Comparison of α-Fetoprotein Criteria and Modified Response Evaluation Criteria in Solid Tumors for the Prediction of Overall Survival of Patients with Hepatocellular Carcinoma after Transarterial Chemoembolization 

Summary

The optimal approach for monitoring disease status following transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) remains uncertain. While multiple imaging-based metrics have been described for this purpose, their performance relative to clinical parameters such as α-fetoprotein (AFP) remains largely unknown. In this study, investigators evaluated 147 patients with unresectable HCC and elevated AFP to determine the utility of AFP criteria for prediction of treatment outcomes, and to compare this method with the modified Response Evaluation Criteria In Solid Tumors (mRECIST) system. Patients were predominantly male (n=142; 96.6%) with Barcelona Clinic Liver Cancer stage C disease (n=106; 72.1%). Results demonstrated only moderate agreement between AFP criteria and mRECIST (κ= 0.549), with the majority of discrepancies observed for the complete response (CR) and progressive disease (PD) categories. While both metrics were predictive of patient outcomes, median overall survival (OS) was significantly lower among patients with AFP-based CR when compared with CR by mRECIST (36.0 mo. vs. 56.0 mo.; p<.001). Conversely, among patients with PD by mRECIST, those with disease control by AFP criteria showed significantly greater OS (9.0 mo. vs 6.0 mo.; p<.001). The authors conclude that both systems provide clinically-relevant information for monitoring disease status following TACE, with mRECIST showing overall greater predictive performance.



Figure 2. Kaplan–Meier curves showing OS for CR, PR, SD, and PD based on AFP criteria and mRECIST. (a) The median OS times were 36.0 months, 17.0 months, 8.0 months, and 6.0 months for AFP-based CR, PR, SD, and PD, respectively (P < .001). (b) The median OS times were 58.0 months, 18.0 months, 8.0 months, and 6.0 months for radiologic CR, PD, SD, and PD, respectively (P < .001).

Commentary

To treat or not to treat? The decision to pursue repeat intervention following loco-regional therapy represents a critical and enduring challenge for interventional radiologists providing care to HCC patients. Many caveats exist with regard to the use of both imaging-based and clinically-based metrics for the assessment of response to treatment. In the present investigation, researchers from China retrospectively evaluated the use of a stratified serum AFP measurement system to categorize treatment responses and predict outcomes following TACE. The physiologic basis for such a system is intuitive and attractive; among HCC tumors with elevated AFP, tumor marker normalization may reflect favorable response to therapy regardless of post-treatment imaging findings, such as lesion size or enhancement pattern. Results in practice, however, appeared more nuanced. Though overall survival was indeed predicted by changes in AFP, there were a number of important disagreements with the more commonly utilized mRECIST system, which was associated with nearly two additional years of overall survival among patients categorized as having achieved complete response. These data emphasize the complexity and limitations of single-metric criteria for evaluating HCC treatment response and suggest that more a comprehensive approach incorporating both clinical and imaging parameters may be required to optimally stratify patients and inform subsequent management decisions. Additional research in this domain is clearly warranted.

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Zhang Y-Q, Jiang L-J, Wen J, et al. Comparison of α-Fetoprotein Criteria and Modified Response Evaluation Criteria in Solid Tumors for the Prediction of Overall Survival of Patients with Hepatocellular Carcinoma after Transarterial Chemoembolization. J Vasc Interv Radiol. 2018;29(12):1654-1661.

Post Author:
Aaron W.P. Maxwell, M.D.
Radiology Resident, PGY-5
Department of Diagnostic Imaging
The Warren Alpert Medical School at Brown University
@DoctorAWPM

The Feasibility of Using Volumetric Phase-Contrast MR Imaging (4D Flow) to Assess for Transjugular Intrahepatic Portosystemic Shunt Dysfunction

The Feasibility of Using Volumetric Phase-Contrast MR Imaging (4D Flow) to Assess for Transjugular Intrahepatic Portosystemic Shunt Dysfunction 

