Impact of adjuvant sorafenib treatment after local ablation for HCC in the phase II SORAMIC trial

Background & Aims

The aim of the study was to evaluate the efficacy and safety of adjuvant sorafenib treatment compared with placebo in patients with hepatocellular carcinoma who underwent local ablation.

Methods

The SORAMIC trial is a randomised controlled trial with diagnostic, local ablation, and palliative sub-study arms. After initial imaging within the diagnostic study, patients were assigned to local ablation or palliative arms. In the local ablation cohort, patients were randomised 1:1 to local ablation + sorafenib vs. local ablation + placebo. The primary endpoint was time-to-recurrence (TTR). Secondary endpoints were local control rate and safety in terms of adverse events and quality-of-life.

Results

The recruitment was terminated prematurely after 104 patients owing to slow recruitment. One patient was excluded because of a technical failure. Fifty-four patients were randomised to local ablation + sorafenib and 49 to local ablation + placebo. Eighty-eight patients who underwent standardised follow-up imaging comprised the per-protocol population. The median TTR was 15.2 months in the sorafenib arm and 16.4 months in the placebo arm (hazard ratio 1.1; 95% CI 0.53-2.2; p = 0.82). Out of 136 lesions ablated within the trial, there was no difference in local recurrence rate between sorafenib (6/69, 8.6%) and placebo groups (5/67, 5.9%; p = 0.792).Overall (92.5% vs. 71.4%, p = 0.008) and drug-related (81.4% vs. 55.1%, p = 0.003) adverse events were more common in the sorafenib arm compared with the placebo arm. Dose reduction because of adverse events were common in the sorafenib arm (79.6% vs. 30.6%, p <0.001).

Conclusions

Adjuvant sorafenib did not improve in TTR or local control rate after local ablation in patients with hepatocellular carcinoma within the limitations of an early terminated trial.

Impact and implications

Local ablation is the standard of care treatment in patients with early stages of hepatocellular carcinoma, along with surgical therapies. However, there is a risk of disease recurrence during follow-up. Sorafenib, an oral medication, is a routinely used treatment for patients with advanced hepatocellular carcinoma. This study found that sorafenib treatment after local ablation in people with early hepatocellular carcinoma did not significantly improve the disease-free period compared with placebo.

Clinical trial number

EudraCT 2009-012576-27, NCT01126645.

Dynamic tumor-tracking stereotactic body radiotherapy with real-time monitoring of liver tumors using a gimbal-mounted linac: A multi-institutional phase II study

Background and purpose

This prospective multicenter phase II study aimed to evaluate the safety and efficacy of dynamic tumor tracking (DTT) stereotactic body radiotherapy (SBRT) with real-time monitoring of liver tumors using a gimbal-mounted system.

Materials and methods

Patients with < 4 primary or metastatic liver tumors with diameters ≤ 50 mm and expected to have a respiratory motion of ≥ 10 mm were eligible. The prescribed dose was 40 Gy in five fractions. The primary endpoint was local control (LC) at 2 years. The secondary endpoints were overall survival (OS), progression-free survival (PFS), treatment-related toxicity, and tracking accuracy.

Results

Between September 2015 and March 2019, 48 patients (48 lesions) with a median age of 74 years were enrolled from four institutions. Of these, 39 were diagnosed with hepatocellular carcinoma and nine with metastatic liver cancer. The median tumor diameter was 17.5 mm. DTT-SBRT was successfully performed in all patients; the median treatment time was 28 min/fraction. The median follow-up period was 36.5 months. The 2-year LC, OS, and PFS rates were 98.0 %, 88.8 %, and 55.1 %, respectively. Disease progression was observed in 33 (68.8 %) patients. One patient (0.2 %) had local recurrence, 31 (64.6 %) developed new hepatic lesions outside the irradiation field, and nine (18.8 %) had distant metastases (including overlap). Grade 3 late adverse events were observed in seven patients (14.5 %). No grade 4 or 5 treatment-related toxicity was observed. The median tracking accuracy was 2.9 mm.

Conclusion

Employing DTT-SBRT to treat liver tumors results in excellent LC with acceptable adverse-event incidence.

What to do about hepatocellular carcinoma: Recommendations for health authorities from the International Liver Cancer Association

Hepatocellular carcinoma (HCC) is a major public health problem worldwide for which the incidence and mortality are similar, pointing to the lack of effective treatment options. Knowing the different issues involved in the management of HCC, from risk factors to screening and management, is essential to improve the prognosis and quality of life of affected individuals. This document summarises the current state of knowledge and the unmet needs for all the different stakeholders in the care of liver cancer, meaning patients, relatives, physicians, regulatory agencies and health authorities so that optimal care can be delivered to patients. The document was commissioned by the International Liver Cancer Association and was reviewed by senior members, including two ex-presidents of the Association. This document lays out the recommended approaches to the societal management of HCC based on the economic status of a given region.

The interventional direct peroral cholangioscopy toolbox for endoscopic snare resection of a high-grade biliary intraductal neoplasia

Video 1Demonstration of techniques for performing direct peroral cholangioscopy.

Comparison of radiofrequency ablation and ablative external radiotherapy for the treatment of intrahepatic malignancies: A hybrid meta-analysis

Background & Aims

Radiofrequency ablation (RFA) and ablative external beam radiotherapy (ablative RT) are commonly used to treat small intrahepatic malignancies. We meta-analysed oncologic outcomes and systematically reviewed the clinical consideration of tumour location and size.

Methods

PubMed, Medline, Embase, and Cochrane Library databases were searched on February 24, 2022. Studies comparing RFA and ablative RT, providing one of the endpoints (local control or survival), and encompassing ≥5 patients in each arm were included.

