- Email: [email protected]
Thrombolytic reperfusion of acute phlegmasia cerulea dolens in congenitally absent IVC
S148
Posters and Exhibits
There were no statistically significant changes in the Mental Health (MH) (70.5 vs 68.5, p¼0.62), General Health (GH) (51.4 vs 49.3, p¼0.58), Physical Functioning (PF) (59.1 vs 52.1, p¼0.19), Role-Physical (RP) (43.5 vs 36.2, p¼0.34), RoleEmotional (RE) (65.9 vs 60, p¼0.4), Social Functioning (SF) (69.9 vs 62.8, p¼0.2), and Bodily Pain (BP) (67.05 vs 63.04, p¼0.483) domains. Statistically significant results favoring nonHCC versus HCC post treatment responses were present in the following domains (RP p¼.02, SF p¼.02, RE p¼.002, VT p¼0.02, GH p¼.01, PF p¼.03). Conclusion: Patients with malignant liver tumors are not likely to perceive decreases throughout any of the SF-36 domains after treatment with outpatient RFA. Patients with non-HCC malignant liver tumors are more likely to perceive increases in vitality, social functioning, emotional problems, vitality, general health, and daily activities after outpatient RFA as compared to HCC liver tumors.
Abstract No. 342 Y-90 radioembolization of primary and metastatic soft tissue sarcomas of the liver
Posters and Exhibits
J.C. Oh1, M.G. Lam1, K.N. Ganjoo2, J.D. Louie1, D.Y. Sze1; 1Interventional Radiology, Stanford University, Palo Alto, CA; 2Medical Oncology, Stanford University, Palo Alto, CA Purpose: Soft tissue sarcomas (STS) are a group of uncommon neoplasms that are difficult to treat when unresectable. We present our initial data on Y-90 radioembolization (RE) of STS, both primary and metastatic to the liver. Materials and Methods: Between November 2006 and June 2012, 11 patients with primary and metastatic STS involving the liver underwent 12 Y-90 RE treatments. Nine of 11 (81.8%) patients had prior unsuccessful treatments to control tumor progression in the liver including systemic chemotherapy, surgery, and locoregional therapies such as bland embolization or RFA. Eleven treatments were with resin and 1 treatment was with glass microspheres. Eight were whole liver treatments, and 4 were single lobar treatments. Sarcomas treated were 4 metastatic leiomyosarcomas (abdominal, retroperitoneal, uterine, and lower extremity in origin), 3 metastatic hemangiopericytomas, 1 metastatic prostatic rhabdomyosarcoma, 1 metastatic pleomorphic spindle cell sarcoma, 1 primary hepatic sarcoma, and 1 primary epithelioid hemangioendothelioma. Clinical and biochemical toxicities were recorded at baseline, 2 weeks, 4 weeks, and every 4 weeks thereafter. Radiographic response was recorded every 3 months. Results: The median dose delivered was 1.68 GBq. The most common toxicities encountered were self-limited grade 1 fatigue in 6/11 (54.5%) and grade 1 abdominal pain in 4/11 (36.4%) patients. Follow up imaging was available in 11 cases. Partial (PR) or complete response (CR) was seen in 8/11 (72.7%) and 9/ 11 (81.8%) patients at 3 and 6 month imaging, respectively, according to mRECIST criteria. CRs were seen in 2 hemangiopericytomas, 1 uterine leiomyosarcoma, and 1 primary hepatic sarcoma. Median overall survival was 261 days with 5 (45.5%) patients surviving 491 days or longer. Two patients died within 50 days of treatment, though hepatic disease was not the cause of death in either patient. Conclusion: Y-90 RE of advanced primary or metastatic STS of the liver appears to be a promising treatment option for patients who are poor surgical candidates or refractory to other salvage therapies.
