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Scientific Session 18 Cancer Therapy
achieved quickly without distal embolization. Rheolytic thrombectomy may represent a useful primary approach to the patient with acute lower extremity ischemia. Excellent results were obtained when the device was employed to rapidly restore flow with or without an abbreviated course of lytic therapy.
Scientific Session 18 Cancer Therapy Moderator: Parmijit S. Chopra, MD
3:00 Intra-Arterial Chemotherapy in Treatment of Unresectable Pancreatic Cancer Comalba Gianpaolo, PhD, Milano, Italy. Cantore Maurizio, PhD. Piazza Elena, phD. Arborio Giancarlo, PhD. Tentori Augusta, PhD. Molani Luigi, PhD PURPOSE Resectability of pancreatic cancer is limitated to
5-22% of cases. Chemotherapy and radiotherapy are scarcely effective. The aim of our study is to evaluate feasibility and impact on life quality and survival of intraarterial chemotherapy with a combination of drugs in treatment of unresectable pancreatic cancer (UPC} 5-fluorouracil, leucovorin, epirubicin and carboplatin (FLEC). MATERIAIS AND METHODS: From January 1994 to June
1997, 73 consecutive patients, 38 male and 35 female, (mean age 61.5 years), underwent FLEC (3 cycles every 21 days); response was evaluated by abdomen CT and CA 19-9. Hematological toxicity, patients' weight and pain were considered at the beginning of treatment and after each cycle to quantify the impact of FLEC on life quality. RESULTS: Results were evaluable in 66 patients with partial
response on CT in 14/66 patients (21%); decrease of CA 19-9 in 30/66 (47%); improvement of disease-related symptoms (pain and weight) in 34/55 (62%). Hematological toxicity was observed in 21/73 patients (29%). Overall median survival was 8.5 months. CONCLUSIONS: FLEC is a treatment well tolerated and effective: it improves disease-related symptoms. It may be a palliative or preoperative approach in management of patients with Upc.
3:15 pm Vascularity of Hepatic Lesions:. Comparison Between Dual-Phase CT and MR Imaging During Arterial Portography Atsuhiro Nakatsuka, MD, Tsu, Mie, Japan. Koichirou Yamakado, MD. Naoshi Tanaka, MD. Hajime Sakuma, MD. Kaname Matsumura, MD. Kan Takeda, MD PURPOSE CT arterial portography (CTAP) is most sen-
190
sitive for detecting hepatic lesions, but it is difficult to judge the exact vascularity of hepatic lesions. In order to
overcome this problem, we evaluate multi-phase MR imaging during arterial portography (MRAP) which may provide more useful information in the detection and evaluating vascularity of focal hepatic lesions. MATERIALS AND METHODS: Thirty-six patients (28 with
cysts, 6 with metastases and 84 with untreated hepatocellular carcinomas [HCCs]) underwent both dual-phase helical CTAP and multi-phase MRAP. The sensitivity and positive predictive value of each modality were evaluated and enhancement ratios of lesions were calculated. RESULTS: The overall detection sensitivity for lesions was superior with MRAP (88%[105/118]) compared with CTAPC70%[83/118J). The positive predictive value for lesions was also better with MRAP(88%[105/118]) compared with CTAPC74%[83/112]). On delayed-phase MRAP images, signal intensity (S.L) of both untreated and recurrent HCCs, those are hypervascular tumors, have significantly increased (almost equal to liver parenchyma) due to systemic circulation of contrast medium more than 5.1. of metastatic tumors, those are hypovascular tumors (mean 209% [n = 10J V.S. 136% [n = 6J, respectively) (P < 0.005). On 2nd-phase CTAP images, however, both hypervascular and hypovascular tumors have showed low attenuation relative to the liver parenchyma (mean 130% V.S. 116%, respectively) (P < 0.05). CONCLUSIONS: Multi-phase MRAP has an important advantage over dual-phase helical CTAP for the detection and the evaluation of the vascularity of hepatic lesions.