Results

Twenty-one studies involving 4,638 patients were included. Regarding survival, the odds ratio (OR) was 1.204 (p = 0.194, favouring RFA, not statistically significant) among all studies, 1.253 (p = 0.153) among hepatocellular carcinoma (HCC) studies, and 1.002 (p = 0.996) among colorectal cancer metastasis studies. Regarding local control, the OR was 0.458 (p <0.001, favouring ablative RT) among all studies, 0.452 (p <0.001) among HCC studies, favouring the ablative RT arm, and 0.649 (p = 0.484) among colorectal cancer metastasis studies. Pooled 1- and 2-year survival rates for HCC studies were 91.8% and 77.7% after RFA, and 89.0% and 76.0% after ablative RT, respectively; and for metastasis studies were 88.2% and 66.4% after RFA and 82.7% and 60.6% after RT, respectively. Literature analysis suggests that ablative RT can be more effective than RFA for tumours larger than 2-3 cm or for specific sublocations in the liver (e.g. subphrenic or perivascular sites), with moderate quality of evidence (reference to the grading system of the American Society for Radiation Oncology Primary Liver Cancer Clinical Guidelines). The pooled grade ≥3 complication rates were 2.9% and 2.8% in the RFA and ablative RT arms, respectively (p = 0.952).

Conclusions

Our study shows that ablative RT can yield oncologic outcomes similar to RFA, and suggests that it can be more effective for the treatment of tumours in locations where RFA is difficult to perform or for large-sized tumours.

Systematic Review Registration

This study was registered with PROSPERO (Protocol No: CRD42022332997).

Impact and implications

Radiofrequency ablation (RFA) and ablative radiotherapy (RT) are non-surgical modalities for the treatment of small intrahepatic malignancies. Ablative RT showed oncologic outcomes at least similar to those of RFA, and was more effective at specific locations (e.g. perivascular or subphrenic locations).

Early hepatocellular carcinoma detection using magnetic resonance imaging is cost-effective in high-risk patients with cirrhosis

Background & Aims

Reinforced hepatocellular carcinoma (HCC) surveillance using magnetic resonance imaging (MRI) could increase early tumour detection but faces cost-effectiveness issues. In this study, we aimed to evaluate the cost-effectiveness of MRI for the detection of very early HCC (Barcelona Clinic Liver Cancer [BCLC] 0) in patients with an annual HCC risk >3%.

Methods

French patients with compensated cirrhosis included in 4 multicentre prospective cohorts were considered. A scoring system was constructed to identify patients with an annual risk >3%. Using a Markov model, the economic evaluation estimated the costs and life years (LYs) gained with MRI vs. ultrasound (US) monitoring over a 20-year period. The incremental cost-effectiveness ratio (ICER) was calculated by dividing the incremental costs by the incremental LYs.

Results

Among 2,513 patients with non-viral causes of cirrhosis (n = 840) and/or cured HCV (n = 1,489)/controlled HBV infection (n = 184), 206 cases of HCC were detected after a 37-month follow-up. When applied to training (n = 1,658) and validation (n = 855) sets, the construction of a scoring system identified 33.4% and 37.5% of patients with an annual HCC risk >3% (3-year C-Indexes 75 and 76, respectively). In patients with a 3% annual risk, the incremental LY gained with MRI was 0.4 for an additional cost of €6,134, resulting in an ICER of €15,447 per LY. Compared to US monitoring, MRI detected 5x more BCLC 0 HCC. The deterministic sensitivity analysis confirmed the impact of HCC incidence. At a willingness to pay of €50,000/LY, MRI screening had a 100% probability of being cost-effective.

Conclusions

In the era of HCV eradication/HBV control, patients with annual HCC risk >3% represent one-third of French patients with cirrhosis. MRI is cost-effective in this population and could favour early HCC detection.

Lay summary

The early identification of hepatocellular carcinoma in patients with cirrhosis is important to improve patient outcomes. Magnetic resonance imaging could increase early tumour detection but is more expensive and less accessible than ultrasound (the standard modality for surveillance). Herein, using a simple score, we identified a subgroup of patients with cirrhosis (accounting for >one-third), who were at increased risk of hepatocellular carcinoma and for whom the increased expense of magnetic resonance imaging would be justified by the potential improvement in outcomes.

Image-guided combined ablation and resection in thoracic surgery for the treatment of multiple pulmonary metastases: A preliminary case series

Objectives

To demonstrate the feasibility and preliminary outcomes of a novel hybrid technique combining percutaneous microwave ablation and wire-assisted wedge resection for patients with multiple pulmonary metastases using intraoperative imaging.

Methods

We describe our technique and present a retrospective case series of 4 patients undergoing iCART at our institution between August 2018 and January 2020. Procedures were performed in a hybrid operating suite using the ARTIS Pheno cone beam computerized tomography scanner (Siemens Healthineers, Erlangen, German). Patient information included past history of malignancy as well as lesion size, depth, location, and histology result. Surgical complications and length of stay were also recorded.

Results

Five procedures were performed on 4 patients during the study period. One patient underwent bilateral procedures 4 weeks apart. All patients underwent at least 1 ablation and 1 wedge resection during the combined procedure. Patient ages ranged from 40 to 66 years and the majority (75%) were men. All had a past history of cancer. Lesions were treated in every lobe. Size and depth ranged from 6 to 24 mm and 21 to 33 mm, respectively, for ablated nodules and 5 to 27 mm and 0 to 22 mm, respectively, for the wedge resected nodules. Three procedures were completed uniportal and operative time ranged from 51 to 210 minutes. All cases sustained <10 mL blood loss. There were 2 intraoperative pneumothorax, 1 prevented successful completion of the ablation. One patient required a prolonged period of postoperative physiotherapy and was discharged on day 6. The other patients were discharged on postoperative day 2 or 3. All 5 histology specimens confirmed metastatic disease.

Conclusions

Our hybrid approach provides a minimally invasive and comprehensive personalized therapy for patients with multiple pulmonary metastases under a single general anesthetic. It provides histology-based diagnosis whilst minimizing lung tissue loss and eliminating the need for transfer from radiology to operating theatre. Emergence of ablation as a treatment for stage 1 non–small cell lung cancer and the expansion of lung cancer screening may widen the application of iCART in the future.

International study on the outcome of locoregional therapy for liver transplant in hepatocellular carcinoma beyond Milan criteria

Background & Aims

Good outcomes after liver transplantation (LT) have been reported after successfully downstaging to Milan criteria in more advanced hepatocellular carcinoma (HCC). We aimed to compare post-LT outcomes in patients receiving locoregional therapies (LRT) before LT according to Milan criteria and University of California San Francisco downstaging (UCSF-DS) protocol and 'all-comers'.

