- Email: [email protected]
Denver peritoneo-venous shunt (DPVS): an essential tool in the management of malignant ascites
S248
Posters and Exhibits
Clinical Findings/Procedure Details: A steep initial learning curve with TRA may inaccurately give the impression of a cumbersome technique. When compared to transfemoral arterial access (TFAA), studies have shown TRAA is associated with decreased complications and superior patient satisfaction. Additional advantages with TRAA include decreased post-procedure recovery time with early ambulation, and possibly decreased cost. This educational exhibit contains a descriptive and pictorial review of basic TRAA access technique, equipment, pre-procedure planning and patient selection, and post-procedure care, optimal for practices looking to introduce this technique. Additionally, descriptive and pictorial information regarding advantages/ disadvantages, pitfalls and pearls specific to TRAA for intraarterial liver-directed therapies will be described. Conclusions: Combined with adequate pre-procedure planning and proper patient selection, TRAA is a viable approach for intra-arterial liver-directed therapies. With future development of equipment and refinement in technique, TRAA will supplant TFAA as the primary approach for intra-arterial liver-directed therapies. References 1. Cooper CJ, et al. Effect of transradial access on quality of life and cost of cardiac catheterization: A randomized comparison. Am Heart J 1999; 138(3 Pt 1):430–436. 2. Fischman AM, Swinburne NC, Patel RS. A Technical Guide Describing the Use of Transradial Access Technique for Endovascular Interventions. Tech Vasc Interv Radiol 2015; 18(2):58–65. 3. Patel A, et al. Transradial intervention: basics. J Vasc Interv Radiol 2015; 26 (5):722.
Abstract No. 562 Is radioembolization equivalent to chemoembolization (DEBDOX) for the treatment of HCC? A propensity matched observational study
Posters and Exhibits
O. Akinwande1, O. Akinwande1, R. Martin2; 1Johns Hopkins University, Randallstown, MD; 2University of Louisville, Louisville, KY Purpose: To compare the performance of radioembolization and Chemoembolization with Doxorubicin Drug Eluting Beads (DEBDOX) in the treatment of hepatocellular carcinoma. Materials: Analysis of our prospectively managed locoregional therapy (LRT) database was performed. 358 patients were treated with LRT for HCC, of which 291 were treated with DEBDOX and 67 with 90Y. Comparative toxicity, tumor response, progression free survival (PFS) and overall survival (OS) were assessed. Propensity score matching (using 12 baseline patient variables) was used to reduce treatment-selection bias, producing 48 pairs. Comparative analysis was repeated after propensity matching. Results: Median age was 67 and 65 years for the DEBDOX and 90Y groups respectively (p ¼ 0.2). Overall survival favored the DEBDOX group (DEBDOX: 15-months, 90Y: 6-months, p¼o0.0001). PFS also favored the DEBDOX group (DEBDOX: 15-months, 90Y: 6-months, po0.0001). All grade adverse events was lower in the DEBDOX group, although not statistically significant (DEBDOX 10%, 90Y 15%, p¼ 0.1). After propensity score matching, again longer
’
JVIR
OS was seen with the DEBDOX group (DEBDOX 13 m., 90Y 4 m.; p¼0.0077). There was also lower all-grade adverse events seen with DEBDOX that did not reach significance (DEBDOX 14%, 90Y 20%, p¼0.3). Both pooled and matched cohorts showed better disease control with DEBDOX than radioembolization (p values 0.0001 and 0.02; respectively). Conclusions: Within limitations, our preliminary observation suggests that DEBDOX may outperform 90Y with superior efficacy and survival with a trend towards lower all-grade toxicity. Further studies are warranted to validate or refute our findings.
