Meta-Analysis Offers Convincing Evidence for use of RFA in Treatment of Unresectable Intrahepatic Cholangiocarcinoma

While surgery with negative resection margins is known to be the only curative treatment option for intrahepatic cholangiocarcinom, most patients are not candidates for curative resection because of advanced stage at the time of initial presentation. Increasingly, radiofrequency ablation has been used in the treatment of hepatic tumors. However, a relatively small amount of research has been performed on this treatment method in this patient population.

The purpose of this study was to perform a meta-analysis and systematic review of the clinical efficacy and safety of radiofrequency ablation in the treatment of intrahepatic cholangiocarcinoma. Authors collected data from Ovid MEDLINE and EMBASE database. Seven out of 144 articles comprising 84 total patients were selected based on strict exclusion criteria. Technical success rate for radiofrequency ablation ranges from 66-100 % with different approaches like ultrasound guided with conscious sedation or intraoperative with general anesthesia. The pooled 1-year, 3-year, and 5-year survival rates were 82% (95% CI, 72%–90%), 47%(95% CI, 28%–65%), and 24% (95% CI, 11%–40%) respectively. While the overall median survival is superior when compared with other arterial-based locoregional therapies, comparison is difficult given a significantly decreased incidence of extrahepatic disease in the present analysis.

Comment:

The present study offers positive data that RFA may be offered in patients with intrahepatic cholangiocarcinoma. While to the interventionalist, it may seem self-evident that RFA would aid in local tumor control in this patient population, this article will aid in the multi-disciplinary setting to demonstrate efficacy and increased use in this difficult patient population. With additional research into ideal ablative technology and factors predictive of recurrence (location, size, grade, etc.) this procedure will become increasingly utilized in the future.


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Citation: Han, K. et al. Radiofrequency Ablation in the Treatment of Unresectable Intrahepatic Cholangiocarcinoma: Systematic Review and Meta-Analysis. Journal of Vascular and Interventional Radiology 26, 943–948 (2015).


Author: Ali Rahmat, MD. Yale University Radiology Resident.

Watershed hepatocellular carcinomas show lower rate of complete response to chemoembolization

"Watershed" hepatocellular carcinomas cross traditional Couinaud hepatic segment boundaries and can be challenging to treat with chemoembolization because they recruit arterial blood supply from multiple segments which can often be difficult to identify. The purpose of this single institution retrospective study was to evaluate complete response rates in watershed and nonwatershed HCCs following a single chemoembolization. One hundred fifty five treatment-naive patients with unresectable HCC that met Milan criteria (83 watershed lesions, 72 non watershed) were treated with superselective chemoembolization (conventional chemoembolization with doxorubicin/cisplatin or drug-eluting embolic agent with doxorubicin). DSA and cone-beam CT were used to identify arterial supply to the tumor prior to treatment. Eight to 12 weeks post embolization, patients were evaluated with cross-sectional imaging and treatment response was assessed using modified RECIST criteria. Complete response after single treatment with chemoembolization was seen in 55.4% of patients with watershed tumors and 72.2% patients with nonwatershed tumors. Watershed tumors with identifiable dual blood supply on cone beam CT showed a trend toward improved complete response rate (61% vs 53%). Disease free survival was longer in the nonwatershed group (336 days) compared to the watershed group (151 days).

Comment: 

Similar to prior studies, watershed tumors in this series were at higher risk of incomplete response following chemoembolization compared to HCCs within a single hepatic segment. In addition, this study suggests the use of cone-beam CT can be helpful to assess dual blood supply of watershed tumors. The interesting data presented suggest that patients with watershed patients should be monitored and treated more aggressively in order to bridge these patients to transplant.


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Images from a 63-year-old man with cirrhosis secondary to hepatitis C and a 2.2-cm HCC in segment IVa/VIII. (a, b) Contrast- enhanced cone-beam CT images demonstrate tumoral supply from segment IV (thick arrow, a), segment VIII (thin arrow, a), and segment III (arrowhead, b) arteries. (c, d) Selective catheterization and delivery of the chemoembolic emulsion was performed via segment IV (c, arrow), segment VIII (d, arrow), and segment III (not shown). Circumferential uptake of the chemoembolic emulsion was confirmed on digital imaging during selective catheterization and by an unenhanced cone-beam CT acquisition at completion (e). (f) Contrast-enhanced, multiphasic MR image obtained at 6 weeks following chemoembolization demonstrates enhancement of the previously treated tumor.