Summary

Doppler US evaluation of transjugular intrahepatic portosystemic shunts (TIPS) carries a high false positive rate, but there is no other currently accepted technique for assessing for TIPS dysfunction.
The authors performed a feasibility study to determine if phase-contrast magnetic resonance (MR) angiography (4D flow) could identify the absence or presence of TIPS stenosis or occlusion. They evaluated 23 patient encounters, 16 of which underwent successful segmentation and analysis of the TIPS stent and portal vein. When clinically indicated, venography was performed. In patients who did not undergo venography, clinical follow-up of at least 6 months was used to exclude stenosis. Time-resolved particle tracings were created to model flow through the stent and allow for qualitative assessment of stenosis. Velocities were also measured using 4D flow. Clinical follow-up was obtained by chart review to determine if symptoms returned, repeat intervention was required, or clinical suspicion of stenosis emerged. Lack of recurrent symptoms or need for intervention was recorded at least 6 months after the MR examination to serve as a reference standard in patients who did not undergo venography. In patient encounters with technically successful 4D flow MR imaging, the rate of dysfunction was 3 of 16 patients (19%). The 3 patients with venography-confirmed stenosis had both abnormal velocities on quantitative and qualitative 4D flow MR imaging. False-positive 4D flow MR imaging results occurred in 6 cases but only if the qualitative and quantitative results were interpreted in isolation. There were no false-positive results if criteria for dysfunction included both abnormal qualitative and quantitative results and there were no false negative cases.



Figure 2. Venography-proven TIPS dysfunction. The measured pressure gradient was 18 mmHg. (a) Still image from particle tracing cine imaging of TIPS stent showing the entire stent (double arrow), inferior vena cava(narrow arrow), portal vein (wide arrow), and elevated velocities with aliasing at the distal TIPS stent (arrowhead). (b) Spectral wave Doppler US interrogation of the distal TIPS showing normal velocities. (c)Grayscale and color Doppler US images with inadequately visualized distal TIPS. (d) Digital subtraction venography showing distal TIPS stenosis (arrowhead)

Commentary

The concordance between TIPS Doppler US and venography is relatively poor. Despite this, performing US for TIPS surveillance is the current standard. This study looks at the feasibility of performing phase-contrast MR imaging for evaluation of TIPS. The authors conclude that this technique can detect patency, stenosis, and occlusion of TIPS. Many patient and technical factors must be considered to optimize the MR imaging of TIPS and prevent failures and the authors nicely describe their imaging protocol. A small number of patients were studied and a randomized controlled trial is still required to determine if volumetric phase-contrast MR imaging will prove to be superior to Doppler US, but the results of this feasibility study suggest MR may be a promising alternative modality for TIPS surveillance.

Click here for abstract

Owen, Joseph, et al. The Feasibility of Using Volumetric Phase-Contrast MR Imaging (4D Flow) to Assess for Transjugular Intrahepatic Portosystemic Shunt Dysfunction. Journal of Vascular and Interventional Radiology. December, 2018. Volume 29, Issue 12, Pages 1717–1724.

Post Author
Zagum Bhatti, MD
Assistant Professor
Department of Radiology, Interventional Radiology Division
University of Texas Health Science Center at Houston, Houston, TX
@ZagumBhatti

Is Long-Term Anticoagulation Required after Stent Placement for Benign Superior Vena Cava Syndrome?

Summary

This is a retrospective review of all de novo SVC stents placed at a single institution over a 9 year period for benign SVC syndrome. In total, 58 patients were identified with benign SVC syndrome, the majority of which were SIR TCVO Type 4 (SVC) obstructions (N = 53). The remaining were Type 3 (bilateral brachiocephalic veins) obstructions. All patients underwent stenting with a variety of stents, frequency of stent selection not described. Technical success was 100% with two major complications, both of which were pericardial hemorrhage (no procedural mortality).

Following stent placement, anticoagulation was then administered at the discretion of the treatment team. 19/58 patients were anticoagulated due to other pre-existing conditions. 17/58 were anticoagulated due to stent placement; the remaining 22/58 were not anticoagulated. The authors noted no difference in these groups in terms of symptom recurrence or percent stenosis on follow-up imaging. It should be noted that overall, 50% of patients required re-intervention, one of whom eventually underwent surgical bypass.

Commentary

This study is useful in showing the clinical success of SVC stents in the setting of benign SVC syndrome. It also demonstrated that while successful, up to 50% of patients will require re-intervention, when driven by clinical symptomatic parameters. A well-known and observed major complication of SVC occlusions, pericardial hemorrhage, is demonstrated here, well-managed with either a covered stent or a pericardial drain.