Educational Exhibit
Abstract No. 563
Denver peritoneo-venous shunt (DPVS): an essential tool in the management of malignant ascites A. Peterson1, C. Hennemeyer2; 1University of Arizona, Tucson, AZ, United States; 2University of Arizona, Tucson, AZ Learning Objectives: DPVS shunting provides an important alternative for the management of malignant ascites. • Describe details of procedure, benefits and complications compared to paracentesis • Report our experience with percutaneous placement, post procedural management and complications (20 cases using CareFusion Denver ascites shunt) Background: DVPS shunting delivers prolonged relief of recurrent and treatment refractory ascites. Originally introduced as an intervention to control cirrhotic effusion refractory to medical management, DVPS shunt placement and management is within the skill set of IR physicians, and further they are useful for the management of recurrent large volume ascites associated with malignant abdominal disease so common in our practices. Clinical Findings/Procedure Details: Criteria- Majority of our patients were end-stage cancer patients with extensive peritoneal or multifocal metastatic disease resulting symptomatic recurrent ascites. Managing oncologist made up the principal referral base. We chose to accept patients with a life expectancy of six months or less, and palliation of symptoms as the end goal. Patients were admitted and followed for potential development of DIC. Benefits- Denver shunts are highly effective in relief of ascites symptoms. Shunting can provide physiologic benefits- increased effective blood volume, renal blood flow and diuresis, retained nutrients and improved nutritional status, improved mobility and respiration and relief of massive, refractory ascites, without the risk/need to undergo recurrent percutaneous paracentesis. Procedure- All 20 of our shunt procedures were performed under conscious sedation and local anesthesia. Subcutaneous pocket formed overlying the lower rib cage. Both jugular venous and peritoneal peel away sheaths were placed and connected to the pocket with subcutaneous tunneling. Pump was positioned over the ribs in a pocket analogous to a port. Conclusions: Complications/Post procedural managementThere are numerous known DVPS complications. However, our observed complications related to luminal plugging of the shunt, or tubing, and one retraction of tubing out of the
JVIR
’
Posters and Exhibits
S249
internal jugular vein. No bleeding episodes occurred. All achieved symptomatic relief. References 1. Seike M, Maetani I, Sakai Y. Treatment of malignant ascites in patients with advanced cancer: peritoneovenous shunt versus paracentesis. J Gastroenterol Hepatol 2007; 22:2161–2166. 2. Martin LG. Percutaneous placement and management of peritovenous shunts. Semin Intervent Radiol 2012; 29:129–134. 3. Bratby MJ, Hussain FF, Lopez AJ. Radiological insertion and management of peritoneovenous shunt. Cardiovasc Intervent Radiol 2007; 30:415–418. 4. Shah, N. CareFusion Protocol, Disseminated Intravascular Coagulation (DIC) 2012.
Abstract No. 564 In vivo cellular MR imaging evaluating anatomic configuration of blood supply contributing to portal vein tumor thrombus in rabbits J. Chen1, Y. Gao2, Z. Guo2, L. Sun2, B. Wu2, W. Xi2, X. Zhang2, J. zhang2; 1Jiangsu Cancer Hospital,Nanjing, Nanjing Jiangsu; 2Jiangsu cancer hospital, Nanjing, Nanjing
Abstract No. 565 Treatment response evaluation by modified RECIST after locoregional therapy in patients with hepatocellular carcinoma: correlation with explant pathology and post-liver transplant survival S. McLafferty, S. Trakroo, R. Bonshock, K. Qureshi, S. Fisher, F. Ramsey, G. Cohen; Temple University Hospital, Philadelphia, PA Purpose: To correlate mRECIST response with survival and explant pathology following liver transplant (LT) in patients with hepatocellular carcinoma (HCC) who received locoregional therapies (LRT) prior to LT. Materials: Patients with HCC listed for LT from 1/1/09 to 8/ 31/14 were included. 