Publications by authors named "William S Rilling"

47 Publications

Biliary-Caval Fistula following Y90 Radioembolization.

Semin Intervent Radiol 2021 Oct 7;38(4):488-491. Epub 2021 Oct 7.

Division of Vascular and Interventional Radiology, Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin.

The safety of radioembolization with yttrium-90 ( Y) is well documented and major complications are rare. Previous studies have demonstrated that biliary complications following Y, including bile duct injury and hepatic abscess formation, occur at an increased rate in patients who have had prior biliary surgery and interventions. This article reviews a case of a patient who developed recurrent cholangitis and sepsis as well as a biliary-caval fistula following radioembolization. Additionally, we review current data regarding biliary complications following radioembolization in patients with prior biliary intervention.
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http://dx.doi.org/10.1055/s-0041-1735605DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8497092PMC
October 2021

Quality of Life and Cost Considerations: Y-90 Radioembolization.

Semin Intervent Radiol 2021 Oct 7;38(4):482-487. Epub 2021 Oct 7.

Division of Vascular and Interventional Radiology, Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin.

 Transarterial radioembolization (TARE) offers a minimally invasive and safe treatment option for primary and metastatic hepatic malignancies. The benefits of TARE are manifold including prolonged overall survival, low associated morbidities, and improved time to progression allowing prolonged treatment-free intervals. The rapid development of new systemic therapies including immunotherapy has radically changed the treatment landscape for primary and metastatic liver cancer. Given the current climate, it is critical for interventional oncologists to understand the benefits of TARE relative to these other therapies. Therefore, this report aims to review quality-of-life outcomes and the cost comparisons of TARE as compared with systemic therapies.
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http://dx.doi.org/10.1055/s-0041-1735570DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8497083PMC
October 2021

VenaTech Convertible Vena Cava Filter 6 Months after Conversion Follow-up.

J Vasc Interv Radiol 2020 Sep 11;31(9):1419-1425. Epub 2020 Aug 11.

Department of Radiology, Medical College of Wisconsin, Froedtert Memorial Lutheran Hospital, 9200 West Wisconsin Avenue, Milwaukee, WI 53226.

Purpose: To report device-related adverse events 6 months after placement or conversion of the VenaTech convertible vena cava filter (VTCF).

Materials And Methods: A review of 6-month follow-up data of an investigational device exemption multicenter, prospective, single-arm study was performed. The VTCF was implanted in 149 patients. Conversion was attempted in 64.4% of those patients (n = 96) and successfully in 96.9% of the patients (n = 93). A total of 76 patients completed imaging evaluation at 6 months after filter conversion. Patients who required continued venous thromboembolism prophylaxis at 6 months did not undergo a conversion attempt and were designated as nonconverted filter subjects. A total of 28 nonconverted filter subjects completed imaging evaluation at 6 months after implantation.

Results: Evaluation of patients at 6 months after conversion demonstrated 1 of 76 (1.3%) inferior vena cava (IVC) perforations with a filter strut greater than 3 mm outside of the caval lumen. No cases of recurrent PE, clinically significant filter migration, filter fracture, or IVC thrombosis were reported in the converted subjects. In the nonconverted filter subjects, there was a 14.3% (4 of 28) complete or nearly complete rate of IVC thromboses. There were no cases of recurrent pulmonary embolism, penetration, fracture, or spontaneous conversion in the nonconverted filter subjects. There was a significant reduction in the rate of IVC thrombosis and migration in the converted cohort compared to that in the nonconverted cohort.

Conclusions: At 6 months, the VTCF demonstrated low adverse event rates in the converted configuration, whereas a minority of patients with the nonconverted configuration demonstrated a high risk of IVC thrombosis.
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http://dx.doi.org/10.1016/j.jvir.2020.05.023DOI Listing
September 2020

Multicenter Trial of the VenaTech Convertible Vena Cava Filter.

J Vasc Interv Radiol 2017 Oct 16;28(10):1353-1362. Epub 2017 Aug 16.

Division of Vascular and Interventional Radiology, Department of Radiology, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Room 2803, Milwaukee, WI 53226.

Purpose: To demonstrate rates of successful filter conversion and 6-month major device-related adverse events in subjects with converted caval filters.

Materials And Methods: An investigational device exemption multicenter, prospective, single-arm study was performed at 11 sites enrolling 149 patients. The VenaTech Convertible Vena Cava Filter (B. Braun Interventional Systems, Inc, Bethlehem, Pennsylvania) was implanted in 149 patients with venous thromboembolism and contraindication to or failure of anticoagulation (n = 119), with high-risk trauma (n = 14), and for surgical prophylaxis (n = 16). When the patient was no longer at risk for pulmonary embolism as determined by clinical assessment, an attempt at filter conversion was made. Follow-up of converted patients (n = 93) was conducted at 30 days, 3 months, and 6 months after conversion. Patients who did not undergo a conversion attempt (n = 53) had follow-up at 6 months after implant.

Results: All implants were successful. One 7-day migration to the right atrium required surgical removal. Technical success rate for filter conversion was 92.7% (89/96). Mean time from placement to conversion was 130.7 days (range, 15-391 d). No major conversion-related events were reported. The mean conversion procedure time was 30.7 minutes (range, 7-135 min). There were 89 converted and 32 unconverted patients who completed 6-month follow-up with no delayed complications.

