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Purpose To determine the association between frailty, 30-day complications, rehospitalization, and transplant-free survival (TFS) following conventional and drug-eluting bead transarterial chemoembolization. Materials and Methods A retrospective analysis was performed on a cohort of 125 patients with treatment-naïve hepatocellular carcinoma who underwent conventional or drug-eluting beads chemoembolization at our institution between 2014 and 2015. Liver function parameters, Barcelona clinic liver cancer tumor stage, and all components of the five-item modified frailty index (mFI-5) were used to determine the patient's frailty status. Key end points included severe (grade 3 or above) adverse events of chemoembolization, 30-day rehospitalization rates, and TFS. Logistic regression analysis was performed on conventional predictors of postoperative complications after chemoembolization. Median survival was estimated and compared using the Kaplan–Meier's estimator and log-rank test. Results Among 125 patients who underwent first-time chemoembolization, higher frailty score was an independent predictor of both 30-day hospital readmission and severe liver toxicity (p = 0.01 and p = 0.03, respectively) on multivariate logistic regression analysis. Each point increase in mFI-5 conferred a threefold or twofold increase in the risk of experiencing 30-day rehospitalization or postoperative severe adverse events, respectively. At the data censor date, patients with mFI-5 score ≥ 2 had decreased overall TFS (28.1 vs. 39.8 months, p = 0.03). Conclusion Increasing frailty as determined by mFI-5 is an independent predictor of 30-day complications and lower TFS following chemoembolization.

Background Tirapazamine (TPZ) is a hypoxia activated drug that may be synergistic with transarterial embolization (TAE). The primary objective was to evaluate the safety of combining TPZ and TAE in patients with unresectable HCC and determine the optimal dose for Phase II. Methods This was a Phase 1 multicenter, open-label, non-randomized trial with a classic 3+3 dose escalation and an expansion cohort in patients with unresectable HCC, Child Pugh A, ECOG 0 or 1. Two initial cohorts consisted of I.V. administration of Tirapazamine followed by superselective TAE while the remaining three cohorts underwent intraarterial administration of Tirapazamine with superselective TAE. Safety and tolerability were assessed using NCI CTCAE 4.0 with clinical, imaging and laboratory examinations including pharmacokinetic (PK) analysis and an electrocardiogram 1 day pre-dose, at 1, 2, 4, 6, 10, and 24 hours post-TPZ infusion and an additional PK at 15- and 30-minutes post-TPZ. Tumor responses were evaluated using mRECIST criteria. Results Twenty-seven patients (mean [range] age of 66.4 [37–79] years) with unresectable HCC were enrolled between July 2015 and January 2018. Two patients were lost to follow-up. Mean tumor size was 6.53 cm ± 2.60 cm with a median of two lesions per patient. Dose limiting toxicity and maximum tolerated dose were not reached. The maximal TPZ dose was 10 mg/m2 I.V. and 20 mg/m2 I.A. One adverse event (AE) was reported in all patients with fatigue, decreased appetite or pain being most common. Grade 3–5 AE were hypertension and transient elevation of AST/ALT in 70.4% of patients. No serious AE were drug related. Sixty percent (95% CI=38.7–78.9) achieved complete response (CR), and 84% (95% CI=63.9–95.5) had complete and partial response per mRECIST for target lesions. Discussion TAE with TPZ was safe and tolerable with encouraging results justifying pursuit of a Phase II trial., Video Abstract Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/ZQdL9fUadAE

