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Abstract No. 188: Pecutaneous Isolated Limb Perfusion in the Treatment of Unresectable or In-Transit Metastases
retrograde nephrostomy catheter placement for the management of ureteral obstruction between January 2000-December 2006. The procedure was performed in three stages: placement of an antegrade percutaneous nephrostomy and/or nephroureterostomy; conversion to a trans-ileal retrograde nephrostomy with covering antegrade nephrostomy; removal of the antegrade nephrostomy after the first successful exchange of the retrograde catheter through the conduit. Medical records were reviewed to determine resolution of signs and symptoms as well as procedure related complications.
relieving dyspnea in patients with benign or malignant central airway obstructions. Our stent design seems to be less prone to migration or mucous retention.
RESULTS: 45 patients with ureteral obstruction underwent image guided placement of 57 antegrade nephrostomy and/or nephroureterostomy catheters followed by attempted conversion to trans-ileal retrograde nephrostomy catheters; 12 patients had bilateral catheters. Technical success (defined as successful completion of all three stages) was achieved in 52 of 57 renal units (91.2 %). Clinical success was seen in 38 of 45 patients (84.4%) with a mean clinical follow-up of 18.6 months. No major complications occurred from initial placement. Minor complications during the initial three stages included pericatheter leakage and tube dislodgement which occurred in 2 patients. Delayed complications were seen in 10.5% of patients and were mostly due to catheter encrustation.
PURPOSE: Acute graft versus host disease (GVHD) is a potentially fatal complication following allogeneic hematopoietic stem cell transplant (HSCT). Standard primary therapy for acute GVHD is systemic methylprednisolone, but failure of systemic steroids to control acute GVHD is common and can result in very high non-relapse mortality. Reports from the early 1990s indicated that 80% of responses to systemic steroids were incomplete or complete but not sustained. Overall, fewer than 30% of patients with resistant GVHD have complete or partial responses to available therapy, and 1 year survival remains 15% or less. There has been no generally accepted therapy for acute GVHD that proves refractory to steroids. Although little data on localized therapy for GVHD is published, intra-arterial injection of high-dose corticosteroids appears to be a viable option.
CONCLUSION: This technique is safe and effective and may serve as definitive treatment for managing postsurgical ureteral obstruction following non-continent urinary diversion procedures. 1:42 PM
Abstract No. 186
MATERIALS AND METHODS: From 2004 to 2007, we performed fluoroscopically guided placement of an internally silicone-covered retrievable metallic stent in 26 consecutive patients with benign (n ⫽ 5) and malignant (n ⫽ 21) central airway obstructions. Stents were woven from a single thread of a 0.2-mm-diameter nitinol wire in a tubular configuration and internally covered with silicone membrane. RESULTS: Technical and clinical success of stent placement were achieved in 93% and 85% of the patients, respectively. A total of eight complications (31%) including tumor overgrowth (n ⫽ 2), stent migration (n ⫽ 1), symptomatic granulation tissue formation (n ⫽ 1), severe pain (n ⫽ 1), improper stent location (n ⫽ 1), symptomatic sputum retention (n ⫽ 1) and esophagorespiratory fistula (n ⫽ 1) occurred after stent placement. Because of complications, five stents were removed by a retrieval hook under fluoroscopic guidance without difficulty. The median survival period and stent patency were 150.0 ⫾ 91.6 days and 143.0 ⫾ 26.7 days, respectively. CONCLUSION: Use of an internally silicone-covered retrievable metallic stent is a safe and effective method for
Intra-Arterial Steroid Injection Therapy for Systemic Steroid Resistant Graft-Versus-Host Disease. C.C. Sung, J.L. Weintraub, R.A. Lookstein, F.S. Nowakowski, A.P. Stangl; Mt. Sinai Medical Center, New York, NY
