Survival after C-arm CT-assisted chemoembolization of unresectable hepatocellular carcinoma

PURPOSE

To compare patient survival after transarterial chemoembolization with and without intraprocedural C-arm computed tomography (CT) in patients with unresectable hepatocellular carcinoma.

MATERIALS AND METHODS

We retrospectively reviewed the records of 130 patients with unresectable hepatocellular carcinoma who underwent lipiodol-based chemoembolization using a C-arm cone-beam system. We compared patients who underwent chemoembolization with angiography alone (69 patients; April 2005-July 2007) to those who underwent C-arm CT-assisted chemoembolization (61 patients; July 2007-April 2010). Overall and local progression-free survivals were compared using the Kaplan-Meier estimator with log-rank testing. Univariate and multivariate analyses were performed using the Cox proportional hazards model.

RESULTS

Overall survival rates of patients who underwent chemoembolization with and without C-arm CT assistance were 94% and 79%, 81% and 65%, and 71% and 44% at 1, 2, and 3 years, respectively. Local progression-free survival rates of these patients were 43% and 27%, 31% and 10%, and 26% and 5% at 1, 2, and 3 years, respectively. Patients receiving C-arm CT-assisted chemoembolization had significantly higher overall (P=0.005) and local progression-free (P=0.003) survival rates than those receiving chemoembolization with angiography alone. Multivariate analysis showed that C-arm CT assistance was an independent factor associated with longer overall survival (hazard ratio, 0.40; P=0.033) and local progression-free survival (hazard ratio, 0.25; P=0.003).

CONCLUSION

C-arm CT usage in addition to angiography during transarterial chemoembolization prolongs survival in patients with unresectable hepatocellular carcinoma.

Study of the torque of the bacterial flagellar motor using a rotating electric field

Bacterial flagella are driven by a rotary motor that is energized by an electrochemical ion gradient across the cell membrane. In this study the torque generated by the flagellar motor was measured in tethered cells of a smooth-swimming Escherichia coli strain by using rotating electric fields to determine the relationship between the torque and speed over a wide range. By measuring the electric current applied to the sample cell and combining the data obtained at different viscosities, the torque of the flagellar motor was estimated up to 55 Hz, and also at negative rotation rates. By this method we have found that the torque of the flagellar motor linearly decreases with rotation rate from negative through positive rate of rotation. In addition, the dependence of torque upon temperature was also investigated. We showed that torque at the high speeds encountered in swimming cells had a much steeper dependence on temperature that at the low speeds encountered in tethered cells. From these results, the activation energy of the proton transfer reaction in the torque-generating unit was calculated to be about 7.0 x 10(-20) J.

Prostate cancer detection with MRI: is dynamic contrast-enhanced imaging necessary in addition to diffusion-weighted imaging?

PURPOSE

To assess the feasibility of using magnetic resonance imaging for prostate cancer detection without using a contrast material.

MATERIALS AND METHODS

T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), and dynamic contrast-enhanced imaging (DCEI) were performed using a phased-array coil at 1.5 T. These examinations were performed in 178 patients with elevated serum prostate-specific antigen levels ( > 4.0 ng/mL) before systematic needle biopsy. Two radiologists independently evaluated images from DWI, DCEI, and a combination of the two techniques by referring to a T2WI image and by using a predefined confidence scale for cancer detection. The right and left halves of the peripheral zone and the central gland were separately rated. The diagnostic performance (A < sub > z < /sub > ) of each technique was assessed by analyzing their associated area under the receiver operating characteristic curves. The results of a biopsy served as a reference standard.

RESULTS

Prostate cancer was detected in 72 (40.4%) of the 178 patients. For the entire prostate, the diagnostic performances of DWI (Az = 0.848) (P < 0.001) and the combined technique (Az = 0.845) (P < 0.001) were significantly more accurate than that of DCEI (Az = 0.746). DWI (74.8%) (P < 0.001) and the combined technique (72.9%) (P < 0.001) were significantly more sensitive than DCEI (52.8%). The numbers of cancer lesions that were interpreted using only DWI or DCEI were 83 (26.1%) and 13 (4.1%) of the 318 study lesions, respectively.