3:30 pm Embolotherapy as a Means of Controlling Pain as Well as Hormonal Symptoms in Neuroendocrine Tumors Metastatic to the liver Karen Teresa Brown, MD, New York, NY. Bong Young Koh, BS. George Isaac Getrajdman, MD. Lynn Alison Brody, MD. Yuman Fong, MD PURPOSE: To evaluate treatment indications and out-
comes in patients with neuroendocrine tumors metastatic to the liver undergoing hepatic embolization with polyvinyl alcohol particles. MATERIALS AND METHODS: Charts and radiographs of
35 patients undergoing 63 separate sessions of embolotherapy between January of 1993 and July of 1997 were reviewed. Patient demographics, tumor type, indication for embolization, and complications were recorded. Symptomatic and morphologic responses to therapy were noted, as well as duration of response. RESULTS: 14 men and 19 women underwent emboliza-
tion of 19 carcinoid and 16 islet cell tumors metastatic to the liver. Symptomatic response was achieved in 48 of 54 (89%) treatments performed for palliation of hormonal symptoms and/or pain. Twelve of 13 embolizations (92%) performed for control of pain alone resulted in symptomatic response. In 9 instances the sole indication for treatment was control of tumor progression. Of these
9 cases, 2 deaths (22%) occurred in patients with extensive hepatic replacement by tumor where embolotherapy was used in an attempt to arrest tumor growth. CONCLUSION: Hepatic embolotherapy in patients with neuroendocrine tumors metastatic to the liver may be used for control of pain, as well as hormonal symptoms. This therapy should be used cautiously, if at all, in an attempt to control progression of disease in the otherwise asymptomatic patient.
3:45 pm Hepatic Arterial Chemoembolization With Streptozotocin in Patients With Liver Metastases of Endocrine Digestive Tumors Alban Denys, MD, Qichy, France. Sophie Dominquez, MD. Annie Sibert, MD. Philippe Ruzniewski, MD. Valerie Vilgrain, MD. Yves Menu, MD PURPOSE: To evaluate the efficacy of chemoembolization of liver metastases from digestive endocrine tumors using Streptozotocin (STZ). This drug is known as the most efficient systemic chemotherapy of this disease. MATERIAL AND METHODS: 15 patients with progressive liver metastases from carcinoid tumors (n = 8) or islet cell carcinomas (ICC, n = 7) were prospectively included in this study. STZ was administered under general anesthesia in emulsion wit Lipiodol and associated to embolization with Gelfoam particles. This treatment was repeated in 12 cases 2 to 6 times (median 3) (one session in 3 cases). Median follow-up was 16 months (1-49). RESULTS: An objective response according to the WHO criterias was obselved in 8 patients (53% median duration 10, 5 months), stabilization in 3 and progression in 4 patients. Carcinoid syndrome disappeared in 3 out of 5 cases during 17, 10 and 11 months. CONCLUSION: STZ seems to be more effective than doxorubicin for palliative treatment of liver metastases from digestive endocrine tumors, probably because of the better specificity of this drug for endocrine tumors. 4:00 pm
Ethanol Ablation of Liver Metastasis Attilio Solinas, MD, San Diego, CA • Horacio R. DAgostino, MD. E. Papi, MD. C. Malaspina, MD. P. Roselli, MD • R. Modesto, MD PURPOSE: To evaluate the safety and efficacy of percutaneous ethanol injection (PEI) in the management of liver metastasis. MATERl41S AND METHOD: 31 patients with liver metastasis were assessed by an oncology team and underwent PEl as part of their treatment. Primary malignancies included colorectal carcinoma (20 patients), breast (3 patients), gastric (2 patients), ovarian (2 patients), melanoma (2 patients), prostate (1 patient), and lung cancer (1 patient). All patients had control of their ptimary tumors and no more
than 3 liver lesions. PEl was performed in multiple sessions (27 patients) or a single session under general anesthesia (4 patients, ethanol volume injected 50-120 ml). Treatment response was evaluated by tumor markers levels, dynamic CT and fine needle biopsy. RESULTS: 17 patients were alive with no active liver disease (range 3 to 30 months, median 6 months); 6 patients were alive with persistent liver disease (range 10 to 15 months, median 10 months); 8 patients died from disease progression (range 4-17 months, median 6 months). PEl adverse effects were moderate to severe pain and fever. Tumor markers serum levels and post PEl biopsy results correlated with disease activity. CONCLUSION: PEl was a safe an effective method for ablation of liver metastasis in selected patients.