MATERIALS AND METHODS: We treated 15 patients with steroid resistant GVHD with intra-arterial injection of highdose corticosteroids. Total of 21 treatments were performed (1-5 treatments per patient) with only three patients receiving more than one treatment. One patient had hepatic GVHD, another had hepatic and gastrointestinal (GI) GVHD and remaining 13 had GI GVHD. Patients with hepatic GVHD received treatments into the hepatic arteries and patients with GI GVHD received treatments into the superior and inferior mesenteric arteries. One patient with GI GVHD also received treatments into both internal iliac arteries and another patient with upper GI GVHD received treatment into the ceilac axis. RESULTS: Four patients (27%) died, three patients from complications of GVHD and one patient from uncontrollable cardiac arrhythmia. Four patients (27%) showed partial response and were discharged on TPN and oral meds 14 to 43 days after the intra-arterial treatment. The remaining 7 patients (46%) showed complete response and were discharged on PO diet and oral meds 1 to 24 days after the intra-arterial treatment. No immediate treatment or procedure related complications were noted. CONCLUSION: Our preliminary results suggest that regional intra-arterial treatment of steroid resistant GVHD appears to be effective and safe. Larger, prospective studies need to be conducted. 2:06 PM
Abstract No. 188
Pecutaneous Isolated Limb Perfusion in the Treatment of Unresectable or In-Transit Metastases. S.P. Johnson, N.W. Pearlman, K.L. Kondo, J.B. Hosmer, N.G. Grant; University of Colorado Hospital, Denver, CO PURPOSE: To evaluate the clinical utility of percutaneous isolated limb perfusion (PILP) with chemotoxic adjuvants in patients with unresectable metastases. S71
WEDNESDAY
PURPOSE: We report our experience with an internally silicone-covered retrievable metallic stent in patients with benign or malignant central airway obstructions.
Abstract No. 187
Scientific Sessions
Use of an Internally Silicone-Covered Retrievable Metallic Stent To Treat Airway Obstruction. J.H. Kim,1 J.H. Shin,1 H.-Y. Song,1 S.C. Lee,2 K.R. Kim,1 C.H. Kang;1 1Asan Medical Center, Seoul, Republic of Korea; 2Seoul National University, Seoul, Republic of Korea
1:54 PM
MATERIALS AND METHODS: Six patients (age range 50-86 years, mean 61.6 years, 4 men, 2 women) with either malignant melanoma (n⫽5) or basal cell carcinoma (n⫽1) underwent a total of 9 PILP procedures (1 patient had 3 PILPs, 1 patient had 2 PILPs) for surgically unresectable metastases. Two 9 Fr metal-reinforced sheaths were passed into the affected limb using standard endovascular technique. A tourniquet was then placed and tightened proximally to the tips of the sheaths. The system was tested for leakage using fluorescein dye. Each sheath was connected to an extracorporeal oxygenation circuit, and a mild hyperthermic environment (35-38°C) achieved. This was followed by the introduction of high dose melphalan (n⫽6) (22-50 mg), carboplatin (n⫽2) (225-250 mg), or cisplatin (n⫽1) (22-28 mg) for a predetermined duration and number of cycles. RESULTS: All 6 patients underwent percutaneous isolated limb perfusion. Complications directly attributed to the percutaneous procedure included femoral artery thrombosis from a closure device (n⫽1), and leakage of fluorescein dye (10 mL, n⫽1; 165 mL, n⫽1). Three patients developed complications associated with chemotherapeutic treatment, such as woody skin induration (n⫽1), acute renal failure (n⫽1), and decreased hematocrit (n⫽1). The median length of hospital stay was 1 day (range 0-12 days). Response rates were consistent with those observed in surgical isolated limb perfusion. All 6 patients required additional treatments, consisting of additional PILP, radiofrequency ablation, resection, amputation or a combination thereof. CONCLUSION: Percutaneous isolated limb perfusion may offer a reasonable less invasive alternative to the more traditional surgical entity of isolated limb perfusion. Possible advantages include decreased post-operative recovery and the ability to perform retreatment.
