Imaging Changes and Clinical Complications After Drug-Eluting Bead Versus Conventional Transarterial Chemoembolization for Unresectable Hepatocellular Carcinoma: Multicenter Study

Biliary Leaks: Multidisciplinary Approach to Diagnosis and Treatment

Bile leaks arise from various causes such as trauma, complications after hepatobiliary surgery, and intrahepatic malignancies or their associated liver-directed treatments. Bile leaks can result in significant morbidity and mortality. Delayed diagnosis is not uncommon due to nonspecific manifestations; therefore, a high clinical suspicion is needed. A multidisciplinary approach for treatment of biliary leaks with prompt referral to tertiary care centers with experienced hepatobiliary surgeons, advanced endoscopists, and interventional radiologists is needed to address these challenging complications. Management of biliary leaks can range from conservative management to open surgical repair. Minimally invasive procedures play a crucial role in biliary leak treatment, and the interventional radiologist can help guide appropriate management on the basis of a clear understanding of the pathophysiology of biliary leaks and a current knowledge of the armamentarium of treatment options. In most cases, a simple diversion of bile to decompress the biliary system may prove effective. However, persistent and high-output biliary leaks require delineation of the source with tailored treatment options to control the leak. This may be done by additional diversions, occluding the source, reestablishing connections, or using a combination of therapies to bridge to more definitive surgical interventions. The authors describe the different treatment options and emphasize the role of interventional radiology. ©RSNA, 2024.

DEB-TACE versus cTACE for unresectable HCC with B1-type bile duct invasion after successful biliary drainage: A propensity score matching analysis

BACKGROUND

Transarterial chemoembolization (TACE) is the standard treatment for intermediate-stage hepatocellular carcinoma (HCC). Given the lack of specific recommendations for conventional TACE (cTACE) and drug-eluting bead TACE (DEB-TACE) in patients having unresectable HCC with tumor infiltrating the common hepatic duct or the first-order branch of the bile ducts (B1-type bile duct invasion; B1-BDI) after biliary drainage, we retrospectively compared the safety and efficacy of DEB-TACE with cTACE in this patient population.

MATERIALS AND METHODS

Using data from five tertiary medical centers (January 2017-December 2021), we compared complications, overall survival (OS), time to progression (TTP), and tumor response rate between patients having unresectable HCC with B1-BDI who underwent DEB-TACE or cTACE after successful biliary drainage. X-tile software calculated the pre-TACE total bilirubin (TBil) cutoff value, indicating optimal timing for sequential TACE after drainage. Propensity score matching (PSM) was performed.

RESULTS

The study included 108 patients with unresectable HCC (B1-BDI) who underwent DEB-TACE and 114 who received cTACE as initial treatment. After PSM (n = 53 for each group), the DEB-TACE group had a longer TTP (8.9 vs. 6.7 months, p = 0.038) and higher objective response rate (64.2% vs. 39.6%, p = 0.011) than did the cTACE group, although OS was comparable (16.7 vs. 15.3 months, p = 0.115). The DEB-TACE group exhibited fewer post-procedural increments in the mean albumin-bilirubin score, TBil, and alanine aminotransferase (ALT), along with a significantly lower incidence of serious adverse events within 30 days (hepatic failure, ALT increase, and TBil increase) than the cTACE group (all p < 0.05). The pre-TACE TBil cutoff value was 99 μmol/L; patients with higher values (>99 μmol/L) had poorer OS in both groups (p < 0.05).

CONCLUSION

DEB-TACE is safe and effective after successful biliary drainage in unresectable HCC with B1-BDI, potentially better than cTACE in terms of liver toxicity, TTP, and ORR. Lowering TBil below 99 μmol/L through successful drainage may create ideal conditions for sequential TACE.

The second-line treatment of hepatocellular carcinoma with CalliSpheres drug-eluting bead transarterial chemoembolization combined with regorafenib: A safety and efficacy analysis

BACKGROUND

This study aimed to investigate the efficacy and safety of CalliSpheres drug-eluting beads transarterial chemoembolization (DEB-TACE) combined with regorafenib in the second-line treatment of unresectable hepatocellular carcinoma.

