[Show abstract][Hide abstract] ABSTRACT: Caudate lobe liver metastases occur commonly in patients with neuroendocrine tumors. It is unknown, however, how these lesions respond to regional therapy and how their presence impacts outcomes. We reviewed our experience treating these lesions using transarterial chemoembolization (TACE).
We reviewed radiographic response to TACE in 86 patients with metastatic neuroendocrine tumors to the liver. We determined the impact of caudate lesions on outcomes in comparison to the cohort of patients without caudate lesions, as well as response of caudate lesions to TACE versus lesions elsewhere in the liver.
Caudate lesions were identified in 45 (52%) patients. All patients had disease in other liver segments. Only seven caudate lesions (12.3%) had a radiographic response to TACE, whereas 82% of lesions elsewhere in the liver demonstrated a response. The presence or absence of a caudate lesion did not impact the overall radiographic (82.2% vs. 82.9%), symptomatic (64.4% vs. 56.1%), or biochemical (97.6% vs. 88.9%) response to TACE (P > 0.1 for all). However, median overall survival was reduced in those presenting with caudate lesions (87.1 vs. 45.6 months, P = 0.031).
Metastatic neuroendocrine tumors to the caudate lobe respond poorly to TACE. Symptomatic or threatening caudate lobe lesions should be considered for palliative resection in spite of additional inoperable liver metastases.
World Journal of Surgical Oncology 05/2015; 13(1):167. DOI:10.1186/s12957-015-0551-4 · 1.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study hypothesized that tumor size, number of tumors, surgical approach, and tumor histology significantly affected microwave ablation (MWA) success and recurrence-free survival.
Although many hepatobiliary centers have adopted MWA, the factors that influence local control are not well described.
Consecutive patients with hepatic malignancy treated by MWA were included from 4 high-volume institutions (2003-2011) and grouped by histology: hepatocellular carcinoma (HCC), colorectal liver metastases, neuroendocrine liver metastases, and other cancers. Independent significance of outcome variables was established with logistic regression and Cox proportional hazards models.
Four hundred fifty patients were treated with 473 procedures (139 HCC, 198 colorectal liver metastases, 61 neuroendocrine liver metastases, and 75 other) for a total of 875 tumors. Median follow-up was 18 months. Concurrent hepatectomy was performed in 178 patients (38%), and when performed was associated with greater morbidity. Complete ablation was confirmed for 839 of 865 tumors (97.0%) on follow-up cross-sectional imaging (10 were unevaluable). A surgical approach (open, laparoscopic, or percutaneous) had no significant impact on complication rates, recurrence, or survival. The local recurrence rate was 6.0% overall and was highest for HCC (10.1%, P = 0.045) and percutaneously treated lesions (14.1%, P = 0.014). In adjusted models, tumor size 3 cm or more predicted poorer recurrence-free survival (hazard ratio: 1.60, 95% CI: 1.02-2.50, P = 0.039).
In this large data set, patients with 3 cm or more tumors showed a propensity for early recurrence, regardless of histology. Higher rates of local recurrence were noted in HCC patients, which may reflect underlying liver disease. There were no significant differences in morbidity or survival based on the surgical approach; however, local recurrence rates were highest for percutaneously ablated tumors.
Annals of surgery 10/2013; 259(6). DOI:10.1097/SLA.0000000000000234 · 7.19 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Transarterial chemoembolization (TACE) is often utilized for patients with inoperable neuroendocrine carcinoma liver metastases. Often, metastatic disease is not limited to the liver. The impact of extrahepatic disease (EHD) on outcomes and response after TACE has not been described. METHODS: We reviewed 192 patients who underwent TACE for large hepatic tumor burden, progression of liver metastases, or poorly controlled carcinoid syndrome due to neuroendocrine carcinoma. Demographics, clinicopathologic characteristics, response to TACE, complications, and survival were compared between patients with (n = 123) and without (n = 69) EHD. RESULTS: Demographics, histopathologic characteristics, and complications were similar between groups. As well, those with and without EHD had similar biochemical (85 vs. 88 %) and radiographic response (76 vs. 79 %) to TACE (all p = NS); however, symptomatic responses were improved in those with EHD (79 vs. 60 %, p = 0.01). The group without EHD had better overall survival compared to those with EHD disease at the time of TACE (median 62 vs. 28 months, p = 0.001). DISCUSSION: Although patients with EHD from neuroendocrine carcinoma experience shorter overall survival after TACE compared to those without EHD, they had similar symptomatic, biochemical, and radiographic response to TACE. Meaningful response to TACE is still possible in the presence of EHD and should be considered, particularly in those with carcinoid syndrome.