’
JVIR
Abstract No. 343 Symptomatic hyperparathyroidism: the utility of venous sampling for parathyroid hormone (PTH) for localization of hypersecreting parathyroid tissue K. Sniderman1, J. Jaskolka1, M. Simons1, M. Davidson2, K. Tan1, J. Beecroft1, J. Kachura1, D. Rajan1; 1Medical Imaging, University Health Network / Mount Sinai Hospital / University of Toronto, Toronto, ON, Canada; 2 Otolaryngology-HNS, Sunnybrook Health Science Centre, Toronto, ON, Canada Purpose: To determine the utility of pre-operative venous sampling for PTH in symptomatic hyperparathyroidism. Materials and Methods: An 8-year audit (2005-2012) of the Medical Imaging database at a single tertiary care institution was performed, using the key words ’’parathyroid’’, ’’venous’’ and ’’sampling’’. Cases of parathyroid venous sampling were extracted. The procedure records, clinical/biochemical records, PTH sampling results, operative findings, and pathology results were reviewed. Results of venous sampling were compared with operative and pathology findings when available. Results were evaluated to determine the utility of pre-operative venous sampling for PTH. Results: Venous sampling for PTH was performed on 93 occasions in 86 patients. Results of operative pathology are available on 62 cases (no surgery N ¼ 15; lost to follow-up N ¼ 16). In these 62, hypersecretion of PTH was identified from a single vein or region in 48 studies. 45/48 were confirmed by pathology (true positive), and 3/48 were not (false positive). Of 14 nonlocalizing studies, 12 had positive lesions at surgery (false negative) and 2 did not (true negative). Sensitivity was 79% (true positive rate) and specificity was 40% (true negative rate). Accuracy was 76%, Positive predictive value was 94% and negative predictive value was 14%. However, since many patients with negative localization do not undergo surgery, results may be biased by the small numbers of confirmed results, giving an unreliable specificity. Conclusion: In symptomatic hyperparathyroidism, pre-operative venous sampling for PTH is useful for localization of hypersecreting parathyroid tissue when a site of hypersecretion is found, but may not be particularly useful for exclusion of a hypersecreting focus when no venous hypersecretion is found. Symptomatic Hyperparathyroidism: The Utility of Venous Sampling for Parathyroid Hormone (PTH) for Localization of Hypersecreting Parathyroid Tissue
þve Sampling -ve Sampling
þve Path
-ve Path
45 12
3 2
Abstract No. 344 Thrombolytic reperfusion of acute phlegmasia cerulea dolens in congenitally absent IVC R. Florek1, R. Batson2, F. Alessi2; 1Radiology, Lourdes Regional Medical Center, Lafayette, LA; 2Vascular Surgery, West Jefferson Medical Center, Marrero, LA Purpose: Absent inferior vena cava(AIVC) is a rare anomaly of the venous system, occurring in 0.15% of general population, and
JVIR
’
Posters and Exhibits
S149
occurs in 5% of patients presenting with unprovoked deep venous thrombosis (DVT) (1,2). AIVC may present as idiopathic phlegmasia cerulea dolens (PCD). Thrombolysis can successfully reduce massive clot burden. Materials and Methods: Three patients were reviewed who presented with acute idiopathic PCD and underwent thrombolytic therapy. All were male, age range 25-42 years, with no comorbidities. CT and venograms demonstrated complete absence of the IVC and thrombosed pelvic collateral veins. Thrombolytic therapy consisted of initial 10 mg tissue plasminogen activator (TPA), followed by 1 mg/hr infusion over three to five days with low dose heparin infusion at 300 U/hr. Results: All three patients showed initial flow around the dilated iliac vein thrombus, which progressively improved. Thigh diameters decreased by 0.5-1.0 cm per day. Venous stasis color improved by day 2 or 3, with decreasing pain. Follow-up venography showed reestablished flow in the ascending paralumbar venous plexus, a collateral pathway for venous drainage. Conclusion: 1. PCD in the setting of AIVC has massive clot load in chronically dilated pelvic veins (3). 2. Acute presenting PCD is caused by thrombosis of the pelvic and ascending lumbar veins. 3. Thrombolytic treatment endpoint is the re-establishment of ascending collateral flow. 4. Low dose TPA infusion may reduce the risk of massive reperfusion injury (4).