Methods

This multicentre cohort study included patients who received any LRT before LT from Europe and Latin America (2000-2018). We excluded patients with alpha-foetoprotein (AFP) above 1,000 ng/ml. Competing risk regression analysis for HCC recurrence was conducted, estimating subdistribution hazard ratios (SHRs) and corresponding 95% CIs.

Results

From 2,441 LT patients, 70.1% received LRT before LT (n = 1,711). Of these, 80.6% were within Milan, 12.0% within UCSF-DS, and 7.4% all-comers. Successful downstaging was achieved in 45.2% (CI 34.8-55.8) and 38.2% (CI 25.4-52.3) of the UCSF-DS group and all-comers, respectively. The risk of recurrence was higher for all-comers (SHR 6.01 [p <0.0001]) and not significantly higher for the UCSF-DS group (SHR 1.60 [p = 0.32]), compared with patients remaining within Milan. The all-comers presented more frequent features of aggressive HCC and higher tumour burden at explant. Among the UCSF-DS group, an AFP value of ≤20 ng/ml at listing was associated with lower recurrence (SHR 2.01 [p = 0.006]) and better survival. However, recurrence was still significantly high irrespective of AFP ≤20 ng/ml in all-comers.

Conclusions

Patients within the UCSF-DS protocol at listing have similar post-transplant outcomes compared with those within Milan when successfully downstaged. Meanwhile, all-comers have a higher recurrence and inferior survival irrespective of response to LRT. Additionally, in the UCSF-DS group, an ALP of ≤20 ng/ml might be a novel tool to optimise selection of candidates for LT.

Clinical trial number

This study was registered as part of an open public registry (NCT03775863).

Lay summary

Patients with more extended HCC (within the UCSF-DS protocol) successfully downstaged to the conventional Milan criteria do not have a higher recurrence rate after LT compared with the group remaining in the Milan criteria from listing to transplantation. Moreover, in the UCSF-DS patient group, an ALP value equal to or below 20 ng/ml at listing might be a novel tool to further optimise selection of candidates for LT.

Electrohydraulic lithotripsy under the mother-baby cholangioscope system using a colonoscope for large common bile duct stones in a patient with Roux-en-Y reconstruction

Video 1After insertion of the cholangioscope into the common bile duct, electrohydraulic lithotripsy was performed. All common bile duct stones were shattered and successfully removed using a basket and balloon catheter.

Insulinoma With Concomitant Insulin Antibodies

Objective

The coexistence of insulinoma and insulin antibodies is extremely rare. The aim of this novel case report is to inform physicians of the possibility of an insulinoma with concomitant insulin antibodies.

Methods

In this report, we describe a patient with symptomatic hypoglycemia confirmed with a 72-hour fast, who was subsequently found to have an insulinoma with concomitant elevation in his immunoglobulin G insulin antibody titer.

Results

The patient presented with initial symptoms of diaphoresis, confusion, and disorientation and was found unresponsive by a bystander. He had a fingerstick blood glucose of 36 mg/dL (reference 74-99 mg/dL), without exogenous insulin or sulfonylurea use. His symptoms resolved with administration of glucose. He was subsequently admitted for a 72-hour fast in which he developed neuroglycopenic symptoms 4 hours into the fast with fingerstick glucose of 47 mg/dL and serum glucose of 44 mg/dL (reference 74-99 mg/dL), C-peptide of 10.8 ng/mL (reference 0.5-2.7 ng/mL), insulin level of 106 μIU/mL (reference <25 μIU/mL), and a proinsulin level of 675 pmol/mL (reference <22 pmol/mL). His insulin-to-C-peptide ratio was 0.20, in which a ratio <1 is indicative of an insulinoma. Endoscopic ultrasound demonstrated a 16 x 11 mm biopsy-proven neuroendocrine tumor. He was found to have a high titer insulin antibody titer at 2.4 U/mL (reference <0.4 U/mL), was started on prednisone, and underwent successful radiofrequency ablation. He was able to be successfully tapered off steroids without recurrence.

Conclusion

The coexistence of insulinoma with insulin antibodies is novel, and to our knowledge, has never been published.

Esophagopericardial Fistula Following Radiofrequency Ablation for Atrial Fibrillation: Insights Into Its Management

An esophagopericardial fistula developed in a 33-year-old patient after radiofrequency ablation for atrial fibrillation. He was initially managed with an esophageal repair and a left atrial bovine pericardial patch and eventually an esophagectomy. At 6-month follow up he had no symptoms. The case highlights the complexities of managing this life-threatening complication. (Level of Difficulty: Advanced.)

Endoscopic radiofrequency ablation for palliative treatment of hilar cholangiocarcinoma

BACKGROUND AND AIMS

Recent data support a role for endoscopic radiofrequency ablation (RFA) in unresectable cholangiocarcinoma by improving stent patency and overall survival.

METHODS

We describe 3 patients with inoperable cholangiocarcinoma with jaundice and cholestasis who were recommended palliative chemotherapy. They underwent endoscopic retrograde cholangiopancreatography with single-operator cholangioscope and intraductal RFA.

RESULTS

The procedures were performed without adverse events in all patients, with clinical and analytical improvement 1 month later.

CONCLUSIONS

RFA is a promising and safe palliative treatment in patients with unresectable cholangiocarcinoma.

Radiofrequency Ablation of Parathyroid Adenoma: A Novel Treatment Option for Primary Hyperparathyroidism

Objective

To present radiofrequency ablation (RFA) of parathyroid adenomas as a safe and effective management strategy for primary hyperparathyroidism in patients who are not eligible for surgery or those who do not want surgery.

Methods

The diagnosis of primary hyperparathyroidism was confirmed by laboratory investigations. A bone density scan showed osteoporosis, which was an indication for the surgical treatment of primary hyperparathyroidism. Ultrasonography of the neck was done to localize the parathyroid adenoma, after which RFA was performed to shrink the adenoma. Laboratory investigations were performed 10 days, 6 months, and 12 months after the procedure. A literature review was also conducted, and other reports of primary hyperparathyroidism cases treated with RFA were identified.