METHODS

A retrospective analysis was made of 34 patients with unresectable hepatocellular carcinoma (HCC) that had progressed after first-line treatment in Linyi Tumor Hospital from October 2019 to June 2021. These patients were divided into observation group (n = 15) and control group (n = 19) based on their treatment plans, who were respectively treated with regorafenib alone and regorafenib combined with DEB-TACE. The objective response rate (ORR) and the disease control rate (DCR) were evaluated by the modified Response Evaluation Criteria in Solid Tumors (mRECIST), and the progression-free survival (PFS) and the overall survival (OS) were calculated; the factors influencing PFS and OS of patients were analyzed by the Cox proportional hazards model; and the adverse reactions to the treatments were observed and recorded.

RESULTS

After 2 months of treatment, the ORR and the DCR of the observation group were 73.3% (11/15) and 86.7% (13/15) respectively, both higher than 10.5% (2/19) and 47.4% (9/19) of the control group. Their differences are statistically significant (P < 0.05). There were no statistically significant differences in the incidences of regorafenib-related adverse reactions including hand-foot skin reactions, fatigue, hypertension, diarrhea, and proteinuria between the two groups (P > 0.05). In the observation group, the main adverse reactions to DEB-TACE such as fever, pain, nausea, and vomiting were relieved after symptomatic treatment, and no serious complications such as ectopic embolization of CalliSpheres drug-eluting beads occurred. As of July 31, 2022, the median follow-up time was 12.5 months, and the average was (14.00 ± 5.69) months. The median PFS was 9 months in the observation group, and 6 months in the control group, presenting a statistically significant difference (P < 0.05), and the median OS was 18 months in the observation group, and 12 months in the control group, also presenting a statistically significant difference (P < 0.05). The results of monofactor prognostic analysis showed that Child grade, AFP level, and treatment method had an influence on the PFS and the OS of liver cancer patients receiving regorafenib second-line treatment (P < 0.05), and the results of multifactor prognostic analysis showed that child grade and treatment method independently influenced the PFS of patients, while treatment method independently influenced the OS of patients (P < 0.05).

CONCLUSIONS

DEB-TACE combined with regorafenib is safe and feasible in the treatment of unresectable HCC, with good efficacy and mild adverse reactions.

Application of temperature-sensitive liquid embolic agent loaded with oxaliplatin in the TACE procedure for rabbit VX2 gastric cancer

As a promising drug delivery system, the temperature-sensitive liquid embolic agent (TempSLE) has yet to be reported in animal experiments in treating gastric cancer. We observed and compared computed tomography (CT) imaging changes, tumor volume, HE staining, and immunohistochemistry after transcatheter arterial chemoembolization (TACE) treatment in rabbit VX2 gastric cancer models to clarify the effectiveness of TempSLE loaded with oxaliplatin (TempSLE/Oxa) in treating gastric cancer. One milliliter TempSLE can be loaded with 20 mg oxaliplatin. The accumulative drug release rate at 30 min was 38.76%, and after 24 h, it reached more than 90%. CT examination 1 week after TACE revealed that the TempSLE/Oxa group presents unenhanced hypodense necrotic foci, the iodinated oil loaded with oxaliplatin (Ioil/Oxa) group presents shrinking tumors but still visible speckled foci of enhancement, and the normal saline (NS) group presents heterogeneous enhancement with larger tumors than before. In the postoperative autopsy of TACE, the tumor volumes of TempSLE/Oxa, Ioil/Oxa, and NS groups were 0.15 ± 0.06 cm3, 0.37 ± 0.11 cm3, and 1.19 ± 0.16 cm3, respectively, all of which were statistically different. The positive vascular endothelial growth factor (VEGF) and proliferating cell nuclear antigen (PCNA) expression percentages in the TempSLE/Oxa, Ioil/Oxa, and NS groups were statistically different and lowest in the TempSLE/Oxa group. In conclusion, the TempSLE can load a high dose of oxaliplatin to meet the demand of clinical applications. TempSLE/Oxa could effectively inhibit tumor cell proliferation and angiogenesis. This study provides experimental evidence for the further clinical application of the TempSLE/Oxa.

Incidence and Risk Factors of Acute Ischemic Cholecystitis after Transarterial Chemoembolization: Correlation with Cone Beam CT Findings

Purpose

Acute cholecystitis is a complication of transarterial chemoembolization (TACE) that occasionally requires surgical intervention. We aimed to analyze the incidence and risk factors of cholecystitis requiring surgical intervention in patients with embolic material uptake on cone beam CT (CBCT) performed immediately after various TACE procedures.