Conclusions: The VenaTech Convertible filter has a high conversion rate and low 6-month device-related adverse event rate. Further studies are necessary to determine long-term safety and efficacy in both converted and unconverted patients.
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http://dx.doi.org/10.1016/j.jvir.2017.06.032DOI Listing
October 2017

Palliative Interventional Oncology.

Cancer J 2016 Nov/Dec;22(6):411-417

From the Division of Vascular & Interventional Radiology, Department of Radiology, Medical College of Wisconsin, Milwaukee, WI.

Interventional oncologists are playing an ever greater role in improving the quality of life of their patients through minimally invasive procedures, many of which can be performed on an outpatient basis. Some of the most common palliative procedures currently performed will be discussed including management of intractable ascites and pleural effusions, neurolytic plexus blocks, and palliation of pain and bleeding associated with metastatic tumors.
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http://dx.doi.org/10.1097/PPO.0000000000000230DOI Listing
July 2017

Geniculate Artery Embolization for Management of Recurrent Hemarthrosis: A Single-Center Experience.

J Vasc Interv Radiol 2016 Jul;27(7):1097-9

Department of Radiology, Division of Vascular and Interventional Radiology, Medical College of Wisconsin, 9200 W. Wisconsin Ave. Milwaukee, WI 53226.

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http://dx.doi.org/10.1016/j.jvir.2016.04.003DOI Listing
July 2016

Lipiodol transarterial chemoembolization for hepatocellular carcinoma: A systematic review of efficacy and safety data.

Hepatology 2016 07 7;64(1):106-16. Epub 2016 Mar 7.

Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT.

Unlabelled: 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 predefined inclusion and exclusion criteria. 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 [CI]: 43.6-61.5). Overall survival (OS) was 70.3% at 1 year, 51.8% at 2 years, 40.4% at 3 years, and 32.4% at 5 years. Median OS was 19.4 months (95% CI: 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 postembolization syndrome. Overall mortality rate was 0.6% and the most common cause of death was related to acute liver insufficiency.

Conclusions: 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. (Hepatology 2016;64:106-116).
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http://dx.doi.org/10.1002/hep.28453DOI Listing
July 2016

Evaluation of catheter infection rates in converted dialysis catheters versus de novo placement in the setting of chlorhexidine use.

J Vasc Access 2016 Mar-Apr;17(2):162-6. Epub 2015 Dec 7.

Department of Radiology, Division of Vascular and Interventional Radiology, Medical College of Wisconsin, Milwaukee, WI - USA.

Purpose: Prior studies have reported infection rates of converting non-tunneled dialysis catheters (NTDCs) to tunneled dialysis catheters (TDCs) versus de novo placement of TDCs using povidone-iodine. Chlorhexidine, per the Center of Disease Control guidelines, has been exclusively used in our institution since 2005. Therefore, our study aims to determine whether there is a difference in infection rates between conversion and de novo placement when utilizing chlorhexidine.

Materials And Methods: A retrospective analysis from 1/1/2009 to 8/10/2012 was performed of patients who underwent placement of NTDCs, which were subsequently converted to TDCs and those who underwent de novo TDC placement. To assess the rate of infection, the following data points were collected: date of procedure(s), indication, outcomes, site of catheter insertion, pre- and post-procedure laboratory values, complications, infection rates within the life of the initially placed catheter, catheter days, and survival.

Results: The conversion cohort was composed of 205 patients, 135 of whom were lost to follow-up, leaving 70 patients. The de novo cohort included 70 randomly selected patients. Of the 70 patients who underwent conversion, 23 developed a catheter-related infection, with an infection rate of 0.26 events per 100 catheter days. Of the 70 de novo catheters, 20 developed infection with an infection rate of 0.25 events per 100 catheters days.

Conclusion: In this series, there is no difference in infection rates between conversion and de novo TDC placement when utilizing chlorhexidine as the sterilization agent. However, these infection rates are superior to those reported when using povidone-iodine.
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http://dx.doi.org/10.5301/jva.5000490DOI Listing
December 2016

90Y Radioembolization of Colorectal Hepatic Metastases Using Glass Microspheres: Safety and Survival Outcomes from a 531-Patient Multicenter Study.

J Nucl Med 2016 May 3;57(5):665-71. Epub 2015 Dec 3.

Section of Interventional Radiology, Department of Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Memorial Hospital, Chicago, Illinois Division of Hematology and Oncology, Department of Medicine, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois

Unlabelled: Hepatic metastases of colorectal carcinoma are a leading cause of cancer-related mortality. Most colorectal liver metastases become refractory to chemotherapy and biologic agents, at which point the median overall survival declines to 4-5 mo. Radioembolization with (90)Y has been used in the salvage setting with favorable outcomes. This study reports the survival and safety outcomes of 531 patients treated with glass-based (90)Y microspheres at 8 institutions, making it the largest (90)Y study for patients with colorectal liver metastases.

Methods: Data were retrospectively compiled from 8 institutions for all (90)Y glass microsphere treatments for colorectal liver metastases. Exposure to chemotherapeutic or biologic agents, prior liver therapies, biochemical parameters before and after treatment, radiation dosimetry, and complications were recorded. Uni- and multivariate analyses for predictors of survival were performed. Survival outcomes and clinical or biochemical adverse events were recorded.