Results

Biochemical cure of primary hyperparathyroidism was achieved by normalization of calcium levels, resolution of symptoms, elimination of complications, and decrease in the volume of the parathyroid adenoma.

Conclusion

RFA of parathyroid adenomas is a viable alternative to parathyroidectomy in patients who do not meet the criteria for surgery or do not wish to undergo surgery.

Horner's Syndrome During High-Intensity Focused Ultrasound Ablation for a Benign Thyroid Nodule

Objective

Horner's syndrome (HS) is a rare complication of high-intensity focused ultrasound (HIFU) and radiofrequency ablation for thyroid nodules. We present such a case and discuss how to avoid this complication in the future.

Methods

This case occurred during HIFU treatment of a benign thyroid nodule (BTN). Ultrasound and fine-needle aspiration cytology (FNAC) were performed before the procedure. Volume reduction was evaluated at 6 weeks, 3, 6, and 12 months. Technical success was ≥50% reduction at 6 months.

Results

A 30-year-old woman presented with a solitary symptomatic thyroid nodule. Her thyroid stimulating hormone was 1.16 (ref 0.4-3.6) μUI/mL), ultrasound found a 13 mL right-thyroid EU-TIRADS 4 nodule. Two FNACs were read as Bethesda II. The subsequent HIFU procedure was conducted with local 2% lidocaine anesthesia. The procedure was painful (visual analogic scale 10/10) and ipsilateral partial ptosis occurred during the procedure. Volume reduction at 12 months was 34.6% of the initial volume with persisting functional and cosmetic complaints, discomfort, and partial ptosis. As the volume reduction was ≤50%, the procedure was a technical failure. A new FNAC was read as Bethesda IV. A right lobectomy was performed without postoperative outcomes and without requiring hormonal replacement therapy. Pathological evaluation found no malignant cells.

Conclusion

HS is a rare complication of HIFU for management of BTNs. It may be symptomatic and have sequalae that persist for months. Severe neck pain may by associated, but further investigation is needed.

Radiofrequency Ablation as a Primary Therapy for Benign Functioning Insulinoma

Objective

Insulinomas are rare, life-threatening pancreatic neuroendocrine tumors. Surgical removal continues to be the treatment of choice, yet it is associated with considerable risk of morbidity. Here, we describe our patient with insulinoma who was successfully treated with radiofrequency ablation.

Methods

The patient was a 56-year-old man with no history of diabetes mellitus. He presented with recurrent episodes of transient ischemic attacks and stroke over the last 3 years. Some changes in his behavior and memory were noticed by family members. During his hospital stay for the second transient ischemic attack, frequent hypoglycemia was documented, which was asymptomatic. Insulinoma was confirmed biochemically. Radiological findings were also compatible with pancreatic neuroendocrine tumor. Treatment modalities were explained to the patient. However, he strongly refused surgery. Meanwhile, he was admitted because of a stroke and concurrent hypoglycemia again. In view of his refusal of the surgical treatment and due to his presentation with acute stroke and high-risk status for surgery, radiofrequency ablation was finalized.

Results

Radiofrequency ablation of the pancreatic tumor using 40.75 Gy over fractions was performed with a favorable outcome. The patient has achieved biochemical normalization and remained euglycemic during his follow- up. Computed tomography scan of the abdomen during follow-up showed a mild regression of the size of the tumor.

Conclusion

This report shows a treatment challenge that required the use of an alternative treatment option other than the standard of care. It highlights the evolving evidence of radiofrequency as a therapeutic modality for patients with insulinoma.

New frontiers in liver resection for hepatocellular carcinoma

Liver resection is one of the main curative options for early hepatocellular carcinoma (HCC) in patients with cirrhosis and is the treatment of choice in non-cirrhotic patients. However, careful patient selection is required to balance the risk of postoperative liver failure and the potential benefit on long-term outcomes. In the last decades, improved surgical techniques and perioperative management, as well as better patient selection, have enabled the indications for liver resection to be expanded. In this review, we aim to describe the main indications for liver resection in the management of HCC, its role compared to percutaneous ablation and liver transplantation in the therapeutic algorithm, as well as the recent advances in liver surgery that could be used to improve the prognosis of patients with HCC.

Predictors, Presentation, and Treatment Outcomes of Recurrent Hepatocellular Carcinoma After Liver Transplantation: A Large Single Center Experience

BACKGROUND

Liver transplantation (LT) is an accepted therapeutic option for hepatocellular carcinoma (HCC) in patients with cirrhosis. Despite careful candidate selection, HCC recurrence occurs. We aimed to describe the predictors of recurrence, clinical presentation, and predictors of survival after HCC recurrence post-LT.

METHODS

Patients with recurrent HCC after LT between January 1996 and December 2017 were retrospectively reviewed.

RESULTS

Of 711 patients, 96 (13.5%) patients had post-LT HCC recurrence. The median time to recurrence was 17.1 months, and the median survival was 10.1 months. Initial recurrence was more often in the graft (34.4%), and most (60.4%) had multiple recurrent lesions, and 26% were in multiple sites. In multivariate analysis, factors associated with shorter survival were poorly differentiated histology in explant (Hazard ratio [HR] = 1.96; p = 0.027), bilirubin ≥1.2 mg/dL (HR = 2.47; p = 0.025), and albumin <3.5 mg/dL (HR = 2.13; p = 0.014) at recurrence, alpha-fetoprotein at recurrence ≥ 1000 ng/mL (HR = 2.96; p = 0.005), and peritoneal disease (HR = 3.20; p = 0.022). There was an increased survival in patients exposed to sirolimus (HR = 0.32; p < 0.0001).

CONCLUSIONS

Recurrent HCC after LT is often in extrahepatic sites with a decreased survival in those with poorly differentiated explant pathology, high bilirubin, low albumin, marked elevation of alpha-fetoprotein at recurrence, and peritoneal recurrence. Sirolimus-based immunosuppression may provide benefit.