2:18 PM
Abstract No. 189
Partial Splenic Embolization for Cancer Patients with Thrombocytopenia Requiring Systemic Chemotherapy. C.R. Kauffman,2 A. Mahvash,1 S. Kopetz,1 R.A. Wolff,1 M.J. Wallace;1 1The University of Texas M.D. Anderson Cancer Center, Houston, TX; 2Baylor College of Medicine, Houston, TX PURPOSE: The purpose of this study is to review our institutional experience with partial splenic embolization (PSE) to treat hypersplenism-related thrombocytopenia to facilitate the administration of systemic therapy (ST). MATERIALS AND METHODS: A retrospective review of cancer patients undergoing PSE was undertaken. Between March 2000 and August 2007, 28 patients with hypersplenism underwent PSE to correct thrombocytopenia and facilitate the initiation or resumption of ST. Primary and secondary endpoints of the study included a platelet count increase above 150 K/UL and initiation of ST, respectively. Peri-procedural laboratory values and adverse events were recorded. RESULTS: 30 PSEs were performed in 28 patients. Two patients underwent repeat PSE due to recurrent thrombocytopenia after successful initiation of ST. For procedures with adequate follow-up, primary and secondary endpoints were achieved in 96.4% (27/28) and 95.8% (23/24), respectively. The mean time to ST was 34 days with an average of 4.5 cycles administered. The mean platelet count was 82 S72
K/UL immediately prior to PSE and peaked at 294 K/UL after PSE. For 24 patients with frequent laboratory followup, the mean time to a platelet count ⬎ 150 K/UL was 10 days. The mean hospital stay was 4.3 days. Post-procedure abdominal pain occurred in all patients. Fever was documented in 16 patients and pulmonary consolidation/atelectasis or effusion was documented in 10 patients; 9 received empiric antibiotic coverage. The median overall survival was 9.40 months [95% CI: (8.2, 10.7)] among the 28 patients after PSE. CONCLUSION: In oncology patients with thrombocytopenia caused by hypersplenism, PSE is a safe and effective means of increasing platelet counts in order to facilitate the initiation or resumption of ST.
2:30 PM
Abstract No. 190
Phase I/II Study of Transjugular Transhepatic Peritoneal Venous Shunt (TTPVS) for Refractory Ascites (JIVROSG-0201). Y. Arai,1 Y. Inaba,2 M. Sone,2 H. Saito,2 Y. Takeuchi,2 Y. Shioyama,2 Y. Nakajima;2 1National Cancer Center, Tokyo, Japan; 2Japan Interventional Radiology in Oncology Study Group (JIVROSG), Japan PURPOSE: This multi-center prospective study was conducted to evaluate the safety and efficacy of transjugular transhepatic peritoneal-venous shunt (TTPVS). MATERIALS AND METHODS: Patients (pts) had refractory asicites (RA); restricted activities by RA; patent SVC & hepatic veins (HV); clear serous ascites; adequate hematologic, hepatic, renal, cardiac and respiratory functions; 0-3 ECOG performance status (PS); estimated prognosis ⬎ 4 wks; written consent. In phases I & II, 9 & 24 pts were enrolled. Adverse events were evaluated by NCI-CTC Ver. 2. Efficacy was classified to SE (significantly effective: improved symptom with body weight decrease to ⬍ 95% or girth decrease to ⬍ 90% or without medication for ⬎ 1 wk), ME (moderately effective: improved symptom without objective findings adjusting SE criteria for ⬎ 1 wk) and NE (not effective: not adjusting SE or ME criteria). Response rate was the ratio of pts with SE or ME in total. TTPVS was made by using the same manner as TIPS, perforating from the distal portion of HV to abdominal cavity (AC), placing TTPVS, 10Fr hydrophilic coated catheter with side-holes in its distal and one-way valve side holes (OVSH) in its middle, and adjusting OVSH to the right atrium. The proximal end of TTPVS catheter was capped and fixed with cervical skin by suture. RESULTS: Procedures were completed in all 33 pts (PS 0, 1, 2, 3 in 1, 11, 6, 15 pts). The right HV was used in 32 pts for perforating route. The pressure gradient between SVC and AC was 17 ⫾ 6 cmH2O (mean ⫾ SD). The required time was 53 ⫾ 30 min (mean ⫾ SD). Eight pts died of primary disease progression in 30 days after the procedure. The major adverse reactions (ⱖ Grade 2) were decreases in serum albumin (n⫽7) & hemoglobin (n⫽6). The response rate was 67% (50-80% in 95% CI) (SE, ME, NE in each 11). Seven pts had re-increase of ascites over 10d post procedure presumed to be caused by fibrin sheath formation around the TTPVS catheter. CONCLUSION: TTPVS is safe and feasible procedure. It can potentially replace the conventional shunt using subcu-
relieving dyspnea in patients with benign or malignant central airway obstructions. Our stent design seems to be less prone to migration or mucous retention.