Results: In total, 531 patients received (90)Y radioembolization for colorectal liver metastases. The most common clinical adverse events were fatigue (55%), abdominal pain (34%), and nausea (19%). Grade 3 or 4 hyperbilirubinemia occurred in 13% of patients at any time. The median overall survival from the first (90)Y treatment was 10.6 mo (95% confidence interval, 8.8-12.4). Performance status, no more than 25% tumor burden, no extrahepatic metastases, albumin greater than 3 g/dL, and receipt of no more than 2 chemotherapeutic agents independently predicted better survival outcomes.

Conclusion: This multiinstitutional review of a large cohort of patients with colorectal liver metastases treated with (90)Y radioembolization using glass microspheres has demonstrated promising survival outcomes with low toxicity and low side effects. The outcomes were reproducible and consistent with prior reports of radioembolization.
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http://dx.doi.org/10.2967/jnumed.115.166082DOI Listing
May 2016

Comparative Effectiveness of Hepatic Artery Based Therapies for Unresectable Colorectal Liver Metastases: A Meta-Analysis.

PLoS One 2015 8;10(10):e0139940. Epub 2015 Oct 8.

Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America.

Background: Patients with unresectable Colorectal Liver Metastases (CRLM) are increasingly being managed using Hepatic Artery Based Therapies (HAT), including Hepatic Arterial Infusion (HAI), Radioembolization (RE), and Transcatheter Arterial Chemoembolization (TACE). Limited data is available on the comparative effectiveness of these options. We hypothesized that outcomes in terms of survival and toxicity were equivalent across the three strategies.

Methods: A meta-analysis was performed using a prospectively registered search strategy at PROSPERO (CRD42013003861) that utilized studies from PubMed (2003-2013). Primary outcome was median overall survival (OS). Secondary outcomes were treatment toxicity, tumor response, and conversion of the tumor to resectable. Additional covariates included prior or concurrent systemic therapy.

Results: Of 491 studies screened, 90 were selected for analyses-52 (n = 3,000 patients) HAI, 24 (n = 1,268) RE, 14 (n = 1,038) TACE. The median OS (95% CI) for patients receiving HAT in the first-line were RE 29.4 vs. HAI 21.4 vs. TACE 15.2 months (p = 0.97, 0.69 respectively). For patients failing at least one line of prior systemic therapy, the survival outcomes were TACE 21.3 (20.6-22.4) months vs. HAI 13.2 (12.2-14.2) months vs. RE 10.7 (9.5-12.0). Grade 3-4 toxicity for HAT alone was 40% in the HAI group, 19% in the RE group, and 18% in the TACE groups, which was increased with the addition of systemic chemotherapy. Level 1 evidence was available in 5 studies for HAI, 2 studies for RE and 1 for TACE.

Conclusion: HAI, RE, and TACE are equally effective in patients with unresectable CRLM with marginal differences in survival.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0139940PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4598149PMC
May 2016

Safety and efficacy of transarterial chemoembolization in patients with transjugular intrahepatic portosystemic shunts.

HPB (Oxford) 2015 Aug;17(8):707-12

Division of Vascular and Interventional Radiology, Medical College of Wisconsin, Milwaukee, WI, USA.

Background: Transarterial chemoembolization (TACE) for the treatment of hepatocellular carcinoma (HCC) is an important option as the majority of patients present with advanced disease. Data regarding treatment outcomes in patients who have undergone transjugular intrahepatic portosystemic shunts (TIPS) are limited. The present study seeks to evaluate the safety and efficacy of TACE in HCC patients with a TIPS.

Methods: A retrospective review identifying patients with HCC and concomitant TIPS who were treated with TACE was performed.

Results: From 1999 to 2014, 16 patients with HCC underwent a total of 27 TACE procedures; eight patients required multiple treatments. The median patient age at the time of the initial TACE was 60.5 years [interquartile range (IQR) : 52.5-67.5] with the majority being male (n = 12, 75%) and Childs-Pugh Class B (n = 12, 75%). At 6 weeks after TACE, 56.3% of patients achieved an objective response rate (complete and partial response) by mRECIST criteria. Clavien Grade 3 or higher complications occurred in 11.1% of TACE procedures. There were no peri-procedural deaths. The median progression-free (PFS) and overall survival (OS) were 9 and 22 months, respectively, when censored for liver transplantation (median follow-up: 11.5 months).

Conclusion: TACE is an effective treatment strategy for HCC in TIPS patients; albeit may be associated with higher complication rates.
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http://dx.doi.org/10.1111/hpb.12433DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4527856PMC
August 2015

Randomized controlled trial of irinotecan drug-eluting beads with simultaneous FOLFOX and bevacizumab for patients with unresectable colorectal liver-limited metastasis.

Cancer 2015 Oct 6;121(20):3649-58. Epub 2015 Jul 6.

Siteman Cancer Center, Washington University in Saint Louis/Barnes-Jewish Hospital, Saint Louis, Missouri.

Background: Reports have demonstrated the superior activity of combining both irinotecan and oxaliplatin (FOLFOXIRI) therapy. An option for gaining similar benefits with less toxicity would be the administration of irinotecan through a hepatic artery approach. The aim of this study was to assess the response and adverse event rates for irinotecan drug-eluting beads (DEBIRI) with folinic acid, 5-fluorouracil, and oxaliplatin (FOLFOX) and bevacizumab as a first-line treatment for unresectable colorectal liver metastasis.