Diverticulosis remains the commonest cause for acute lower gastrointestinal tract bleeding (GIB). Conservative management is initially sufficient for most patients, followed by elective diagnostic tests. However, if acute lower GIB persists, it can be investigated with colonoscopy, CT angiography (CTA), or red blood cell (RBC) scan. Colonoscopy can identify the site and cause of bleeding and provide effective treatment. CTA is a noninvasive diagnostic tool that is better tolerated by patients, can identify actively bleeding site or a potential bleeding lesion in vast majority of patients. RBC scan can identify intermittent bleeding, and with single-photon emission computed tomography, can more accurately localize it to a small segment of bowel. If patients are hemodynamically unstable, CTA and transcatheter arteriography/embolization can be performed. Colonoscopy can also be considered in these patients if rapid bowel preparation is feasible. Transcatheter arteriography has a low rate of major complications; however, targeted transcatheter embolization is only feasible if extravasation is seen, which is more likely in hemodynamically unstable patients. If bleeding site has been previously localized but the intervention by colonoscopy and transcatheter embolization have failed to achieve hemostasis, surgery may be required. Among patients with obscure (nonlocalized) recurrent bleeding, capsule endoscopy and CT enterography can be considered to identify culprit mucosal lesion(s). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The success of liver transplant (LT) for hepatocellular carcinoma (HCC) is dependent on accurate tumor staging using validated imaging criteria, and adherence to acceptable criteria based on tumor size and number. Other factors including α-fetoprotein (AFP) and response to local regional therapy (LRT) have now played a larger role in candidate selection. Tumor downstaging is defined as reduction in the size of viable tumors using LRT to meet acceptable criteria for LT, and serves as a selection tool for a subgroup of HCC with more favorable biology. The application of tumor downstaging requires a structured approach involving three key components in tumor staging—initial tumor stage and eligibility criteria, tumor viability assessment following LRT, and target tumor stage prior to LT—and incorporation of AFP into staging and treatment response assessments. In this review, we provide in-depth discussions of the key role of these staging definitions in ensuring successful outcome.

Background Liver transplant hepatic venous anastomoses are usually created using “bicaval” or “piggyback” techniques, which may result in unfavorable angulation between the inferior vena cava and hepatic veins, and makes hepatic vein catheterization and tissue sampling during transjugular liver biopsy (TLB) technically challenging. Purpose To compare the technical successes and complications of TLBs for recipients of liver transplants with bicaval and piggyback hepatic vein anastomoses. Material and Methods Information on type of hepatic vein surgical anastomosis was available for 190 adult patients in whom 306 consecutive TLBs were performed during 2009–2017: 158 with bicaval and 148 with piggyback anastomoses. The primary outcome of procedural success was defined as obtaining a tissue sample sufficient to make a pathologic diagnosis. Results A technical success rate of 97% with adequate liver tissue for diagnosis was similar between the anastomotic groups ( P = 0.50). TLB was unsuccessful in 3% of patients with piggyback anastomoses due to unfavorable hepatic venous anatomy whereas biopsy was successful in all patients with bicaval anastomoses ( P = 0.02). Fluoroscopy times were not significantly different (12.1 vs. 13.9 min, P = 0.08). Rates of major complication were similar between the two groups (3% vs. 3%, P > 0.99). Conclusion TLB is safe and effective for liver transplant patients regardless of the type of hepatic vein anastomosis. While failure to catheterize or advance the stiffened biopsy cannula into the hepatic vein is more likely to occur in patients with piggyback anastomoses, this is a rare occurrence.

Carcinoid crisis is a life-threatening manifestation of carcinoid syndrome characterized by profound autonomic instability in the setting of catecholamine release from stress, tumor manipulation, or anesthesia. Here, we present an unusual case of carcinoid crisis leading to acute systolic heart failure requiring mechanical circulatory support. (Level of Difficulty: Intermediate.), Graphical abstract

Purpose The purpose of this study was to evaluate the effectiveness and adverse outcomes of percutaneous cryoablation (CA) for treatment of renal masses in a large cohort of patients. Materials and Methods This retrospective analysis included 299 CA procedures (297 masses in 277 patients) performed between July 2007 and May 2018 at a single institution. The mean patient age was 66.1 years (range, 30–93 years) with 65.8% being male. A total of 234 (78.8%) masses were biopsy-proven renal cell carcinoma (RCC). The mean maximal tumor diameter was 2.5 cm (range, 0.7–6.6 cm). Efficacy was assessed only for ablations of biopsy-proven RCC, whereas the evaluation of adverse events and renal function included all masses. Complications were graded according to the Society of International Radiology classification. Results Major complications occurred in 3.0% of procedures (n = 9), none of which resulted in death or permanent disability. The mean imaging follow-up period was 27.4 months (range, 1–115) for the 199 RCC patients (204 ablated tumors) with follow-up imaging available. Complete response on initial follow-up imaging at mean 4.2 months (range, 0.3–75.6) was achieved in 195 of 204 tumors (95.6%) after a single session and in 200 of 204 tumors (98.0%) after 1 or 2 sessions. Of the RCC patients achieving complete response initially, local recurrence during the follow-up period occurred in 3 of 200 tumors (1.5%). Metastatic progression occurred in 10 of 193 (5.2%) RCC patients without prior metastatic disease during follow-up. Conclusions CA for renal masses is safe and remains efficacious through intermediate- and long-term follow-up.