Multicenter case series of patients with small-bowel angiodysplasias treated with a small-bowel radiofrequency ablation catheter

Background and Aims

GI angiodysplasia is the most common cause of small-bowel bleeding. Argon plasma coagulation (APC) is preferred for ablation because of its availability, ease of use, and perceived safety, but it has limitations. An instrument capable of repeated use through the enteroscope, which covers more area of intestinal mucosa per treatment with low risk of damage to healthy mucosa, and which improves ablation, is desirable. A series of patients treated with a through-the-scope radiofrequency ablation (RFA) catheter is reported.

Methods

Patients with a previous diagnosis of small-bowel angiodysplasia (SBA) and ongoing bleeding with melena, hematochezia, or iron-deficiency anemia were eligible for treatment. A small-bowel radiofrequency ablation (SBRFA) catheter was passed through the enteroscope instrument channel. The treatment paddle was pushed against the SBA, achieving coaptive coagulation, and the SBA was treated up to 2 times at standard settings of 10 J/cm². The patients' demographics, pretreatment and posttreatment hemoglobin levels, time to recurrence of bleeding, and need for more therapy were recorded. This study was approved by the institutional review boards of the respective institutions.

Results

Twenty consecutive patients were treated from March until October 2018 and followed up until March 2019. There were 6 women (average age 68 years, standard deviation ± 11.1), and 14 men (average age 73 years, standard deviation ± 10.4). All had undergone at least 1 previous EGD and colonoscopy; 14 patients (70%) had SBA on video capsule endoscopy, and 14 patients had undergone previous endoscopic treatment of SBA with APC. A median of 23 treatments were applied (range, 2-99). The median follow-up time was 195 days (range, 30-240 days). Four patients, including 3 with a left ventricular assist device (LVAD), had recurrent bleeding between 45 and 210 days after treatment, and 2 patients received repeated blood transfusions. Three of those patients underwent repeated endoscopies, including a push enteroscopy and an upper endoscopy with no treatment, and a repeated enteroscopy with SBA treated with APC, respectively. One patient with LVAD underwent arterial embolization.

Conclusions

In this case series, bleeding recurred in 20% of patients in a follow-up time of ≤240 days. Notably, 3 of the 4 patients who had recurrent bleeding had an LVAD. These rates compare favorably with reported bleeding recurrence after APC of SBA. More studies on the benefits of SBRFA, which may include reduced risk of recurrent bleeding or prolonging the time to recurrent bleeding, resource utilization, and factors associated with bleeding recurrence are needed.

Left Atrial Intramural Hematoma Post-Ablation of Supraventricular Tachycardia: A Rare Complication Treated Successfully

We report successful management of left atrial hematoma after ablation of supraventricular tachycardia. A 43-year-old female patient experienced chest pain immediately after radiofrequency ablation of a symptomatic left posterolateral accessory pathway. Transthoracic echocardiography demonstrated a large mass occupying the left atrium. Computed tomography and transesophageal echocardiography results were consistent with posterolateral intramural hematoma. She became hemodynamically unstable, requiring emergent surgery. The mass resolved completely by 6 weeks. (Level of Difficulty: Beginner.)

Transient, Marked ST-Segment Elevation During Successful Epicardial Substrate Ablation in a Patient With Brugada Syndrome

A 37-year-old man with Brugada syndrome and frequent appropriate implantable cardioverter-defibrillator shocks received an epicardial substrate ablation. During the procedure to eliminate delayed potentials, transient, marked ST-segment elevation in lead V₂ was observed, particularly in the anterior right ventricle with a borderline between normal and low-voltage areas. (Level of Difficulty: Intermediate.).

Ablative Therapy for Unresectable Intrahepatic Cholangiocarcinoma: A Systematic Review and Meta-Analysis

BACKGROUND

Intrahepatic cholangiocarcinoma (iCCA) is usually a fatal malignancy with rising incidence globally. Surgical resection currently remains the only curative treatment. However, as only a minority of iCCA is amenable to resection, new therapeutic modalities are needed. Our aims were to systematically review and perform a meta-analysis on the existing literature regarding the use of ablative therapies for iCCA and to assess their efficacy as a treatment modality by calculating pooled survival results and investigate associations between prognostic factors and survival.

METHODS

A comprehensive search of the PubMed database for relevant articles was performed. Studies assessing survival in patients with iCCA undergoing ablation were included. Data were extracted on patient, tumour and treatment characteristics and survival. Random effects meta-analysis was used to pool the data. Galbraith plots were used to investigate heterogeneity; bubble plots were formulated using regression-based meta-analysis.

RESULTS

A total of 10 studies were included in the final analysis, yielding an aggregate of 206 patients (69.5% males, median age: 51.2-72.5) and 320 tumours. Of all patients, 70.4% were recurrent cases of iCCA, and 29.6% were cases of primary iCCA. The median overall survival ranged from 8.7 to 52.4 months. Pooled 1-, 3- and 5-year survival rates were 76% (95% confidence interval: 68-83%), 33% (21-44%) and 16% (7-26%), respectively. No significant association was found between the median age, number of tumours or median tumour size and 1-year survival.

CONCLUSIONS

Ablative therapies display promising potential as treatment modalities for iCCA. However, further research is necessary to validate these findings.

Hepatocellular Carcinoma: Etiology and Current and Future Drugs

Hepatocellular carcinoma (HCC) is swiftly increasing in prevalence globally with a high mortality rate. The progression of HCC in patients is induced with advanced fibrosis, mainly cirrhosis, and hepatitis. The absence of proper preventive or curative treatment methods encouraged extensive research against HCC to develop new therapeutic strategies. The Food and Drug Administration-approved Nexavar (sorafenib) is used in the treatment of patients with unresectable HCC. In 2017, Stivarga (regorafenib) and Opdivo (nivolumab) got approved for patients with HCC after being treated with sorafenib, and in 2018, Lenvima (lenvatinib) got approved for patients with unresectable HCC. But, owing to the rapid drug resistance development and toxicities, these treatment options are not completely satisfactory. Therefore, there is an urgent need for new systemic combination therapies that target different signaling mechanisms, thereby decreasing the prospect of cancer cells developing resistance to treatment. In this review, HCC etiology and new therapeutic strategies that include currently approved drugs and other potential candidates of HCC such as Milciclib, palbociclib, galunisertib, ipafricept, and ramucirumab are evaluated.

