal Stent Placement for the Treatment of Esophageal Cancer with Dysphagia

PurposeTo compare the outcomes of self-expandable metal stent placement and percutaneous gastrostomy (PG) for the treatment of patients with esophageal cancer (EC) and dysphagia.Materials and MethodsThis retrospective observational study consisted of 113 patients with EC and dysphagia who underwent either stent placement (n = 47) or PG (n = 66) at a single center between June 2014 and June 2018.ResultsThere were 63 men and 50 women, with a mean age of 76.5 years (standard deviation 4.9 years). The 2 groups had similar baseline characteristics, except that the PG group had a higher percentage of patients with cervical EC (22.7% vs 2.1%, P < .001). The PG group had better maintenance of nutritional status in terms of reduction in serum albumin level (P = .039) and weight loss (P = .041). Compared with the stent group, the PG group demonstrated a lower incidence of local severe pain (0% vs 21.3%, P < .001) and lower incidence of dislodgment of device (1.5% vs 19.1%, P = .002). The PG group demonstrated longer overall survival compared with the stent group for Stages II and III (201 vs 185 days, P = .034) and Stage IV (122 vs 86 days, P = .001).ConclusionsCompared with stent insertion, PG is associated with better maintenance of nutritional status, fewer complications, and better survival. Thus, PG may be the preferred choice for treating malnutrition in patients with EC and dysphagia.     

Single-Use versus Reusable Endoscopes for Percutaneous Biliary Endoscopy with Lithotripsy: Technical Metrics,Clinical Outcomes,and Cost Comparison

PurposeTo compare procedure and fluoroscopy time, technical and clinical success, and costs between single-use and reusable endoscopes in patients undergoing percutaneous biliary endoscopy (PBE) with lithotripsy.Material and MethodsThirty-four patients (67 procedures) were retrospectively included in the study. The patients were treated with PBE for gallstone removal from October 24, 2014, to February 12, 2020, using reusable (28 procedures) or single-use (39 procedures) endoscopes. The procedure time, fluoroscopy time, technical success rate (accessing the biliary system and locating the gallstone), clinical success rate (at least partial gallstone removal), complication rate, and cost of use were compared between the procedures.ResultsThe mean (± standard deviation) procedure time was not significantly different between single-use (136 minutes ± 45) and reusable endoscopes (136 minutes ± 51) (P = .47). The mean fluoroscopy time was significantly shorter for single-use endoscopes (11 minutes ± 8.4) than for reusable endoscopes (18 minutes ± 12) (P = .01). When comparing single-use versus reusable endoscopes, the technical success (95% [n = 37] vs 93% [n = 26]) and the clinical success (90% [n = 35] vs 75% [n = 21]) rates were not significantly different (both, P > .05). Only 1 complication was noted in the reusable endoscope group (P = .42). The cost per case was lower for single-use ($1,500) than for reusable ($3,987) endoscope procedures, primarily due to differences in capital costs and repair costs.ConclusionsSingle-use endoscopes offer the potential for lower patient radiation exposure and lower cost per case, which may reduce the financial barriers to offering PBE in interventional radiology practices. The clinical and technical success rates did not differ by endoscope type.     

Uterine Artery Embolization following Cesarean Delivery but prior to Hysterectomy in the Management of Patients with Invasive Placenta

PurposeTo evaluate outcomes of patients with placenta accreta spectrum (PAS) disorders who underwent uterine artery embolization (UAE) following cesarean delivery but before hysterectomy.Materials and MethodsA retrospective review of patients with PAS treated with cesarean-hysterectomy (C-hyst) was performed. Patients in the UAE group underwent UAE after cesarean delivery but before hysterectomy; patients in the control group underwent C-hyst alone. Estimated blood loss (EBL), transfusion requirements, length of intensive care unit (ICU) stay, and adverse events were evaluated.ResultsThe study included 31 patients, 7 in the UAE group and 24 in the control group. Median EBL, transfusion requirements, and length of ICU stay in the UAE group compared with control group were 1,500 mL (range, 500–2,000 mL) vs 2,000 mL (range, 1,000–4,500 mL) (P = .04), 150 mL (range, 0–650 mL) vs 550 mL (range, 0–3,125 mL) (P = .10), and 0 d (range, 0–1 d) vs 0.5 d (range, 0–2 d) (P = .07). All patients in the UAE group had placenta increta; patients in the control group had placenta accreta (29%), increta (54%), and percreta (17%) (P = .10). Subgroup analysis of patients with placenta increta demonstrated that the UAE group had a significant decrease in median EBL (P = .004), transfusion requirements (P = .009), and length of ICU stay (P = .04). No adverse events following UAE were noted.ConclusionsUAE following cesarean delivery but before hysterectomy in patients with placenta increta appears to be safe and effective in decreasing EBL, transfusion requirements, and length of ICU stay compared with C-hyst alone.     