Methods: Patients with colorectal liver metastases were randomly assigned to modified FOLFOX (mFOLFOX) and bevacizumab or mFOLFOX6, bevacizumab, and DEBIRI (FOLFOX-DEBIRI). The primary endpoint was the response rate. The secondary endpoints were adverse events, the rate of conversion to resection, and progression-free survival.

Results: The intention-to-treat population comprised 70 patients: 10 patients in the pilot and then 30 patients randomly assigned to the FOLFOX-DEBIRI arm and 30 patients randomly assigned to the FOLFOX/bevacizumab arm. The 2 groups were similar with respect to the extent of liver involvement (30% vs 30%), but a greater percentage of patients in the FOLFOX-DEBIRI arm had an Eastern Cooperative Oncology Group performance status of 1 or 2 (57% vs 31%) and extrahepatic disease (56% vs 32%, P = .02). The median numbers of chemotherapy cycles were similar (10 vs 9), and there were similar rates of grade 3/4 adverse events (54% for the FOLFOX-DEBIRI group vs 46% for the FOLFOX/bevacizumab group). The overall response rate was significantly greater in the FOLFOX-DEBIRI arm versus the FOLFOX/bevacizumab arm at 2 (78% vs 54%, P = .02), 4 (95% vs 70%, P = .03), and 6 months (76% vs 60%, P = .05). There was significantly more downsizing to resection in the FOLFOX-DEBIRI arm versus the FOLFOX/bevacizumab arm (35% vs 16%, P = .05), and there was improved median progression-free survival (15.3 vs 7.6 months).

Conclusions: The simultaneous administration of mFOLFOX6 (with or without bevacizumab) and DEBIRI through the hepatic artery (FOLFOX-DEBIRI) is safe and does not cause treatment delays or increase the systemic toxicity of chemotherapy. This strategy leads to improved overall response rates, improved hepatic progression-free survival, and more durable overall progression-free survival in patients downsized to resection.
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http://dx.doi.org/10.1002/cncr.29534DOI Listing
October 2015

Radiofrequency ablation of stage IA non-small cell lung cancer in medically inoperable patients: Results from the American College of Surgeons Oncology Group Z4033 (Alliance) trial.

Cancer 2015 Oct 19;121(19):3491-8. Epub 2015 Jun 19.

Vanderbilt University Medical Center, Vanderbilt Clinic, Nashville, Tennessee.

Background: This study evaluated the 2-year overall survival rate, adverse event rate, local control rate, and impact on pulmonary function tests for medically inoperable patients with stage IA non-small cell lung cancer (NSCLC) undergoing computed tomography (CT)-guided radiofrequency ablation (RFA) in a prospective, multicenter trial.

Methods: Fifty-four patients (25 men and 29 women) with a median age of 76 years (range, 60-89 years) were enrolled from 16 US centers; 51 patients were eligible for evaluation (they had biopsy-proven stage IA NSCLC and were deemed medically inoperable by a board-certified thoracic surgeon). Pulmonary function tests were performed within the 60 days before RFA and 3 and 24 months after RFA. Adverse events were recorded and categorized. Patients were followed with CT and fludeoxyglucose positron emission tomography. Local control rate and recurrence patterns were analyzed.

Results: The overall survival rate was 86.3% at 1 year and 69.8% at 2 years. The local tumor recurrence-free rate was 68.9% at 1 year and 59.8% at 2 years and was worse for tumors > 2 cm. In the 19 patients with local recurrence, 11 were re-treated with RFA, 9 underwent radiation, and 3 underwent chemotherapy. There were 21 grade 3 adverse events, 2 grade 4 adverse events, and 1 grade 5 adverse event in 12 patients within the first 90 days after RFA. None of the grade 4 or 5 adverse events were attributable to RFA. There was no significant change in the forced expiratory volume in the first second of expiration or the diffusing capacity of lung for carbon monoxide after RFA. A tumor size less than 2.0 cm and a performance status of 0 or 1 were associated with statistically significant improved survival of 83% and 78%, respectively, at 2 years.

Conclusions: RFA is a single, minimally invasive procedure that is well tolerated in medically inoperable patients, does not adversely affect pulmonary function tests, and provides a 2-year overall survival rate that is comparable to the rate reported after stereotactic body radiotherapy in similar patients.
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http://dx.doi.org/10.1002/cncr.29507DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4578219PMC
October 2015

A single-center experience in capturing inpatient evaluation and management for an IR practice.

J Vasc Interv Radiol 2015 Jul 27;26(7):958-62. Epub 2015 Apr 27.

Department of Radiology, Division of Vascular and Interventional Radiology, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226.

Purpose: To demonstrate that interventional radiologists can capture work relative value units (wRVUs) for the work that is already being performed providing evaluation and management (E&M) clinical services.

Materials And Methods: A team approach was implemented to optimize revenue capture for inpatient E&M. Structured templates were created for inpatient documentation to ensure that maximum wRVUs were captured. Inpatient billing was audited from fiscal year 2011 (1 year before meeting and structured template creation) through fiscal year 2014. Specifically, data were collected on total charges, collections, wRVUs and total number of inpatient E&M encounters, and the level of the billed encounter.

Results: Retrospective annual audits revealed that overall inpatient E&M billing charges increased by 722%, whereas collections increased by 831% from 2011 to 2014. The wRVUs increased in 2011 from 181.74 to 1,396.9 (669% increase) in 2014, and the number of inpatient E&M encounters billed increased from 130 to 693 (433% increase) over that same time period. Lower level billing (level I) declined from 30% to 19%, and complex billing levels (level II or higher) increased from 70% to 81%.