131I-Evans blue: evaluation of necrosis targeting property and preliminary assessment of the mechanism in animal models

Necrosis is a form of cell death, which is related to various serious diseases such as cardiovascular disease, cancer, and neurodegeneration. Necrosis-avid agents (NAAs) selectively accumulated in the necrotic tissues can be used for imaging and/or therapy of related diseases. The aim of this study was to preliminarily investigate necrosis avidity of ¹³¹I-evans blue (¹³¹I-EB) and its mechanism. The biodistribution of ¹³¹I-EB at 24 h after intravenous administration showed that the radioactivity ratio of necrotic to viable tissue was 3.41 in the liver and 11.82 in the muscle as determined by γ counting in model rats. Autoradiography and histological staining displayed preferential uptake of ¹³¹I-EB in necrotic tissues. In vitro nuclear extracts from necrotic cells exhibited 82.3% of the uptake in nuclei at 15 min, as well as 79.2% of the uptake at 2 h after ¹³¹I-EB incubation. The DNA binding study demonstrated that evans blue (EB) has strong binding affinity with calf-thymus DNA (CT-DNA) (K_sv=5.08×10⁵ L/(mol/L)). Furthermore, the accumulation of ¹³¹I-EB in necrotic muscle was efficiently blocked by an excess amount of unlabeled EB. In conclusion, ¹³¹I-EB can not only detect necrosis by binding the DNA released from necrotic cells, but also image necrotic tissues generated from the disease clinically.

Epidemiologic Factors, Clinical Presentation, Causes, and Outcomes of Liver Abscess: A 35-Year Olmsted County Study

Objective

To report the changing incidence, clinical presentation, microbiologic spectrum, and outcomes of pyogenic liver abscess (PLA) in Olmsted County, Minnesota, over the past 35 years.

Patients and Methods

The Rochester Epidemiology Project was used to identify residents with PLA from January 1, 1980, through December 31, 2014. The study included all patients older than 18 years, with the diagnosis of PLA confirmed through radiographic review and microbiologic cultures.

Results

In total, 72 patients received a diagnosis of PLA from 1980 through 2014. The age-adjusted incidence for men was 3.92 cases per 100,000 person-years (95% CI, 2.76-5.09 cases per 100,000 person-years) compared with 1.87 cases per 100,000 person-years (95% CI, 1.15-2.59 cases per 100,000 person-years) for women. Incidence was higher in the period from January 1, 2001, through December 31, 2014, than in the period from January 1, 1980, through December 31, 2000, for women (incidence rate ratio [IRR], 3.8; 95% CI, 1.43-10.09; P=.007) but not for men (IRR, 0.99; 95% CI, 0.55-1.76; P=.96). Fifteen additional patients had postintervention PLA (1980-2000: n=3 of 29 [10.3%] vs 2001-2015: n=12 of 58 [20.6%]). A significant association was seen between age- and sex-adjusted incidence rates of PLA and year of diagnosis (per year since 1980: IRR, 1.04; 95% CI, 1.02-1.07; P<.001) after including postintervention PLA. Streptococcus milleri was the most common organism identified (52.5%). Organisms with multidrug resistance were more common in the period from 2001 through 2014 than in the period from 1980 through 2000 (51% vs 14%; P=.005). The overall mortality rate of PLA was 16.8% (95% CI, 7.6%-25.0%) at 6 months.

Conclusion

The incidence of PLA is increasing, probably because of increase in frequency of hepatobiliary interventions and organisms with multidrug resistance.

Comparison of Contrast Enhanced Ultrasound With Contrast Enhanced Computed Tomography for the Diagnosis of Hepatocellular Carcinoma

BACKGROUND/AIMS

The most common primary malignant tumor of liver is hepatocellular carcinoma (HCC). The highest risk of developing HCC is seen in patients of cirrhosis. Ultrasound is used for surveillance in these patients. This study evaluates the role of contrast enhanced ultrasound (CEUS) in the diagnosis of HCC and compares CEUS to contrast enhanced computed tomography (CECT).

MATERIALS AND METHODS

This prospective study included 22 patients with cirrhosis and suspected to have HCC on the basis of gray scale ultrasound or elevated Alpha-fetoprotein. Multiphasic CECT and CEUS were done. On both CECT and CEUS, arterial phase enhancement patterns of the lesions were classified as heterogeneously hyperenhancing, homogeneously hyperenhancing, isoenhancing or nonenhancing. The enhancement patterns of the lesions in portal venous phase were classified as hyperenhancing, isoenhancing, washout or nonenhancing. Presence or absence of neovascularity and peripheral capsule were also noted. The diagnosis of HCC was made as per American Association for the Study of Liver Diseases (AASLD) guidelines.

RESULTS

There was moderate degree of agreement between the two modalities in characterizing the enhancement pattern in arterial phase, as calculated by using kappa test (k = 0.59, P < 0.05). Substantial agreement between them, for demonstrating the neovascularity, was also seen (k = 0.772, P < 0.05). CEUS was found to be superior to CECT in demonstrating portal venous phase wash out and peripheral capsule. Only fair agreement was seen between them, with kappa value for portal venous washout being k = 0.38 (P < 0.05) and for peripheral capsule being k = 0.328 (P < 0.05).

CONCLUSION

CEUS is comparable to CECT in demonstrating the arterial phase enhancement pattern of HCC and the neovascularity. CEUS was found to be better than CECT in demonstrating the portal venous phase washout and peripheral capsule.

Porcine Esophageal Submucosal Gland Culture Model Shows Capacity for Proliferation and Differentiation

BACKGROUND & AIMS

Although cells comprising esophageal submucosal glands (ESMGs) represent a potential progenitor cell niche, new models are needed to understand their capacity to proliferate and differentiate. By histologic appearance, ESMGs have been associated with both overlying normal squamous epithelium and columnar epithelium. Our aim was to assess ESMG proliferation and differentiation in a 3-dimensional culture model.

METHODS

We evaluated proliferation in human ESMGs from normal and diseased tissue by proliferating cell nuclear antigen immunohistochemistry. Next, we compared 5-ethynyl-2'-deoxyuridine labeling in porcine ESMGs in vivo before and after esophageal injury with a novel in vitro porcine organoid ESMG model. Microarray analysis of ESMGs in culture was compared with squamous epithelium and fresh ESMGs.

