Ethanol ablation of renal cell carcinoma for palliation of symptoms in advanced disease

The Guidelines for Percutaneous Transhepatic Portal Vein Embolization: English Version

Preoperative portal vein embolization is a beneficial option to reduce the risk of postoperative liver failure by promoting the growth of the future liver remnant. In particular, a percutaneous transhepatic procedure (percutaneous transhepatic portal vein embolization) has been developed as a less-invasive approach. Although percutaneous transhepatic portal vein embolization is widely recognized as a safe procedure, various complications, including rare but fatal adverse events, have been reported. Currently, there are no prospective clinical trials regarding percutaneous transhepatic portal vein embolization procedures and no standard guidelines for the PTPE procedure in Japan. As a result, various methods and various embolic materials are used in each hospital according to each physician's policy. The purpose of these guidelines is to propose appropriate techniques at present and to identify issues that should be addressed in the future for safer and more reliable percutaneous transhepatic portal vein embolization techniques.

Oncopharmacology in Interventional Radiology

The broad scope of malignancies treated in interventional oncology is mirrored by the breadth of oncotherapeutics, drugs used to treat cancer. Many of these treatments are administered endovascularly, though a group of therapies can be delivered percutaneously. Perhaps the best taxonomy of oncotherapeutics is based on their biological inactivity or activity and the mechanism by which they interact with treated and targeted tissues. As the fields of interventional oncology and oncotherapeutics continue to grow and expand, this framework may provide a more organized approach in helping distinguish and select the best therapy for patients.

Trans-arterial embolization of renal cell carcinoma: a systematic review and meta-analysis

PURPOSE

To evaluate if trans-arterial embolization (TAE) of the primary tumor in patients with renal cell carcinoma (RCC) improves symptomatology such as pain and hematuria or oncologic outcomes such as progression-free survival (PFS) and overall survival (OS).

MATERIALS AND METHODS

The systematic review search included PubMed, Ovid/MEDLINE, and Embase for full-text English articles including randomized and non-randomized prospective trials as well as prospective and retrospective case series. To be included, prospective trials needed ≥ 25 patients in each arm while case series and retrospective chart reviews required at least two patients. Evaluated outcomes included PFS, OS, change in tumor size, improvements in pain, improvements in hematuria, and adverse events (AEs).

RESULTS

1327 articles were retrieved and screened. Nine studies met inclusion criteria (retrospective case series, n = 8; non-randomized prospective trial, n = 1) which included 237 patients (M = 156 (65.8%); F = 56 (23.6%); gender unreported = 25 (10.5%); mean age: 69.4 (range: 38-87)) with a mean tumor diameter of 9.3 cm (5.2-10.5). When reported, the TNM stages were stage I (n = 10), II (n = 18), III (n = 36), and IV (n = 121). 60 patients were treated for pain and hematuria. After TAE, pain improved in 59 patients (98.3%) and hematuria improved in 57 patients (95%). A meta-analysis for improvements in pain and hematuria demonstrated an event rate of pain improvement of 0.952 (0.788-0.990; p < 0.001) and an event rate for hematuria improvement of 0.923 (0.809-0.971; p < 0.001). Median OS ranged from 1 to 39 months but only one study reported PFS (10.5 months). Only one study demonstrated a statistically significant improvement in OS with TAE when compared with patients that did not undergo TAE (p = 0.02). A reduction in tumor size was only achieved in 17 patients (17/49; 34.7%) limiting evaluation. AEs included fever (n = 115/237; 48.5%), flank pain (n = 72/237; 30.4%), nausea (n = 58/237; 24.5%), hematuria (n = 12/237; 5.1%), hypertension (n = 12/237; 5.1%), reduced GFR (n = 6/237; 2.5%), hematoma (n = 6/237,2.5%), and ileus (n = 3/237; 1.3%).

CONCLUSION

TAE monotherapy of the primary tumor in patients with RCC improves symptomatology such as pain and hematuria with an acceptable safety profile.