53 patients received LRT prior to LT. 37/ 53 had an imaging study after LRT prior to LT, these patients were included in our study. The remaining 16 were excluded for lack of imaging post-LRT. Studies were retrospectively reviewed using mRECIST guidelines by two radiologists blinded to pathology and outcomes. Concordance between mRECIST and explant pathology was assessed based on the presence or absence of viable tumor and percentage of tumor necrosis, statistical significance was analyzed using a Fisher’s Exact Test. Kaplan-Meier analysis was used to evaluate for an impact on survival following LT for responders (CR þ PR) versus nonresponders (SD þ PD). Results: There were 15 cases (40.5%) of complete response (CR), 4 cases (10.8%) of partial response (PR), 12 cases (32.4%) of stable disease (SD) and 6 cases (16.2%) of progressive disease (PD). Concordance between mRECIST and explant pathology was seen in 28 cases (75.6%), this was shown to not be statistically significant. Discordance was observed in 9 cases (24.4%), underestimation of response was present in 3 cases (8.1%) and overestimation of response in 6 cases (16.2%). Responders (CR þ PR) did not demonstrate a difference in overall survival following LT when compared with nonresponders (SD þ PD). Conclusions: Evaluation of response to LRT using mRECIST criteria was discordant with explant pathology in 24.4% of cases, the majority of cases overestimating response to treatment. This is in keeping with what other researchers have shown in retrospective studies1. Response to LRT prior to LT did not demonstrate a difference in overall survival
Posters and Exhibits
Purpose: to investigate blood flow of hepatic artery and portal vein contributing to portal vein tumor thrombus (PVTT) in rabbits. Materials: A total of 40 adult New Zealand White rabbits were used for this study. Twelve rabbits were used for collecting peripheral blood to isolate MNCs. Four rabbits were used as tumor carriers for the study rabbits and 24 study rabbits underwent implantation in the portal vein with VX2 tumor. These study rabbits were then randomly assigned to four groups of 6 animals each (groups A, B, C and D): group A, B and C animals received iron-labeled mononuclear cells infusion through hepatic artery, portal vein and auricular vein respectively, whereas group D animals were treated with normal saline injection via auricular vein 7 days after the implantation of VX2 tumors in portal vein. Peripheral blood MNCs were isolated and labeled using PLL-SPIO in vitro. In vivo MR imaging was performed and the average signal intensitie (SI) of the PVTT were measured on T2WI 1 day after the iron labeled cells transfusion. Rrepresentative Prussian blue-stained PVTT slides from groups A, B and C were examined to determine accumulation of iron labeled cells in the PVTT. Clinical Findings/Procedure Details: PVTTs in animals of four groups were clearly observed on T1WI and T2WI. Significant SI decline was observed on T2WI in rabbits of goupe A and B. The SI of PVTT in group A was significantly less than that in group C and group D (262.250±96.753 vs. 575.033±261.593, U ¼ 4.000, p¼ 0.025; 262.250±96.753 vs. 584.300±169.210, U ¼ 2.000, p¼ 0.010). The SI of PVTT in group B was significantly less than that in group C and group D (251.117±73.036 vs. 575.033±261.593, U ¼ 4.000, p¼ 0.025; 251.117±73.036 vs. 584.300±169.210, U ¼ 1.000, p¼ 0.006). No significant SI difference of PVTT was presented between group A and group B (262.250±96.753 vs. 251.117±73.036, U ¼ 18.000, p¼ 1.000). Conclusions: Initial evidence from the study implies that portal vein as well as hepatic artery supplies to PVTT in rabbits.
References 1. Fong Y, Sun RL, Jarnagin W, Blumgart LH. An analysis of 412 cases of hepatocellular carcinoma at a Western center. Ann Surg 1999; 229(6):790–799; discussion 799–800. 2. European Association for the Study of the Liver; European Organisation For Research and Treatment of Cancer. EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol 2012; 6 (4):908–943. 3. Bruix J, Sherman M. American Association for the Study of Liver Diseases. Management of hepatocellular carcinoma: an update. Hepatology 2011; 53 (3):1020–1022. 4. Shiotani M, Ku Y, Kusunoki N, Kitagawa T, Maeda I, Tominaga M, Tanigawara Y, Kuroda Y, Saitoh Y. Pharmacokinetic comparison of intraarterial and intraportal infusion of adriamycin in regional chemotherapy of the liver. Gan To Kagaku Ryoho 1995, 22(11):1560–1562. 5. Song do S, Bae SH, Song MJ, Lee SW, Kim HY, Lee YJ, Oh JS, Chun HJ, Lee HG, Choi JY, Yoon SK. Hepatic arterial infusion chemotherapy in hepatocellular carcinoma with portal vein.
