Faculty Bibliography

PURPOSE/OBJECTIVE:To compare the safety and efficacy of transarterial chemoembolization for hepatocellular carcinoma (HCC) in patients with and without transjugular intrahepatic portosystemic shunts (TIPS). MATERIALS AND METHODS/METHODS:This single-institution study included a retrospective review of 50 patients who underwent transarterial chemoembolization for HCC between January 2010 and April 2017. Twenty-five patients had preexisting TIPS, and 25 patients were selected to control for age, sex, and target tumor size. Baseline median Model for End-Stage Liver Disease (MELD; 13 TIPS, 9 control; P < .001) and albumin-bilirubin (ALBI; 3 TIPS, 2 control; P < .001) differed between groups. Safety was assessed on the basis of Common Terminology Criteria for Adverse Events (CTCAE) and change in MELD and ALBI grade assessed between 3 and 6 months. Efficacy was assessed by tumor response and time to progression (TTP). RESULTS:There was 1 severe adverse event (CTCAE grade >2) in the TIPS group. There was no difference in the change in MELD or ALBI grade. Although there was no difference in tumor response (P = .19), more patients achieved a complete response in the control group (19/25, 76%) than in the TIPS group (13/25, 52%). There was no difference in TTP (P = .82). At 1 year, 2 patients in the control group and 3 patients in the TIPS group received a liver transplant. Seven patients died in the TIPS group. CONCLUSIONS:Transarterial chemoembolization is as safe and effective in patients with TIPS as in patients without TIPS, despite worse baseline liver function. Severe adverse events are rare and may be transient.

PURPOSE/OBJECTIVE:To investigate the safety of yttrium-90 radioembolization in combination with checkpoint inhibitor immunotherapy for the treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS/METHODS:This single-center retrospective study included 26 consecutive patients with HCC who received checkpoint inhibitor immunotherapy within 90 days of radioembolization from April 2015 to May 2018. Patients had preserved liver function (Child-Pugh scores A-B7) and either advanced HCC due to macrovascular invasion or limited extrahepatic disease (21 patients) or aggressive intermediate stage HCC that resulted in earlier incorporation of systemic immunotherapy (5 patients). Clinical documentation, laboratory results, and imaging results at 1- and 3-month follow-up intervals were reviewed to assess treatment-related adverse events and treatment responses. RESULTS:The median follow-up period after radioembolization was 7.8 months (95% confidence interval [CI], 5.6-11.8). There were no early (30-day) mortality or grades 3/4 hepatobiliary or immunotherapy-related toxicities. Delayed grades 3/4 hepatobiliary toxicities (1-3 months) occurred in 2 patients in the setting of HCC disease progression. One patient developed pneumonitis. The median overall survival from first immunotherapy was 17.2 months (95% CI, 10.9-23.4). The median overall survival from first radioembolization was 16.5 months (95% CI, 6.6-26.4). From first radioembolization, time to tumor progression was 5.7 months (95% CI, 4.2-7.2), and progression-free survival was 5.7 months (95% CI, 4.3-7.1). CONCLUSIONS:Radioembolization combined with checkpoint inhibitor immunotherapy in cases of HCC appears to be safe and causes limited treatment-related toxicity. Future prospective studies are needed to identify the optimal combination treatment protocols and evaluate the efficacy of combination therapy.

Familiarity with different instruments and understanding the basics of image guidance techniques are essential for interventional radiology trainees. However, there are no structured references in the literature, and trainees are left to "pick it up as they go". Puncture needles, guidewires, sheath systems, and catheters represent some of the most commonly used daily instruments by interventional radiologists. There is a large variety of instruments, and understanding the properties of each tool will allow trainees to better assess which type is needed for each specific procedure. Along with understanding the tools required to perform various interventional radiology procedures, it is important for trainees to learn how to organize the room, procedural table, and various equipment that is used during the procedure. Minimizing clutter and improving organization leads to improved efficiency and decreased errors. In addition, having a fundamental knowledge of fluoroscopy, the most commonly used imaging modality, is an integral part of beginning training in interventional radiology.