at one institution. Dose calculation was based on body surface area (resin) or liver weight partition model (glass). Radiographic response was measured at 3 and 6 months according to mRECIST criteria. Laboratory and clinical follow-up was performed at 2, 4, 8 and 12 weeks. Parameters of toxicity and efficacy were compared. Results: Seventy patients were treated (54 M, 16 F; median age 61; 18 resin, 52 glass microspheres). Baseline laboratory, tumor, and clinical parameters were comparable between groups, with the exception of a higher ECOG-score in the glass microsphere patients (p ¼ 0.001). Patients treated with resin microspheres received less activity (1.41 versus 3.76 GBq; p o 0.001) with a lower whole liver absorbed dose (51 vs 123 Gy; p o 0.001), resulting in a lower response rate at 3 months (18 vs 77%; p ¼ 0.002) and 6 months (20 vs 88%; p ¼ 0.01). The choice of microspheres, the administered activity and the absorbed dose were the only predictors of response. In multivariate analysis, the microsphere choice was the strongest predictor of response at 3 months (p o 0.01) and 6 months (p ¼ 0.01). Responders survived longer than non-responders (21.0 vs 13.8 months; p o 0.05). Median overall survivals for glass and resin microspheres were 18.1 and 16.8 months respectively. Toxicity was acceptable for all groups with no significant differences. Conclusion: Higher dose glass microspheres may have a subtle response and survival advantage for yttrium-90 RE of HCC.
Educational Exhibit
Abstract No. 346
References 1. Interruption or congenital stenosis of the inferior vena cava: prevalence, imaging and clinical findings. Koc Z, Oguzkurt L. Eur J Radiol. 2007 May;62(2):257-66. 2. Inferior vena cava agenesis and deep vein thrombosis: 10 patients and review of the literature. Lambert M, Marboeuf P, Midulla M, et al. Vasc Med. 2010 Dec. 15(6): 451-9. 3. Superficial and deep vein thrombosis associated with congenital absence of the inferior vena cava in a young male. O’Connor DB, O’Brien N, Khani T. Ann Vasc Surg. 2011 Jul;25(5):697.e1-4. 4. Fatal reperfusion injury following successful thrombolysis for phlegmasia cerulea dolens. Lessne ML, Bajwa JM. J Vasc Interv Radiol JVIR suppl Mar 2012. Vol 22, no. 3s p. s172.
Abstract No. 345 Comparison between resin and glass microspheres for Yttrium-90 radioembolization treatment of hepatocellular carcinoma M.G. Lam1,2, B.A. Seinstra2, M. van den Bosch2, J.D. Louie1, D.Y. Sze1; 1Interventional Radiology, Stanford University School of Medicine, Stanford, CA; 2 Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, Netherlands
M.T. Gudmundsson, M.M. Morshedi, S. Kikolski, S. Rose, H. Aryafar; Radiology, UC San Diego Medical Center, San Diego, CA Learning Objectives: To describe the indications for thrombolytic therapy in the setting of acute, symptomatic portal vein thrombosis. To depict the different approaches to gaining access in the setting of acute portal vein thrombosis, as well as describe the pros and cons of each method. To provide useful hints in order to prevent common pitfalls. Background: Portal vein thrombosis is a cause of significant morbidity amongst patients with endstage liver disease/hepatocellular carcinoma. Treatment in the acute, symptomatic setting may help to prevent life-threatening complications resulting from portal hypertension including variceal bleeding and mesenteric ischemia. Treatment may also help to prevent cavernous transformation of the portal vein, which can hinder transplant eligibility. Clinical Findings/Procedure Details: The exhibit will include a pictorial review of cases describing different methods of obtaining access in the setting of acute portal vein thrombosis. Methods of access will include percutaneous routes as well as access via TIPS and DIPS placement. Cases will be followed by a description of the advantages and disadvantages of each method as well as a few helpful hints for troubleshooting based on the experience of multiple IRs at our academic institution. Conclusion and/or Teaching Points: The use of thrombolytic therapy for the treatment of acute portal vein thrombosis can be
Posters and Exhibits
Purpose: Yttrium-90 radioembolization (RE) treatment of hepatocellular carcinoma (HCC) may be performed with either resin or glass microspheres. Differences include specific activity, microsphere size and density, embolic effect, and dose calculation. We retrospectively reviewed the differences in outcome between patients treated with glass microspheres and patients treated with resin microspheres prior to availability of glass microspheres at two centers. Materials and Methods: All patients with HCC treated with either resin or glass microspheres at two collaborating centers were reviewed, including patients treated with glass microspheres
Optimizing access in the treatment of acute portal vein thrombosis: a pictorial review of different methods of obtaining access to the portal venous system for the purpose of lytic therapy with emphasis on the advantages and disadvantages of each technique
Posters and Exhibits
There were no statistically significant changes in the Mental Health (MH) (70.5 vs 68.5, p¼0.62), General Health (GH) (51.4 vs 49.3, p¼0.58), Physical Functioning (PF) (59.1 vs 52.1, p¼0.19), Role-Physical (RP) (43.5 vs 36.2, p¼0.34), RoleEmotional (RE) (65.9 vs 60, p¼0.4), Social Functioning (SF) (69.9 vs 62.8, p¼0.2), and Bodily Pain (BP) (67.05 vs 63.04, p¼0.483) domains. Statistically significant results favoring nonHCC versus HCC post treatment responses were present in the following domains (RP p¼.02, SF p¼.02, RE p¼.002, VT p¼0.02, GH p¼.01, PF p¼.03). Conclusion: Patients with malignant liver tumors are not likely to perceive decreases throughout any of the SF-36 domains after treatment with outpatient RFA. Patients with non-HCC malignant liver tumors are more likely to perceive increases in vitality, social functioning, emotional problems, vitality, general health, and daily activities after outpatient RFA as compared to HCC liver tumors.