Posters and Exhibits
Clinical Findings/Procedure Details: A steep initial learning curve with TRA may inaccurately give the impression of a cumbersome technique. When compared to transfemoral arterial access (TFAA), studies have shown TRAA is associated with decreased complications and superior patient satisfaction. Additional advantages with TRAA include decreased post-procedure recovery time with early ambulation, and possibly decreased cost. This educational exhibit contains a descriptive and pictorial review of basic TRAA access technique, equipment, pre-procedure planning and patient selection, and post-procedure care, optimal for practices looking to introduce this technique. Additionally, descriptive and pictorial information regarding advantages/ disadvantages, pitfalls and pearls specific to TRAA for intraarterial liver-directed therapies will be described. Conclusions: Combined with adequate pre-procedure planning and proper patient selection, TRAA is a viable approach for intra-arterial liver-directed therapies. With future development of equipment and refinement in technique, TRAA will supplant TFAA as the primary approach for intra-arterial liver-directed therapies. References 1. Cooper CJ, et al. Effect of transradial access on quality of life and cost of cardiac catheterization: A randomized comparison. Am Heart J 1999; 138(3 Pt 1):430–436. 2. Fischman AM, Swinburne NC, Patel RS. A Technical Guide Describing the Use of Transradial Access Technique for Endovascular Interventions. Tech Vasc Interv Radiol 2015; 18(2):58–65. 3. Patel A, et al. Transradial intervention: basics. J Vasc Interv Radiol 2015; 26 (5):722.
Abstract No. 562 Is radioembolization equivalent to chemoembolization (DEBDOX) for the treatment of HCC? A propensity matched observational study
Posters and Exhibits
O. Akinwande1, O. Akinwande1, R. Martin2; 1Johns Hopkins University, Randallstown, MD; 2University of Louisville, Louisville, KY Purpose: To compare the performance of radioembolization and Chemoembolization with Doxorubicin Drug Eluting Beads (DEBDOX) in the treatment of hepatocellular carcinoma. Materials: Analysis of our prospectively managed locoregional therapy (LRT) database was performed. 358 patients were treated with LRT for HCC, of which 291 were treated with DEBDOX and 67 with 90Y. Comparative toxicity, tumor response, progression free survival (PFS) and overall survival (OS) were assessed. Propensity score matching (using 12 baseline patient variables) was used to reduce treatment-selection bias, producing 48 pairs. Comparative analysis was repeated after propensity matching. Results: Median age was 67 and 65 years for the DEBDOX and 90Y groups respectively (p ¼ 0.2). Overall survival favored the DEBDOX group (DEBDOX: 15-months, 90Y: 6-months, p¼o0.0001). PFS also favored the DEBDOX group (DEBDOX: 15-months, 90Y: 6-months, po0.0001). All grade adverse events was lower in the DEBDOX group, although not statistically significant (DEBDOX 10%, 90Y 15%, p¼ 0.1). After propensity score matching, again longer
’
JVIR
OS was seen with the DEBDOX group (DEBDOX 13 m., 90Y 4 m.; p¼0.0077). There was also lower all-grade adverse events seen with DEBDOX that did not reach significance (DEBDOX 14%, 90Y 20%, p¼0.3). Both pooled and matched cohorts showed better disease control with DEBDOX than radioembolization (p values 0.0001 and 0.02; respectively). Conclusions: Within limitations, our preliminary observation suggests that DEBDOX may outperform 90Y with superior efficacy and survival with a trend towards lower all-grade toxicity. Further studies are warranted to validate or refute our findings.
