Michael C Soulen

University of Pennsylvania, Filadelfia, Pennsylvania, United States

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Publications (247)699.59 Total impact

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    ABSTRACT: Transarterial chemoembolization (TACE) using Lipiodol-based regimens including the administration of an anticancer-in-oil emulsion followed by embolic agents is widely used in the treatment of hepatocellular carcinoma (HCC). This approach has been supported by meta-analyses of randomized controlled trials (RCTs) performed more than a decade ago. We performed a systematic review to understand current efficacy and safety data of Lipiodol TACE in treatment of HCC. A search of the literature published between January 1, 1980, and June 30, 2013 was performed using MEDLINE and EMBASE databases. All potentially relevant publications were reviewed and articles were selected based on pre-defined inclusion and exclusion criteria. Out of a total of 1,564 articles reviewed, 101 articles including a total of 10,108 patients treated with Lipiodol TACE were selected for the efficacy analysis. Objective response rate was 52.5% (95% confidence interval, 43.6% – 61.5%). Overall survival was 70.3% at 1 year, 51.8% at 2 years, 40.4% at 3 years, and 32.4% at 5 years. Median overall survival was 19.4 months (95% confidence interval, 16.2 – 22.6). A total of 217 articles presenting precise description on numbers of adverse events (AEs) were selected for the safety review: in these studies, a total of 21,461 AEs were reported in 15,351 patients. Liver enzyme abnormalities were the most commonly observed AE, followed by the symptoms associated with post-embolization syndrome. The overall mortality rate was 0.6% and the most common cause of death was related to acute liver insufficiency. Conclusion: in a systematic literature review, survival figures of HCC patients undergoing Lipiodol TACE appear to be in line with those reported in previous RCTs, and no new or unexpected safety concerns were identified. This article is protected by copyright. All rights reserved.
    No preview · Article · Jan 2016 · Hepatology
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    ABSTRACT: Purpose: To determine if CT characteristics of intraprocedural ice balls correlate with outcomes after cryoablation. Materials and methods: A retrospective review was performed on 63 consecutive patients treated with renal cryoablation. Preprocedural and intraprocedural images were used to identify the size and location of renal tumors and ice balls as well as the tumor coverage and ice-ball margins. Review of follow-up imaging (1 mo and then 3-6-mo intervals) distinguished successful ablations from cases of residual tumor. Results: Patients who underwent successful ablation (n = 50; 79%) had a mean tumor diameter of 2.5 cm (range, 0.9-4.3 cm) and mean ice-ball margin of 0.4 cm (range, 0.2-1.2 cm). Patients with residual tumor (n = 13; 21%) had a mean tumor diameter of 3.8 cm (range, 1.8-4.5 cm) and mean ice-ball margin of -0.4 cm (range, -0.9 to 0.4 cm). Residual and undertreated tumors were larger and had smaller ice-ball margins than successfully treated tumors (P < .01). Ice-ball diameters were significantly smaller after image reformatting (P < .01). Ice-ball margins of 0.15 cm had 90% sensitivity, 92% specificity, and 98% positive predictive value for successful ablation. Success was independent of tumor location or number of cryoprobes. Conclusions: Ice-ball margin and real-time intraprocedural reformatting could be helpful in predicting renal cryoablation outcomes. Although a 0.5-cm margin is preferred, a well-centered ice ball with a short-axis margin greater than 0.15 cm strongly correlated with successful ablation.