[Show abstract][Hide abstract] ABSTRACT: Introduction: Regional therapy with trans-arterial chemoembolization (TACE) is a common treatment for unresectable hepatocellular carcinoma (HCC). Outcomes were examined in patients with the best radiological response (BR) after the initial TACE. Methods: This was a retrospective cohort study of patients who underwent TACE as the initial treatment for HCC between the years 2000 and 2010. BR was defined as complete disappearance of the tumour or no enhancement with contrast on the first cross-sectional imaging study after the initial TACE. Results: Seventy-eight out of 104 total consecutive patients were identified with the potential for a BR to TACE therapy for unresectable HCC, and 24 met the criteria for BR. Patients with BR had a median survival of 12.8 months (2.2-54.9) compared with 18.9 months(1.3-56.7) for the entire cohort (P= 0.313). The median time to progression was 10.6 months (1.2-24.3) in the BR group and 3.2 months (0.7-49.2) in the patients without a BR (P= 0.003). Discussion: BR to initial TACE for unresectable HCC is associated with comparable survival to those without BR in spite of a longer time to cancer progression. It may be reasonable to consider further therapy such as repeat TACE or biological/systemic therapy in patients with HCC even when the radiological response to the initial TACE is favourable.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: The serum neutrophil-lymphocyte ratio (NLR) is associated with outcomes in several solid organ cancers, including hepatocellular carcinoma (HCC). METHODS: We reviewed our experience in patients with HCC who underwent transarterial chemoembolization (TACE) as the initial treatment. Serum complete blood counts were used to calculate the NLR before and after TACE. The Kaplan-Meier method was used to determine survival and significant differences between groups by the log-rank test. RESULTS: There were 103 patients identified who underwent TACE for HCC. The median age was 60.5 years. Median overall survival was 12.6 (95 % confidence interval 8.3-17) months. Median survival in patients with a high preprocedural NLR was 4.2 months compared to 15 months in those with a normal NLR (p = 0.021). In those whose NLR either rose 1 month after treatment or remained elevated, survival was worse compared to those who normalized or remained normal (18.6 vs. 10.6 months, p = 0.026). The same was true at 6 months (21.3 vs. 9.5 months, p = 0.002). An unresponsive NLR was associated with very poor outcome (median survival 3.7 months). Multivariate analysis of clinicopathologic factors showed that presence of extrahepatic disease and high NLR were independent factors associated with worse survival. CONCLUSIONS: Our study demonstrates that periprocedural trends of serum NLR are associated with outcome in unresectable HCC undergoing TACE. Serum NLR is easy to calculate from a routine complete blood count with differential. Along with liver function, serum NLR may be helpful to clinicians in providing prognostic information and monitoring response to therapy.
[Show abstract][Hide abstract] ABSTRACT: Few patients with metastatic colorectal cancer (mCRC) are candidates for resection of their hepatic disease. Yttrium-90 ((90)Y) radioembolization has promise in the treatment of unresectable mCRC. We conducted a retrospective study to assess the efficacy in patients with refractory mCRC who underwent (90)Y radioembolization.
Patients with unresectable mCRC with liver metastases treated at The Ohio State University were included in this analysis. Demographic data, carcinoembryonic antigen (CEA) values, observed toxicities, and information on prior therapies were collected. Response was assessed by RECIST (Response Evaluation Criteria in Solid Tumors) 1.1 criteria. Overall survival (OS) and progression-free survival (PFS) were estimated by the Kaplan-Meier method.