Purpose: As Y90 radioembolization has been shown to activate an immune response, synergistic effects with check-point inhibitor immunotherapy have been proposed. However, the safety of concurrent Y90 and immunotherapy has not been reported. This study retrospectively evaluated the safety of Y90 with concurrent immunotherapy in patients with primary or metastatic liver cancer. Materials: The retrospective study was conducted with IRB approval. Patients who received Y90 treatment within 30 days of immunotherapy were considered to have concurrent therapy. Baseline laboratory values obtained within one month prior to Y90 and at 1 and 3 months after Y90 were evaluated. Hepatobiliary and immunotherapy-related adverse events were characterized according to NCI CTCAE v5.0. Patient survival was estimated using Kaplan-Meier analysis.
Result(s): Between June 2015 and March 2018, 18 patients received concurrent therapy. 14 patients had hepatocellular carcinoma (3 BCLC B, and 11 BCLC C), and 4 had metastatic disease to the liver (3 melanoma, 1 gastric cancer). The median interval between Y90 and immunotherapy was 7 days. Grade >=3 hepatobiliary toxicity occurred in 1 patient at 1 month (6%) and in 3 patients at 3 months (17%) after Y90. Grade >=3 toxicities occurred only in patients with advanced HCC (BCLC C). No grade >=3 immune-associated toxicities occurred at 1 or 3 months in any patients. Median overall survival from first Y90 was 27.4 months for patients with HCC and 13.7 months for patients with metastatic disease to the liver.
Conclusion(s): Concurrent Y90 radioembolization and checkpoint-inhibitor immunotherapy appears to be safe with a low incidence of toxicity. Toxicities were limited to patients with advanced HCC and may be confounded by disease progression.
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Purpose: The abscopal effect refers to the immune mediated regression of distant tumor after localized therapy and is typically enhanced by administration of immunotherapy agents such as check-point inhibitors. There are emerging case reports of the abscopal effect after Y90 radioembolization to hepatic malignancy, but systematic investigations are lacking. Here, we investigated the response of extra-hepatic tumors in patients who received both hepatic Y90 radioembolization and systemic immunotherapy. Materials: This single-center retrospective study includes patients with concomitant intra-and extra-hepatic tumor burden who received both Y90 radioembolization and immunotherapy within a 6 month time period between 6/2015-3/2018. The overall survival was evaluated by Kaplan-Meier analysis. The treatment responses of extra-hepatic malignancy at 1 month, 3 months and 6 months intervals were evaluated according to RECIST 1.1 criteria. Result(s): Of 136 total Y90 patients, 26 patients were eligible for analysis. 11 patients (7 HCC, 1 cholangiocarcinoma, and 3 metastatic liver cancer) had Y90 prior to initiation of immunotherapy and 15 patients (7 HCC, 8 metastatic liver cancer) had Y90 after immunotherapy. Objective response at 6-month follow up includes 1 partial response (3.8%), 8 stable disease (30.8%), and 16 progressive disease (61.5%). The median survival time for patients with metastatic hepatic malignancy cannot be determined (2/11 died), and the median survival time for patients with primary liver cancer is 27 months (9/15 died). Conclusion(s): In this systematic, large institutional review, no patients displayed complete regression in distant sites after receiving Y90 and immunotherapy, suggesting that the type of clear abscopal regression reported anecdotally is uncommon. Interestingly, multiple patients demonstrated unexpectedly long-term stable metastatic disease, which could be related to the abscopal effect and motivates subsequent dedicated studies of the immune environment of stable distant tumors.

Purpose To report long-term outcomes of radiation segmentectomy (RS) for early hepatocellular carcinoma (HCC). The authors hypothesized that outcomes are comparable to curative treatments for patients with solitary HCC less than or equal to 5 cm and preserved liver function. Materials and Methods This retrospective study included 70 patients (median age, 71 years; range, 22-96 years) with solitary HCC less than or equal to 5 cm not amenable to percutaneous ablation who underwent RS (dose of >190 Gy) between 2003 and 2016. Patients who underwent subsequent curative liver transplantation were excluded to eliminate this confounding variable affecting survival. Radiologic response of time to progression and median overall survival were estimated by using the Kaplan-Meier method per the guidelines of the European Association for the Study of the Liver (EASL) and the World Health Organization (WHO). Results Seventy patients were treated with RS over 14 years. Sixty-three patients (90%) showed response by using EASL criteria, of which 41 (59%) showed complete response. Fifty patients (71%) achieved response by using WHO criteria, of which 11 (16%) achieved complete response. Response rates at 6 months were 86% and 49% by using EASL and WHO criteria, respectively. Median time to progression was 2.4 years (95% confidence interval: 2.1, 5.7), with 72% of patients having no target lesion progression at 5 years. Median overall survival was 6.7 years (95% confidence interval: 3.1, 6.7); survival probability at 1, 3, and 5 years was 98%, 66%, and 57%, respectively. Overall survival probability at 1, 3, and 5 years was 100%, 82%, and 75%, respectively, in patients with baseline tumor size less than or equal to 3 cm (n = 45) and was significantly longer than in patients with tumors greater than 3 cm (P = .026). Conclusion RS provides response rates, tumor control, and survival outcomes comparable to curative-intent treatments for selected patients with early-stage HCC who have preserved liver function. ^© RSNA, 2018 Online supplemental material is available for this article.