RESULTS: 45 patients with ureteral obstruction underwent image guided placement of 57 antegrade nephrostomy and/or nephroureterostomy catheters followed by attempted conversion to trans-ileal retrograde nephrostomy catheters; 12 patients had bilateral catheters. Technical success (defined as successful completion of all three stages) was achieved in 52 of 57 renal units (91.2 %). Clinical success was seen in 38 of 45 patients (84.4%) with a mean clinical follow-up of 18.6 months. No major complications occurred from initial placement. Minor complications during the initial three stages included pericatheter leakage and tube dislodgement which occurred in 2 patients. Delayed complications were seen in 10.5% of patients and were mostly due to catheter encrustation.
PURPOSE: Acute graft versus host disease (GVHD) is a potentially fatal complication following allogeneic hematopoietic stem cell transplant (HSCT). Standard primary therapy for acute GVHD is systemic methylprednisolone, but failure of systemic steroids to control acute GVHD is common and can result in very high non-relapse mortality. Reports from the early 1990s indicated that 80% of responses to systemic steroids were incomplete or complete but not sustained. Overall, fewer than 30% of patients with resistant GVHD have complete or partial responses to available therapy, and 1 year survival remains 15% or less. There has been no generally accepted therapy for acute GVHD that proves refractory to steroids. Although little data on localized therapy for GVHD is published, intra-arterial injection of high-dose corticosteroids appears to be a viable option.
CONCLUSION: This technique is safe and effective and may serve as definitive treatment for managing postsurgical ureteral obstruction following non-continent urinary diversion procedures. 1:42 PM
Abstract No. 186
MATERIALS AND METHODS: From 2004 to 2007, we performed fluoroscopically guided placement of an internally silicone-covered retrievable metallic stent in 26 consecutive patients with benign (n ⫽ 5) and malignant (n ⫽ 21) central airway obstructions. Stents were woven from a single thread of a 0.2-mm-diameter nitinol wire in a tubular configuration and internally covered with silicone membrane. RESULTS: Technical and clinical success of stent placement were achieved in 93% and 85% of the patients, respectively. A total of eight complications (31%) including tumor overgrowth (n ⫽ 2), stent migration (n ⫽ 1), symptomatic granulation tissue formation (n ⫽ 1), severe pain (n ⫽ 1), improper stent location (n ⫽ 1), symptomatic sputum retention (n ⫽ 1) and esophagorespiratory fistula (n ⫽ 1) occurred after stent placement. Because of complications, five stents were removed by a retrieval hook under fluoroscopic guidance without difficulty. The median survival period and stent patency were 150.0 ⫾ 91.6 days and 143.0 ⫾ 26.7 days, respectively. CONCLUSION: Use of an internally silicone-covered retrievable metallic stent is a safe and effective method for
Intra-Arterial Steroid Injection Therapy for Systemic Steroid Resistant Graft-Versus-Host Disease. C.C. Sung, J.L. Weintraub, R.A. Lookstein, F.S. Nowakowski, A.P. Stangl; Mt. Sinai Medical Center, New York, NY
MATERIALS AND METHODS: We treated 15 patients with steroid resistant GVHD with intra-arterial injection of highdose corticosteroids. Total of 21 treatments were performed (1-5 treatments per patient) with only three patients receiving more than one treatment. One patient had hepatic GVHD, another had hepatic and gastrointestinal (GI) GVHD and remaining 13 had GI GVHD. Patients with hepatic GVHD received treatments into the hepatic arteries and patients with GI GVHD received treatments into the superior and inferior mesenteric arteries. One patient with GI GVHD also received treatments into both internal iliac arteries and another patient with upper GI GVHD received treatment into the ceilac axis. RESULTS: Four patients (27%) died, three patients from complications of GVHD and one patient from uncontrollable cardiac arrhythmia. Four patients (27%) showed partial response and were discharged on TPN and oral meds 14 to 43 days after the intra-arterial treatment. The remaining 7 patients (46%) showed complete response and were discharged on PO diet and oral meds 1 to 24 days after the intra-arterial treatment. No immediate treatment or procedure related complications were noted. CONCLUSION: Our preliminary results suggest that regional intra-arterial treatment of steroid resistant GVHD appears to be effective and safe. Larger, prospective studies need to be conducted. 2:06 PM
Abstract No. 188
Pecutaneous Isolated Limb Perfusion in the Treatment of Unresectable or In-Transit Metastases. S.P. Johnson, N.W. Pearlman, K.L. Kondo, J.B. Hosmer, N.G. Grant; University of Colorado Hospital, Denver, CO PURPOSE: To evaluate the clinical utility of percutaneous isolated limb perfusion (PILP) with chemotoxic adjuvants in patients with unresectable metastases. S71
WEDNESDAY
PURPOSE: We report our experience with an internally silicone-covered retrievable metallic stent in patients with benign or malignant central airway obstructions.