Background: Given the high frequency of liver metastases in neuroendocrine tumor patients, we aimed to determine whether hepatic intra-arterial (IA) injection of 90Y-DOTATOC Peptide Receptor Radionuclide Therapy (PRRT) would achieve higher intratumoral concentrations than intravenous (IV) injection, thus maintaining efficacy while reducing systemic toxicity. Methods: PRRT-naive adult NET patients with liver-dominant metastases involving

Iliofemoral venous thrombosis carries a high risk for pulmonary embolism, recurrent deep vein thrombosis, and post-thrombotic syndrome complicating 30% to 71% of those affected. The clinical scenarios in which iliofemoral venous thrombosis is managed may be diverse, presenting a challenge to identify optimum therapy tailored to each situation. Goals for management include preventing morbidity from venous occlusive disease, and morbidity and mortality from pulmonary embolism. Anticoagulation remains the standard of care for iliofemoral venous thrombosis, although a role for more aggressive therapies with catheter-based interventions or surgery exists in select circumstances. Results from recent prospective trials have improved patient selection guidelines for more aggressive therapies, and have also demonstrated a lack of efficacy for certain conservative therapies. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Background/aim The majority of colorectal cancer (CRC) cases, which are microsatellite stable (MSS) and do not harbor mismatch repair deficiency/microsatellite instability, are resistant to immunotherapy. Identification of patients with exceptional responses in MSS CRC and predictive biomarkers is an unmet need that needs to be addressed. Case report We report three cases of MSS CRC with durable clinical benefit from immunotherapy with anti-PD-1 checkpoint inhibitors. Two cases bear a POLE P286R mutation, which has been associated with lack of immunotherapy response in MSS CRC. Two cases bear alterations in Ataxia-Telangiectasia Mutated (ATM) which may contribute to observed responses, including interaction with a co-administered intratumoral stimulator of interferon genes (STING) pathway agonist in one patient. Conclusion Novel DNA damage repair alterations, including mutations in ATM, can provide insight into additional mechanisms by which genomic alterations can sensitize MSS CRC to diverse immunotherapies.

Purpose To evaluate efficacy and safety of transjugular liver biopsy (TJLB) via the left hepatic vein in patients with left lobe–only liver transplants (LLOTs). Materials and Methods Retrospective review revealed 43 TJLBs performed in 26 patients with LLOTs (mean age 51.3 y; range, 18–73 y) between January 2009 and June 2016 at a single institution. A comparison group of 44 randomly selected TJLBs performed in 37 orthotopic whole liver transplant (OWLT) recipients (mean age 57.6 y; range, 35–74 y) during the same time period was evaluated. Patient demographics, type and age of transplant, technical success, adequacy of samples, number of portal tracts obtained, pathologic diagnosis, and complication rate were reviewed. Results Technical success was achieved in 98% (42/43) of LLOT procedures. TJLB failed in 1 patient with LLOT, in whom no patent hepatic veins were identified. Technical success was achieved in 100% (44/44) in the OWLT group. Mean (SD) number of needle passes was 4.12 (1.25) in the LLOT group vs 3.95 (1.28) in the OWLT group (P = .54). Mean (SD) specimen length was 1.16 (0.75) cm in the LLOT group vs 1.19 (0.58) cm in the OWLT group (P = .78). Mean (SD) number of portal tracts obtained in the LLOT group was 10.7 (5.26) vs 12.3 (4.68) in the OWLT group (P = .17). No major complications were observed in either group. Conclusions TJLB in adult patients with LLOTs appears safe and feasible, with favorable rates of technical success and adequacy of sampling.