    No preview · Article · Jan 2016 · Journal of vascular and interventional radiology: JVIR
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    ABSTRACT: Purpose For digestive tract cancers, the bilirubin threshold for administration of systemic chemotherapy can be 5 or 2 mg/dL (85.5 or 34.2 μmol/L) depending upon the regimen. We examined the ability of percutaneous biliary drainage (PBD) in patients with malignant biliary obstruction to achieve these clinically relevant endpoints. Methods 106 consecutive patients with malignant biliary obstruction and a baseline serum bilirubin >2 mg/dL underwent PBD. Time to achieve a bilirubin of 5 mg/dL (85.5 μmol/L), 2 mg/dL (34.2 μmol/L), and survival was estimated by Kaplan–Meier analysis. Potential technical and clinical prognostic factors were subjected to univariate and multivariate analysis. Categorical variables were analyzed by the log rank test. Hazard ratios were calculated for continuous variables. Results Median survival was 100 days (range 1–3771 days). Among 88 patients with a pre-drainage bilirubin >5 mg/dL, 62% achieved a serum bilirubin ≤5 mg/dL within 30 days and 84% within 60 days, median 21 days. Among 106 patients with a pre-drainage bilirubin >2 mg/dL, 37% achieved a serum bilirubin ≤2 mg/dL by 30 days and 70% within 60 days, median 43 days. None of the technical or clinical factors evaluated, including pre-drainage bilirubin, were significant predictors of time to achieve a bilirubin ≤2 mg/dL (p = 0.51). Size and type of biliary device were the only technical variables found to affect time to bilirubin of 5 mg/dL (p = 0.016). Conclusion PBD of malignant obstruction achieves clinically relevant reduction in serum bilirubin in the majority of patients within 1–2 months, irrespective of the pre-drainage serum bilirubin, sufficient to allow administration of systemic chemotherapy. However, the decision to undergo this procedure for this indication alone must be considered in the context of patients’ prognosis and treatment goals.
    No preview · Article · Jan 2016
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    ABSTRACT: Purpose: To report outcomes of bronchial artery embolization (BAE) for hemoptysis, including recurrent bleeding, survival, and longitudinal pulmonary function. Materials and methods: A prospective database identified 69 patients who underwent 97 BAE procedures (n = 1-7 per patient) at a tertiary academic medical center over a period of 11 years. Technical and clinical success were determined. Recurrent bleeding and survival were compared by etiology of lung disease. Rates of change in pulmonary function (forced expiratory volume in 1 s [FEV1] and forced vital capacity [FVC]) were measured and compared before and after index BAE by linear regression in 17 patients. Results: The technical success rate of BAE was 90%. Clinical success rates at 24 hours and 30 days were 82% and 68%, respectively. Thirty percent of patients had recurrent bleeding that required bronchoscopy (7%) or additional embolization (23%). Median time to recurrent bleeding was 29 days among the 13 patients with sarcoidosis, compared with 293 days among patients without sarcoidosis (P = .0013). The hazard ratio for death in patients with sarcoidosis compared with those without sarcoidosis was 4 (95% confidence interval, 2.6-14.6). Analyzing all instances of pulmonary function tests, slopes of decline in FEV1 and FVC were significantly different (FEV1, P = .0048; FVC, P < .0001) before and after index BAE, with an improvement after BAE (FEV1, 0.8%/y; FVC, 1%/y) and a decrease before BAE (FEV1, -1.6%/y; FVC, -1.4%/y). Conclusions: BAE is an effective therapy for hemoptysis, but patients with sarcoidosis are at significant risk of recurrent bleeding and death compared with patients with other lung diseases. BAE does not accelerate deterioration in lung function.
    No preview · Article · Oct 2015 · Journal of vascular and interventional radiology: JVIR
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    ABSTRACT: Transarterial chemoembolization with Lipiodol (Lipiodol TACE), also called conventional TACE, was developed in the early 1980s and widely adopted worldwide after randomized control trials and meta-analysis demonstrated superiority of Lipiodol TACE to best supportive care. Presently, there is no level one evidence that other TACE techniques are superior to Lipiodol TACE for intermediate stage hepatocellular carcinoma (HCC), which includes patients with preserved liver function and nonsurgical large or multinodular HCC without distant metastases. In addition, TACE is part of the treatment for progressive or symptomatic liver metastases from gastroenteropancreatic neuroendocrine tumors. When injected into the hepatic artery, Lipiodol has the unique property of selective uptake and retention in hyperarterialyzed liver tumors. Lipiodol/drug emulsion followed by particle embolization has been demonstrated to improve the pharmacokinetic of the drug and tumor response. Radio opacity of Lipiodol helps to monitor treatment delivery, with retention of Lipiodol serving as an imaging biomarker for tumor response. For 30 years, Lipiodol TACE has been inconsistently referenced in many publications with various levels of details for the method of preparation and administration, with reported progressive outcomes following improvements in the technique and the devices used to deliver the treatment and better patient selection. Consequently, there is no consensus on the standard method of TACE regarding the use of anticancer agents, embolic material, technical details, and the treatment schedule. In order to develop an internationally validated technical recommendation to standardize the Lipiodol TACE procedure, a worldwide panel of experts participated in a consensus meeting held on May 10, 2014 .