Abstract No. 342 Y-90 radioembolization of primary and metastatic soft tissue sarcomas of the liver
Posters and Exhibits
J.C. Oh1, M.G. Lam1, K.N. Ganjoo2, J.D. Louie1, D.Y. Sze1; 1Interventional Radiology, Stanford University, Palo Alto, CA; 2Medical Oncology, Stanford University, Palo Alto, CA Purpose: Soft tissue sarcomas (STS) are a group of uncommon neoplasms that are difficult to treat when unresectable. We present our initial data on Y-90 radioembolization (RE) of STS, both primary and metastatic to the liver. Materials and Methods: Between November 2006 and June 2012, 11 patients with primary and metastatic STS involving the liver underwent 12 Y-90 RE treatments. Nine of 11 (81.8%) patients had prior unsuccessful treatments to control tumor progression in the liver including systemic chemotherapy, surgery, and locoregional therapies such as bland embolization or RFA. Eleven treatments were with resin and 1 treatment was with glass microspheres. Eight were whole liver treatments, and 4 were single lobar treatments. Sarcomas treated were 4 metastatic leiomyosarcomas (abdominal, retroperitoneal, uterine, and lower extremity in origin), 3 metastatic hemangiopericytomas, 1 metastatic prostatic rhabdomyosarcoma, 1 metastatic pleomorphic spindle cell sarcoma, 1 primary hepatic sarcoma, and 1 primary epithelioid hemangioendothelioma. Clinical and biochemical toxicities were recorded at baseline, 2 weeks, 4 weeks, and every 4 weeks thereafter. Radiographic response was recorded every 3 months. Results: The median dose delivered was 1.68 GBq. The most common toxicities encountered were self-limited grade 1 fatigue in 6/11 (54.5%) and grade 1 abdominal pain in 4/11 (36.4%) patients. Follow up imaging was available in 11 cases. Partial (PR) or complete response (CR) was seen in 8/11 (72.7%) and 9/ 11 (81.8%) patients at 3 and 6 month imaging, respectively, according to mRECIST criteria. CRs were seen in 2 hemangiopericytomas, 1 uterine leiomyosarcoma, and 1 primary hepatic sarcoma. Median overall survival was 261 days with 5 (45.5%) patients surviving 491 days or longer. Two patients died within 50 days of treatment, though hepatic disease was not the cause of death in either patient. Conclusion: Y-90 RE of advanced primary or metastatic STS of the liver appears to be a promising treatment option for patients who are poor surgical candidates or refractory to other salvage therapies.