Conclusions: By implementing a systems approach to revenue management, which includes physician and billing staff meetings and the use of structured templates, billing capture from inpatient E&M services can be improved.
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http://dx.doi.org/10.1016/j.jvir.2015.03.013DOI Listing
July 2015

Microwave ablation for hepatic malignancies: a call for standard reporting and outcomes.

Am J Surg 2014 Aug 12;208(2):284-94. Epub 2014 Apr 12.

Department of Surgery, University of Louisville, Louisville, KY, USA. Electronic address:

Background: Clinical standards of reporting microwave ablation outcomes have not been defined with regard to ablation success, 90-day morbidity, local recurrence after ablation, and nonablation hepatic recurrence. We propose recommendations for microwave ablation reporting and quality standards.

Methods: Literature review of clinical studies focusing on microwave ablation of primary and metastatic hepatic tumors was reported.

Results: Ablation success remains the highest quality reporting standard with variations in nomenclature, but with a universal agreement of complete destruction of the target lesion within 1 month after initial microwave ablation. Local recurrence after ablation remains highly variable, with reports as low as 2.2% to as high as 22%; standards lack a common, clearly defined distance from the initial target ablated lesion and the requirement that the target lesion be defined as an ablation success before it can be called a recurrence. Nonablation hepatic recurrence, nonhepatic recurrence, and 90-day morbidity and mortality remain limited in the current literature.

Conclusions: Standardization of hepatic microwave ablation reporting standards are proposed. Current reporting standards in microwave ablation of hepatic malignancies are suboptimal and lack standardization for comparison across institutions.
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http://dx.doi.org/10.1016/j.amjsurg.2014.02.002DOI Listing
August 2014

Percutaneous in utero thoracoamniotic shunt creation for fetal thoracic abnormalities leading to nonimmune hydrops.

J Vasc Interv Radiol 2014 Jun 1;25(6):889-94. Epub 2014 Apr 1.

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Oregon Health and Science University, Portland, Oregon; Department of Obstetrics and Gynecology, Marshfield Clinic, Marshfield, Wisconsin.

Purpose: To describe a transabdominal, transuterine Seldinger-based percutaneous approach to create a shunt for treatment of fetal thoracic abnormalities.

Materials And Methods: Five fetuses presented with nonimmune fetal hydrops secondary to fetal thoracic abnormalities causing severe mass effect. Under direct ultrasound guidance, an 18-gauge needle was used to access the malformation. Through a peel-away sheath, a customized pediatric transplant 4.5-F double J ureteral stent was advanced; the leading loop was placed in the fetal thorax, and the trailing end was left outside the fetal thorax within the amniotic cavity.

Results: Seven thoracoamniotic shunts were successfully placed in five fetuses; one shunt was immediately replaced because of displacement during the procedure, and another shunt was not functioning at follow-up requiring insertion of a second shunt. All fetuses had successful decompression of the thoracic malformation, allowing lung reexpansion and resolution of hydrops. Three of five mothers had meaningful (> 7 d) prolongation of their pregnancies. All pregnancies were maintained to > 30 weeks (range, 30 weeks 1 d-37 weeks 2 d). There were no maternal complications.

Conclusions: A Seldinger-based percutaneous approach to draining fetal thoracic abnormalities is feasible and can allow for prolongation of pregnancy and antenatal lung development and ultimately result in fetal survival.
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http://dx.doi.org/10.1016/j.jvir.2014.02.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4671206PMC
June 2014

Transarterial treatment of colorectal cancer liver metastases with irinotecan-loaded drug-eluting beads: technical recommendations.

J Vasc Interv Radiol 2014 Mar;25(3):365-9

Division of Surgical Oncology, University of Louisville, Louisville, Kentucky.

Transcatheter hepatic arterial administration of irinotecan-loaded drug-eluting beads (DEBIRI) is used to treat liver-only or liver-dominant metastatic disease from colorectal cancer (CRC). Eligibility for DEBIRI should be established in each individual patient by a multidisciplinary team based on comprehensive clinical, imaging, and laboratory assessment. Standardization of DEBIRI technique and protocols would be expected to lead to improved efficacy and safety. The present article provides a set of technical recommendations for the use of DEBIRI in the treatment of hepatic CRC metastases.
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http://dx.doi.org/10.1016/j.jvir.2013.11.027DOI Listing
March 2014

Transarterial therapies for the treatment of intrahepatic cholangiocarcinoma.

Semin Intervent Radiol 2013 Mar;30(1):21-7

Division of Interventional Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin.

Cholangiocarcinoma, whether arising from the intrahepatic or extrahepatic biliary system, is a rare but devastating malignancy. Prognosis is poor, with 5-year overall survival <5% including patients undergoing surgery. Resection is the only curative treatment; however, only ∼30% of patients present at a resectable stage, and intrahepatic recurrence is common even after complete resection. This article discusses the current role of transarterial therapies in the treatment of intrahepatic cholangiocarcinoma.
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http://dx.doi.org/10.1055/s-0033-1333650DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700793PMC
March 2013

Endovascular management of a traumatic renal-caval arteriovenous fistula in a pediatric patient.

Ann Vasc Surg 2014 May 19;28(4):1031.e1-5. Epub 2013 Dec 19.

Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, WI. Electronic address:

Traumatic renal arteriovenous fistula involving the inferior vena cava (IVC) are exceptionally rare, but if left untreated can have devastating clinical consequences, including development of renovascular hypertension, cardiomegaly, and congestive heart failure. We report a rare, pediatric case of a renal-caval arteriovenous fistula that developed after a gunshot wound to the abdomen and its subsequent treatment with endovascular means. We review our case and the world literature on the evaluation and management of trauma-related renal-caval arteriovenous fistulae.
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http://dx.doi.org/10.1016/j.avsg.2013.04.028DOI Listing
May 2014

Neutrophil-to-lymphocyte ratio as a predictor of outcomes for patients with hepatocellular carcinoma: a Western perspective.

J Surg Oncol 2014 Feb 4;109(2):95-7. Epub 2013 Oct 4.

Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin.

Background And Objectives: Neutrophil-to-lymphocyte ratio (NLR) is simple, inexpensive, and has been proposed to be predictive in hepatocellular carcinoma (HCC) in Europe and Asia. We aimed to evaluate whether NLR at presentation in a Western center provides any prognostic value compared to other common prognostic scores.

Methods: NLR was calculated for 75 consecutive patients at presentation with HCC and regression models were used to analyze its value for predicting treatment strategy and short-term survival with Child-Pugh and Model for End Stage Liver Disease (MELD).

Results: NLR was not predictive of future treatment regimens with hepatectomy, liver transplant, or transarterial chemoembolization (TACE; odds ratio [OR]: 0.85, 95% confidence interval [CI]: 0.71-1.02, P = 0.079) as compared the predictive value of MELD (OR: 0.81, CI: 0.72-0.93, P = 0.002) or Child-Pugh (OR: 0.48, CI: 0.34-0.69, P < 0.001). Adding additional adjustment for treatment, NLR did not correlate with short-term overall survival (hazard ratio [HR]: 1.09, CI: 0.95-1.24, P = 0.227). MELD also did not correlate with overall survival (HR: 1.04, CI: 0.96-1.13, P = 0.357) whereas Child-Pugh (HR: 1.56, CI: 1.10-2.19, P = 0.011) was predictive.

Conclusions: This study does not support the prognostic value of NLR to guide therapy for HCC in a Western center, whereas MELD and Child-Pugh score were more predictive.
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http://dx.doi.org/10.1002/jso.23448DOI Listing
February 2014

Microwave ablation for hepatic malignancies: a multiinstitutional analysis.

Ann Surg 2014 Jun;259(6):1195-200

*Department of Surgery, Medical College of Wisconsin; Milwaukee, WI †Department of General Surgery, Carolinas Medical Center; Charlotte, NC ‡Division of Surgical Oncology, Ohio State University Wexner Medical Center; Columbus, OH §Department of Radiology, Ohio State University Wexner Medical Center; Columbus, OH ¶Department of Surgery, University of Louisville; Louisville, KY ∥Department of Radiology, Medical College of Wisconsin; Milwaukee, WI.

Objective: This study hypothesized that tumor size, number of tumors, surgical approach, and tumor histology significantly affected microwave ablation (MWA) success and recurrence-free survival.

Background: Although many hepatobiliary centers have adopted MWA, the factors that influence local control are not well described.

Methods: 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.

Results: 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).

Conclusions: 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.
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http://dx.doi.org/10.1097/SLA.0000000000000234DOI Listing
June 2014

Recurrence after microwave ablation of liver malignancies: a single institution experience.

HPB (Oxford) 2013 May 11;15(5):365-71. Epub 2012 Oct 11.

Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA.

Background: Microwave ablation (MWA) is increasingly used to achieve local control for liver tumours. This study sought to examine a monocentric experience with MWA, with a primary hypothesis that primary tumour histology was a significant predictor of early recurrence.

Methods: Retrospective single-institution review identified consecutive patients with liver tumours treated by MWA. Cox proportional hazards models assessed significance of prognostic variables.

Results: Seventy-two patients (43 female, 60%) underwent 83 MWA procedures for 157 tumours. Tumour histologies included hepatocellular cancer (10 operations), colorectal metastases (39), metastatic carcinoid (20) and other (14). The median tumour size was 2.0 cm. A concomitant liver resection was performed in 50 cases (60%). Crude peri-operative morbidity and mortality rates were 16% and 1%, respectively. The median follow-up was 16 months. Ablations were complete for 149 out of 157 tumours (95%). The median overall and recurrence-free survivals were 36 and 18 months, respectively. There was no difference in time to recurrence between the primary tumour types. In multivariable models, recurrence-free survival was independently associated with the use of neoadjuvant [hazard ratio (HR): 2.90, 95% confidence interval (CI): 1.09-7.76, P = 0.034] and adjuvant chemotherapy (HR: 0.36, 95% CI: 0.15-0.82, P = 0.016).

Conclusions: MWA is a safe and feasible approach for local control of liver tumours. While chemotherapy administration was associated with time to recurrence after MWA, larger studies are needed to corroborate these findings.
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http://dx.doi.org/10.1111/j.1477-2574.2012.00585.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3633038PMC
May 2013

Radiofrequency ablation of medically inoperable stage IA non-small cell lung cancer: are early posttreatment PET findings predictive of treatment outcome?

AJR Am J Roentgenol 2011 Aug;197(2):334-40

Department of Diagnostic Imaging, Warren Alpert Medical School, Rhode Island Hospital, 593 Eddy St, Providence, RI 02903, USA.