The authors conclude that stent placement for benign SVC syndrome may not require anticoagulation if confirmed on subsequent studies. Additional studies do seem needed, given the small sample size of this retrospective study. There is no discussion as to the power of this study, and in the figures, the confidence intervals suggest that a difference in measured outcomes may be present but not distinguishable, given the current study population.

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Haddad MM, Thompson SM, McPhail IR, et al. Is Long-Term Anticoagulation Required after Stent Placement for Benign Superior Vena Cava Syndrome? J Vasc Interv Radiol. 2018; 29(12): 1741-1747.

Post Author:
Daniel P. Sheeran, MD
Assistant Professor
Department of Radiology and Medical Imaging
Division of Vascular and Interventional Radiology
University of Virginia

Cost-Effectiveness of TIPS vs Large-Volume Paracentesis in Refractory Ascites: Results of a Markov Model Incorporating Individual Patient-Level Meta-Analysis and Nationally Representative Cost Data

Summary:

Refractory ascites is a common complication of decompensated cirrhosis which causes severe limitations to patient quality of life as well as extensive health care costs. The main therapeutic options are serial large volume paracentesis (LVP) and transjugular intrahepatic portosystemic shunt (TIPS) creation, each of which have their own set of risks and benefits. In this study, a decisional Markov model was developed to estimate payer cost and quality-adjusted life-years (QALY) with both of these treatment options using survival and symptomatology estimates from multiple prospective randomized clinical trials. Procedural and hospital cost values were derived from a national claims database and pharmaceutical costs from the 2015 Medicare Part D Prescriber Public Use Files. These costs were then inflated to 2017 US dollars with annual inflation rates for medical expenditures. Outcomes were measured in quality adjusted life years gained and an incremental cost-effectiveness ratio of each therapeutic strategy. LVP resulted in 1.72 QALYs gained at $41,391 and TIPS resulted in 2.76 QALYs gained at $100,538. The incremental cost-effectiveness ratio of TIPS vs LVP was $57,003/QALY. The cost effectiveness acceptability curve showed a 62% probability of TIPS being acceptable relative to LVP at a willingness to pay (WTP) ratio of $100,000/QALY. A threshold of 2-3 times the per capita annual income has been argued by the World Health Organization. This would imply a WTP ratio of $110,000-$160,000/QALY for the US. Using these parameters, TIPS would be considered a more cost-effective therapy for refractory ascites in decompensated cirrhosis for the United States. 

Figure 1: Markov model for different treatment strategies and associated outcomes. Various health utility values were given depending on the strength of an individual’s preferences for specific health outcomes 

Figure 2: Probability sensitivity analysis of cost effectiveness acceptability curve for willingness to pay ranging $0-$100,000. At $50,000-$55,000 the probability of cost effectiveness begins to trend in favor of TIPS. A 62% probability of TIPS being more cost effective is demonstrated at $100,000.

Commentary:

The global prevalence of cirrhosis has been estimated to effect up to 9.5% of the general population. Cirrhosis causes a significant mortality and morbidity which reduce patient’s quality of life and cost the United States approximately $1.4 billion annually (excluding hepatitis C virus treatment). With repeated large volume paracentesis and TIPS creations as the mainstays for therapeutic options, it is an important and relevant question as to which treatment is more appropriate. TIPS has been shown to achieve higher rates of ascites control but a greater incidence of encephalopathy than LVP. However, the initial creation is high risk and costly upfront. Whereas serial LVP costs and risks are low initially, they will continue to accrue as well as potentially have a less positive impact on quality of life. The study suggests TIPS should be considered more cost effective when high monetary value is placed on health improvements, while LVP may be more effective in countries with lower levels of health care resources.

Click here for abstract

Kwan, S. W., Allison, S. K., Gold, L. S., & Shin, D. S. (2018). Cost-Effectiveness of Transjugular Intrahepatic Portosystemic Shunt versus Large-Volume Paracentesis in Refractory Ascites: Results of a Markov Model Incorporating Individual Patient-Level Meta-Analysis and Nationally Representative Cost Data. Journal of Vascular and Interventional Radiology, 29(12), 1705-1712.