’
JVIR
Abstract No. 343 Symptomatic hyperparathyroidism: the utility of venous sampling for parathyroid hormone (PTH) for localization of hypersecreting parathyroid tissue K. Sniderman1, J. Jaskolka1, M. Simons1, M. Davidson2, K. Tan1, J. Beecroft1, J. Kachura1, D. Rajan1; 1Medical Imaging, University Health Network / Mount Sinai Hospital / University of Toronto, Toronto, ON, Canada; 2 Otolaryngology-HNS, Sunnybrook Health Science Centre, Toronto, ON, Canada Purpose: To determine the utility of pre-operative venous sampling for PTH in symptomatic hyperparathyroidism. Materials and Methods: An 8-year audit (2005-2012) of the Medical Imaging database at a single tertiary care institution was performed, using the key words ’’parathyroid’’, ’’venous’’ and ’’sampling’’. Cases of parathyroid venous sampling were extracted. The procedure records, clinical/biochemical records, PTH sampling results, operative findings, and pathology results were reviewed. Results of venous sampling were compared with operative and pathology findings when available. Results were evaluated to determine the utility of pre-operative venous sampling for PTH. Results: Venous sampling for PTH was performed on 93 occasions in 86 patients. Results of operative pathology are available on 62 cases (no surgery N ¼ 15; lost to follow-up N ¼ 16). In these 62, hypersecretion of PTH was identified from a single vein or region in 48 studies. 45/48 were confirmed by pathology (true positive), and 3/48 were not (false positive). Of 14 nonlocalizing studies, 12 had positive lesions at surgery (false negative) and 2 did not (true negative). Sensitivity was 79% (true positive rate) and specificity was 40% (true negative rate). Accuracy was 76%, Positive predictive value was 94% and negative predictive value was 14%. However, since many patients with negative localization do not undergo surgery, results may be biased by the small numbers of confirmed results, giving an unreliable specificity. Conclusion: In symptomatic hyperparathyroidism, pre-operative venous sampling for PTH is useful for localization of hypersecreting parathyroid tissue when a site of hypersecretion is found, but may not be particularly useful for exclusion of a hypersecreting focus when no venous hypersecretion is found. Symptomatic Hyperparathyroidism: The Utility of Venous Sampling for Parathyroid Hormone (PTH) for Localization of Hypersecreting Parathyroid Tissue
þve Sampling -ve Sampling
þve Path
-ve Path
45 12
3 2
Abstract No. 344 Thrombolytic reperfusion of acute phlegmasia cerulea dolens in congenitally absent IVC R. Florek1, R. Batson2, F. Alessi2; 1Radiology, Lourdes Regional Medical Center, Lafayette, LA; 2Vascular Surgery, West Jefferson Medical Center, Marrero, LA Purpose: Absent inferior vena cava(AIVC) is a rare anomaly of the venous system, occurring in 0.15% of general population, and
JVIR
’
Posters and Exhibits
S149
occurs in 5% of patients presenting with unprovoked deep venous thrombosis (DVT) (1,2). AIVC may present as idiopathic phlegmasia cerulea dolens (PCD). Thrombolysis can successfully reduce massive clot burden. Materials and Methods: Three patients were reviewed who presented with acute idiopathic PCD and underwent thrombolytic therapy. All were male, age range 25-42 years, with no comorbidities. CT and venograms demonstrated complete absence of the IVC and thrombosed pelvic collateral veins. Thrombolytic therapy consisted of initial 10 mg tissue plasminogen activator (TPA), followed by 1 mg/hr infusion over three to five days with low dose heparin infusion at 300 U/hr. Results: All three patients showed initial flow around the dilated iliac vein thrombus, which progressively improved. Thigh diameters decreased by 0.5-1.0 cm per day. Venous stasis color improved by day 2 or 3, with decreasing pain. Follow-up venography showed reestablished flow in the ascending paralumbar venous plexus, a collateral pathway for venous drainage. Conclusion: 1. PCD in the setting of AIVC has massive clot load in chronically dilated pelvic veins (3). 2. Acute presenting PCD is caused by thrombosis of the pelvic and ascending lumbar veins. 3. Thrombolytic treatment endpoint is the re-establishment of ascending collateral flow. 4. Low dose TPA infusion may reduce the risk of massive reperfusion injury (4).