PURPOSE:To inductively characterize perceptions of quality in interventional oncology (IO) based on values and experiences of patients and referring providers. MATERIALS AND METHODS:Brief ethnographic interviews were completed with referring providers and patients before and after a variety of liver-directed procedures about their experiences, concerns, and perceptions of IO services at a single institution. Constructivist grounded theory was used to systematically analyze interview transcripts for themes until thematic saturation was achieved. All transcripts were analyzed by a reviewer with 3-years of experience performing such analyses, and 50% were randomly selected to be coded by 2 additional blinded reviewers. Interreviewer agreement was assessed via Cohen κ. RESULTS:Interviews with 22 patients (mean age, 65 y ± 13; 9 women) and 12 providers (mean age, 54 y ± 9; 6 women) were required to reach and confirm thematic saturation. Interreviewer agreement for interview themes was excellent (κ = 0.78; P < .001). Perceptions of high-quality IO care relied on interventional radiologists being responsive, friendly, and open; engaging in multidisciplinary collaboration; having thoughtful, dedicated support staff; and facilitating well-coordinated care after procedures and follow-up more than technical expertise and periprocedural comfort. Patient and provider perceptions of quality differed, but disjointed care after procedures was the most common critique among both groups. CONCLUSIONS:An inductive qualitative approach effectively characterized specific aspects of perceptions of high-quality IO care among patients and referring providers.

PURPOSE/OBJECTIVE:To analyze long-term outcomes in patients bridged/downstaged to orthotopic liver transplantation (OLT) by transarterial chemoembolization (TACE) or yttrium-90 radioembolization (Y90) for hepatocellular carcinoma (HCC). METHODS:172 HCC patients who underwent OLT after being treated with transarterial liver-directed therapies (LDTs) (Y90: 93; TACE: 79) were identified. Pre-LDT and pre-OLT clinical/imaging/laboratory characteristics including United Network for Organ Sharing (UNOS) staging and alpha-fetoprotein values (AFP) were tabulated. Post-OLT HCC recurrence was assessed by imaging follow-up per standard of care. Recurrence-free (RFS) and overall survival (OS) were calculated. Uni/multivariate and sub-stratification analyses were performed. RESULTS:Time-to-OLT was longer in the Y90 group (Y90: 6.5 months; TACE: 4.8 months; p=0.02). With a median post-OLT follow-up of 26.1 months (IQR: 11.1-49.7), tumor recurrence was found in 6/79 (8%) TACE and 8/93 (9%) Y90 patients. Time-to-recurrence was 26.6 (CI: 7.0-49.5) and 15.9 months (CI: 7.8-46.8) for TACE and Y90, respectively (p=0.48). RFS (Y90: 79 months; TACE: 77 months; p=0.84) and OS (Y90: 57% alive at 100 months; TACE: 84.2 months; p=0.57) were similar. 54/155 patients (Y90: 29; TACE: 25) were downstaged to UNOS T2 or less. RFS hazard ratios for patients downstaged to ≤T2 versus those that were not were 0.6 (CI: 0.33-1.1) and 1.7 (CI: 0.9-3.1) respectively (p=0.13). 17/155 patients (Y90: 8; TACE: 9) that were >T2 were downstaged to UNOS T2 or less (within transplant criteria). Distribution (unilobar/bilobar), AFP, and pre-transplant UNOS stage affected RFS on univariate analyses. CONCLUSION/CONCLUSIONS:Despite longer time-to-OLT for Y90 patients, post-OLT outcomes were similar between patients bridged or downstaged by TACE or Y90. A trend towards improved RFS for downstaged patients was identified.