4:15 pm Percutaneous Hot Saline Injection Therapy: Effectiveness in Chemoembolization-Limited Large Hepatocellular Carcinoma Hyun-Ki Yoon, MD, Seoul, South Korea. Ho-Young Song, MD • Kyu-Bo Sung, MD. Yong-Ho Auh, MD PURPOSE: To report on the efficacy of percutaneous hot saline injection therapy (PSrD in the treatment of chemoembolization-limited large hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Twenty-nine patients with 31 HCCs underwent PSlT. Physiologic saline was mixed with contrast medium and Lipiodol, boiled, and was injected into the tumor. Mean tumor diameter was 7.0 cm. Follow-up computed tomography, angiography, and alpha-fetoprotein level measurement were performed in every three months. Regression rates were analyzed according to the diameter (Group A, <5 cm; Group B, 5-10 cm; Group C, >10 cm), location (central vs. peripheral), and growth pattern (encapsulated vs. infiltrative) of each HCC. RESULTS: The regression rate (RR) for all tumors was 42% (13/31). RRs for group A,B, and C were 86%, 45%, and 15%, respectively (P < 0.05). RRs for centrally and peripherally located tumors were 73% and 25% (p < 0.05). RRs for encapsulated and infiltrative tumors were 48% and 17% (P > 0.05). No major complications were encountered. CONCLUSION: PSlT is a safe and favorable alternative treatment for large HCC when transcatheter arterial chemoembolization is not feasible or has failed.
Wednesday, March 4, 1998 8:00 am-9:30 am Scientific Session 19 Risk Reduction in Diagnostic Angiography Moderator: John A. Kaufman, MD
191
Scientific Session 18 Cancer Therapy Moderator: Parmijit S. Chopra, MD
3:00 Intra-Arterial Chemotherapy in Treatment of Unresectable Pancreatic Cancer Comalba Gianpaolo, PhD, Milano, Italy. Cantore Maurizio, PhD. Piazza Elena, phD. Arborio Giancarlo, PhD. Tentori Augusta, PhD. Molani Luigi, PhD PURPOSE Resectability of pancreatic cancer is limitated to
5-22% of cases. Chemotherapy and radiotherapy are scarcely effective. The aim of our study is to evaluate feasibility and impact on life quality and survival of intraarterial chemotherapy with a combination of drugs in treatment of unresectable pancreatic cancer (UPC} 5-fluorouracil, leucovorin, epirubicin and carboplatin (FLEC). MATERIAIS AND METHODS: From January 1994 to June
1997, 73 consecutive patients, 38 male and 35 female, (mean age 61.5 years), underwent FLEC (3 cycles every 21 days); response was evaluated by abdomen CT and CA 19-9. Hematological toxicity, patients' weight and pain were considered at the beginning of treatment and after each cycle to quantify the impact of FLEC on life quality. RESULTS: Results were evaluable in 66 patients with partial
response on CT in 14/66 patients (21%); decrease of CA 19-9 in 30/66 (47%); improvement of disease-related symptoms (pain and weight) in 34/55 (62%). Hematological toxicity was observed in 21/73 patients (29%). Overall median survival was 8.5 months. CONCLUSIONS: FLEC is a treatment well tolerated and effective: it improves disease-related symptoms. It may be a palliative or preoperative approach in management of patients with Upc.