    No preview · Article · Sep 2015 · CardioVascular and Interventional Radiology
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    ABSTRACT: Treatment of metastatic gastroenteropancreatic neuroendocrine tumors (GEP-NETs) with peptide receptor radionuclide therapy (PRRT) is effective in retarding tumor growth. Renal dysfunction, anemia, and thrombocytopenia are well-described treatment-related toxicities. However, hepatotoxicity is not well recognized. We performed a retrospective cohort study of consecutive patients with GEP-NETs seen in a tertiary NET clinic from January 2010 to September 2013 (n = 211) with the primary study cohort being patients with metastatic disease to the liver (n = 93). The study exposure was PRRT, and the primary outcome of interest was hepatotoxicity. Hepatotoxicity was defined as a grade 2 or greater injury according to the Common Terminology Criteria for Adverse Events version 3.0 of the National Cancer Institute. Seventeen (18%) of 93 patients with liver metastases received PRRT after radiographic confirmation of disease progression despite receipt of other traditional therapies. Peptide receptor radionuclide therapy patients were similar to the unexposed patient population in terms of sex, age, baseline laboratory values, prior treatment exposure, and duration of disease. In the unexposed group, 23 (30%) of 76 patients had hepatotoxicity related to traditional GEP-NET therapy. In the exposed group, 10 (59%) of 17 patients had an episode of hepatotoxicity. Ascites developed in 59% of the PRRT group versus 6.6% in the unexposed group (P < 0.001). The calculated relative risk of hepatotoxicity related to PRRT exposure in metastatic GEP-NET patients was 1.94 (95% confidence interval, 1.15-3.28). Hepatotoxicity after PRRT for metastatic GEP-NET is more common than previously reported.
    No preview · Article · Aug 2015 · Clinical nuclear medicine
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    ABSTRACT: To evaluate the technical feasibility of a coaxial electrode configuration to rapidly create a mechanically defined electrochemical ablation zone monitored by magnetic resonance (MR) imaging in real time. A direct current generator supplied the nitinol cathode cage and central platinum anode for coaxial electrochemical ablation. Safety and efficacy were evaluated by measuring local pH, temperature, and current scatter in saline solutions. Ablation zone diameters of 3-6 cm (n = 72) were created on ex vivo bovine liver and verified by gross pathology. Feasibility of MR monitoring was evaluated using 8 swine livers to create ablations of 3 cm (n = 12), 4 cm (n = 4), and 5 cm (n = 4) verified by histology. Local pH was 3.2 at the anode and 13.8 at the cathode. Current scatter was negligible. Ablation progress increased relative to local ion concentration, and MR signal changes corresponded to histologic findings. In the ex vivo model, the times to achieve complete ablation were 15 minutes, 20 minutes, 35 minutes, and 40 minutes for diameters of 3 cm, 4 cm, 5 cm, and 6 cm, respectively. Ablation times for the in situ model were 15 minutes, 35 minutes, and 50 minutes for 3 cm, 4 cm, and 5 cm, respectively. The coaxial configuration mechanically defined the electrochemical ablation zone with times similar to comparably sized thermal ablations. MR compatibility allowed for real-time monitoring of ablation progress. Copyright © 2015 SIR. Published by Elsevier Inc. All rights reserved.
    Full-text · Article · Aug 2015 · Journal of vascular and interventional radiology: JVIR
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    ABSTRACT: Previous attempts at meta-analysis and systematic review have not provided clear recommendations for the clinical application of thermal ablation in metastatic colorectal cancer. Many authors believe that the probability of gathering randomised controlled trial (RCT) data is low. Our aim is to provide a consensus document making recommendations on the appropriate application of thermal ablation in patients with colorectal liver metastases. This consensus paper was discussed by an expert panel at The Interventional Oncology Sans Frontières 2013. A literature review was presented. Tumour characteristics, ablation technique and different clinical applications were considered and the level of consensus was documented. Specific recommendations are made with regard to metastasis size, number, and location and ablation technique. Mean 31 % 5-year survival post-ablation in selected patients has resulted in acceptance of this therapy for those with technically inoperable but limited liver disease and those with limited liver reserve or co-morbidities that render them inoperable. In the absence of RCT data, it is our aim that this consensus document will facilitate judicious selection of the patients most likely to benefit from thermal ablation and provide a unified interventional oncological perspective for the use of this technology. • Best results require due consideration of tumour size, number, volume and location. • Ablation technology, imaging guidance and intra-procedural imaging assessment must be optimised. • Accepted applications include inoperable disease due to tumour distribution or inadequate liver reserve. • Other current indications include concurrent co-morbidity, patient choice and the test-of-time approach. • Future applications may include resectable disease, e.g. for small solitary tumours.