Venous thromboembolism (VTE)—deep vein thrombosis and pulmonary embolism—is a common cause of morbidity and mortality. The mainstay of VTE prophylaxis and therapy is anticoagulation. In select patients with VTE, inferior vena cava (IVC) filters are used to prevent pulmonary embolism by trapping emboli as they pass from the lower extremity venous system through the IVC. These guidelines review the indications for placement of IVC filters in acute and chronic VTE, as well as the indications for retrieval of implanted IVC filters. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Purpose To compare the complication rate of the Denali and Option-ELITE inferior vena cava (IVC) filters. Materials and Methods All patients who had a Denali or Option-ELITE IVC filter placed between March 2014 and March 2016 were retrospectively identified from the electronic medical records. Of the 245 IVC filters placed, the positions of 93 devices (21 Denali and 72 Option-ELITE) were documented on follow-up computed tomography (CT) examinations obtained for reasons unrelated to filter placement. In situations where multiple CT studies were obtained after placement, each study was reviewed, for a total of 200 examinations. Images were assessed for filter complication including caval wall penetration by filter components, associated damage to pericaval tissues, filter tilt, migration, and fracture. Results Penetration of at least one strut was observed in 13% of all filters imaged by CT, (Denali: 14%; Option-ELITE: 13%; p = 1.00). No patients had damage to pericaval tissues or documented symptoms attributed to penetration. Neither the Denali nor the Option-ELITE filters demonstrated significant tilt (> 15 degrees of tilt), migration, or fracture. Compared with Denali; the Option-ELITE filter demonstrated an increasing strut penetration rate with longer indwell times (z = –3.67, p < 0.01). Conclusions No significant difference was observed between the rates of caval penetration of the Denali and Option-ELITE IVC filters assessed by CT. Additionally, no findings of filter fracture or migration were noted, suggesting that the Denali filter is non-inferior to the Option-ELITE filter with respect to penetration, fracture, tilt, and migration. The Option-ELITE filter demonstrated a time-dependent tendency toward greater strut penetration with longer indwell times.

Background To evaluate the efficacy of percutaneous and endoscopic therapeutic interventions for biliary strictures and leaks following LT in children. Methods Retrospective analysis of 49 consecutive pediatric liver transplant recipients (27 girls, 22 boys, mean age at transplant 3.9 years) treated at our institution from 1989 to 2019 for biliary leak and/or biliary stricture was performed. Minimally invasive approach was considered clinically successful if it resulted in patency of the narrowed biliary segment and/or correction of the biliary leak. Results Forty-two patients had a stricture at the biliary anastomosis; seven had a biliary leak. After an average 13.8 years of follow-up, long-term clinical success with minimally invasive treatment (no surgery or re-transplant) was achieved for 24 children (57%) with biliary stricture and 4 (57%) with biliary leaks. Eight patients required re-transplant; however, only one was due to failure of both percutaneous and surgical management. For biliary strictures, failure of non-surgical management was associated with younger age at stricture diagnosis (p Conclusions Percutaneous and endoscopic management of biliary strictures and leaks after LT in children is associated with a durable result in >50% of children.

The incidence of hepatocellular carcinoma continues to increase worldwide. Fortunately, there have been notable recent advances in locoregional and systemic therapy. In this current review, we will highlight these new developments and future directions of hepatocellular carcinoma treatment and address the importance of a multidisciplinary approach to treatment.

Neuroendocrine tumor liver metastases are treated by a multidisciplinary cohort of physicians that work together to achieve optimal clinical results for their patients. This review addresses critical concepts in diagnosis and workup of such patients followed by medical, surgical, and liver-directed arterial and ablative therapies. Specific perioperative care for these patients is crucial in avoiding dreaded complications related to Carcinoid Crisis. The recent introduction of Peptide Receptor Radionuclide Therapy as a therapeutic option has impacted some of the algorithms for timing and selection of arterial embolotherapies.

With the growing use of 177Lu-DOTATATE peptide receptor radionuclide therapy (PRRT), there are many unanswered questions regarding patient selection. In this document, we review the literature on the use of 177Lu-DOTATATE in neuroendocrine tumors (NETs) of different primary origin, discuss issues of

Given the high frequency of liver metastases in neuroendocrine tumor patients, we aimed to determine whether hepatic intraarterial administration of

In patients with a liver malignancy and a history of biliary instrumentation who undergo transarterial radioembolization with 90Y microspheres, infectious complications and morbidities such as liver abscess and cholangitis occur but are uncommon.