Superselective vesical artery embolization for intractable bladder hemorrhage related to pelvic malignancy

BACKGROUND

Intractable bladder hemorrhage from pelvic malignancy can be potentially life-threatening and its management can be a challenging clinical problem.

PURPOSE

To evaluate safety, efficacy, and clinical outcome of superselective vesical artery embolization for the control of intractable bladder hemorrhage from pelvic malignancy.

MATERIAL AND METHODS

Between January 2010 and September 2018, 20 patients underwent superselective vesical artery embolization for intractable hematuria secondary to pelvic malignancy arising from or invading the bladder. Treatment details and clinical outcomes were obtained.

RESULTS

There were 12 men and 8 women (mean age = 77 years). Bilateral embolization was performed in 10 patients and unilateral approach in 10 patients. Two patients died within four days after embolization due to underlying heart failure and systemic metastasis, respectively. The remaining 18 patients had a follow-up of >30 days. Bleeding was controlled after the first embolization in 17/18 patients and after a repeat embolization in the remaining one patient. The mean follow-up period of 18 patients was 10.6 months (range = 1-77 months). Late recurrent hemorrhage (≥ 30 days after embolization) was reported in 6 (33.3%) patients. Five of these six patients underwent repeat embolization. There were no major complications related to embolization.

CONCLUSION

Palliative superselective vesical artery embolization is a feasible, effective, and safe procedure to control intractable hematuria in patients with pelvic malignancy.

Renal Artery Embolization for Acute Renal Hemorrhage: A Single-Center Experience

Background

Emergency renal artery embolization (RAE) is a useful method in treating renal trauma and bleeding renal tumors. The aim of this study was to evaluate the clinical efficacy and safety of emergency RAE, and factors associated with RAE failure.

Methods

This retrospective study included patients treated with emergency RAE for acute renal hemorrhage between 1 January 2009 and 31 October 2019 in Srinagarind Hospital. The embolization was performed using coils, glues, and/or gel foams. Factors associated with unsuccessful outcomes were analyzed using univariate and multivariate regression analyses.

Results

A total of 94 patients were treated at the center during the study period with the clinical success rate of 91.5%. The most common cause of acute renal hemorrhage was iatrogenic injury (76.5%). Factors associated with unsuccessful RAE according to multivariate analyses were hypertension (adjusted odds ratio [AOR] 24.2) and ruptured tumor/aneurysm (AOR 26.8).

Conclusion

RAE is an effective procedure for acute renal hemorrhage. Hypertension and ruptured tumor/aneurysm were negative predictors for success.

A 13-gene risk score system and a nomogram survival model for predicting the prognosis of clear cell renal cell carcinoma

BACKGROUND

Renal cell carcinoma (RCC) is the second common malignant tumor in the urinary system, and 85% of RCC cases are clear cell RCC (ccRCC). This study is designed to build a risk score system for ccRCC.

METHODS

The gene methylation and expression data of ccRCC samples were downloaded from The Cancer Genome Atlas database (training set) and ArrayExpress database (validation set). The differentially methylated genes (DMGs) and differentially expressed genes (DEGs) were identified by limma package, and their intersecting genes with negative Pearson correlation coefficients were remained using cor.test function. Prognosis-associated genes were identified by survival package, and the optimal DMGs were obtained using penalized package. After risk score system was built, nomogram survival model was constructed using rms package. Additionally, pathways were enriched for the DEGs between high- and low-risk groups using Gene Set Enrichment Analysis.

RESULTS

There were 3,638 DMGs and 2,702 DEGs between tumor and normal samples. Among the 312 intersecting genes, 43 prognosis-associated genes were identified. A total of 13 optimal DMGs (BTBD19, ADAM8, BGLAP, TNFRSF13C, JPH4, BEST1, GNRH2, UBE2QL1, CHODL, GDF9, UPB1, KCNH3; and ADAMTSL4) were obtained for building the risk score system. After pathological M, pathological T, platelet qualitative, and RS status were revealed to be independent prognostic factors, a nomogram survival model was constructed. For the 920 DEGs between the high- and low-risk samples, 6 significant pathways were enriched.