    Full-text · Article · May 2015 · European Radiology
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    ABSTRACT: To evaluate long-term patency and symptomatic recurrence rates following transjugular intrahepatic portosystemic shunt (TIPS) creation with expanded polytetrafluoroethylene (ePTFE)-covered stent grafts and to determine the necessity of extended clinical follow-up beyond 2 years after TIPS creation. A retrospective review including 262 TIPSs created with ePTFE-covered stent grafts between July 2002 and October 2012 was performed. Primary, primary assisted, and secondary patency rates were calculated. Assessment of clinical data included technical, hemodynamic, and clinical success rates, as well as mortality after TIPS creation. Primary patency rates at 2, 4, and 6 years were 74%, 62%, and 50%, respectively. Primary assisted patency rates at 2, 4, and 6 years were 93%, 85%, and 78%, respectively. Secondary patency rates at 2, 4, and 6 years were 99%, 91%, and 84%, respectively. Technical and hemodynamic success rates were 99% and 93%, respectively. Clinical success rates for refractory ascites were 66% (complete response) and 90% (partial response); clinical success rate for bleeding/varices was 90%. Mortality rates at 2, 4, and 6 years after TIPS creation were 27%, 38%, and 46%, respectively. At the median wait time until transplantation, patients had an 84% chance of being alive. TIPS dysfunction developed in 21% of patients; 30% of revisions occurred later than 2 years during follow-up. Beyond 2 years after TIPS creation, patency rates gradually decrease, mortality rates continue to increase, and the chance of recurrent ascites or bleeding remains present. Together, these findings suggest that continued clinical follow-up beyond 2 years is necessary in patients with a TIPS created with an ePTFE-covered stent graft. Copyright © 2015 SIR. Published by Elsevier Inc. All rights reserved.
    No preview · Article · May 2015 · Journal of vascular and interventional radiology: JVIR
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    ABSTRACT: To quantify the effect of central venous percutaneous transluminal angioplasty (PTA) on blood flow within hemodialysis access circuits in patients with symptomatic central venous stenosis (CVS). This prospective study enrolled 30 adults with symptoms attributable to CVS ipsilateral to their access. Five subjects were deregistered because of a lack of CVS (n = 1), untreatable lesion (n = 1), or improper flow measurement timing (n = 3); 25 completed the study (15 men and 10 women; mean age, 62 y; age range, 33-87 y). There were 7 fistulae, 15 grafts, and 3 hybrid access circuits. Mean access age was 675 days (range, 16-3,039 d). Mean CVS symptom duration was 37 days (range, 3-120 d). Peripheral stenoses, if present, were treated first. Intraaccess flow was measured immediately before and immediately after CVS treatment (PTA, stent). Eleven patients had only CVS, whereas 14 had at least 1 peripheral lesion in addition to CVS. All stenoses underwent PTA. Mean flow rates were 1,424 mL/min (range, 565-2,765 mL/min) before PTA and 1,535 mL/min (range, 598-2,545 mL/min) afterward, yielding a mean increase of 111 mL/min ± 456 or 15% ± 34 (range, -70% to +100%; 95% confidence interval, 1%-29%). Flow was decreased in 9 patients (36%). CVS symptoms were reduced in 24 patients (96%) and recurred in 14 (58%) within a mean of 110 days (range, 7-459 d) after initial PTA. Mean follow-up was 371 days (range, 17-592 d). CVS symptoms were observed to occur over a wide range of blood flow rates. On average, central venous PTA only mildly increased flow yet reduced symptoms regardless of flow change. Copyright © 2015 SIR. Published by Elsevier Inc. All rights reserved.