Abstract No. 187
Scientific Sessions
Use of an Internally Silicone-Covered Retrievable Metallic Stent To Treat Airway Obstruction. J.H. Kim,1 J.H. Shin,1 H.-Y. Song,1 S.C. Lee,2 K.R. Kim,1 C.H. Kang;1 1Asan Medical Center, Seoul, Republic of Korea; 2Seoul National University, Seoul, Republic of Korea
1:54 PM
MATERIALS AND METHODS: Six patients (age range 50-86 years, mean 61.6 years, 4 men, 2 women) with either malignant melanoma (n⫽5) or basal cell carcinoma (n⫽1) underwent a total of 9 PILP procedures (1 patient had 3 PILPs, 1 patient had 2 PILPs) for surgically unresectable metastases. Two 9 Fr metal-reinforced sheaths were passed into the affected limb using standard endovascular technique. A tourniquet was then placed and tightened proximally to the tips of the sheaths. The system was tested for leakage using fluorescein dye. Each sheath was connected to an extracorporeal oxygenation circuit, and a mild hyperthermic environment (35-38°C) achieved. This was followed by the introduction of high dose melphalan (n⫽6) (22-50 mg), carboplatin (n⫽2) (225-250 mg), or cisplatin (n⫽1) (22-28 mg) for a predetermined duration and number of cycles. RESULTS: All 6 patients underwent percutaneous isolated limb perfusion. Complications directly attributed to the percutaneous procedure included femoral artery thrombosis from a closure device (n⫽1), and leakage of fluorescein dye (10 mL, n⫽1; 165 mL, n⫽1). Three patients developed complications associated with chemotherapeutic treatment, such as woody skin induration (n⫽1), acute renal failure (n⫽1), and decreased hematocrit (n⫽1). The median length of hospital stay was 1 day (range 0-12 days). Response rates were consistent with those observed in surgical isolated limb perfusion. All 6 patients required additional treatments, consisting of additional PILP, radiofrequency ablation, resection, amputation or a combination thereof. CONCLUSION: Percutaneous isolated limb perfusion may offer a reasonable less invasive alternative to the more traditional surgical entity of isolated limb perfusion. Possible advantages include decreased post-operative recovery and the ability to perform retreatment.