Purpose To assess the effectiveness of disposable radiation-absorbing surgical drapes on operator radiation dose during transjugular liver biopsy (TJLB). Materials and Methods This dual-arm prospective, randomized study was conducted between May 2017 and January 2018 at a single institution. TJLB procedures (N = 62; patient age range, 19–80 y) were assigned at a 1:1 ratio to the use of radiation-absorbing surgical drapes or standard surgical draping. The primary outcome was cumulative radiation equivalent dose incident on the operator, as determined by an electronic personal dosimeter worn at the chest during each procedure. Cumulative kerma–area product (KAP), total fluoroscopy time, and total number of exposures used during each liver biopsy procedure were also determined. Results Mean radiation dose incident on the operator decreased by 56% with the use of radiation-absorbing drapes (37 μSv ± 35; range, 4–183 μSv) compared with standard draping (84 μSv ± 58; range, 11–220 μSv). Radiation incident on the patient was similar between groups, with no significant differences in mean KAP, total fluoroscopy time, and number of exposures acquired during the procedures. Conclusions Use of disposable radiation-absorbing drapes reduces scatter radiation to interventionalists performing TJLB.

Background Neuroendocrine neoplasms (NENs) comprise a rare and heterogenous group of cancers, for which the role of radiation therapy continues to evolve. The purpose of this study is to analyze oncologic outcomes after the use of high-dose radiation in management of NENs at a tertiary hospital. Materials and methods We performed a retrospective review of patients who received high-dose radiation with intent to cure or provide durable local control (defined as biologically effective dose (BED) ≥40, α/β = 10) for a localized or metastatic NEN from 2006 to 2019. Evaluation of disease status after radiation was performed according to Response Evaluation Criteria in Solid Tumors (RECIST) criteria when possible. Patients were grouped by differentiation (well-differentiated (WD) or poorly-differentiated (PD)) and stage (localized/locally advanced disease (L) or metastatic (M)) in analysis of probabilities of progression after radiation. Results 45 patients completed a radiation course with BED ≥40 for a NEN (median BED 72). With a median follow-up of 24 months after radiation, the 2-year actuarial rates of local relapse-free survival, new metastasis-free survival, progression-free survival, and overall survival after radiation were 98%, 45%, 41%, and 69%, respectively. 25 patients (56%) developed new metastases after completion of radiation, including 33% (n = 3) of patients with WD-L disease, 44% (n = 8) of WD-M, 77% (n = 10) of PD-L, and 80% (n = 4) of PD-M, with progressively shorter median times to progression (26, 9, 8, and 3 months, respectively; p = 0.093). Of the 25 patients evaluable by RECIST, 68% (n = 17) achieved either a complete or partial best response in the irradiated lesion. Conclusions These data suggest that focal, high-dose radiation has a role in the management of selected patients with NENs. Local failure is rare in patients with both well-differentiated and poorly-differentiated disease, although the predominant pattern of failure remains development of new metastases.

The purpose of this review is to outline the various toxicities of liver-directed therapy approaches employed for treatment of liver-limited hepatocellular carcinoma. The covered topics span toxicities related to ablative and transarterial treatment approaches, including radiofrequency and microwave ablation, cryoablation, percutaneous ethanol injection, transarterial chemoembolization, and yttrium-90 radioembolization. Both common entities, such as postablation, and post(radio)embolization syndrome and hepatotoxicity, as well as uncommon topics (nontarget organ damage, cryoshock, infections, bile duct injuries) are described. Appropriate treatments for management of these side effects are suggested.