Twenty-four patients (median age, 63 years) were included. Of the patients, 54% had extrahepatic disease; 67% had bilobar involvement. The patients had received a median of 3 prior therapies. No objective responses were observed. Five patients had a CEA response. Median PFS and OS were 3.9 months (95% CI, 2.4-4.8 months) and 8.9 months (95% CI, 4.2-16.7 months), respectively. Patients older than 65 years had improved PFS (4.6 vs. 2.4 months) and OS (14 vs. 5.5 months) vs. younger patients, likely due to receipt of (90)Y treatment earlier in their disease course. The presence of extrahepatic disease and the absence of CEA response appeared negatively predictive of efficacy. Toxicities were expected and manageable.
(90)Y radioembolization is active in select patients with refractory mCRC and with liver metastases, and is safe and well tolerated in the elderly. In patients with extensive extrahepatic disease, (90)Y should be used in combination with chemotherapy. CEA may be a predictor of efficacy.
Clinical Colorectal Cancer 01/2012; 11(3):195-9. DOI:10.1016/j.clcc.2011.12.002 · 2.91 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Persistent left superior vena cava (PLSVC) represents the most common congenital venous anomaly of the thoracic systemic venous return, occurring in 0.3% to 0.5% of individuals in the general population, and in up to 12% of individuals with other documented congential heart abnormalities. In this regard, there is very little in the literature that specifically addresses the potential importance of the incidental finding of PLSVC to surgeons, interventional radiologists, and other physicians actively involved in central venous access device placement in cancer patients. In the current review, we have attempted to comprehensively evaluate the available literature regarding PLSVC. Additionally, we have discussed the clinical implications and relevance of such congenital aberrancies, as well as of treatment-induced or disease-induced alterations in the anatomy of the thoracic central venous system, as they pertain to the general principles of successful placement of central venous access devices in cancer patients. Specifically regarding PLSVC, it is critical to recognize its presence during attempted central venous access device placement and to fully characterize the pattern of cardiac venous return (i.e., to the right atrium or to the left atrium) in any patient suspected of PLSVC prior to initiation of use of their central venous access device.
World Journal of Surgical Oncology 12/2011; 9:173. DOI:10.1186/1477-7819-9-173 · 1.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Radiomicrosphere therapy (RT) utilizing yttrium-90 (90Y) microspheres has been shown to be an effective regional treatment for primary and secondary hepatic malignancies. We sought to determine a large academic institution's experience regarding the extent and frequency of gastrointestinal complications.
Between 2004 and 2007, 27 patients underwent RT for primary or secondary hepatic malignancies. Charts were subsequently reviewed to determine the incidence and severity of GI ulceration.
Three patients presented with gastrointestinal bleeding and underwent upper endoscopy. Review of the pretreatment angiograms showed normal vascular anatomy in one patient, sclerosed hepatic vasculature in a patient who had undergone prior chemoembolization in a second, and an aberrant left hepatic artery in a third. None had undergone prophylactic gastroduodenal artery embolization. Endoscopic findings included erythema, mucosal erosions, and large gastric ulcers. Microspheres were visible on endoscopic biopsy. In two patients, gastric ulcers were persistent at the time of repeat endoscopy 1-4 months later despite proton pump inhibitor therapy. One elderly patient who refused surgical intervention died from recurrent hemorrhage.
Gastrointestinal ulceration is a known yet rarely reported complication of 90Y microsphere embolization with potentially life-threatening consequences. Once diagnosed, refractory ulcers should be considered for aggressive surgical management.
World Journal of Surgical Oncology 10/2008; 6:93. DOI:10.1186/1477-7819-6-93 · 1.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hepatic artery chemoembolization (HACE) is a treatment option in the management of metastatic carcinoid. We reviewed our experience to identify potential factors that influence survival.
The records of 122 patients with metastatic carcinoid tumor undergoing HACE were reviewed. Log-rank analysis and Cox proportional hazards were applied to identify factors predictive of decreased survival.
Median follow-up after HACE was 21.5 months. Complications occurred in 23% with periprocedural mortality of 5%. Radiographic tumor regression was seen in 82%, with stabilization of disease in 12%. Median duration of CT response was 19 months. Improvement in symptoms occurred in 92% for median duration of 13 months. HACE resulted in complete normalization of serum pancreastatin in 14%, with greater than 20% reduction in another 66%. Median overall survival was 33.3 months after HACE. Only pancreastatin level > or =5,000 pg/ml was associated with decreased survival by multivariate analysis.