Materials and Methods

After a retrospective review of 2633 TACE procedures performed over a 6-year period, 120 patients with embolic material retention in the gallbladder wall on CBCT immediately after TACE were selected. We analyzed the incidence of and risk factors for acute cholecystitis.

Results

The overall incidence of acute cholecystitis requiring surgical intervention was 0.45% (12 of 2633 TACE procedures); however, it was present in 10% (12 of 120) of procedures that showed high-density embolic material retention in the gallbladder wall on CBCT performed immediately after TACE. Acute cholecystitis requiring surgical intervention occurred in eight patients (66.7%) who underwent direct cystic arterial embolization. Surgical intervention was performed 15 days (mean) after TACE.

Conclusion

Most unintended chemolipiodol deposits in the gallbladder wall resolved without intervention or surgery. However, superselective direct cystic arterial chemoembolization was associated with a high incidence of acute cholecystitis requiring surgery, and patients who undergo this procedure should be closely monitored.

The Incidences and Related CT Features of Vascular Lake Phenomenon on Angiography Before Chemoembolization

PURPOSE

To elucidate incidence rates of vascular lake phenomenon (VLP) in hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC), hepatic metastasis (HMT) on transarterial angiography before chemoembolization, and to identity CT features predictive for it.

MATERIALS AND METHODS

A comprehensive evaluation involved 665 subjects for incidence analysis, comprising 527 of HCC, 33 of ICC and 105 of HMT. VLP was characterized as intratumoral contrast material pool persisting late into venous phase. Incidences were cataloged on both super-selective and common hepatic artery angiography. For CT features analysis, a subset of 182 cases were analyzed. Enhancement ratio served as an index for comparative analysis of nodule enhancement degrees.

RESULTS

In HCC, incidence of VLP ascertained via super-selective angiography was 13.5%, whereas it as 7.8% on common hepatic artery angiography. Remarkably, no incidences of VLP were recorded in either ICC or HMT cases. On pre-interventional CT, the prevalence of pseudocapsule was statistically greater in VLP group than Non-VLP group (66.6% vs. 37.6%, P = 0.015). The Houndsfield units (HU) of tumors in plain scan (P = 0.007), arterial phase (P = 0.001), venous phase (P = 0.041), arterial phase enhancement ratio (P < 0.001) were statistically higher in VLP group compared to Non-VLP group. Arterial phase enhancement ratio (P = 0.025), presence of pseudocapsule (P = 0.001), HU of tumor in plain scan (P = 0.035) serve as independent risk factors for VLP manifestation.

CONCLUSION

VLP is a distinct angiography phenomenon uniquely associated with HCC. High arterial phase enhancement ratio, presence of pseudocapsule, high HU of tumor in plain scan are independent risk factors for VLP.

Safety evaluation of combination treatment of drug-eluting bead transarterial chemoembolization and immune checkpoint inhibitors for hepatocellular carcinoma: An increased risk of liver abscess with treatment interval less than one month

PURPOSE

To analyze the safety of combination treatment comprising drug-eluting bead transarterial chemoembolization (DEB-TACE) and immune checkpoint inhibitors (ICIs) in hepatocellular carcinoma (HCC).

METHOD

In total, 208 HCC patients receiving DEB-TACE were enrolled for this retrospective single-institution study. Among them, 50 patients who received ICIs at an interval less than one month from DEB-TACE were categorized into the DEB-ICI group; the remaining 158 patients were categorized into the DEB group. Albumin-bilirubin (ALBI) score before and at three months after DEB-TACE were recorded to evaluate liver function changes. Adverse events within three months after DEB-TACE were considered TACE-related and were compared between the two groups.

RESULTS

The DEB-ICI group had significantly higher incidence of liver abscess than the DEB group (14.0 % versus 5.1 %, p-value = 0.0337). No significant difference in the other TACE-related adverse events and change of ALBI score between the groups. Univariate logistic regression confirmed that combination with ICIs was an independent risk factor for liver abscess after DEB-TACE (odds ratio = 3.0523, 95 % confidence interval: 1.0474-8.8947, p-value = 0.0409); other parameters including subjective angiographic chemoembolization endpoint scale and combined targeted therapy were nonsignificant risk factors in this study population. In the DEB-ICI group, patients who received ICIs before DEB-TACE exhibited a trend toward liver abscess formation compared with those who received DEB-TACE before ICIs (23.8 % versus 6.9 %, p-value = 0.0922).