    No preview · Article · Apr 2015 · Journal of vascular and interventional radiology: JVIR
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    ABSTRACT: To develop a clinically relevant, minimally invasive technique for transarterial embolization in a translational rat model of hepatocellular carcinoma (HCC). Oral diethylnitrosamine was administered to 53 male Wistar rats ad libitum for 12 weeks. Tumor induction was monitored using magnetic resonance imaging. Minimally invasive lobar or segmental transarterial embolization was performed through a left common carotid artery approach. Necropsy was performed to evaluate periprocedural mortality. Histologic analysis of tumors that received embolization was performed to assess percent tumor necrosis. Severe cirrhosis and autochthonous HCCs were characterized in a cohort of rats composed of two groups of rats identically treated with diethylnitrosamine with median survival times of 101 days and 105 days (n = 10/group). A second cohort was used to develop minimally invasive transarterial embolization of HCCs (n = 10). In a third cohort, lobar embolization was successfully performed in 9 of 10 rats and demonstrated a high rate of periprocedural mortality (n = 5). Necropsy performed for periprocedural mortality after lobar embolization demonstrated extensive tissue necrosis within the liver (n = 3) and lungs (n = 2), indicating nontarget embolization as the likely cause of mortality. In a fourth cohort of rats, a segmental embolization technique was successfully applied in 10 of 13 rats. Segmental embolization resulted in a reduction in periprocedural mortality (P = .06) relative to selective embolization and a 19% increase in average tumor necrosis (P = .04). Minimally invasive, segmental embolization mimicking the currently applied clinical approach is feasible in a translational rat model of HCC and offers the critical advantage of reduced nontarget embolization relative to lobar embolization. Copyright © 2015 SIR. Published by Elsevier Inc. All rights reserved.
    Full-text · Article · Apr 2015 · Journal of vascular and interventional radiology: JVIR
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    ABSTRACT: Purpose: To evaluate readmission rate and complications in patients undergoing same-day discharge following percutaneous thermal ablation of renal tumors. Materials and methods: Patients undergoing same-day discharge following thermal ablation of renal tumors were reviewed. The primary outcome was the rate of readmission within 30 days of same-day discharge. The secondary outcomes included the rate and clinical outcomes of periprocedural complications. Results: Same-day discharge occurred in 166/174 patients (95%), of whom 2/166 (1%) required short-term readmission due to pulmonary embolism and acute-on-chronic kidney injury. Both patients recovered without permanent morbidity. Admission due to complications occurred in 8/174 (5%) cases, the majority of which were related to hemorrhage. No significant differences in rates of complications or admission were found between cryoablation and RF ablation. Major complications (Clavien-Dindo grade II or higher, SIR grade C or higher) occurred in 7/174 (4%) cases, the majority related to hemorrhage. All cases were detected in the standard 4 hour postprocedural observation period and managed conservatively. The mean hemorrhage volume was significantly larger in patients requiring admission versus those discharged the same day (289 mL vs 34 mL; P = .02). Higher-volume hemorrhage occurred in larger tumors (mean, 4.0 cm vs 3.0 cm; P = .04). There was no association between major complications and central tumor or age. Conclusions: Routine same-day discharge following percutaneous renal tumor thermal ablation can be performed with a low rate of short-term readmission. The majority of periprocedural complications can be managed conservatively, and patients can be discharged the same day.
    No preview · Article · Feb 2015 · Journal of Vascular and Interventional Radiology
  • C.N. Weber · B.H. Ge · T. Clark · M.C. Soulen · G. Nadolski

    No preview · Article · Feb 2015 · Journal of Vascular and Interventional Radiology
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    Full-text · Article · Feb 2015 · Journal of Vascular and Interventional Radiology

  • No preview · Article · Feb 2015 · Journal of Vascular and Interventional Radiology
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    ABSTRACT: To evaluate long-term outcomes of a structured protocol for percutaneous treatment of benign biliary stricture. Seventy-one patients (37 men, 34 women; mean age, 54 y; age range, 23-84 y) entered the protocol, which consisted of staged upsizing of internal/external biliary catheters, balloon dilation (nominally 8 mm), and prolonged stent treatment (6 mo) at maximal catheter size (nominally 18 F). It concluded with a capping trial and catheter removal if the stricture remained patent. Fifty-three patients completed the protocol and 18 did not (6 died, 6 underwent alternative treatment, 4 were lost to follow-up, and 2 underwent repeat transplantation). Stricture features, treatment parameters, complications, and outcomes were reviewed, and Kaplan-Meier analysis was conducted. Strictures were anastomotic in 45 patients (64%), intrahepatic in 14 (20%), extrahepatic in 7 (10%), and multiple (intra- and extrahepatic) in 5 (7%). A right-sided approach was used in 47 patients (66%) patients, a left-sided approach in 18 (25%), and a bilateral approach in 6 (9%). Forty-six patients who entered the protocol (65%) and 46 patients who completed the protocol (87%) showed stricture patency. Four of 7 patients in whom a capping trial failed underwent surgical revision, 2 required chronic biliary drainage, and 1 received a metal stent. Follow-up (range, 0-12 y; mean, 4.7 y) was obtained for 42 of 53 patients who completed the protocol (79%). Kaplan-Meier analysis showed stricture patency probabilities of 84% at 1 year after treatment, 78% at 2 years, 74% at 5 years, and 67% at 10 years. Use of a structured protocol for the percutaneous treatment of benign biliary strictures yields durable long-term results, suggesting that percutaneous treatment is an effective therapy. Copyright © 2015 SIR. Published by Elsevier Inc. All rights reserved.