Educational Exhibit
Abstract No. 563
Denver peritoneo-venous shunt (DPVS): an essential tool in the management of malignant ascites A. Peterson1, C. Hennemeyer2; 1University of Arizona, Tucson, AZ, United States; 2University of Arizona, Tucson, AZ Learning Objectives: DPVS shunting provides an important alternative for the management of malignant ascites. • Describe details of procedure, benefits and complications compared to paracentesis • Report our experience with percutaneous placement, post procedural management and complications (20 cases using CareFusion Denver ascites shunt) Background: DVPS shunting delivers prolonged relief of recurrent and treatment refractory ascites. Originally introduced as an intervention to control cirrhotic effusion refractory to medical management, DVPS shunt placement and management is within the skill set of IR physicians, and further they are useful for the management of recurrent large volume ascites associated with malignant abdominal disease so common in our practices. Clinical Findings/Procedure Details: Criteria- Majority of our patients were end-stage cancer patients with extensive peritoneal or multifocal metastatic disease resulting symptomatic recurrent ascites. Managing oncologist made up the principal referral base. We chose to accept patients with a life expectancy of six months or less, and palliation of symptoms as the end goal. Patients were admitted and followed for potential development of DIC. Benefits- Denver shunts are highly effective in relief of ascites symptoms. Shunting can provide physiologic benefits- increased effective blood volume, renal blood flow and diuresis, retained nutrients and improved nutritional status, improved mobility and respiration and relief of massive, refractory ascites, without the risk/need to undergo recurrent percutaneous paracentesis. Procedure- All 20 of our shunt procedures were performed under conscious sedation and local anesthesia. Subcutaneous pocket formed overlying the lower rib cage. Both jugular venous and peritoneal peel away sheaths were placed and connected to the pocket with subcutaneous tunneling. Pump was positioned over the ribs in a pocket analogous to a port. Conclusions: Complications/Post procedural managementThere are numerous known DVPS complications. However, our observed complications related to luminal plugging of the shunt, or tubing, and one retraction of tubing out of the
JVIR
’
Posters and Exhibits
S249
internal jugular vein. No bleeding episodes occurred. All achieved symptomatic relief. References 1. Seike M, Maetani I, Sakai Y. Treatment of malignant ascites in patients with advanced cancer: peritoneovenous shunt versus paracentesis. J Gastroenterol Hepatol 2007; 22:2161–2166. 2. Martin LG. Percutaneous placement and management of peritovenous shunts. Semin Intervent Radiol 2012; 29:129–134. 3. Bratby MJ, Hussain FF, Lopez AJ. Radiological insertion and management of peritoneovenous shunt. Cardiovasc Intervent Radiol 2007; 30:415–418. 4. Shah, N. CareFusion Protocol, Disseminated Intravascular Coagulation (DIC) 2012.
Abstract No. 564 In vivo cellular MR imaging evaluating anatomic configuration of blood supply contributing to portal vein tumor thrombus in rabbits J. Chen1, Y. Gao2, Z. Guo2, L. Sun2, B. Wu2, W. Xi2, X. Zhang2, J. zhang2; 1Jiangsu Cancer Hospital,Nanjing, Nanjing Jiangsu; 2Jiangsu cancer hospital, Nanjing, Nanjing
Abstract No. 565 Treatment response evaluation by modified RECIST after locoregional therapy in patients with hepatocellular carcinoma: correlation with explant pathology and post-liver transplant survival S. McLafferty, S. Trakroo, R. Bonshock, K. Qureshi, S. Fisher, F. Ramsey, G. Cohen; Temple University Hospital, Philadelphia, PA Purpose: To correlate mRECIST response with survival and explant pathology following liver transplant (LT) in patients with hepatocellular carcinoma (HCC) who received locoregional therapies (LRT) prior to LT. Materials: Patients with HCC listed for LT from 1/1/09 to 8/ 31/14 were included. 