Percutaneous CT-Guided Abdominal and Pelvic Biopsies: Comparison of an Electromagnetic Navigation System and CT Fluoroscopy

PurposeTo compare electromagnetic navigation (EMN) with computed tomography (CT) fluoroscopy for guiding percutaneous biopsies in the abdomen and pelvis.Materials and MethodsA retrospective matched-cohort design was used to compare biopsies in the abdomen and pelvis performed with EMN (consecutive cases, n = 50; CT-Navigation; Imactis, Saint-Martin-d’Hères, France) with those performed with CT fluoroscopy (n = 100). Cases were matched 1:2 (EMN:CT fluoroscopy) for target organ and lesion size (±10 mm).ResultsThe population was well-matched (age, 65 vs 65 years; target size, 2.0 vs 2.1 cm; skin-to-target distance, 11.4 vs 10.7 cm; P > .05, EMN vs CT fluoroscopy, respectively). Technical success (98% vs 100%), diagnostic yield (98% vs 95%), adverse events (2% vs 5%), and procedure time (33 minutes vs 31 minutes) were not statistically different (P > .05). Operator radiation dose was less with EMN than with CT fluoroscopy (0.04 vs 1.2 μGy; P < .001), but patient dose was greater (30.1 vs 9.6 mSv; P < .001) owing to more helical scans during EMN guidance (3.9 vs 2.1; P < .001). CT fluoroscopy was performed with a mean of 29.7 tap scans per case. In 3 (3%) cases, CT fluoroscopy was performed with gantry tilt, and the mean angle out of plane for EMN cases was 13.4°.ConclusionsPercutaneous biopsies guided by EMN and CT fluoroscopy were closely matched for technical success, diagnostic yield, procedure time, and adverse events in a matched cohort of patients. EMN cases were more likely to be performed outside of the gantry plane. Radiation dose to the operator was higher with CT fluoroscopy, and patient radiation dose was higher with EMN. Further study with a wider array of procedures and anatomic locations is warranted.     

Single-Center Retrospective Comparative Analysis of Transradial,Transbrachial, and Transfemoral Approach for Mesenteric Arterial Procedures

PurposeTo assess feasibility and safety of transradial access (TRA) compared with transfemoral access (TFA) and transbrachial access (TBA) for mesenteric arterial endovascular procedures.Materials and MethodsA retrospective cohort analysis was performed including all consecutive patients who underwent a mesenteric arterial procedure in a tertiary referral center between May 2012 and February 2018. Exclusion criteria were absence of data and lost to follow-up within 24 hours after the procedure. During the study period, 103 patients underwent 148 mesenteric arterial procedures (TBA, n = 52; TFA, n = 39; TRA, n = 57). Mean patient age was 64.3 years ± 13.3, and 91 patients (62%) were women. Primary outcomes were vascular access specified technical success rate and access site complication rate, as reported in hospital records.ResultsTechnical success rate specified for the vascular access technique did not differ between the 3 approaches (TBA 96%, TFA 87%, TRA 91%; TRA vs TBA, P = .295; TBA vs TFA, P = .112; TRA vs TFA, P = .524), and overall access site complication rate was not different between the 3 approaches (TBA 42%, TFA 23%, TRA 35%; TRA vs TBA, P = .439; TBA vs TFA, P = .055; TRA vs TFA, P = .208). However, more major access site complications were reported for TBA than for TRA or TFA (TBA 17%, TFA 3%, TRA 2%; TRA vs TBA, P = .005; TBA vs TFA, P = .026; TRA vs TFA, P = .785).ConclusionsTRA is a safe and feasible approach for mesenteric arterial procedures comparable to TFA, but with a significantly lower major access site complication rate than TBA.     