3:15 pm Vascularity of Hepatic Lesions:. Comparison Between Dual-Phase CT and MR Imaging During Arterial Portography Atsuhiro Nakatsuka, MD, Tsu, Mie, Japan. Koichirou Yamakado, MD. Naoshi Tanaka, MD. Hajime Sakuma, MD. Kaname Matsumura, MD. Kan Takeda, MD PURPOSE CT arterial portography (CTAP) is most sen-
190
sitive for detecting hepatic lesions, but it is difficult to judge the exact vascularity of hepatic lesions. In order to
overcome this problem, we evaluate multi-phase MR imaging during arterial portography (MRAP) which may provide more useful information in the detection and evaluating vascularity of focal hepatic lesions. MATERIALS AND METHODS: Thirty-six patients (28 with
cysts, 6 with metastases and 84 with untreated hepatocellular carcinomas [HCCs]) underwent both dual-phase helical CTAP and multi-phase MRAP. The sensitivity and positive predictive value of each modality were evaluated and enhancement ratios of lesions were calculated. RESULTS: The overall detection sensitivity for lesions was superior with MRAP (88%[105/118]) compared with CTAPC70%[83/118J). The positive predictive value for lesions was also better with MRAP(88%[105/118]) compared with CTAPC74%[83/112]). On delayed-phase MRAP images, signal intensity (S.L) of both untreated and recurrent HCCs, those are hypervascular tumors, have significantly increased (almost equal to liver parenchyma) due to systemic circulation of contrast medium more than 5.1. of metastatic tumors, those are hypovascular tumors (mean 209% [n = 10J V.S. 136% [n = 6J, respectively) (P < 0.005). On 2nd-phase CTAP images, however, both hypervascular and hypovascular tumors have showed low attenuation relative to the liver parenchyma (mean 130% V.S. 116%, respectively) (P < 0.05). CONCLUSIONS: Multi-phase MRAP has an important advantage over dual-phase helical CTAP for the detection and the evaluation of the vascularity of hepatic lesions.
3:30 pm Embolotherapy as a Means of Controlling Pain as Well as Hormonal Symptoms in Neuroendocrine Tumors Metastatic to the liver Karen Teresa Brown, MD, New York, NY. Bong Young Koh, BS. George Isaac Getrajdman, MD. Lynn Alison Brody, MD. Yuman Fong, MD PURPOSE: To evaluate treatment indications and out-
comes in patients with neuroendocrine tumors metastatic to the liver undergoing hepatic embolization with polyvinyl alcohol particles. MATERIALS AND METHODS: Charts and radiographs of
35 patients undergoing 63 separate sessions of embolotherapy between January of 1993 and July of 1997 were reviewed. Patient demographics, tumor type, indication for embolization, and complications were recorded. Symptomatic and morphologic responses to therapy were noted, as well as duration of response. RESULTS: 14 men and 19 women underwent emboliza-
tion of 19 carcinoid and 16 islet cell tumors metastatic to the liver. Symptomatic response was achieved in 48 of 54 (89%) treatments performed for palliation of hormonal symptoms and/or pain. Twelve of 13 embolizations (92%) performed for control of pain alone resulted in symptomatic response. In 9 instances the sole indication for treatment was control of tumor progression. Of these
9 cases, 2 deaths (22%) occurred in patients with extensive hepatic replacement by tumor where embolotherapy was used in an attempt to arrest tumor growth. CONCLUSION: Hepatic embolotherapy in patients with neuroendocrine tumors metastatic to the liver may be used for control of pain, as well as hormonal symptoms. This therapy should be used cautiously, if at all, in an attempt to control progression of disease in the otherwise asymptomatic patient.