Mesenteric vascular insufficiency is a serious medical condition that may lead to bowel infarction, morbidity, and mortality that may approach 50%. Recommended therapy for acute mesenteric ischemia includes aspiration embolectomy, transcatheter thrombolysis, and angioplasty with or without stenting for the treatment of underlying arterial stenosis. Nonocclusive mesenteric ischemia may respond to transarterial infusion of vasodilators such as nitroglycerin, papaverine, glucagon, and prostaglandin E1. Recommended therapy for chronic mesenteric ischemia includes angioplasty with or without stent placement and, if an endovascular approach is not possible, surgical bypass or endarterectomy. The diagnosis of median arcuate ligament syndrome is controversial, but surgical release may be appropriate depending on the clinical situation. Venous mesenteric ischemia may respond to systemic anticoagulation alone. Transhepatic or transjugular superior mesenteric vein catheterization and thrombolytic infusion can be offered depending on the severity of symptoms, condition of the patient, and response to systemic anticoagulation. Adjunct transjugular intrahepatic portosystemic shunt creation can be considered for outflow improvement. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Purpose To assess safety and efficacy of doxorubicin drug-eluting embolic (DEE) transarterial chemoembolization of hepatocellular carcinoma (HCC) by extrahepatic collateral arteries. Materials and Methods Records of 177 patients with HCC who underwent 338 consecutive DEE chemoembolization procedures from 2011 to 2014 were retrospectively reviewed. A subgroup of 16 patients (13 men, 3 women, median age 66 y) underwent 24 procedures for 17 HCCs via extrahepatic arteries and was included in the study. Median tumor size was 3.1 cm (range, 1.0–10.3 cm). Extrahepatic collaterals included right inferior phrenic (19 procedures; 12 patients), adrenal (4 procedures; 3 patients), and cystic arteries (2 procedures; 2 patients). Radiographic response was assessed by Modified Response Evaluation Criteria in Solid Tumors criteria. Complications were defined by National Cancer Institute Common Terminology Criteria for Adverse Events. Results DEE chemoembolization achieved stable disease in 6 (35.3%), partial response in 6 (35.3%), and complete response in 4 (23.5%) HCCs. Disease progression was ultimately observed in 8 tumors (47.1%), with mean time to progression of 8.3 months after chemoembolization (range, 2–13 mo). Three minor and 5 major complications occurred in 8 patients; 2 minor complications were rash in vascular distribution after right inferior phrenic artery DEE chemoembolization. The 5 major complications were transient hepatotoxicity that resolved within 4–80 days; 1 was accompanied by pleural effusion requiring hospitalization. A mean 13.4 months after DEE chemoembolization, 67% of transplant candidates proceeded to liver transplant. Conclusions DEE transarterial chemoembolization via extrahepatic collaterals was effective and facilitated bridging to transplant. It was generally well tolerated; transient hepatotoxicity was the most common major complication.

The purpose of the study was to evaluate prognostic factors for survival outcomes following embolotherapy for neuroendocrine tumor (NET) liver metastases.This was a multicenter retrospective study of 155 patients (60 years mean age, 57 % male) with NET liver metastases from pancreas (n = 71), gut (n = 68), lung (n = 8), or other/unknown (n = 8) primary sites treated with conventional transarterial chemoembolization (TACE, n = 50), transarterial radioembolization (TARE, n = 64), or transarterial embolization (TAE, n = 41) between 2004 and 2015. Patient-, tumor-, and treatment-related factors were evaluated for prognostic effect on hepatic progression-free survival (HPFS) and overall survival (OS) using unadjusted and propensity score-weighted univariate and multivariate Cox proportional hazards models.Median HPFS and OS were 18.5 and 125.1 months for G1 (n = 75), 12.2 and 33.9 months for G2 (n = 60), and 4.9 and 9.3 months for G3 tumors (n = 20), respectively (p 0.05). Tumor burden 50 % hepatic volume demonstrated 5.5- and 26.8-month shorter median HPFS and OS, respectively, versus burden ≤50 % (p 0.05). There were no significant differences in HPFS or OS between gut or pancreas primaries. In multivariate HPFS analysis, there were no significant differences among embolotherapy modalities. In multivariate OS analysis, TARE had a higher hazard ratio than TACE (unadjusted Cox model: HR 2.1, p = 0.02; propensity score adjusted model: HR 1.8, p = 0.11), while TAE did not differ significantly from TACE.Higher tumor grade and tumor burden prognosticated shorter HPFS and OS. TARE had a higher hazard ratio for OS than TACE. There were no significant differences in HPFS among embolotherapy modalities.