CT Fluoroscopy for Image-Guided Procedures: Physician Radiation Dose During Full-Rotation and Partial-Angle CT Scanning

PurposeTo determine physician radiation exposure when using partial-angle computed tomography (CT) fluoroscopy (PACT) vs conventional full-rotation CT and whether there is an optimal tube/detector position at which physician dose is minimized.Materials and MethodsPhysician radiation dose (entrance air kerma) was measured for full-rotation CT (360°) and PACT (240°) at all tube/detector positions using a human-mimicking phantom placed in a 64-channel multidetector CT. Parameters included 120 kV, 20- and 40-mm collimation, and 100 mA. The mean, standard deviation, and increase/decrease in physician dose compared with a full-rotation scan were reported.ResultsPhysician radiation exposure during CT fluoroscopy with PACT was highly dependent on the position of the tube/detector during scanning. The lowest PACT physician dose was when the physician was on the detector side (center view angle 116°; ?35% decreased dose vs full-angle CT). The highest PACT physician dose was with the physician on the tube side (center view angle 298°; +34% increased dose vs full-angle CT), all doses P <.05 vs full-rotation CT.ConclusionsPartial-angle CT has the potential to both significantly increase or decrease physician radiation dose during CT fluoroscopy-guided procedures. The detector/tube position has a profound effect on physician dose. The lowest dose during PACT was achieved when the physician was located on the detector side (ie, distant from the tube). This data could be used to optimize CT fluoroscopy parameters to reduce physician radiation exposure for PACT-capable scanners.     

The Lutonix AV Randomized Trial of Paclitaxel-Coated Balloons in Arteriovenous Fistula Stenosis: 2-Year Results and Subgroup Analysis

PurposeTo present final, 2-year results of a randomized trial comparing paclitaxel-coated vs uncoated balloon angioplasty following vessel preparation with ultra–high-pressure percutaneous transluminal angioplasty (PTA) in hemodialysis arteriovenous fistulae (AVFs).Materials and MethodsTwenty-three sites enrolled 285 subjects with dysfunctional AVFs located in the arm. Before 1:1 randomization, successful vessel preparation was achieved (full waist effacement, < 30% residual stenosis). Follow-up was clinically driven except for a 6-month office visit.ResultsNinety-six of 141 subjects in the drug-coated balloon (DCB) arm and 111 of 144 in the control arm completed the study. Target lesion primary patency (TLPP) rates for the DCB and control groups were 58% ± 4 vs 46% ± 4 (P = .02) at 9 months, 44% ± 5 vs 36% ± 4 (P = .04) at 12 months, 34% ± 5 vs 28% ± 4 (P = .06) at 18 months, and 27% ± 4 vs 24% ± 4 (P = .09) at 24 months, respectively. Mean time to TLPP event for subjects with an event was longer for DCBs (322 vs 207 d; P < .0001). Fewer interventions were needed to maintain target lesion patency in the DCB group at 9 months (P = .02) but not at 12 (P = .08), 18 (P = .13), or 24 months (P = .19). The noninferiority safety target was met at all intervals (P < .01). Mortality did not differ between groups (P = .27). Post hoc analyses showed equivalent DCB effect in all subgroups.ConclusionsTwo-year results demonstrate long-term safety and variable efficacy of DCB angioplasty in AVFs.     