CONCLUSIONS

Combination treatment involving DEB-TACE and ICIs at an interval less than one month increased the risk of liver abscess after DEB-TACE. Greater caution is therefore warranted for HCC patients who receive ICIs and DEB-TACE with this short interval.

The impact of drug-eluting bead (vs. conventional) transarterial chemoembolization on hepatic fibrosis in treating intermediate or advanced hepatocellular carcinoma

OBJECTIVE

Limited studies have reported the impact of drug-eluting bead transarterial chemoembolization (DEB-TACE) on hepatic fibrosis in hepatocellular carcinoma (HCC). This study evaluated multiple hepatic fibrosis indicators, aiming to comprehensively compare the influence of DEB-TACE and conventional transarterial chemoembolization (cTACE) on hepatic fibrosis in treating HCC patients.

METHODS

Intermediate/advanced HCC patients (N = 121) were divided into the DEB-TACE group (n = 62) and the cTACE group (n = 59) based on their chosen treatment. Serum hyaluronic acid (HA), pro-collagen type-III (PC-III), collagen type-IV (IV-C), and laminin (LN) were detected; aminotransferase to platelet ratio index (APRI) and fibrosis index based on the four factors (FIB-4) were calculated; liver stiffness measurement (LSM) was assessed by real-time shear wave elastography.

RESULTS

HA, PC-III, IV-C, and LN at 1 month after the second TACE and at 12 months after the first TACE were all decreased in DEB-TACE group compared with cTACE group (all P < .050). Then, APRI, FIB-4, and LSM were further assessed, which also showed a decreasing trend at aforementioned timepoints in DEB-TACE group compared with cTACE group (all P < .050). Additionally, the multivariate logistic regression analysis revealed that DEB-TACE (vs. cTACE) was independently associated with reduced occurrence of severe hepatic fibrosis at 12 months (OR = 0.215, 95%CI: 0.058-0.802, P = .022). Concerning the liver function indexes, alanine aminotransferase, aspartate aminotransferase, and total bilirubin after treatment were not different between the two groups (all P > .050).

CONCLUSION

DEB-TACE displays attenuated hepatic fibrosis progression and noninferior tolerance compared to cTACE in treating intermediate- or advanced-stage HCC patients.

Risks and benefits of TIPS in HCC and other liver malignancies: a literature review

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) is a well-validated treatment option for clinically significant portal hypertension (CSPH) in the context of liver cirrhosis. Its high efficacy and safety in the management of treatment-refractory ascites and variceal bleeding have been extensively proven. Contraindications for TIPS include severe right heart failure, hepatic encephalopathy, and sepsis. However, the role of liver malignancy in TIPS is debatable. Mostly, primary liver malignancies such as hepatocellular carcinoma (HCC) emerge from advanced liver diseases. Coexisting portal hypertension in HCC often results in limited treatment options and a poor prognosis. Previous studies have shown that TIPS implantation in patients with HCC is technically feasible and is usually not associated with major adverse events. Furthermore, TIPS may help in bridging the time to liver transplantation in early HCC and allow for locoregional treatment in advanced HCC. However, several studies suggest that seeding tumour cells to the lungs by TIPS placement might worsen the prognosis.

CONCLUSIONS

TIPS placement in patients with coexisting liver malignancy remains a case-by-case decision, and there is no profound evidence allowing general recommendations. This review aims to provide a state-of-the-art overview of the potential risks and benefits of TIPS placement in patients with liver malignancies.

Incidence and predictors of abdominal pain after transarterial chemoembolization of hepatocellular carcinoma: a single-center retrospective study

PURPOSE

To assess the incidence and predictive factors of abdominal pain following transarterial hepatic chemoembolization (TACE) in patients with hepatocellular carcinoma.

METHODS

In this single-center retrospective cohort study, abdominal pain was defined as a score of 4 or more within 72 h after TACE and requiring additional drug intervention. Patient, tumor characteristics, and technical factors associated with severe pain were identified using the decision tree and binary logistic regression model.

RESULTS

Of 220 patients who were included in the study, 126 (57.3%) had abdominal pain after 206 of 420 TACE procedures (49.0%). A predictive model built based on the logistic regression identified the drug-eluting bead TACE (DEB-TACE) (odds ratio [OR] = 3.340; 95% confidence interval [CI] 2.169-5.141), the number of tumors (OR = 2.235; 95% CI 1.060-4.713), embolization of both hepatic lobes (OR = 2.310; 95% CI 1.109-4.813), and concomitant extrahepatic artery embolism (OR = 2.654; 95% CI 1.227-5.739) as the independent predictors of severe abdominal pain. Similarly, the decision tree confirmed the DEB-TACE as the strongest predictor of subsequent performance, followed by the history of hepatectomy and the embolization in the right or both lobes. The area under the receiver operating characteristic curve (AUC) of the classification prediction effect of the two models was 0.706 for the logistic regression and 0.676 for the decision tree. Internal validation results show that the accuracy of logistic regression model prediction was 71.4%.

