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Learning Objectives: Describe the indications, technical details and procedural pitfalls relevant to this interventional therapy. Background: Malignant biliary obstruction (MBO) portends a poor prognosis. Preferred treatment is surgical resection, but is not an option in most patients. Palliative care for these patients often involves placement of percutaneous transhepatic biliary drains (PTBD) or biliary stents. Radiation and/or chemotherapy are additional palliative techniques. Radiation therapy may be delivered by teletherapy or intraluminal brachytherapy (ILBT). Recent studies suggest that PTBD followed by ILBT in patients with MBO leads to improved quality of life, decreased symptoms and potentially increased survival. The interventional radiologist will play a leading role in this novel therapy and must be aware of the technical considerations necessary to aid the radiation oncologist and provide optimal benefit to the patient. Clinical Findings/Procedure Details: Initially, PTBD is performed using standard techniques. Once the patient convalesces clinically, the PTBD is exchanged for a radiopaque pigtail catheter. Cholangiography is performed to delineate the biliary anatomy, correlating the ampulla of Vater and the site of malignant obstruction with internal bony landmarks. The patient is then transported to the radiation oncology department where high-dose-rate (HDR) brachytherapy is performed via the pigtail catheter using a remote afterloader to deliver the Ir-192 source. Verification of appropriate source placement can be performed by the radiation oncologist with either CT or fluoroscopy, using landmarks established with cholangiography. Following HDR treatment, the patient returns to the interventional radiology suite for replacement of a PTBD which is left to drain overnight. The following day, the PTBD is exchanged in the IR suite for a percutaneously placed plastic endobiliary stent that can be exchanged at regular intervals endoscopically. Conclusion and/or Teaching Points: PTBD placement followed by ILBT is a promising treatment protocol for patients with MBO. In order to limit complications and improve outcomes, the interventional radiologist must work closely with the radiation oncologist to ensure precise brachytherapy delivery. [Copyright &y& Elsevier]

Purpose: To evaluate the outcomes of diagnostic and therapeutic percutaneous transhepatic choledochoscopy (PTCS) in patients with surgically altered small bowel anatomy and cholangiographic abnormalities. Materials and Methods: Over a 5 year period 31 procedures were performed in 20 patients (13 females; median age 55, range 19-82) with surgically altered anatomy precluding the successful use of advanced ERCP techniques. Surgical anatomy included Roux-en-y hepaticojejunostomy in 55% (11/20), Gastric Bypass Roux-en-Y in 20% (4/20), pancreaticoduodenectomy in 15% (3/20) and Billroth II in 10% (2/20). Prior to cholangioscopy, all patients had at least one clinically relevant cholangiographic finding requiring further management. A 7.5 French choledochoscope was passed through an established 10 to 18 French percutaneous transhepatic route into the biliary system. Therapies included direct visual guidance of biopsy and lithotripsy. Results: Diagnostic cholangioscopy was successfully performed in all patients. No complications were reported. Management changing diagnosis and/or treatment was made in all patients. All patients with stones (12/20) had additional findings at cholangioscopy. A mean of 1.7 cholangiographic procedures were utilized to treat and confirm complete stone clearance. Other cholangioscopic findings included the following; benign strictures (5/20), tube related inflammation (3/20), Papillomas (3/20), intrabiliary suture material (2/20), mucinous producing lesion (1/20), villous adenoma (1/20) and a small wind-sock biliary diverticulum (1/20). A total of 65% (13/20) of the patients had biliary drainage catheters removed after diagnosis and treatment of the biliary lesion. Conclusion: PTCS can significantly change the clinical course of patients when utilized as a problem solving tool for diagnosis and treatment of cholangiographic abnormalities in patients with surgically altered anatomy preventing ERCP. [Copyright &y& Elsevier]

Purpose: To determine if volumetric changes of contrast-enhanced and diffusion-weighted magnetic resonance (MR) imaging can help assess early tumor response and predict survival in patient with metastatic uveal melanoma after a single session of transarterial chemoembolization (TACE). Materials and Methods: This IRB approved retrospective analysis of prospectively enrolled patients included nine patients with a total of 36 lesions who did not undergo previous systemic and/or locoregional therapies. All patients underwent MR imaging 3-4 weeks before and after the first TACE. MR analysis evaluated the lesion characteristics (signal intensities, WHO, RECIST, tumor volume (vRECIST), mRECIST, EASL and volumetric tumor enhancement using the quantitative EASL (qEASL)) in all patients and apparent diffusion coefficient (ADC) values in a subset of patients (n=5). The lesions were segmented using a semi-automatic 3D volumetric software to provide volumetric contrast-enhanced MR imaging in the hepatic arterial phase and ADC. Tumor response was defined as a decrease in volumetric enhancement of ≥ 50 %. Images before and after TACE were compared using the paired t-test with its exact permutation distribution. Survival for responders and non-responders was estimated with the Kaplan-Meier method and compared using the log-rank test with its exact permutation distribution. Results: In targeted lesions, the mean percentage of volumetric tumor enhancement (qEASL) decreased from 63.9% to 36.5% (P = .021). No significant change was observed in target lesions using the other response criteria. In non-targeted lesions, mean WHO, RECIST, vRECIST, mRECIST, EASL and qEASL were significantly increased. Mean volumetric ADC increased from 1.01 ± .26 to 1.22 ± .28 10-3 mm2/s (P = .033), whereas ADC values for non-targeted lesions remained unchanged. Median survival of all patients was 7.1 months. qEASL was the only method to accurately predict survival amongst non-responders and responders (4.8 vs 29.5 months, respectively; P = .024). Conclusion: Volumetric tumor enhancement may be used as a new surrogate biomarker for survival in patient with uveal melanoma metastatic to the liver after a single session of TACE. [Copyright &y& Elsevier]