Yttrium-90 Radiation Segmentectomy of Hepatocellular Carcinoma: A Comparative Study of the Effectiveness,Safety, and Dosimetry of Glass-Based versus Resin-Based Microspheres

PurposeTo evaluate the differences in safety, effectiveness, and dosimetry between glass-based and resin-based ablative yttrium-90 (⁹⁰Y) transarterial radioembolization (TARE) of hepatocellular carcinoma (HCC).Materials and MethodsUsing the modified Response Evaluation Criteria in Solid Tumors and Common Terminology Criteria for Adverse Events, both tumor response and adverse events (AEs) were assessed at 3 months after ⁹⁰Y-TARE. Post procedure ⁹⁰Y-bremsstrahlung single-photon emission computed tomography/computed tomography voxel-based dosimetry analysis was used to create tumor dose (TD) and normal tissue dose (NTD) volume histograms, and to calculate tumor particle loading and specific activity. The TD and NTD receiver operating characteristic curves evaluated the dose threshold able to predict objective (partial or complete) and complete tumor responses in addition to any-grade and grade ≥3 AE incidences. The chi-square test and Student t-test were used to assess variable differences where appropriate.ResultsBetween 2019 and 2020, 81 patients with HCC (20 in the resin-based cohort and 61 in the glass-based cohort) underwent ablative ⁹⁰Y-TARE. The resin-based cohort had more males (89% vs 65%, P = .03), lower tumor-to-normal ratio (1.81 ± 0.39 vs 2.22 ± 0.94, P = .03), higher tumor particle loading (40,172 particles/mL ± 28,039 vs 17,081 particles/mL ± 12,555, P = .0001), lower specific activity (158 Bq/particle ± 3 vs 1,058 Bq/particle ± 331, P = .001), and lower mean TD (308 Gy ± 210 vs 794 Gy ± 523, P = .0002) than the glass-based cohort. No significant differences in baseline characteristics or posttreatment AEs were noted. The overall objective and complete response rates were 85% (95% resin-based vs 82% glass-based; P = .1) and 65% (95% resin-based vs 56% glass-based; P = .003), respectively. The mean TD thresholds able to predict the objective and complete responses were 176 Gy and 247 Gy for resin-based radioembolization and 290 Gy and 481 Gy for glass-based radioembolization, respectively. A maximum NTD of 999 Gy predicted any-grade AEs in glass-based ablative ⁹⁰Y-TARE.ConclusionsCompared with glass-based ablative ⁹⁰Y-TARE, resin-based ablative ⁹⁰Y-TARE can offer comparable safety and effectiveness profiles for patients with HCC. The impact of the significantly different tumor particle loading, particle specific activities, and delivered TDs on tumor response outcomes merits further investigation.     

Socioeconomic and Survival Analysis of Radioembolization in Patients with Intrahepatic Cholangiocarcinoma: A Propensity Score–Adjusted Study

PurposeTo determine whether transarterial radioembolization (TARE) is associated with longer survival of patients with intrahepatic cholangiocarcinoma (ICC) and whether access to TARE is influenced by socioeconomic factors.Materials and MethodsRetrospective review of patients with ICC in the National Cancer Database from 2004 to 2018 was performed with Cox regression analysis to identify predictors of survival. Overall survival (OS) was estimated using the Kaplan-Meier method. Socioeconomic factors were compared between 2 groups using the Wilcoxon rank-sum test and χ² test. Propensity score–matched cohorts were created between patients with ICC who did and did not undergo TARE.ResultsThe number of patients receiving TARE for ICC increased over time from 1 in 2004 to 210 in 2018. Patients in the TARE group were more likely to be White (87.9% vs 84.3%; P = .012) and less likely to be Hispanic/Latino (7.7% vs 11.0%; P = .009). Fewer patients who underwent TARE were uninsured (0.9% vs 2.8%; P = .012). Older age, male sex, non-White race, higher tumor grade size, and stage, earlier year of diagnosis, lack of treatment with surgery or systemic therapy, and presence of lymphatic or vascular invasion exhibited significant associations with decreased survival (P < .05 for all). Patients who underwent TARE had longer survival in both unadjusted and adjusted cohorts, with an OS of 17.5 months (vs 7.2 months in the non-TARE group) after propensity matching.ConclusionsPatients with ICC who had undergone TARE experienced significantly longer survival than that experienced by those who had not after adjusting for measurable confounders. Significant socioeconomic disparities in access to TARE remain.     