CONCLUSION

The model suggests that DEB-TACE and multiple treatment sites are predictors of abdominal pain after TACE in patients with hepatocellular carcinoma. It may help improve nursing management practices.

Ethnic differences in hepatocellular carcinoma prevalence and therapeutic outcomes

BACKGROUND

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death worldwide. The incidence of HCC is affected by genetic and non-genetic factors. Genetically, mutations in the genes, tumor protein P53 (TP53), catenin beta 1 (CTNNB1), AT-rich interaction domain 1A (ARIC1A), cyclin dependent kinase inhibitor 2A (CDKN2A), mannose 6-phosphate (M6P), smooth muscle action against decapentaplegic (SMAD2), retinoblastoma gene (RB1), cyclin D, antigen presenting cells (APC), AXIN1, and E-cadherin, have been shown to contribute to the occurrence of HCC. Non-genetic factors, including alcohol consumption, exposure to aflatoxin, age, gender, presence of hepatitis B (HBV), hepatitis C (HCV), and non-alcoholic fatty liver disease (NAFLD), increase the risk of HCC.

RECENT FINDINGS

The severity of the disease and its occurrence vary based on geographical location. Furthermore, men and minorities have been shown to be disproportionately affected by HCC, compared with women and non-minorities. Ethnicity has been reported to significantly affect tumorigenesis and clinical outcomes in patients diagnosed with HCC. Generally, differences in gene expression and/or the presence of comorbid medical diseases affect or influence the progression of HCC. Non-Caucasian HCC patients are significantly more likely to have poorer survival outcomes, compared to their Caucasian counterparts. Finally, there are a number of factors that contribute to the success rate of treatments for HCC.

CONCLUSION

Assessment and treatment of HCC must be consistent using evidence-based guidelines and standardized outcomes, as well as international clinical practice guidelines for global consensus. Standardizing the assessment approach and method will enable comparison and improvement of liver cancer research through collaboration between researchers, healthcare providers, and advocacy groups. In this review, we will focus on discussing epidemiological factors that result in deviations and changes in treatment approaches for HCC.

Evaluation of the Safety and Efficacy of Conventional Transarterial Chemoembolization (cTACE) and Drug-Eluting Bead (DEB)-TACE in the Management of Unresectable Hepatocellular Carcinoma: A Systematic Review

Transarterial chemoembolization (TACE) is considered the preferred loco-regional treatment option for hepatocellular carcinoma (HCC) not amenable to resection due to its distinctive blend of precise drug administration, localized tumor management, and reduced systemic adverse effects, setting it apart from the plethora of alternative treatments available. There is an ongoing debate regarding the optimal choice for managing HCC using TACE, particularly between its two major types: conventional TACE (cTACE) and drug-eluting bead TACE (DEB-TACE). The medical community remains divided on which approach offers superior safety and efficacy, with conflicting evidence and varied outcomes adding to the complexity of this nuanced decision. Given the lack of consensus surrounding the preferred TACE technique in treatment-naive patients for HCC, we conducted a rigorous systematic review to assess and contrast the relative safety and efficacy of cTACE versus DEB-TACE in patients diagnosed with HCC who did not receive any prior treatment for HCC. Our study aimed to provide much-needed clarity on this controversial topic, shedding light on the two approaches' comparative safety and efficacy to inform clinical decision-making. After a comprehensive search of databases and search engines and through a methodical screening process, including standardized quality assessments and relevant filter application based on our eligibility criteria, we identified 10 articles pertinent to our research query comprising two randomized controlled trials, one meta-analysis, and seven observational studies. The collective sample size of the studies was 5,288 patients with HCC, of which 2,959 were in the cTACE arm and 2,324 were in the DEB-TACE arm.