CONCLUSION

DWI and the combined technique are more accurate and sensitive than DCEI in the detection of prostate cancer; however, DWI and DCEI play complementary roles in the accurate detection of prostate cancer.

Ablation margin assessment of liver tumors with intravenous contrast-enhanced C-arm computed tomography

AIM: To evaluate the feasibility of intravenous contrast-enhanced C-arm computed tomography (CT) for assessing ablative areas and margins of liver tumors.

METHODS: Twelve patients (5 men, 7 women; mean age, 69.5 years) who had liver tumors (8 hepatocellular carcinomas, 4 metastatic liver tumors; mean size, 16.3 mm; size range, 8-20 mm) and who underwent percutaneous radiofrequency ablations (RFAs) with a flat-detector C-arm system were retrospectively reviewed. Intravenously enhanced C-arm CT and multidetector computed tomography (MDCT) images were obtained at the end of the RFA sessions and 3-7 d after RFA to evaluate the ablative areas and margins. The ablated areas and margins were measured using axial plane images acquired by both imaging techniques, with prior contrast-enhanced MDCT images as the reference. The sensitivity, specificity, and positive and negative predictive values of C-arm CT for detecting insufficient ablative margins (< 5 mm) were calculated. Statistical differences in the ablative areas and margins evaluated with both imaging techniques were compared using a paired t-test.

RESULTS: All RFA procedures were technically successful. Of 48 total ablative margins, 19 (39.6%) and 20 (41.6%) margins were found to be insufficient with C-arm CT and MDCT, respectively. Moreover, there were no significant differences between these 2 imaging techniques in the detection of these insufficient ablative margins. The sensitivity, specificity, and positive and negative predictive values for detecting insufficient margins by C-arm CT were 90.0%, 96.4%, 94.7% and 93.1%, respectively. The mean estimated ablative areas calculated from C-arm CT (462.5 ± 202.1 mm²) and from MDCT (441.2 ± 212.5 mm²) were not significantly different. The mean ablative margins evaluated by C-arm CT (6.4 ± 2.2 mm) and by MDCT (6.0 ± 2.4 mm) were also not significantly different.

CONCLUSION: The efficacy of intravenous contrast-enhanced C-arm CT in assessing the ablative areas and margins after RFA of liver tumors is nearly equivalent to that of MDCT.

Local tumor progression following lipiodol-based targeted chemoembolization of hepatocellular carcinoma: a retrospective comparison of miriplatin and epirubicin

Purpose

We aimed to compare the local control rates between miriplatin and epirubicin in lipiodol-based transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC).

Patients and methods

Patients who underwent targeted TACE using miriplatin (47 patients, 66 lesions) or epirubicin (64 patients, 79 lesions) as the sole therapy were enrolled. The local control rates were compared using the Kaplan–Meier estimator with the log-rank test. The patient and tumor parameters were subjected to univariate and multivariate analyses using the Cox proportional hazards model.

Results

The overall local recurrence rates were 39.3% and 31.6% for the miriplatin and epirubicin groups, respectively. The local control rate was significantly higher in the epirubicin group than in the miriplatin group (P < 0.001). The local control rates at 6 months and 1 year were 70.7% and 44.8% for the miriplatin group and 83.4% and 69.2% for the epirubicin group, respectively. Multivariate analysis showed that the serum α-fetoprotein level ≥ 20 ng/mL (hazard ratio 2.96; P < 0.001), miriplatin usage (hazard ratio 2.53; P = 0.002), and Child-Pugh class B (hazard ratio 1.89; P = 0.042) affected local progression.

Conclusion

Lipiodol-based targeted TACE using miriplatin had inferior local control rates as compared to epirubicin in patients with HCC.