3:45 pm Hepatic Arterial Chemoembolization With Streptozotocin in Patients With Liver Metastases of Endocrine Digestive Tumors Alban Denys, MD, Qichy, France. Sophie Dominquez, MD. Annie Sibert, MD. Philippe Ruzniewski, MD. Valerie Vilgrain, MD. Yves Menu, MD PURPOSE: To evaluate the efficacy of chemoembolization of liver metastases from digestive endocrine tumors using Streptozotocin (STZ). This drug is known as the most efficient systemic chemotherapy of this disease. MATERIAL AND METHODS: 15 patients with progressive liver metastases from carcinoid tumors (n = 8) or islet cell carcinomas (ICC, n = 7) were prospectively included in this study. STZ was administered under general anesthesia in emulsion wit Lipiodol and associated to embolization with Gelfoam particles. This treatment was repeated in 12 cases 2 to 6 times (median 3) (one session in 3 cases). Median follow-up was 16 months (1-49). RESULTS: An objective response according to the WHO criterias was obselved in 8 patients (53% median duration 10, 5 months), stabilization in 3 and progression in 4 patients. Carcinoid syndrome disappeared in 3 out of 5 cases during 17, 10 and 11 months. CONCLUSION: STZ seems to be more effective than doxorubicin for palliative treatment of liver metastases from digestive endocrine tumors, probably because of the better specificity of this drug for endocrine tumors. 4:00 pm
Ethanol Ablation of Liver Metastasis Attilio Solinas, MD, San Diego, CA • Horacio R. DAgostino, MD. E. Papi, MD. C. Malaspina, MD. P. Roselli, MD • R. Modesto, MD PURPOSE: To evaluate the safety and efficacy of percutaneous ethanol injection (PEI) in the management of liver metastasis. MATERl41S AND METHOD: 31 patients with liver metastasis were assessed by an oncology team and underwent PEl as part of their treatment. Primary malignancies included colorectal carcinoma (20 patients), breast (3 patients), gastric (2 patients), ovarian (2 patients), melanoma (2 patients), prostate (1 patient), and lung cancer (1 patient). All patients had control of their ptimary tumors and no more
than 3 liver lesions. PEl was performed in multiple sessions (27 patients) or a single session under general anesthesia (4 patients, ethanol volume injected 50-120 ml). Treatment response was evaluated by tumor markers levels, dynamic CT and fine needle biopsy. RESULTS: 17 patients were alive with no active liver disease (range 3 to 30 months, median 6 months); 6 patients were alive with persistent liver disease (range 10 to 15 months, median 10 months); 8 patients died from disease progression (range 4-17 months, median 6 months). PEl adverse effects were moderate to severe pain and fever. Tumor markers serum levels and post PEl biopsy results correlated with disease activity. CONCLUSION: PEl was a safe an effective method for ablation of liver metastasis in selected patients.
4:15 pm Percutaneous Hot Saline Injection Therapy: Effectiveness in Chemoembolization-Limited Large Hepatocellular Carcinoma Hyun-Ki Yoon, MD, Seoul, South Korea. Ho-Young Song, MD • Kyu-Bo Sung, MD. Yong-Ho Auh, MD PURPOSE: To report on the efficacy of percutaneous hot saline injection therapy (PSrD in the treatment of chemoembolization-limited large hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Twenty-nine patients with 31 HCCs underwent PSlT. Physiologic saline was mixed with contrast medium and Lipiodol, boiled, and was injected into the tumor. Mean tumor diameter was 7.0 cm. Follow-up computed tomography, angiography, and alpha-fetoprotein level measurement were performed in every three months. Regression rates were analyzed according to the diameter (Group A, <5 cm; Group B, 5-10 cm; Group C, >10 cm), location (central vs. peripheral), and growth pattern (encapsulated vs. infiltrative) of each HCC. RESULTS: The regression rate (RR) for all tumors was 42% (13/31). RRs for group A,B, and C were 86%, 45%, and 15%, respectively (P < 0.05). RRs for centrally and peripherally located tumors were 73% and 25% (p < 0.05). RRs for encapsulated and infiltrative tumors were 48% and 17% (P > 0.05). No major complications were encountered. CONCLUSION: PSlT is a safe and favorable alternative treatment for large HCC when transcatheter arterial chemoembolization is not feasible or has failed.
Wednesday, March 4, 1998 8:00 am-9:30 am Scientific Session 19 Risk Reduction in Diagnostic Angiography Moderator: John A. Kaufman, MD
191