Complications Related to Transarterial Treatment of Hepatocellular Carcinoma: A Comprehensive Review

Currently, various types of transarterial treatments are performed for hepatocellular carcinoma from the early to advanced stages. Its indications and efficacy have been widely investigated. However, procedure-related complications have not been updated in the literature, although new types of transarterial treatments, such as drug-eluting bead transarterial chemoembolization and transarterial radioembolization, are common in daily practice. Herein, a comprehensive literature review was carried out, and complications were organized according to the organs affected and treatment modalities.

Comparison of CalliSpheres® microspheres drug-eluting beads and conventional transarterial chemoembolization in hepatocellular carcinoma patients: a randomized controlled trial

BACKGROUND

This trial aimed to compare the outcomes of drug-eluting beads transarterial chemoembolization (DEB-TACE) with CalliSpheres^® microspheres (CSM) and conventional transarterial chemoembolization cTACE in the treatment of patients with unresectable hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

A total of 90 patients were divided into DEB-TACE group (n = 45) and cTACE group (n = 45). The treatment response, overall survival (OS), progression-free survival (PFS), and the safety were compared between the two groups.

RESULTS

The objective response rate (ORR) in the DEB-TACE group was significantly higher than that in cTACE group at 1, 3, and 6 months of follow-up (P = 0.031, P = 0.003, P = 0.002). The complete response (CR) in DEB-TACE group was significantly higher than that in cTACE group at 3 months (P = 0.036). Survival analysis revealed that, DEB-TACE group had better survival benefits than cTACE group (median OS: 534 days vs. 367 days, P = 0.027; median PFS: 352 days vs. 278 days P = 0.004). The degree of liver function injury was more serious in DEB-TACE group at 1 week, but was similar between the two groups at 1 month. DEB-TACE with CSM caused a high incidence of fever and a severe abdominal pain (P = 0.031, P = 0.037).

CONCLUSIONS

DEB-TACE with CSM showed better treatment response and survival benefits than cTACE group. Although a transient more severe liver damage, high incidence of fever and a severe abdominal pain occurred in the DEB-TACE group, it could be resolved through symptomatic treatment.

Intraarterial Therapies for the Management of Hepatocellular Carcinoma

Image-guided locoregional therapies play a crucial role in the management of patients with hepatocellular carcinoma (HCC). Transarterial therapies consist of a group of catheter-based treatments where embolic agents are delivered directly into the tumor via their supplying arteries. Some of the transarterial therapies available include bland embolization (TAE), transarterial chemoembolization (TACE), drug-eluting beads-transarterial chemoembolization (DEB-TACE), selective internal radioembolization therapy (SIRT), and hepatic artery infusion (HAI). This article provides a review of pre-procedural, intra-procedural, and post-procedural aspects of each therapy, along with a review of the literature. Newer embolotherapy options and future directions are also briefly discussed.

Transarterial Chemoembolization Combined With Tyrosine Kinase Inhibitors for Intermediate-Stage Hepatocellular Carcinoma, What Else Can We Do?

Transarterial chemoembolization (TACE) has been considered the standard treatment for intermediate-stage hepatocellular carcinoma (HCC). However, intermediate‐stage HCC is highly heterogeneous with a broad population with varying tumour burdens, liver function. This suggests that TACE monotherapy treatment might not be suitable for all patients with intermediate‐stage HCC. The administration of tyrosine kinase inhibitors (TKIs) has become an important treatment option for improving the prognosis of patients with advanced HCC. Over the years, several trials have been conducted to explore the effects of TACE combined with TKIs for intermediate-stage HCC. However, the clinical efficacy is still controversial, and its potential clinical utility needs to be confirmed. This review will focus on the recent progress of TACE combined TKIs for intermediate-stage HCC.

Transcatheter Arterial Chemoembolization with Drug-Eluting Beads for the Treatment of Hepatocellular Carcinoma: Recommended Selection for Small-Caliber (<100 μm) Beads

Drug-eluting beads transarterial chemoembolization (DEB-TACE) is an alternative to conventional lipiodol-based TACE (cTACE) to treat hepatocellular carcinoma (HCC). With the advancement in pharmacology, small-caliber DEB-TACE (<100 μm) has been introduced since 2016. For the treatment of hepatic neoplasms or HCC, there is a tendency to use smaller beads by DEB-TACE to achieve more extensive tumor necrosis and a significant reduction in liver toxicity in comparison with that caused by cTACE. However, the indications and potential complications of small-caliber DEB-TACE remain uncertain and have not been well established, due to lack of randomized phase III clinical trials. Instead of systematic or meta-analysis review, this narrative review article describes the suggested indications and contraindications of DEB-TACE with small DEBs, benefit of super-selective embolization of the feeding arteries and the recommended selection of small-caliber DEB. This review was approved by the institutional review board (File Number: 1-105-05-158).