Transarterial Radioembolization versus Transarterial Chemoembolization Plus Percutaneous Ablation for Unresectable,Solitary Hepatocellular Carcinoma of ≥3 cm: A Propensity Score–Matched Study

PurposeTo compare the safety and effectiveness of transarterial radioembolization (TARE) and transarterial chemoembolization with drug-eluting embolic agents combined with percutaneous ablation (transarterial chemoembolization [TACE] + ablation) in the treatment of treatment-naïve, unresectable, solitary hepatocellular carcinoma (HCC) of ≥3 cm.Materials and MethodsTwenty-nine patients with treatment-naïve, unresectable, solitary HCC of ≥3 cm received combined TACE + ablation, and 40 patients received TARE at a single institution. Local tumor response, tumor progression-free survival (PFS), overall survival, need for reintervention, bridge to transplant, and major complications were compared. Clinical variables and outcomes were compared before and after propensity score matching (PSM).ResultsBefore PSM, patients who underwent TARE had a larger tumor size (3.7 vs 5.5 cm; P = .0005) and were older (61.5 vs 69.3 years; P = .0014). After PSM, there was no difference in baseline characteristics between the 2 groups, with the mean tumor sizes measuring 3.9 and 4.1 cm in the TACE + ablation and TARE cohorts, respectively. After PSM (n = 19 in each group), no statistically significant difference was observed in local radiological response (disease control rates, 100% vs 94.7%; P = .31), survival (subdistribution hazard ratio [SHR], 0.71; 95% confidence interval [CI], 0.28–1.80; P = .469), PFS (SHR, 0.61; 95% CI, 0.21–1.71; P = .342), bridge to transplant (21.1% vs 31.6%, P = .46), and major adverse event rates (15.8% vs 10.5%, P = .63) between the 2 groups. The mean total number of locoregional interventions was higher in the TACE + ablation cohort (1.9 vs 1.3 sessions, P = .02), with an earlier median reintervention trend (SHR, 0.61; 95% CI, 0.20–1.32; P = .167).ConclusionsThe present study showed that TARE and the combination of TACE and ablation are comparable in safety and effectiveness for treating treatment-naïve, unresectable, solitary HCC of ≥3 cm.     

Idarubicin-Loaded ONCOZENE Drug-Eluting Bead Chemoembolization in a Rabbit Liver Tumor Model: Investigating Safety,Therapeutic Efficacy,and Effects on Tumor Microenvironment

PurposeTo investigate toxicity, efficacy, and microenvironmental effects of idarubicin-loaded 40-μm and 100-μm drug-eluting embolic (DEE) transarterial chemoembolization in a rabbit liver tumor model.Materials and MethodsTwelve male New Zealand White rabbits with orthotopically implanted VX2 liver tumors were assigned to DEE chemoembolization with 40-μm (n = 5) or 100-μm (n = 4) ONCOZENE microspheres or no treatment (control; n = 3). At 24–72 hours postprocedurally, multiparametric magnetic resonance (MR) imaging including dynamic contrast-enhanced (DCE), diffusion-weighted imaging (DWI), and biosensor imaging of redundant deviation in shifts (BIRDS) was performed to assess extracellular pH (pHe), followed by immediate euthanasia. Laboratory parameters and histopathologic ex vivo analysis included fluorescence confocal microscopy and immunohistochemistry.ResultsDCE MR imaging demonstrated a similar degree of devascularization of embolized tumors for both microsphere sizes (mean arterial enhancement, 8% ± 12 vs 36% ± 51 in controls; P = .07). Similarly, DWI showed postprocedural increases in diffusion across the entire lesion (apparent diffusion coefficient, 1.89 × 10⁻³ mm²/s ± 0.18 vs 2.34 × 10⁻³ mm²/s ± 0.18 in liver; P = .002). BIRDS demonstrated profound tumor acidosis at baseline (mean pHe, 6.79 ± 0.08 in tumor vs 7.13 ± 0.08 in liver; P = .02) and after chemoembolization (6.8 ± 0.06 in tumor vs 7.1 ± 0.04 in liver; P = .007). Laboratory and ex vivo analyses showed central tumor core penetration and greater increase in liver enzymes for 40-μm vs 100-μm microspheres. Inhibition of cell proliferation, intratumoral hypoxia, and limited idarubicin elution were equally observed with both sphere sizes.ConclusionsNoninvasive multiparametric MR imaging visualized chemoembolic effects in tumor and tumor microenvironment following DEE chemoembolization. Devascularization, increased hypoxia, coagulative necrosis, tumor acidosis, and limited idarubicin elution suggest ischemia as the predominant therapeutic mechanism. Substantial size-dependent differences indicate greater toxicity with the smaller microsphere diameter.     