Fusion of intravenous contrast-enhanced C-arm CT and pretreatment imaging for ablation margin assessment of liver tumors: A preliminary study

The aim of this preliminary study was to evaluate the feasibility of assessing ablation margins after radiofrequency ablation (RFA) of liver tumors from fusion images of post-treatment C-arm computed tomography (CT) images fused to pretreatment images. Five patients with liver tumors underwent RFA. Intravenous contrast-enhanced C-arm CT images were obtained for all patients immediately after RFA, and multi-detector CT (MDCT) images were obtained 3-7 days later. The C-arm CT and MDCT images were fused to pretreatment images using a multimodality image fusion software. The minimum ablation margins were assessed in the C-arm CT and MDCT fusion images. Ablation margins after RFA of liver tumors can be measured using intravenous contrast-enhanced C-arm CT images fused with pretreatment images. This technique has the potential for use in the intra-procedural assessment of liver tumor ablation.

Chemoembolization-induced arterial damage: Evaluation of three different chemotherapeutic protocols using epirubicin and miriplatin

AIM

We aimed to evaluate hepatic vascular changes following lipiodol-based transarterial chemoembolization of hepatocellular carcinoma using epirubicin (EPI), miriplatin (MPT) and miriplatin plus low-dose epirubicin (MPT+EPI).

METHODS

A total of 185 arteries in 118 patients who underwent chemoembolization using EPI (67 arteries in 48 patients), MPT (64 arteries in 37 patients) and MPT+EPI (54 arteries in 33 patients) were retrospectively examined. The maximum dose limit of MPT was 140 mg and that of EPI was 50 and 20 mg for the EPI and MPT+EPI groups, respectively. Vascular changes and local recurrence were evaluated by subsequent angiography. Factors affecting arterial damage were analyzed using multivariate logistic regression analysis.

RESULTS

More severe arterial damage was observed in the EPI group (88.1%) than in the MPT+EPI (72.2%) and the MPT (18.7%) groups (P = 0.044 and P < 0.001, respectively). EPI usage (hazard ratio [HR] = 12.8, P < 0.001), selective chemoembolization (HR = 5.4, P < 0.001) and MPT usage (HR = 0.28, P = 0.020) were significant predictors for arterial damage induction. The local recurrence rate was lower for the lesions exhibiting arterial occlusion after chemoembolization (39.4%) than for the lesions exhibiting no vascular attenuation (73.9%) or wall irregularity (75.8%) (P = 0.001 and P = 0.005, respectively).

CONCLUSION

High-dose EPI, MPT, and low-dose EPI plus MPT usage in chemoembolization for hepatocellular carcinoma induced the greatest, the least, and intermediate vascular damages, respectively. Therapeutic occlusion of tumor feeder vessels is associated with lower local recurrence.

Transarterial chemoembolization with miriplatin-lipiodol emulsion for neuroendocrine metastases of the liver

Miriplatin, a cisplatin derivative with a high affinity for iodized oil, is a novel chemotherapeutic agent designed for use in the transarterial treatment of hepatocellular carcinoma. This case report describes our experience with transarterial chemoembolization (TACE) using miriplatin in 2 patients with neuroendocrine liver metastases. A 38-year-old man with multiple neuroendocrine liver metastases was treated by whole liver chemoembolization, and a 35-year-old woman with a single hepatic lesion was treated by superselective chemoembolization. No serious adverse events were noted during the interventional procedures, or during the observation period of 3 mo in either patient. Sufficient iodized oil uptake was observed in the hypervascular lesions on the unenhanced computed tomography (CT) at 7 d after the procedure. Contrast-enhanced CT obtained at 3 mo after chemoembolization revealed that all hepatic lesions were substantially reduced in size irrespective of tumor vascularity or degree of cystic degeneration, although iodized oil accumulation was only marginal for lesions with cystic degeneration. Thus, TACE with miriplatin can be a safe and effective therapeutic option for the treatment of neuroendocrine metastases of the liver.