RESULTS

Marked proliferation was observed in human ESMGs of diseased tissue. This activated ESMG state was recapitulated after esophageal injury in an in vivo porcine model, ESMGs assumed a ductal appearance with increased proliferation compared with control. Isolated and cultured porcine ESMGs produced buds with actively cycling cells and passaged to form epidermal growth factor-dependent spheroids. These spheroids were highly proliferative and were passaged multiple times. Two phenotypes of spheroids were identified: solid squamous (P63+) and hollow/ductal (cytokeratin 7+). Microarray analysis showed spheroids to be distinct from parent ESMGs and enriched for columnar transcripts.

CONCLUSIONS

Our results suggest that the activated ESMG state, seen in both human disease and our porcine model, may provide a source of cells to repopulate damaged epithelium in a normal manner (squamous) or abnormally (columnar epithelium). This culture model will allow the evaluation of factors that drive ESMGs in the regeneration of injured epithelium. The raw microarray data have been uploaded to the National Center for Biotechnology Information Gene Expression Omnibus (accession number: GSE100543).

Comparative study evaluating the efficiency of cooled and uncooled single-treatment MWA in thyroid nodules after a 3-month follow up

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cMWA and uMWA both lead to a significant reduction of thyroid nodule volume.

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Patient pain level during uMWA is significantly higher than during cMWA.

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cMWA reduces the risk of side effects.

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Single-treatment session shows comparable results to multiple treatment sessions.

Objective

The aim of this study was to evaluate and compare the efficacy of single-treatment cooled and uncooled microwave ablation in thyroid nodules.

Methods

Eighteen patients (11 women) with an average age of 62 years (range: 41–80) with 18 cold, mainly solid or solid thyroid nodules were treated with cooled or uncooled microwave ablation. Pain during the treatment was measured on a 10-point score. Side effects revealed by ultrasound or patients’ complaints were documented. Laboratory data was evaluated before, 24 h and three months after MWA. Nodule volumes were measured before and three months after MWA.

Results

Cooled MWA was better tolerated than uncooled MWA. A significant reduction of thyroid nodule volume was observed in all cases. The reduction after cMWA was higher (40%) than after uMWA (29%). Pain intensity during cMWA was significantly lower than after uMWA. CMWA and uMWA led to a significant decrease of nodule blood circulation and echogenicity and to a significant increase of nodule elasticity. Thyroid function remained intact in all cases. The energy (kJ/s) administered into the nodules in relation to the ablation time during cMWA was higher than during uMWA.

Conclusions

CMWA leads to a slightly higher but statistically not significant nodule volume reduction than uMWA. Patient comfort during cMWA is higher than during uMWA. The risk of unintended side effects is less in cMWA. A Single-treatment provides sufficient results.

Clinically feasible approaches to potentiating cancer cell-based immunotherapies

The immune system exerts both tumor-destructive and tumor-protective functions. Mature dendritic cells (DCs), classically activated macrophages (M1), granulocytes, B lymphocytes, aβ and ɣδ T lymphocytes, natural killer T (NKT) cells, and natural killer (NK) cells may be implicated in antitumor immunoprotection. Conversely, tolerogenic DCs, alternatively activated macrophages (M2), myeloid-derived suppressor cells (MDSCs), and regulatory T (Tregs) and B cells (Bregs) are capable of suppressing antitumor immune responses. Anti-cancer vaccination is a useful strategy to elicit antitumor immune responses, while overcoming immunosuppressive mechanisms. Whole tumor cells or lysates derived thereof hold more promise as cancer vaccines than individual tumor-associated antigens (TAAs), because vaccinal cells can elicit immune responses to multiple TAAs. Cancer cell-based vaccines can be autologous, allogeneic or xenogeneic. Clinical use of xenogeneic vaccines is advantageous in that they can be most effective in breaking the preexisting immune tolerance to TAAs. To potentiate immunotherapy, vaccinations can be combined with other modalities that target different immune pathways. These modalities include 1) genetic or chemical modification of cell-based vaccines; 2) cross-priming TAAs to T cells by engaging dendritic cells; 3) T-cell adoptive therapy; 4) stimulation of cytotoxic inflammation by non-specific immunomodulators, toll-like receptor (TLR) agonists, cytokines, chemokines or hormones; 5) reduction of immunosuppression and/or stimulation of antitumor effector cells using antibodies, small molecules; and 6) various cytoreductive modalities. The authors envisage that combined immunotherapeutic strategies will allow for substantial improvements in clinical outcomes in the near future.

Alarmins released during local antitumor treatments play an essential role in enhancing tumor growth inhibition at treated and non-treated sites via a derivative of CCL3

ECI301 (eMIP), a single amino-acid substituted CCL3 (MIP-1α), enhanced tumor growth inhibition and the abscopal effect (an effect distal to the target) following local antitumor therapy such as radiation, radiofrequency ablation (RFA), or hyperthermia treatment. The recent elucidation of the underlying mechanism may lead to a better antitumor therapy.

Treatment Response Evaluation and Follow-up in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is one of the major causes of morbidity, mortality and healthcare expenditure in patients with chronic liver disease. The management of HCC is evolving because of recently introduced novel therapeutic approaches. Optimal outcome requires an early and accurate assessment of tumor response to therapy. Current imaging modalities, such as computed tomography (CT) and magnetic resonance (MR) imaging; provide reliable and reproducible anatomical data in order to demonstrate tumor burden changes. However, in the setting of novel targeted therapies and liver directed treatments, simple tumor anatomical changes can be less informative and usually appear later than biological changes. There has been a growing interest to monitor the therapeutic response, at an early phase of treatment, by measuring tumor viability and/or perfusion. Therefore the importance of tumor viability assessment is increasingly being recognized. The tumor viability measurement guidelines have recently been amended to include the measurement of only the longest diameter of the enhancing tumors to formally amend RECIST to modified RECIST (mRECIST). Viable tumor should be defined as uptake of contrast agent in the arterial phase. In this review, we discuss criteria of response evaluation in HCC and further follow-up of patients receiving curative and palliative treatment.