Post Author:
Bradley Unruh, MD PGY-3
Department of Radiology
Wake Forest Baptist Medical Center
@WakeForest_IR

High Epithelial Cell Adhesion Molecule–Positive Circulating Tumor Cell Count Predicts Poor Survival of Patients with Unresectable Hepatocellular Carcinoma Treated with Transcatheter Arterial Chemoembolization 

Summary

The detection of peripheral blood circulating tumor cells (CTCs) has been used to develop the association between recurrence and prognosis after surgical resection or liver transplantation in patients with hepatocellular carcinoma (HCC). Through a prospective analysis, the authors sought to assess the role of epithelial cell adhesion molecule (EpCAM)–positive CTC count in predicting survival outcomes of chemoembolization in patients with unresectable HCC. 89 patients with a pathologic or clinical diagnosis of HCC had peripheral blood samples analyzed through the CellSearch system for EpCAM positive CTCs 1-2 days prior to chemoembolization and were stratified into three groups for analysis (0-1 CTC, 2-5 CTCs, and ≥ 6 CTCs) based on the Cox proportional-hazards model. Chemoembolization was performed using oxaliplatin, pirarubicin, and fluorouridine; disease progression was evaluated per modified Response Evaluation Criteria In Solid Tumors as identified by 2 senior radiologists who were blinded to the clinical information.

After controlling for Child-Pugh class, ECOG status, presence of vascular invasion, number of tumors, tumor size, and AFP, the authors found that a CTC was an independent predictor of overall survival (OS) in patients with HCC treated with chemoembolization (P = .049). The risk of death in the high-level and moderate-level groups was 2.819 fold (P = .016) and 1.301 fold (P = .477) higher, respectively, than in the low-level group. The median OS times of patients with high, middle, and low CTC levels were 5.3 months, 10.5 months, and 19 months, respectively (P < .001). Analysis regarding progression free survival (PFS) showed that the risk of progression was 4.745 fold greater (P <.0001) in the high-level group and 1.525 fold greater (P =.201) in the moderate-level group compared with the low level group. High EpCAM-positive CTC counts appear to be associated with poor survival of patients with unresectable HCC treated with chemoembolization.



Table

Note–Groups 0, 1, and 2 represent low level group (CTC count 0/1), moderate level group (CTC count 2–5), and high level group (CTC count ≥ 6). Variable CTC was compared vs group 0 in Cox analysis.

AFP = a-fetoprotein; CTC = circulating tumor cell; ECOG = Eastern Cooperative Oncology Group; HR = hazard ratio; OS = overall survival; PS = performance status.

*Refers to imaging diagnosis, not pathologic diagnosis.

Commentary

The results of the present study are in accordance with previous studies with regard to EpCAM-positive CTC counts correlating with tumor recurrence and survival, particularly in patients with high-level counts (CTC ≥ 6). The association between higher CTC counts and malignant features of HCC including satellite foci, vascular invasion, and poorly differentiated tumors is the suggested explanation for these findings.

However, the findings of the study must be interpreted with caution as 63 of the included patients had previously received treatment with 50 of those patients undergoing previous chemoembolization. The variation between primary chemoembolization and repeat chemoembolization on CTC counts and patient responsiveness is unknown. Further, the implications of added cost and potential for false positive results (0.6 %– 5.3%) must be considered when implementing this prognostic tool. As CTC counts seem to correlate with malignant HCC features and late BCLC stage, the value added by this test to prognostication for unresectable HCC beyond that already established by previous staging/imaging findings appears limited. Despite these reservations, using CTCs to detect and predict the responsiveness of various oncologic treatments appears to be a promising field of investigation.

Click here for abstract

Shen J, Wang W-S, Zhu X-L, Ni C-F. High Epithelial Cell Adhesion Molecule–Positive Circulating Tumor Cell Count Predicts Poor Survival of Patients with Unresectable Hepatocellular Carcinoma Treated with Transcatheter Arterial Chemoembolization. Journal of Vascular and Interventional Radiology [Internet]. 2018 Nov 1;0(0).

Post Author:
Jacob Bundy, MD, MPH
PGY-1
Department of Surgery
University of Michigan Health System
@JBundyRad

Irinotecan-Eluting 75-150-µm Embolics Lobar Chemoembolization in Patients with Colorectal Cancer Liver Metastases: A Prospective Single-Center Phase I Study 