Radiation Segmentectomy for the Treatment of Solitary Hepatocellular Carcinoma: Outcomes Compared with Those of Surgical Resection

PurposeTo investigate the outcomes of radiation segmentectomy (RS) versus standard-of-care surgical resection (SR).Materials and MethodsA multisite, retrospective analysis of treatment-naïve patients who underwent either RS or SR was performed. The inclusion criteria were solitary hepatocellular carcinoma ≤8 cm in size, Eastern Cooperative Oncology Cohort performance status of 0–1, and absence of macrovascular invasion or extrahepatic disease. Target tumor and overall progression, time to progression (TTP), and overall survival rates were assessed. Outcomes were censored for liver transplantation.ResultsA total of 123 patients were included (RS, 57; SR, 66). Tumor size, Child-Pugh class, albumin-bilirubin score, platelet count, and fibrosis stage were significantly different between cohorts (P ≤ .01). Major adverse events (AEs), defined as grade ≥3 per the Clavien-Dindo classification, occurred in 0 patients in the RS cohort vs 13 (20%) patients in the SR cohort (P < .001). Target tumor progression occurred in 3 (5%) patients who underwent RS and 5 (8%) patients who underwent SR. Overall progression occurred in 19 (33%) patients who underwent RS and 21 (32%) patients who underwent SR. The median overall TTP was 21.9 and 29.4 months after RS and SR, respectively (95% confidence interval [CI], 15.5–28.2 and 18.5–40.3, respectively; P = .03). Overall TTP subgroup analyses showed no difference between treatment cohorts with fibrosis stages 3–4 (P = .26) and a platelet count of <150 × 10⁹/L (P = .29). The overall progression hazard ratio for RS versus SR was not significant per the multivariate Cox regression analysis (1.16; 95% CI, 0.51–2.63; P = .71). The median overall survival was not reached for either of the cohorts. Propensity scores were calculated but were too dissimilar for analysis.ConclusionsRS and SR were performed in different patient populations, which limits comparison. RS approached SR outcomes, with a lower incidence of major AEs, in patients who were not eligible for hepatectomy.     

Stereotactic Body Radiotherapy for Stage I Renal Cell Carcinoma: National Treatment Trends and Outcomes Compared to Partial Nephrectomy and Thermal Ablation

PurposeTo assess use of stereotactic body radiotherapy (SBRT) for stage I renal cell carcinoma (RCC) and compare outcomes with thermal ablation and partial nephrectomy (PN).Materials and MethodsThe 2004–2015 National Cancer Database was investigated for histopathologically proven stage I RCC treated with PN, cryoablation, radiofrequency (RF) or microwave (MW) ablation, or SBRT. Patients were propensity score–matched to account for potential confounders, including patient age, sex, race, comorbidities, tumor size, histology, grade, tumor sequence, administration of systemic therapy, treatment in academic vs nonacademic centers, treatment location, and year of diagnosis. Overall survival (OS) was evaluated with Kaplan-Meier plots, log-rank tests, and Cox proportional hazards models.ResultsA total of 91,965 patients were identified (SBRT, n = 174; PN, n = 82,913; cryoablation, n = 5,446; RF/MW ablation, n = 3,432). Stage I patients who received SBRT tended to be older women with few comorbidities treated at nonacademic centers in New England states. After propensity score matching, a cohort of 636 patients was obtained with well-balanced confounders between treatment groups. In the matched cohort, OS after SBRT was inferior to OS after PN and thermal ablation (PN vs SBRT, hazard ratio [HR] = 0.29, 95% confidence interval [CI] 0.19–0.46, P < .001; cryoablation vs SBRT, HR = 0.40, 95% CI 0.26–0.60, P < .001; RF/MW ablation vs SBRT, HR = 0.46, 95% CI 0.31–0.67, P < .001). Compared with PN, neither cryoablation nor RF/MW ablation showed significant difference in OS (cryoablation vs PN, HR = 1.35, 95% CI 0.80–2.28, P = .258; RF/MW ablation vs PN, HR = 0.64, 95% CI 0.95–2.55, P = .079).ConclusionsCurrent SBRT protocols show lower OS compared with thermal ablation and PN, whereas thermal ablation and PN demonstrate comparable outcomes.     