2:18 PM
Abstract No. 189
Partial Splenic Embolization for Cancer Patients with Thrombocytopenia Requiring Systemic Chemotherapy. C.R. Kauffman,2 A. Mahvash,1 S. Kopetz,1 R.A. Wolff,1 M.J. Wallace;1 1The University of Texas M.D. Anderson Cancer Center, Houston, TX; 2Baylor College of Medicine, Houston, TX PURPOSE: The purpose of this study is to review our institutional experience with partial splenic embolization (PSE) to treat hypersplenism-related thrombocytopenia to facilitate the administration of systemic therapy (ST). MATERIALS AND METHODS: A retrospective review of cancer patients undergoing PSE was undertaken. Between March 2000 and August 2007, 28 patients with hypersplenism underwent PSE to correct thrombocytopenia and facilitate the initiation or resumption of ST. Primary and secondary endpoints of the study included a platelet count increase above 150 K/UL and initiation of ST, respectively. Peri-procedural laboratory values and adverse events were recorded. RESULTS: 30 PSEs were performed in 28 patients. Two patients underwent repeat PSE due to recurrent thrombocytopenia after successful initiation of ST. For procedures with adequate follow-up, primary and secondary endpoints were achieved in 96.4% (27/28) and 95.8% (23/24), respectively. The mean time to ST was 34 days with an average of 4.5 cycles administered. The mean platelet count was 82 S72
K/UL immediately prior to PSE and peaked at 294 K/UL after PSE. For 24 patients with frequent laboratory followup, the mean time to a platelet count ⬎ 150 K/UL was 10 days. The mean hospital stay was 4.3 days. Post-procedure abdominal pain occurred in all patients. Fever was documented in 16 patients and pulmonary consolidation/atelectasis or effusion was documented in 10 patients; 9 received empiric antibiotic coverage. The median overall survival was 9.40 months [95% CI: (8.2, 10.7)] among the 28 patients after PSE. CONCLUSION: In oncology patients with thrombocytopenia caused by hypersplenism, PSE is a safe and effective means of increasing platelet counts in order to facilitate the initiation or resumption of ST.
2:30 PM
Abstract No. 190
Phase I/II Study of Transjugular Transhepatic Peritoneal Venous Shunt (TTPVS) for Refractory Ascites (JIVROSG-0201). Y. Arai,1 Y. Inaba,2 M. Sone,2 H. Saito,2 Y. Takeuchi,2 Y. Shioyama,2 Y. Nakajima;2 1National Cancer Center, Tokyo, Japan; 2Japan Interventional Radiology in Oncology Study Group (JIVROSG), Japan PURPOSE: This multi-center prospective study was conducted to evaluate the safety and efficacy of transjugular transhepatic peritoneal-venous shunt (TTPVS). MATERIALS AND METHODS: Patients (pts) had refractory asicites (RA); restricted activities by RA; patent SVC & hepatic veins (HV); clear serous ascites; adequate hematologic, hepatic, renal, cardiac and respiratory functions; 0-3 ECOG performance status (PS); estimated prognosis ⬎ 4 wks; written consent. In phases I & II, 9 & 24 pts were enrolled. Adverse events were evaluated by NCI-CTC Ver. 2. Efficacy was classified to SE (significantly effective: improved symptom with body weight decrease to ⬍ 95% or girth decrease to ⬍ 90% or without medication for ⬎ 1 wk), ME (moderately effective: improved symptom without objective findings adjusting SE criteria for ⬎ 1 wk) and NE (not effective: not adjusting SE or ME criteria). Response rate was the ratio of pts with SE or ME in total. TTPVS was made by using the same manner as TIPS, perforating from the distal portion of HV to abdominal cavity (AC), placing TTPVS, 10Fr hydrophilic coated catheter with side-holes in its distal and one-way valve side holes (OVSH) in its middle, and adjusting OVSH to the right atrium. The proximal end of TTPVS catheter was capped and fixed with cervical skin by suture. RESULTS: Procedures were completed in all 33 pts (PS 0, 1, 2, 3 in 1, 11, 6, 15 pts). The right HV was used in 32 pts for perforating route. The pressure gradient between SVC and AC was 17 ⫾ 6 cmH2O (mean ⫾ SD). The required time was 53 ⫾ 30 min (mean ⫾ SD). Eight pts died of primary disease progression in 30 days after the procedure. The major adverse reactions (ⱖ Grade 2) were decreases in serum albumin (n⫽7) & hemoglobin (n⫽6). The response rate was 67% (50-80% in 95% CI) (SE, ME, NE in each 11). Seven pts had re-increase of ascites over 10d post procedure presumed to be caused by fibrin sheath formation around the TTPVS catheter. CONCLUSION: TTPVS is safe and feasible procedure. It can potentially replace the conventional shunt using subcu-