Imaging update in spondyloarthropathy

Although our understanding of axial spondyloarthropathy (axSpA) has increased recently, there has not been a concurrent improvement in patient diagnosis with delays contributing to patient morbidity. Imaging findings of axSpA can be subtle and may be dismissed often due to lack of understanding by reporters and importantly clinicians who do not suspect the disease. Recognition of the importance of imaging has led to the inclusion of MRI as part of the diagnostic criteria for axSpA. With this in mind, a number of advancements have been made in an attempt to increase our diagnostic accuracy on imaging. This article will give an overview of these techniques as well as a recap of the imaging features of axSpA.

Treatment of Malignant Bile Duct Obstruction: What the Interventional Radiologist Needs to Know

Management of malignant bile duct obstruction is both a clinically important and technically challenging aspect of caring for patients with advanced malignancy. Bile duct obstruction can be caused by extrinsic compression, intrinsic tumor/stone/debris, or by biliary ischemia, inflammation, and sclerosis. Common indications for biliary intervention include lowering the serum bilirubin level for chemotherapy, ameliorating pruritus, treating cholangitis or bile leak, and providing access for bile duct biopsy or other adjuvant therapies. In some institutions, biliary drainage may also be considered prior to hepatic or pancreatic resection. Prior to undertaking biliary intervention, it is essential to have high-quality cross-sectional imaging to determine the level of obstruction, the presence of filling defects or atrophy, and status of the portal vein. High bile duct obstruction, which we consider to be obstruction above, at, or just below the confluence (Bismuth classifications IV, III, II, and some I), is optimally managed percutaneously rather than endoscopically because interventional radiologists can target specific ducts for drainage and can typically avoid introducing enteric contents into isolated undrained bile ducts. Options for biliary drainage include external or internal/external catheters and stents. In the setting of high obstruction, placement of a catheter or stent above the ampulla, preserving the function of the sphincter of Oddi, may lower the risk of future cholangitis by preventing enteric contamination of the biliary tree. Placement of a primary suprapapillary stent without a catheter, when possible, is the procedure most likely to keep the biliary tree sterile.

Quantitative Chest CT analysis in discriminating COVID-19 from non-COVID-19 patients

INTRODUCTION

COVID-19 pneumonia is characterized by ground-glass opacities (GGOs) and consolidations on Chest CT, although these CT features cannot be considered specific, at least on a qualitative analysis. The aim is to evaluate if Quantitative Chest CT could provide reliable information in discriminating COVID-19 from non-COVID-19 patients.

MATERIALS AND METHODS

From March 31, 2020 until April 18, 2020, patients with Chest CT suggestive for interstitial pneumonia were retrospectively enrolled and divided into two groups based on positive/negative COVID-19 RT-PCR results. Patients with pulmonary resection and/or CT motion artifacts were excluded. Quantitative Chest CT analysis was performed with a dedicated software that provides total lung volume, healthy parenchyma, GGOs, consolidations and fibrotic alterations, expressed both in liters and percentage. Two radiologists in consensus revised software analysis and adjusted areas of lung impairment in case of non-adequate segmentation. Data obtained were compared between COVID-19 and non-COVID-19 patients and p < 0.05 were considered statistically significant. Performance of statistically significant parameters was tested by ROC curve analysis.

RESULTS

Final population enrolled included 190 patients: 136 COVID-19 patients (87 male, 49 female, mean age 66 ± 16) and 54 non-COVID-19 patients (25 male, 29 female, mean age 63 ± 15). Lung quantification in liters showed significant differences between COVID-19 and non-COVID-19 patients for GGOs (0.55 ± 0.26L vs 0.43 ± 0.23L, p = 0.0005) and fibrotic alterations (0.05 ± 0.03 L vs 0.04 ± 0.03 L, p < 0.0001). ROC analysis of GGOs and fibrotic alterations showed an area under the curve of 0.661 (cutoff 0.39 L, 68% sensitivity and 59% specificity, p < 0.001) and 0.698 (cutoff 0.02 L, 86% sensitivity and 44% specificity, p < 0.001), respectively.

CONCLUSIONS

Quantification of GGOs and fibrotic alterations on Chest CT could be able to identify patients with COVID-19.