Feasibility of using vessel-detection software for the endovascular treatment of visceral arterial bleeding

We aimed to investigate the feasibility of using vessel-detection software to identify damaged arteries during endovascular embolization in five patients with visceral arterial hemorrhages. We used a software program originally developed to detect tumor feeder vessels in liver tumor embolization with C-arm computed tomography datasets to detect the vessels responsible for the arterial hemorrhages in patients with splenic artery pseudoaneurysms (n=2), lower gastrointestinal bleeding (n=2), and bladder tumor bleeding (n=1). In all cases, the injured vessel was identified accurately on a three-dimensional vascular map at the optimal working angle with a relatively short mean processing time of 118 s (range, 107-136 s). The operating angiographers used this information to direct the catheter into the damaged artery without sequential angiographic runs. The software analysis was also used to plan coil delivery to the most appropriate site in the injured artery. The results suggest that the vessel-detection software for liver tumor embolization can also be used to detect damaged vessels and to plan treatment strategies in endovascular embolization of visceral arterial hemorrhage.

Visualization of gastric varices using angiographic C-arm CT during retrograde transvenous sclerotherapy

During retrograde transvenous sclerotherapy for gastric varices, sufficient opacification of the target varices on venography is essential for successful treatment. However, venography sometimes cannot identify target varices due to overlapping adjacent collateral vessels or leakage of contrast medium to other outflow veins. We report how C-arm CT images acquired using a flat-panel detector angiography system helped to identify target varices and predict the distribution of a sclerosant, which resulted in safer sclerotherapy and increased operator confidence.

Systemic artery to pulmonary artery fistula associated with mitral regurgitation: successful treatment with endovascular embolization

We present the case of a 60-year-old woman with symptomatic mitral regurgitation caused by a left-to-right shunt via anastomoses consisting of microfistulae, most likely of inflammatory origin, between the right subclavian artery and the right pulmonary artery. The three arteries responsible for fistulous formation, including the internal mammary, thyrocervical, and lateral thoracic arteries, were successfully occluded by transcatheter embolization using superabsorbent polymer microsphere (SAP-MS) particles combined with metallic coils. No complications have been identified following treatment with SAP-MS particles. This approach significantly reduced the patient's mitral regurgitation and she has remained asymptomatic for more than 4 years.

Radiation therapy for gastric wall metastasis from esophageal carcinoma

An 86-year-old man with dysphagia underwent gastrointestinal fiberscopy (GIF) and was found to have a circumferential type 3 advanced carcinoma in the upper thoracic esophagus and a type 2 tumor in the posterior wall of the gastric body. Microscopic examination of biopsy specimens of both tumors demonstrated moderately differentiated squamous cell carcinoma. He was diagnosed as having stage IVb (T3N0M1b) esophageal carcinoma with gastric wall metastasis. A total of 60 Gy in 30 fractions of three-dimensional conformal radiation therapy (3D-CRT) was first administered to the esophageal carcinoma, next to the gastric wall metastasis. Concurrent chemotherapy was not given because of the patient's refusal. No subjective morbidity was observed during the treatment. In the GIF study immediately after 3D-CRT, both esophageal and gastric wall tumors had attained a complete response. The dysphagia dissolved as the esophageal tumor shrunk. The patient has been doing well for 17 months after the start of 3D-CRT. No local recurrence was observed in either the esophagus or the stomach during follow-up GIF. Considering the dismal prognosis of esophageal carcinoma patients with intramural metastasis to the stomach, a watchful follow-up is needed.

Initial safety and outcomes of miriplatin plus low-dose epirubicin for transarterial chemoembolisation of hepatocellular carcinoma

AIM

To evaluate the initial safety and efficacy of combination therapy using miriplatin plus low-dose epirubicin for transarterial chemoembolisation (TACE) of unresectable hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

Patients who underwent TACE using miriplatin plus epirubicin (n=48) and control patients who underwent TACE using miriplatin-alone (n=51) were included in this study.