Citation: Kothary, N. et al. Watershed Hepatocellular Carcinomas: The Risk of Incomplete Response following Transhepatic Arterial Chemoembolization. Journal of Vascular and Interventional Radiology 26, 1122–1129 (2015).


Post author: Menaka Nadar, MD. VIR Pathway Resident at University of Virginia

TIPS shows Improved Oxygenation in patients with Hepatopulmonary Syndrome

Hepatopulmonary Syndrome (HPS) results in the deterioration of arterial oxygenation in the setting of liver disease, which is associated with the formation of intrapulmonary vascular dilations (IPVD). The exact cause of such IPVDs is not known but may be related to an increase in vasodilators such as nitric oxide. IPVDs subsequently result in increased ventilation-perfusion mismatch, increased alveolar-arterial gradient (PA-aO2), and decreased partial arterial O2 pressure (PaO2). The only current recognized treatment for HPS is liver transplantation (LT). The authors conducted a MEDLINE literature search which detected patients 18 years or older with HPS undergoing transjugular intrahepatic portosystemic shunt (TIPS) formation for any indication from January 1990 to April 2015. The study identified 12 patients, 10 of which had either very severe or severe HPS, and all of which underwent successful TIPS placement and were followed for an average of 9.3 months. Of the 12 patients, 9 patients had improvements in oxygenation while the remaining 3 did not significantly change. After 4 months, 2 of the 9 patients with initial improvements reverted back to levels before TIPS, and 1 of the 3 patients without a change in oxygenation eventually worsened. Five of the 12 patients identified in the literature review underwent MAA shunt fraction evaluation, and 4 of which demonstrated improvements with decreased shunt fractions following TIPS. The authors conclude that the results of this literature search warrant further evaluation of TIPS in the management of HPS.

Comment: 

Although the authors do acknowledge the limitations of this literature search, namely the small sample size and short follow up duration, the positive initial improvements in arterial oxygenation after TIPS in 9 of the 12 HPS patients identified certainly is encouraging. Additionally the authors underline the lack of complications reported in the series of patients, which is notable given that most of the patients had very severe HPS, which disputes the conceivable conclusion that these patients would be more susceptible to intra-procedural complications. After more investigation, TIPS may play a much larger role in the management of HPS.


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Citation: Tsauo, J. et al. Role of Transjugular Intrahepatic Portosystemic Shunts in the Management of Hepatopulmonary Syndrome: A Systemic Literature Review. Journal of Vascular and Interventional Radiology (2015). doi:10.1016/j.jvir.2015.04.017


Post Author: Brian Gardner, MD VIR Pathway Resident at University of Virginia

No significant increase in hematoma rates for small and large caliber arterial access closure, using the 8-F Angio-Seal Device

Many arterial endovascular interventions now require greater than 8-F access, but the options for approved endovascular closure are limited to suture-mediated devices. This retrospective study was performed to evaluate access complications when using the 8-F Angio-Seal device in closing ≤ 8-F arteriotomies compared to 9-F to 12-F arteriotomies.

137 consecutive patients were identified retrospectively, all who received the 8-F Angio-Seal Device. 76 patients had < 8-F accesses closed (mean sheath size 7.2-F), and 61 patients had 9-F to 12-F accesses closed (mean sheath size 9.7-F). Complication rate for all closures was 8%, with no statistically increased risk with closure of the larger accesses. Note is made, that of the 6 access complications seen with 9-F to 12-F access, none required intervention beyond manual compression (45 minutes ± 15), a Type 1 complication. Two of the five complications for 8-F or less group required intervention (Type 2 complication).

Comment: 

This study was well-designed and demonstrates the safety of use of the 8-F Angio-Seal device for 9-F to 12-F arteriotomies when compared to < 8-F arteriotomies. However, this study was limited by its somewhat small sample size and retrospective nature and this remains an off-label use of the device. While, there are other proven safe endovascular closure devices for accesses larger than 8-F, consideration should be given to the use of this device in access sites >8-F.


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Citation: Baumann, F. et al. Single-Center Experience Comparing the Application of Small-Caliber versus Large-Caliber Arterial Access Closure in a Consecutive Series of Patients. Journal of Vascular and Interventional Radiology (2015). doi:10.1016/j.jvir.2015.04.024


Post Author: Daniel Sheeran, MD. VIR Pathway Resident at University of Virginia