Treatment algorithms for managing hepatocellular carcinoma

Early diagnosis and aggressive therapy improves outcome in hepatocellular carcinoma (HCC). Several potentially curative as well as palliative treatment options are available for patients. The choice of therapy is influenced by factors such as extent of tumor and severity of underlying liver dysfunction as well as availability of resources and of expertise. A systematic, algorithmic approach would ensure optimal therapy for each patient and is likely to improve outcomes. Even after receiving therapy for HCC, patients remain at risk for recurrent HCC as well as progression of underlying cirrhosis. Proper assessment and monitoring is needed for the underlying liver disease, which may progress to liver failure and have a major impact on long-term survival. Comprehensive care for patients with cirrhosis includes interventions such as antiviral therapy for HBV and HCV, abstention from alcohol, management of fatty liver disease, endoscopic surveillance and treatment for complications of portal hypertension and, if indicated, immunization against HAV and HBV. An algorithmic approach is useful for choosing the most appropriate treatment option for the individual patient from among the various options that are available. The general consensus is that the BCLC system should be preferred for staging HCC as it is useful in predicting outcomes and planning treatment. The BCLC system classifies patients with HCC into five categories: very early, early, intermediate, advanced, and terminal. It incorporates data on tumor status (number and size of nodules, vascular invasion, extra-hepatic spread), liver function (CTP status, presence of portal hypertension) and overall health status (constitutional symptoms, cancer symptoms, performance status). Treatment allocation according to sub-class of patients is a merit of the BCLC system; a few limitations have been noted, particularly with respect to patients with BCLC stage B and C disease. The treatment algorithm as per BCLC system is summarized in this review.

Resection for hepatocellular carcinoma

Hepatocellular Carcinoma (HCC) continues to present major challenges in management, which is further complicated by the presence of associated chronic liver disease. Key issues in surgical resection of HCC include the site, size, and number of lesions, the severity of the chronic liver disease, and the size of the functional liver remnant. De novo HCC in the absence of chronic liver disease can be treated by major liver resection with little risk of postoperative liver failure. Liver resection can also be used a bridge to liver transplantation as it affords the possibility of determining the pathologic grade of the tumortumor and its invasiveness, and thereby the prognosis. This review summarizes the current treatment approaches to surgical resection for HCC.

Role of local ablative therapy for hepatocellular carcinoma

Percutaneous local ablation (PLA) techniques are currently considered as the best treatment option for patients with early-stage hepatocellular carcinoma (HCC) who are not candidates for surgical resection. They are safe, minimally invasive, efficacious and cost-effective. Radiofrequency ablation (RFA) is considered as the first line treatment in some centers, though most of the guidelines recommend it for small HCCs, where surgical resection is not feasible. In developing countries percutaneous ethanol injection (PEI) and percutaneous acetic acid injection (PAI) may be used instead of RFA. For large HCCs, advances in electrode designs and newer techniques of ablation, including microwave ablation, are increasingly been used. Combination treatment modalities have shown promising results as compared to single modality for large tumors. The selection of the most appropriate modality depends on the size, number of lesions, the liver function status, patient's financial resources, availability of a particular technique and the expertise available.

Role of external beam radiation therapy in management of hepatocellular carcinoma

Diagnosis at advanced disease stage and early vascular invasion are the bane of majority of patients with hepatocellular carcinoma (HCC) in India. The currently standardized curative and palliative treatment modalities [surgery, ablative techniques, trans-catheter chemotherapy, systemic chemotherapy] are suboptimal for a significant proportion of disease stages. Interest in radiotherapy for hepatocellular carcinoma has seen a resurgence with revolutionary improvements in targeting radiation doses safely. Encouraging results have been reported with a host of radiation techniques from conformal radiotherapy, stereotactic whole body radiation therapy to charged particle based therapies. The dissemination of this knowledge has been slow across other specialties involved in care of patients with HCC. However the increasing availability of radiotherapy services predicts a hopeful future for wider evaluation of radiotherapy in HCC.

Perioperative bacterial infections in deceased donor and living donor liver transplant recipients

BACKGROUND

Deceased donor (DDLT) and living donor (LDLT) liver transplant (LT) is in vogue in several centers in India. Most centers are resorting to LDLT as a preferred surgery due to shortage of deceased donor liver. The risk of infection and its effect on survival in both groups of recipients from the Indian subcontinent are not known. The study was conducted to compare the bacterial infection rates among LDLT and DDLT recipients and their impact on survival at a tertiary referral center.

METHODS

Retrospective data on 67 LT recipients were reviewed. Data on pre-, per-, and postoperative bacterial infection rates and the common isolates were obtained.

RESULTS

Thirty-five patients had LDLT and 32 had DDLT. The prevalence of pre-operative bacterial infection and the isolates was similar in both groups. The perioperative bacterial infection rates were significantly higher in DDLT recipients (P < 0.01) (relative risk: 1.44 95% confidence interval 1.04-1.9). In both LDLT and DDLT, the common source was urinary tract followed by bloodstream infection. The common bacterial isolates in either transplant were Klebsiella followed by Escherichia coli, Pseudomonas spp. and nonfermenting gram-negative bacteria. Six patients (four LDLT; two DDLT) were treated for tuberculosis. Among the risk factors, cold ischemic time, and duration of stay in the intensive care unit was significantly higher for DDLT (p < 0.01). The death rates were not significantly different in the two groups. However, the odds for death were significantly high at 26.8 (p < 0.05) for postoperative bacterial infection and 1.8 (p < 0.001) for past alcohol.

CONCLUSION

Liver transplant recipients are at high-risk for bacterial infection irrespective of type of transplant, more so in DDLT.

Can Radiofrequency Ablation Be Used as a Treatment Modality for the Management of Pulmonary Metastatic Ameloblastoma?

We report the case of a 59-year-old woman who presented with metastatic ameloblastoma involving the lungs, 20 years after resection of the primary tumor in the mandible. The lesions were debulked on multiple occasions with radiofrequency ablation over an eight-year period with local response. There were no complications related to the procedures. We suggest that radiofrequency ablation is a possible treatment modality for the management and control of metastatic ameloblastoma.