Diagnosis and Treatment of Nonmaturing Fistulae for Hemodialysis Access via Transradial Approach: A Case-Control Study

PurposeTo compare outcomes of transradial access for endovascular treatment of nonmaturing hemodialysis fistulae compared to brachial arteriography followed by unidirectional or bidirectional fistula access for intervention.Materials and MethodsIn this institutional review board-approved, retrospective, case-control study, 56 consecutive patients with nonmaturing arteriovenous fistulae underwent percutaneous intervention between 2015 and 2018. The transradial group (n = 28) underwent radial artery access for diagnostic fistulography and intervention. The control group (n = 28) underwent retrograde brachial artery access for fistulography followed by unidirectional/bidirectional fistula access for intervention. Both groups had similar demographics, fistula characteristics, and stenosis locations.ResultsFewer punctures were required in the transradial group compared to controls (1.2 vs 2.4, P < .0001), and procedure time was shorter (64.9 vs 91.3 minutes, P = .0016). Anatomic, technical, and clinical success rates trended higher in the transradial group compared to controls (93% vs 86%, 96% vs 89%, and 82% vs 64%, respectively). Nonmaturation resulting in fistula abandonment was lower in the transradial group (3.7% vs 25%, P = .025). Primary unassisted patency at 3, 6, and 12 months was 77.1% ± 8.2%, 73.1% ± 8.7%, and 53.3% ± 10.6% in the transradial group, respectively, and 63.0% ± 9.3%, 55.6% ± 9.6%, and 48.1% ± 9.6% in the control group, respectively (P = .76). Primary assisted patency at 12 months was 92.3% ± 5.3% in the transradial group compared to 61.8% ± 9.6% at 12 months in the control group (P = .021). No major complications occurred. Minor complications were lower in the transradial group than in the control group (14% vs 39%, P = .068).ConclusionsTreatment of nonmaturing fistulae via a transradial approach was safe, improved midterm patency, and was associated with lower rates of fistula abandonment.     

Preliminary Study of Microwave Ablation for Multifocal Papillary Thyroid Microcarcinoma in Nonoperative Candidates

PurposeTo study the feasibility, safety, and effectiveness of microwave ablation (MWA) in patients with multifocal papillary thyroid microcarcinoma (PTMC).Materials and MethodsThis retrospective study included patients who underwent MWA for multifocal PTMC (number of nodules ≤3). A total of 44 patients were included, and the mean age was 43 years (SD ± 11). After ablation, progression-free survival (PFS) at 6, 12, 24, 36, and 48 months; disease progression; change in tumor size and volume; tumor disappearance rate; and adverse events (AEs) were assessed, and the feasibility, safety, and effectiveness of MWA for PTMC were evaluated on the basis of statistical analysis.ResultsThe median follow-up period was 18 months (interquartile range, 12–33 months). The PFS rates at 6, 12, 24, 36, and 48 months were 100.0%, 96.4%, 96.4%, 70.3%, and 52.7%, respectively. The disease progression rate was 11.4% (5 of 44 patients). The maximum diameter (MD) and volume of the ablation zone were larger at the 3-month follow-up than before ablation (median MD, 13.0 vs 7.0 mm; P < .001; median volume, 503.8 vs 113.0 mm³; P < .001). Subsequently, the tumors exhibited a reduction in both size and volume after 18 months (median MD, 4.0 vs 7.0 mm; P = .04; median volume, 12.6 vs 113.0 mm³; P = .055). At the end of the follow-up period, the complete response rate was 59% (26 of 44 patients). The overall AE rate was 6.8%.ConclusionsMWA is a feasible treatment for PTMC (number of nodules ≤3), and this study preliminarily demonstrated the safety and effectiveness of this technique.     