RESULTS

The objective response rate in the miriplatin plus epirubicin group (91%) was significantly higher than that in the miriplatin group (74%, p=0.024). Concomitant use of miriplatin and epirubicin was an independent factor associated with higher objective response rate (hazard ratio=0.18; p=0.012). Overall incidence adverse events was not significantly different between the miriplatin plus epirubicin group (50%) and the miriplatin group (49%, p=0.575).

CONCLUSION

TACE using miriplatin plus low-dose epirubicin was associated with an increased objective response rate and comparable adverse effects compared to TACE using miriplatin-alone.

Detection of Portal Perfusion Abnormalities

OBJECTIVE

To estimate the accuracy, sensitivity, and specificity of 3 ferucarbotran-enhanced magnetic resonance (MR) imaging sequences prospectively for the detection of nontumoral portal perfusion abnormalities.

METHODS

Thirty-nine noncirrhotic patients with liver metastases underwent computed tomography during arterial portography (CTAP) and MR imaging comprising T1-weighted gradient recalled echo (GRE), T2-weighted fast spin echo (FSE), and T2*-weighted GRE sequences with and without ferucarbotran. Magnetic resonance images were reviewed by 4 blinded observers for rating based on the confidence scale. The accuracy, sensitivity, and specificity for each sequence were measured by receiver operating characteristic analysis. Contrast-to-noise ratio (CNR) and relative signal-to-noise ratio changes were statistically compared.

RESULTS

Thirty-nine nontumoral perfusion defects were observed in 22 patients by CTAP. Receiver operating characteristic analysis showed the accuracy was higher for T2*-weighted GRE (0.884) than for T1-weighted GRE (0.572) and T2-weighted FSE (0.597). T2*-weighted imaging achieved the highest sensitivity (81.4%) and the lowest specificity (86.6%). Postenhanced T2*-weighted imaging achieved the highest CNR (19.3 +/- 9.2).

CONCLUSIONS

T2*-weighted imaging was the most accurate and sensitive method for detecting portal perfusion abnormalities compared with T1- or T2-weighted imaging, whereas T1- or T2-weighted imaging is superior in specificity to T2*-weighted imaging during ferucarbotran-enhanced MR imaging.

Effect of transarterial chemoembolization with miriplatin plus epirubicin on local control of hepatocellular carcinoma: a retrospective comparison with miriplatin monotherapy

Objective

We aimed to evaluate local tumor control after transarterial chemoembolization (TACE) for hepatocellular carcinoma using miriplatin and low-dose epirubicin combination therapy.

Methods

We retrospectively analyzed the records of patients who underwent TACE using miriplatin plus low-dose epirubicin (30 patients, 61 nodules, August 2011–March 2012) and control patients who underwent TACE using miriplatin alone (36 patients, 70 nodules, June 2010–July 2011). The local control rate was compared between the two groups using the Kaplan–Meier estimator and the log-rank test. Factors affecting local tumor recurrence were analyzed using multivariate logistic regression analysis. Treatment-related toxicity was evaluated using the Common Terminology Criteria for Adverse Events.

Results

The local control rates at 6 months and 1 year were 87% and 65% for the miriplatin plus low-dose epirubicin group, and 61% and 43% for the miriplatin group, respectively. Local tumor control rates were significantly better in the miriplatin plus low-dose epirubicin group than in the miriplatin group (P = 0.038). Multivariate analysis showed that the addition of epirubicin was an independent factor associated with better local tumor control (hazard ratio 0.2, P = 0.001). Overall incidence rates for adverse events were not significantly different between the two groups.

Conclusion

Additional usage of low-dose epirubicin for TACE using miriplatin improved local tumor control of hepatocellular carcinoma with adverse effects comparable to those observed with TACE using miriplatin alone.