Objective: The purpose of this study was to evaluate initial experience with (18)F-FDG PET/CT after pulmonary radiofrequency ablation of stage IA non-small cell lung cancer to determine whether treatment success or residual disease can be predicted with early postablation PET.

Subjects And Methods: Thirty patients with medically inoperable stage IA non-small cell lung cancer (12 men, 18 women; median age, 76 years; range, 60-87 years) underwent outpatient CT-guided radiofrequency ablation over a 33-month period. Mean tumor size was 2.0 cm (range, 1.3-2.9 cm). PET/CT was performed within 60 days before radiofrequency ablation (RFA), within 4 days after RFA, and 6 months after RFA. Metabolic response was categorized as complete response or partial or no response at early post-RFA PET/CT and complete response, partial response, or progressive metabolic disease at 6-month post-RFA PET/CT and was compared with the 1-year clinical event rate (death, disease progression at contrast-enhanced CT, or repeat ablation).

Results: Early PET/CT images, obtained within 4 days of RFA, were evaluable for 26 patients (23 at 6 months). Patients with a complete metabolic response at early PET/CT had a 1-year event rate of 43%, whereas those with partial or no response or disease progression had a 1-year event rate of 67% (p = 0.27). Patients with a complete metabolic response at 6-month PET/CT had a 1-year event rate of 0%. Those with a partial response and those with disease progression had an overall event rate of 75% (p = 0.001).

Conclusion: Early post-RFA PET/CT is not necessary and 6-month post-RFA PET/CT findings correlate better with clinical outcome at 1 year.
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http://dx.doi.org/10.2214/AJR.10.6108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4063295PMC
August 2011

Longitudinal quality of life assessment of patients with hepatocellular carcinoma after primary transarterial chemoembolization.

J Vasc Interv Radiol 2010 Jul 4;21(7):1024-30. Epub 2010 Jun 4.

Department of Radiology, University of Missouri Kansas City School of Medicine, Saint Luke's Hospital, 4401 Wornall Rd, Kansas City, MO 64111, USA.

Purpose: To determine the effects of primary chemoembolization on the health-related quality of life (HRQOL) of patients with hepatocellular carcinoma (HCC).

Materials And Methods: Single-center prospective data collection with longitudinal analysis of HRQOL scores obtained via the Short Form-36 (SF-36) assessment tool was performed before and during serial chemoembolization procedures in 73 patients with HCC. Baseline HRQOL scores were evaluated for significant (P < .05) change within the total patient population during 4, 8, and 12 months of treatment, and separately within a subset of 23 patients who underwent three or more chemoembolization procedures.

Results: Patients had decreased pretreatment baseline scores within all eight scales of the SF-36 compared with healthy age-adjusted norms. Within the total population, mental health scores improved after 4 months of chemoembolization (rate of change, 5.6; P = .05; n = 48), but no significant change was present at 8 or 12 months. Subset patients experienced improvements of mental health scores after the first (score change, 13; P = .008; n = 21) and second procedures (score change, 12.2; P = .002; n = 23) and improvements of bodily pain scores (score change, 9.9; P = .047; n = 21) after the initial procedure. Vitality scores worsened (score change, -7.8; P = .044; n = 21) in the subset after the first chemoembolization.

Conclusions: Patients with HCC are likely to perceive improved mental health during the first 4 months of primary treatment with chemoembolization. In addition, if patients ultimately undergo more than two procedures, they are likely to perceive improved mental health during the first two sessions, with decreased bodily pain during the initial session. Patient-perceived vitality will likely worsen after the initial procedure.
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http://dx.doi.org/10.1016/j.jvir.2010.03.005DOI Listing
July 2010

Technical success and safety of retrieval of the G2 filter in a prospective, multicenter study.

J Vasc Interv Radiol 2009 Nov;20(11):1449-53

Department of Radiology, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA.

Purpose: To assess the technical success and safety for retrieval of the G2 filter.

Materials And Methods: The authors performed a prospective, multicenter study of 100 patients with temporary indication for caval interruption. Patients were enrolled consecutively between December 2005 and July 2006. There were 67 men and 33 women with a mean age of 52.1 years (range, 19-82 years). Indications for filter placement were trauma (n = 56), perioperative risk (n = 16), and medical indications (n = 28). Forty-two patients had venous thromboembolism at filter placement. Fifty-eight filters were placed prophylactically.

Results: Retrieval was attempted in 61 patients. Fifty-eight of the 61 filters (95%) were successfully retrieved after a mean dwell time of 140 days (range, 5-300 days). In all failed retrievals, the filter tip was against the caval wall. There was no difference in dwell times between successful and unsuccessful retrievals. Although there were no cases of cranial migration, caudal migrations were observed in 12% of cases (10 of 85 patients with a complete data set). Other device-related complications included filter fracture (1/85, 1.2%), filter tilt of more than 15 degrees (15/85, 18%), and leg penetration (16/61, 26%). The recurrent pulmonary embolism (PE) rate was 2%, with no PE in the 30-day period after filter retrieval.

Conclusions: Retrieval of the Recovery G2 filter was safe and successful in most patients. Caudal migration was observed as an unexpected phenomenon.
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http://dx.doi.org/10.1016/j.jvir.2009.08.007DOI Listing
November 2009

Transcatheter therapy for hepatic malignancy: standardization of terminology and reporting criteria.