Mitigation of Sarcopenia after Peritoneovenous Shunt Placement in Patients with Refractory Ascites

PurposeTo evaluate the effect of peritoneonvenous shunt placement on metrics of sarcopenia in patients with refractory ascites.Materials and MethodsAn institutional review board–approved single-institution retrospective analysis of all patients who underwent peritoneovenous shunt (Denver Shunt; BD, Franklin Lakes, New Jersey) placement (N = 29) and a comparator cohort of patients with cirrhosis who underwent serial paracentesis (N = 42) from 2009 to 2019 with baseline and follow-up cross-sectional imaging of at least 3 months was performed. Axial muscle area measurements (psoas, paraspinal, and total abdominal wall) were performed using free-hand region-of-interest technique. Patient records were reviewed for demographic characteristics, referring indication, laboratory studies, and performance status. Statistical analyses were performed with Student t test, Welch unequal variances, Fisher exact test, and Wilcoxon signed rank test.ResultsThe most common indications for peritoneovenous shunt placement were metastatic disease or cirrhosis. In the shunt cohort, there were no significant differences in the aggregate psoas muscle area (13.4 vs 14.0 cm²; P = .223) or paraspinal muscle area (43.0 vs 42.2 cm²; P = .471). In the paracentesis cohort, there were significant decreases in aggregate psoas (18.1 vs 15.7 cm²; P < .0001) and erector spinae (43.4 vs 39.9 cm²; P < .0001) muscle area. In addition, there was a significant decrease in serum albumin level (3.2 vs 3.0 g/dL; P = .015) and Eastern Cooperative Oncology Group performance status score (1.0 vs 1.3; P < .0001) in the paracentesis group, compared with no significant changes in the shunt cohort.ConclusionsIn patients with refractory ascites who are not candidates for transjugular intrahepatic portosystemic shunt placement, peritoneovenous shunt mitigates loss of truncal muscle and, in some instances, promotes muscle growth.     

Transarterial Chemoembolization Followed by Radiofrequency Ablation for Hepatocellular Carcinoma: Impact of the Time Interval between the Two Treatments on Outcome

PurposeTo compare the efficacy of radiofrequency (RF) ablation after transarterial chemoembolization within or beyond 30 days for medium-large or multiple recurrent hepatocellular carcinomas (HCCs).Materials and MethodsIn this single-center retrospective study conducted from 2007 through 2015, 135 patients with a single recurrent HCC (>3 cm) or multiple (2–5 tumors) recurrent HCCs underwent transarterial chemoembolization plus RF ablation. A total of 62 patients underwent RF ablation after transarterial chemoembolization within 30 days (sequential group) and 73 patients underwent RF ablation after transarterial chemoembolization beyond 30 days (delayed group). Outcomes of interests included overall survival (OS), progression-free survival (PFS), and complete response (CR) rate.ResultsThe median OS and PFS were 49.8 and 38.0 months for sequential group, and 31.0 and 11.6 months for the delayed group. The sequential group experienced significantly better OS (hazard ratio [HR]: 0.517; P = .002) and PFS (HR, 0.621; P = .021). Among patients with multiple tumors or a single tumor >5 cm, the sequential group still had significantly longer OS (P = .022; P = .018, respectively) and PFS (P = 0.042; P = .036, respectively) than the delayed group, although no significant differences were observed among patients with solitary 3- to 5-cm tumors (P = .138; P = .803, respectively). The sequential group had a significantly better CR rate than the delayed group (85.4% vs. 68.5%, respectively; P = .035). Significant predictors of OS and PFS included maximum tumor size, number of tumors, and time interval between transarterial chemoembolization and RF ablation.ConclusionsTransarterial chemoembolization plus sequential RF ablation within 30 days was more effective for recurrent HCCs than transarterial chemoembolization plus delayed RF ablation. The time interval within 30 days is required for treating large or multiple HCCs but may not be necessary for solitary medium-sized HCC.