at one institution. Dose calculation was based on body surface area (resin) or liver weight partition model (glass). Radiographic response was measured at 3 and 6 months according to mRECIST criteria. Laboratory and clinical follow-up was performed at 2, 4, 8 and 12 weeks. Parameters of toxicity and efficacy were compared. Results: Seventy patients were treated (54 M, 16 F; median age 61; 18 resin, 52 glass microspheres). Baseline laboratory, tumor, and clinical parameters were comparable between groups, with the exception of a higher ECOG-score in the glass microsphere patients (p ¼ 0.001). Patients treated with resin microspheres received less activity (1.41 versus 3.76 GBq; p o 0.001) with a lower whole liver absorbed dose (51 vs 123 Gy; p o 0.001), resulting in a lower response rate at 3 months (18 vs 77%; p ¼ 0.002) and 6 months (20 vs 88%; p ¼ 0.01). The choice of microspheres, the administered activity and the absorbed dose were the only predictors of response. In multivariate analysis, the microsphere choice was the strongest predictor of response at 3 months (p o 0.01) and 6 months (p ¼ 0.01). Responders survived longer than non-responders (21.0 vs 13.8 months; p o 0.05). Median overall survivals for glass and resin microspheres were 18.1 and 16.8 months respectively. Toxicity was acceptable for all groups with no significant differences. Conclusion: Higher dose glass microspheres may have a subtle response and survival advantage for yttrium-90 RE of HCC.
Educational Exhibit
Abstract No. 346
References 1. Interruption or congenital stenosis of the inferior vena cava: prevalence, imaging and clinical findings. Koc Z, Oguzkurt L. Eur J Radiol. 2007 May;62(2):257-66. 2. Inferior vena cava agenesis and deep vein thrombosis: 10 patients and review of the literature. Lambert M, Marboeuf P, Midulla M, et al. Vasc Med. 2010 Dec. 15(6): 451-9. 3. Superficial and deep vein thrombosis associated with congenital absence of the inferior vena cava in a young male. O’Connor DB, O’Brien N, Khani T. Ann Vasc Surg. 2011 Jul;25(5):697.e1-4. 4. Fatal reperfusion injury following successful thrombolysis for phlegmasia cerulea dolens. Lessne ML, Bajwa JM. J Vasc Interv Radiol JVIR suppl Mar 2012. Vol 22, no. 3s p. s172.
Abstract No. 345 Comparison between resin and glass microspheres for Yttrium-90 radioembolization treatment of hepatocellular carcinoma M.G. Lam1,2, B.A. Seinstra2, M. van den Bosch2, J.D. Louie1, D.Y. Sze1; 1Interventional Radiology, Stanford University School of Medicine, Stanford, CA; 2 Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, Netherlands
M.T. Gudmundsson, M.M. Morshedi, S. Kikolski, S. Rose, H. Aryafar; Radiology, UC San Diego Medical Center, San Diego, CA Learning Objectives: To describe the indications for thrombolytic therapy in the setting of acute, symptomatic portal vein thrombosis. To depict the different approaches to gaining access in the setting of acute portal vein thrombosis, as well as describe the pros and cons of each method. To provide useful hints in order to prevent common pitfalls. Background: Portal vein thrombosis is a cause of significant morbidity amongst patients with endstage liver disease/hepatocellular carcinoma. Treatment in the acute, symptomatic setting may help to prevent life-threatening complications resulting from portal hypertension including variceal bleeding and mesenteric ischemia. Treatment may also help to prevent cavernous transformation of the portal vein, which can hinder transplant eligibility. Clinical Findings/Procedure Details: The exhibit will include a pictorial review of cases describing different methods of obtaining access in the setting of acute portal vein thrombosis. Methods of access will include percutaneous routes as well as access via TIPS and DIPS placement. Cases will be followed by a description of the advantages and disadvantages of each method as well as a few helpful hints for troubleshooting based on the experience of multiple IRs at our academic institution. Conclusion and/or Teaching Points: The use of thrombolytic therapy for the treatment of acute portal vein thrombosis can be
Posters and Exhibits
Purpose: Yttrium-90 radioembolization (RE) treatment of hepatocellular carcinoma (HCC) may be performed with either resin or glass microspheres. Differences include specific activity, microsphere size and density, embolic effect, and dose calculation. We retrospectively reviewed the differences in outcome between patients treated with glass microspheres and patients treated with resin microspheres prior to availability of glass microspheres at two centers. Materials and Methods: All patients with HCC treated with either resin or glass microspheres at two collaborating centers were reviewed, including patients treated with glass microspheres
Optimizing access in the treatment of acute portal vein thrombosis: a pictorial review of different methods of obtaining access to the portal venous system for the purpose of lytic therapy with emphasis on the advantages and disadvantages of each technique