The endoscopic enteroenteral bypass could revolutionize the treatment of small bowel obstruction (SBO) in inoperable patients. We describe the technique of endoscopic delivery of a magnetic compression anastomosis device and the creation of an enteroenteral anastomosis in a patient with recurrent acute on chronic SBOs and prohibitively high operative risk. In this novel procedure, a magnetic compression anastomosis device is delivered on either side of the obstruction using a hybrid endoscopic/fluorographic technique, effectively bypassing the obstruction and relieving symptoms. The anastomosis was endoscopically evaluated at regular intervals postprocedure. By 7 days, healthy villi were visible through the mated magnetic rings. By 10 days, the anastomosis was widely patent. The rings passed through the ileostomy and were evacuated, and the patient's symptoms completely resolved. The anastomosis remained widely patent at 1 year. In summary, this case demonstrates the benefit of magnetic compression anastomosis in a patient with SBO and high operative risk.

OBJECTIVES The objective of this study was to describe the periprocedural management of patients with well-differentiated neuroendocrine tumors with hepatic metastases who underwent liver-directed procedures. METHODS We performed a retrospective review of patients with metastatic neuroendocrine tumors who underwent liver resection, ablation, or embolotherapy at a single center from 2012 to 2016. The primary outcome was occurrence of documented carcinoid crisis (CC) or hemodynamic instability (HDI), defined as 10 minutes or more of systolic blood pressure less than 80 or greater than 180 mm Hg, or pulse greater than 120 beats per minute. RESULTS We identified 75 patients who underwent liver resection/ablation (n = 38) or embolotherapy (n = 37). Twenty-four patients (32%) experienced CC or HDI (CC/HDI); CC occurred in 3 patients. No clinicopathologic or procedural factors, including procedure type, octreotide or long-acting somatostatin analog use, and history of carcinoid syndrome, were associated with CC/HDI. Grades 2 to 4 complications were reported in 42% of patients who experienced CC/HDI versus in 16% of patients who did not experience CC/HDI (P < 0.05). CONCLUSIONS A significant portion of patients developed CC/HDI, and these patients were more likely to develop severe postprocedural complications. Periprocedural octreotide use was not associated with lower CC/HDI occurrence, but continued use is advised given its safety profile until additional studies definitively demonstrate lack of benefit.

Nicholas Fidelman,1 Curt Johanson,1 Maureen P Kohi,1 K Pallav Kolli,1 Ryan M Kohlbrenner,1 Evan D Lehrman,1 Andrew G Taylor,1 R Kate Kelley,2 Francis Y Yao,3 John P Roberts,4 Robert K Kerlan11Department of Radiology and Biomedical Imaging; 2Department of Medicine – Division of Gastrointestinal Oncology; 3Department of Medicine – Division of Hepatology; 4Department of Surgery – Division of Transplant Surgery, University of California San Francisco, San Francisco, CA, USAPurpose: To determine whether chemoembolization using drug-eluting beads (DEB-TACE) is safe and effective for liver transplantation candidates with liver-limited hepatocellular carcinoma (HCC) without vascular invasion and baseline hepatic dysfunction.Materials and methods: Seventeen adult liver transplantation candidates (median age 66 years, range 58–73 years; 13 men) with HCC were treated with DEB-TACE as a part of Stage 1 of a prospective single-institution Phase II trial. All patients had marginal hepatic reserve based on at least one of the following criteria: ascites (n=14), bilirubin between 3 and 6 mg/dL (n=5), AST 5–10 times upper normal limit (n=1), INR between 1.6 and 2.5 (n=4), portal vein thrombosis (n=2), and/or portosystemic shunt (n=2). Primary study objectives were safety and best observed radiographic response.Results: Thirty-seven DEB-TACE procedures were performed. Objective response rate and disease control rate were 63% and 88%, respectively. HCC progression was observed in 12 patients. Median time to progression was 5.6 months (range 0.9–13.6 months). Within 1 month following DEB-TACE, 13 patients (76%) developed grade 3 or 4 AE attributable to the procedure. Four patients (all within Milan Criteria) were transplanted (2.7–6.9 months after DEB-TACE), and 12 patients died (1.8–32 months after DEB-TACE). All deaths were due to liver failure that was either unrelated to HCC (n=5), in the setting of metastatic HCC (n=5), or in the setting of locally advanced HCC (n=2). Mortality rate at 1 month was 0%.Conclusions: DEB-TACE achieves tumor responses but carries a high risk of hepatotoxicity for liver transplant candidates with HCC and marginal hepatic reserve.Keywords: hepatocellular carcinoma, chemoembolization, liver transplantation