HACE offers symptom palliation and long-term survival in patients with incurable carcinoid metastases. Although safe, it should be approached cautiously in patients with significant tumor burden as evidenced by pancreastatin levels > or =5,000 pg/ml. We do not recommend whole-liver embolization in these patients but prefer a staged approach to each lobe of the liver.
Journal of Gastrointestinal Surgery 03/2007; 11(3):264-71. DOI:10.1007/s11605-007-0089-z · 2.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To study loin pain-hematuria syndrome (LPHS) pathogenesis, we evaluated 43 consecutive patients for whom urological evaluation failed to disclose the cause of their recurrent flank pain and hematuria. Each underwent percutaneous kidney biopsy. In 9 patients, the biopsy specimen showed immunoglobulin A nephritis, an established cause of LPHS. We suggest these cases be designated secondary LPHS. They are not included in this analysis. The remaining patients (N = 34) are designated idiopathic (primary) LPHS. They are the basis of this report.
Demographics of patients with primary LPHS are mean age of 30.8 +/- 10.3 years; 74% women; 94% white; and history of kidney stones, 47%, although none was obstructing.
Primary LPHS kidney biopsy specimens showed red blood cells (RBCs) in multiple tubules, consistent with glomerular hematuria. Glomeruli were normal by means of light and immunofluorescent microscopy; however, more than 50% of biopsy specimens showed unusually thin or thick glomerular basement membranes. To assess whether the biopsy itself caused RBCs in tubules, we compared RBCs in renal tubular cross-sections from primary LPHS biopsies with those of normal kidneys (donors, n = 10). The mean percentage of tubular cross-sections containing RBCs was greater in primary LPHS than normal specimens (7.2% +/- 6.5% versus 1.6% +/- 1.0% [SD]; P < 0.0001), confirming glomerular hematuria in patients with primary LPHS.
Primary LPHS pathogenesis includes glomerular hematuria, apparently from structurally abnormal glomerular basement membrane. Primary LPHS pain may be initiated by obstructing RBC casts and perhaps microcrystals in those with a history of urolithiasis. Nevertheless, other factors are needed to explain the severe pain in patients with primary LPHS.
American Journal of Kidney Diseases 03/2006; 47(3):419-27. DOI:10.1053/j.ajkd.2005.11.029 · 5.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Neuroendocrine tumors often metastasize to the liver and present with disabling hormonal symptoms. Hepatic artery chemoembolization (HACE) combined with somatostatin therapy, pre-embolization, peri-embolization and post-embolization, at doses to control symptoms, is an aggressive approach that can relieve hormonal symptoms with minimal morbidity and mortality.
Chemoembolization was performed using 30 mg of adriamycin, 50 mg of mitomycin, 12 ml of hexabrix, 10 ml of ethiodol, and 360-500-microm particles. Pancreastatin, a split product of chromogranin A, was measured pre-HACE and post-HACE in all patients.
Forty-three chemoebolization procedures were performed in 34 symptomatic patients from December 1995 to August 1999. Seventeen patients had intestinal primaries (50%), seven had pancreatic primaries (20%), five had bronchial primaries (15%), and five had unknown primaries (15%). Systemic pancreastatin levels were improved or stable in 31 patients (78%). Symptoms were improved in these 31 patients (78%). Systemic serotonin levels were improved or stable in 24 patients (60%). Radiographic improvement or stability was seen in 18 patients (45%). Procedural related morbidity included pain, fevers, nausea, vomiting, and transient elevations of liver function studies in 75-100% of patients. There was one procedural related mortality (2%). Less than 20% improvement in pancreastatin levels from baseline was associated with death in five of five patients (100%). This was not observed with serotonin levels.
Measurement of serum pancreastatin levels is an easy and useful method to predict success in patients who undergo HACE plus somatostatin therapy for metastatic neuroendocrine tumors to the liver. This therapeutic approach is effective in relieving symptoms in 78% of patients, with minimal major morbidity or mortality.