53 patients received LRT prior to LT. 37/ 53 had an imaging study after LRT prior to LT, these patients were included in our study. The remaining 16 were excluded for lack of imaging post-LRT. Studies were retrospectively reviewed using mRECIST guidelines by two radiologists blinded to pathology and outcomes. Concordance between mRECIST and explant pathology was assessed based on the presence or absence of viable tumor and percentage of tumor necrosis, statistical significance was analyzed using a Fisher’s Exact Test. Kaplan-Meier analysis was used to evaluate for an impact on survival following LT for responders (CR þ PR) versus nonresponders (SD þ PD). Results: There were 15 cases (40.5%) of complete response (CR), 4 cases (10.8%) of partial response (PR), 12 cases (32.4%) of stable disease (SD) and 6 cases (16.2%) of progressive disease (PD). Concordance between mRECIST and explant pathology was seen in 28 cases (75.6%), this was shown to not be statistically significant. Discordance was observed in 9 cases (24.4%), underestimation of response was present in 3 cases (8.1%) and overestimation of response in 6 cases (16.2%). Responders (CR þ PR) did not demonstrate a difference in overall survival following LT when compared with nonresponders (SD þ PD). Conclusions: Evaluation of response to LRT using mRECIST criteria was discordant with explant pathology in 24.4% of cases, the majority of cases overestimating response to treatment. This is in keeping with what other researchers have shown in retrospective studies1. Response to LRT prior to LT did not demonstrate a difference in overall survival
Posters and Exhibits
Purpose: to investigate blood flow of hepatic artery and portal vein contributing to portal vein tumor thrombus (PVTT) in rabbits. Materials: A total of 40 adult New Zealand White rabbits were used for this study. Twelve rabbits were used for collecting peripheral blood to isolate MNCs. Four rabbits were used as tumor carriers for the study rabbits and 24 study rabbits underwent implantation in the portal vein with VX2 tumor. These study rabbits were then randomly assigned to four groups of 6 animals each (groups A, B, C and D): group A, B and C animals received iron-labeled mononuclear cells infusion through hepatic artery, portal vein and auricular vein respectively, whereas group D animals were treated with normal saline injection via auricular vein 7 days after the implantation of VX2 tumors in portal vein. Peripheral blood MNCs were isolated and labeled using PLL-SPIO in vitro. In vivo MR imaging was performed and the average signal intensitie (SI) of the PVTT were measured on T2WI 1 day after the iron labeled cells transfusion. Rrepresentative Prussian blue-stained PVTT slides from groups A, B and C were examined to determine accumulation of iron labeled cells in the PVTT. Clinical Findings/Procedure Details: PVTTs in animals of four groups were clearly observed on T1WI and T2WI. Significant SI decline was observed on T2WI in rabbits of goupe A and B. The SI of PVTT in group A was significantly less than that in group C and group D (262.250±96.753 vs. 575.033±261.593, U ¼ 4.000, p¼ 0.025; 262.250±96.753 vs. 584.300±169.210, U ¼ 2.000, p¼ 0.010). The SI of PVTT in group B was significantly less than that in group C and group D (251.117±73.036 vs. 575.033±261.593, U ¼ 4.000, p¼ 0.025; 251.117±73.036 vs. 584.300±169.210, U ¼ 1.000, p¼ 0.006). No significant SI difference of PVTT was presented between group A and group B (262.250±96.753 vs. 251.117±73.036, U ¼ 18.000, p¼ 1.000). Conclusions: Initial evidence from the study implies that portal vein as well as hepatic artery supplies to PVTT in rabbits.
References 1. Fong Y, Sun RL, Jarnagin W, Blumgart LH. An analysis of 412 cases of hepatocellular carcinoma at a Western center. Ann Surg 1999; 229(6):790–799; discussion 799–800. 2. European Association for the Study of the Liver; European Organisation For Research and Treatment of Cancer. EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol 2012; 6 (4):908–943. 3. Bruix J, Sherman M. American Association for the Study of Liver Diseases. Management of hepatocellular carcinoma: an update. Hepatology 2011; 53 (3):1020–1022. 4. Shiotani M, Ku Y, Kusunoki N, Kitagawa T, Maeda I, Tominaga M, Tanigawara Y, Kuroda Y, Saitoh Y. Pharmacokinetic comparison of intraarterial and intraportal infusion of adriamycin in regional chemotherapy of the liver. Gan To Kagaku Ryoho 1995, 22(11):1560–1562. 5. Song do S, Bae SH, Song MJ, Lee SW, Kim HY, Lee YJ, Oh JS, Chun HJ, Lee HG, Choi JY, Yoon SK. Hepatic arterial infusion chemotherapy in hepatocellular carcinoma with portal vein.