    No preview · Article · Feb 2015 · Journal of Vascular and Interventional Radiology
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    B.H. Ge · C.N. Weber · G. Nadolski · T.P. Gade · S. Hunt · M.C. Soulen · M. Itkin

    Full-text · Article · Feb 2015 · Journal of Vascular and Interventional Radiology
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    Full-text · Article · Feb 2015 · Journal of Vascular and Interventional Radiology
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    Full-text · Article · Feb 2015 · Journal of Vascular and Interventional Radiology
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    ABSTRACT: The purpose of this study was to investigate the treatment effects of antivascular ultrasound (US) with dynamic contrast-enhanced magnetic resonance imaging (MRI), contrast-enhanced sonography, and histopathologic analysis in a murine melanoma model. Subcutaneous K1735 murine melanoma tumors were grown in syngeneic C3H/HeN mice. Quantitative tumor perfusion characteristics were measured before antivascular US treatment with both dynamic contrast-enhanced MRI and high-resolution contrast-enhanced sonography. Tumors were subsequently treated with 1 or 3 minutes of continuous low-intensity US after intravenous administration of a US contrast agent. Treatment effects were assessed by quantitative dynamic contrast-enhanced MRI, contrast-enhanced sonography, histopathologic analysis, and immunohistochemistry. Low-intensity antivascular US treatment resulted in approximately a doubling and tripling of the time to peak enhancement on dynamic contrast-enhanced MRI in the 1- and 3-minute treatment groups, respectively, along with a significant decrease in contrast wash-out (P < .01). There was a potent reduction in tumor perfusion on contrast-enhanced sonography, with approximately 40% and 70% reductions in the tumor area perfused as assessed by contrast-enhanced sonography after 1 (P < .05) and 3 (P < .01) minutes of antivascular US. The pathologic and histologic changes spatially correlated with the regions of diminished perfusion seen on contrast-enhanced sonography and dynamic contrast-enhanced MRI. Antivascular US therapy resulted in a significant increase in the number of hypoxia-inducible factor 1A(+) cells, indicating tumor hypoxia (P < .01), and of CD45(+)/CD3(+) cells in tumors after treatment, in keeping with increased T-cell infiltration (P < .01). Antivascular US treatment effects extend beyond direct cytotoxicity from hemorrhagic necrosis to include ischemia-mediated cytotoxicity, enhanced small molecule retention, and intratumoral immune activation. © 2015 by the American Institute of Ultrasound in Medicine.
    Full-text · Article · Feb 2015 · Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine

Publication Stats

5k Citations
699.59 Total Impact Points

Institutions

  • 1995-2015
    • University of Pennsylvania
      • • Perelman School of Medicine
      • • Department of Radiology
      Filadelfia, Pennsylvania, United States
  • 1994-2015
    • William Penn University
      Filadelfia, Pennsylvania, United States
  • 1993-2015
    • Hospital of the University of Pennsylvania
      • Department of Radiology
      Filadelfia, Pennsylvania, United States
  • 2007
    • New York University
      • Department of Radiology
      New York, New York, United States
  • 2005
    • Northwestern Memorial Hospital
      • Department of Radiology
      Chicago, Illinois, United States
  • 1998
    • The Reading Hospital and Medical Center
      West Reading, Pennsylvania, United States
  • 1990-1995
    • Thomas Jefferson University Hospitals
      • Department of Radiology
      Filadelfia, Pennsylvania, United States
  • 1991
    • Jefferson College
      Хиллсборо, Missouri, United States