J Vasc Interv Radiol 2009 Jul;20(7 Suppl):S425-34

Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA.

The field of interventional oncology includes tumor ablation as well as the use of transcatheter therapies such as embolization, chemoembolization, and radioembolization. Terminology and reporting standards for tumor ablation have been developed. The development of standardization of terminology and reporting criteria for transcatheter therapies should provide a similar framework to facilitate the clearest communication among investigators and provide the greatest flexibility in comparing established and emerging technologies. An appropriate vehicle for reporting the various aspects of catheter directed therapy is outlined, including classification of therapies and procedure terms, appropriate descriptors of imaging guidance, and terminology to define imaging and pathologic findings. Methods for standardizing the reporting of outcomes toxicities, complications, and other important aspects that require attention when reporting clinical results are addressed. It is the intention of the group that adherence to the recommendations will facilitate achievement of the group's main objective: improved precision and communication for reporting the various aspects of transcatheter management of hepatic malignancy that will translate to more accurate comparison of technologies and results and, ultimately, to improved patient outcomes.
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http://dx.doi.org/10.1016/j.jvir.2009.04.021DOI Listing
July 2009

Resonance metallic ureteral stents do not successfully treat ureteroenteric strictures.

J Endourol 2009 Jul;23(7):1199-201; discussion 1202

Department of Urology, Medical College of Wisconsin, Milwaukee, WI 53226, USA.

Purpose: To report the outcomes of patients with ureteroenteric strictures after ileal conduit urinary diversion that were managed with Resonance metallic ureteral stents.

Patients And Methods: Ten ureteroenteric strictures in patients with ileal conduits that were managed with metallic ureteral stenting were retrospectively identified. Charts were examined for patient age, anastomosis type, stricture cause, stricture laterality, complications, and follow-up.

Results: Nine of 10 (90%) cases resulted in distal stent migration. Mean time to stent migration was 21 days (range 3-60 d).

Conclusions: Placement of Resonance metallic stents in patients with ileal conduits is ineffective for management of ureteroenteric strictures because of the high rate of distal migration.
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http://dx.doi.org/10.1089/end.2008.0454DOI Listing
July 2009

Safety and effectiveness of repeat arterial closure using the AngioSeal device in patients with hepatic malignancy.

J Vasc Interv Radiol 2008 Dec 31;19(12):1704-8. Epub 2008 Oct 31.

Department of Radiology, Medical College of Wisconsin-Froedtert Memorial Lutheran Hospital, 9200 West Wisconsin Avenue, Room 2803, Milwaukee, WI 53226, USA.

Purpose: To retrospectively evaluate the safety and effectiveness of the use of the AngioSeal device for repeat arterial closure in patients with hepatic malignancy.

Materials And Methods: A retrospective analysis of patients with hepatic malignancy who had undergone repeated arterial closure with the AngioSeal device was performed. All charts for patients undergoing transarterial chemoembolization or TheraSphere radioembolization were reviewed for the method of hemostasis and the number of arterial closures. A total of 53 patients (58.5% men, 41.5% women; mean age, 58.7 years) had repeat AngioSeal arterial puncture closure after chemoembolization or TheraSphere treatment. Percutaneous closure of the common femoral artery with the AngioSeal device was performed in accordance with the manufacturer's recommendations. The patients were examined for complications on follow-up. Effectiveness was defined by the ability to obtain satisfactory hemostasis. Safety was assessed by the absence of groin complications and by vessel patency on follow-up angiograms of the puncture site obtained at subsequent liver-directed therapy sessions.

Results: Fifty-three patients in this study group had a total of 203 common femoral artery punctures. There were a total of 161 closures with the AngioSeal device (79.3%): 58 (36%) single closures and 103 (64.0%) repeat closures. Of the 161 attempts at AngioSeal closure, there was one closure failure in the single-puncture group, yielding a success rate of 98.3%; and one closure failure in the repeat-puncture group, yielding a success rate of 99%. In these two patients, hemostasis was achieved with traditional manual compression without the need for any other device, and no complications were noted. The overall success rate of AngioSeal device closure was 98.7%.

Conclusions: The repeat use of the AngioSeal closure device is safe and effective in patients with hepatic malignancy undergoing regional oncologic interventional procedures.
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http://dx.doi.org/10.1016/j.jvir.2008.09.003DOI Listing
December 2008

Treatment of diffuse large B-cell lymphoma of the liver with yttrium-90 microsphere embolization.

Nat Clin Pract Oncol 2008 Nov 16;5(11):677-81. Epub 2008 Sep 16.

Division of Neoplastic Diseases and Related Disorders, Medical College of Wisconsin, Milwaukee, WI 53226, USA.

Background: A 41-year-old male with a 4-year history of chronic hepatitis C presented with a 1-month history of abdominal pain, fatigue, weight loss, and night sweats.

Investigations: Laboratory examinations, chest, abdomen, and pelvic CT scans, PET-CT scans, ultrasound-guided needle biopsies of liver lesions, bone-marrow biopsy, flow cytometry, and immunohistochemical staining for B-cell markers including CD20.

Diagnosis: Chemoresistant diffuse large B-cell lymphoma, with gradual loss of CD20 antigen expression.

Management: Embolization of hepatic tumors using yttrium-90 microspheres (Therasphere, Theragenics Corporation, Buford, GA).
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http://dx.doi.org/10.1038/ncponc1227DOI Listing
November 2008
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