CONCLUSION

The 13-gene risk score system and the nomogram survival model might be used for prognostic prediction of ccRCC patients.

Palliative Embolization for Refractory Bleeding

Bleeding is a common and often challenging complication of malignancy. Etiologies of hemorrhage in this patient population vary, and bleeding may present as an acute, life-threatening emergency or a chronic, low-volume blood loss. For patients with advanced malignancies, interventions to manage bleeding must be balanced by the patient's life expectancy and quality of life. As such, minimally invasive procedures such as transarterial embolization are useful therapeutic options in appropriately selected patients. There is a rich history of palliative transarterial embolization for refractory bleeding in cancer patients. This technique was first applied in the 1970s and has since become an established treatment tool for malignancy-related bleeding throughout the body. While the preponderance of published data comprised case reports and small retrospective studies, the use of embolization continues to expand as experience grows and techniques are refined. In this review, we summarize the literature and provide our perspective on embolization for refractory bleeding in cancer patients.

Role of embolization in the treatment of renal masses

Renal arterial embolization (RAE) performed for the treatment of renal masses has been proven to be a safe and effective technique, with several decades of experience. RAE is well tolerated with few complications, particularly if the time interval from embolization to surgery is reduced to less than 48 hours. Review of the literature suggests that RAE is also extremely effective for palliation of symptoms in the setting of nonoperative advanced stage renal cell carcinoma. In addition, this technique plays a large role in the management of angiomyolipomas that are symptomatic or at risk of spontaneous rupture. To date, RAE has not been evaluated in a randomized controlled setting, which has contributed to its underutilization. All of these potential benefits warrant the need for prospective studies for further validation.

Multimodal approach to the endovascular treatment of embolisation or exclusion of the renal arteries and their distal and/or polar branches: personal experience

PURPOSE

This study reviews our experience over the last 10 years with procedures of embolisation and/or exclusion of the renal arteries, their parenchymal branches and the polar arteries [renal artery embolisation (RAE)].

MATERIALS AND METHODS

Twenty-seven patients (19 men and eight women; age range 37-93 years; mean 74 years) underwent RAE. The indications were: symptomatic gross haematuria in nine patients (33.3%) (tumour-related in seven and iatrogenic in two), symptomatic inoperable renal tumour in five (18.5%), large subcapsular or perirenal haematoma in three (11.1%) and aneurysm of the main renal artery in two (7.4%). Eight patients (29.6%) scheduled for endovascular aneurysm repair (EVAR) of the abdominal aorta underwent prophylactic embolisation of the renal polar branch arising from the aneurysmal sac or the subrenal aortic neck to prevent the possible revascularisation of the sac. Different embolisation agents were used: coils (17 cases), embolisation particles (14 cases), glue (one case), coated stent (two cases) and mechanical occlusion devices (two cases). In 11 cases, two to three different embolisation agents were used together.

RESULTS

Technical success was achieved in 26/27 patients (96.3%); in one case, embolisation of a polar artery arising from the aneurysmal sac was not possible. One case of gross haematuria recurred 13 months after the procedure and was re-treated with success. There were no cases of major or minor complications.

CONCLUSIONS

RAE is an effective and minimally invasive procedure in the treatment of neoplastic/iatrogenic symptomatic gross haematuria and in the palliative treatment of inoperable renal tumours. One possible new indication is the prophylactic exclusion of the polar artery arising from the neck or the sac of an abdominal aortic aneurysm in patients who are candidates for EVAR. In our experience, we observed very low morbidity and a short hospital stay. This procedure requires the availability of various materials for performing embolisation and experience in their use.