Summary

Interventional oncologists have long been involved in treatment of hepatic metastatic disease from colorectal cancer, offering ablation, radioemboliztion, and bland/chemoembolization. Given the propensity of disease, colorectal cancer is number three cause of cancer related death in the US with 60% of patients developing liver metastases at some point, this remains a great interest to IO’s despite transarterial therapy being third line therapy at best. This single center prospective trial evaluates feasibility and safety of using a smaller embolic bead, 75-150 µm, with irinotecan, an established chemotherapeutic for patients who have failed 5-FU therapies While the primary end-points are relatively modest, the group also evaluated treatment efficacy, irinotecan pharmacokinetics, and angiogenesis biomarkers. Ultimately, 14 patients with liver dominant colorectal cancer metastatic disease who had progressed through at least 1 line of systemic therapy were treated. Treatment cycles were 6 weeks, and a patient could be treated twice prior to initial follow up imaging. A maximum of 4 treatment cycles were performed. Retreatment was based on presence of new disease, progression of disease, or stable disease on follow up imaging. The study used 1 vial of LC Bead M1 loaded with 100 mg of irinotecan infused in a lobar manner. Embolization was stopped prior to complete dose delivery if 2-5 heart beat stasis was achieved.

Feasibility was defined as the ability to deliver the entire dose to 80% of the patients. Procedural complications and 30-day adverse events were recorded to determine safety. All 32 embolizations in the 14 patients were completed with delivery of the entire dose each time. There were no procedural complications. The most common 30-day adverse event was abdominal pain, seen in 50% of the patients, with 28.6% qualifying as a severe (grade 3-4). Median overall survival from the first treatment was 18.1 months with 1 year survival of 65%. By EASL criteria, 3 patients had partial response, 4 patients had stable disease, and 6 patients had progression.



Figure 1. (a) Partial response demonstrated in 2 patients based on EASL criteria. On contrast-based imaging (venous phase), the tumor measurements before and after transarterial chemoembolization were, respectively, 3.44 x 3.11 cm and 1.90 x 2.49 cm for patient 1 (71 year old male) and 3.99 x 3.68 cm and 1.47 and 1.37 cm for patient 2 (58 year old male). (b) Kaplan-Meier curves demonstrating MOS and 1-year survival.

Commentary

While chemoembolization, specifically with irinotecan, has been relatively well studied from 2006 to present, both as third line or salvage treatment and in conjunction with systemic chemotherapy, there has been little research involving smaller sized beads. The advantages of smaller embolics include more distal penetration into the tumor bed and ability for more uniform coverage throughout the target zone. Despite the small number of patients, this data supports the existing data that chemoembolization using 75-150 µm embolics is indeed safe and feasible. Obviously, this study is limited do to sample size, short follow up interval, and hetereogenous pre-existing and subsequent cancer therapies. While this adds to our literature supporting safety of transarterial chemoembolization for colorectal metstatic disease, many questions still remain. There is still no clear position for transarterial chemoembolization nor transarterial radioembolization in the armamentarium for treatment of mestastatic colorectal cancer. Should these be considered third line, fourth line, or salvage therapy? Is radiation or chemoembolic superior? What size embolic is ideal for chemoembolization? Clearly, more research needs to be performed in this realm, especially to compete with systemic chemotherapy trials and seemingly endless supply of novel chemotherapeutics emerging on the market.

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Fereydooni A, Letzen B, Ghani M, et al. Irinotecan-Eluting 75-150-µm Embolics Lobar Chemoembolization in Patients with Colorectal Cancer Liver Metastases: A Prospective Single-Center Phase I Study. J Vasc Interv Radiol. 2018. Oct 15.

Post Author:
David M Mauro, MD
Assistant Professor
Department of Radiology
Vascular and Interventional Radiology
University of North Carolina
@DavidMauroMD

Primary Endovascular Elective Repair and Repair of Ruptured Isolated Iliac Artery Aneurysms Is Durable—Results of 72 Consecutive Patients

Summary

Research from the University Hospital of Zurich (Switzerland) recently evaluated the outcome of elective/emergent endovascular repair of isolated iliac artery aneurysms (IIAAs) as the first treatment option. A retrospective study was conducted including 72 patients with 85 IIAAs. Treatment strategy included coiling of the internal iliac artery, stent graft placement in the common to external iliac artery, or placement of a bifurcated aortoiliac stent graft. The following arterial segments were involved: common iliac (63 patients; 74.1%), internal iliac (21 patients; 24.7%), and external iliac (1 patient; 1.2%). Mean diameter was 5 cm (range, 2.5–11 cm). Emergent repair was performed in 19 patients due to rupture (26.4%). Mean follow-up of 4.3 years ± 3.3 (median 3.8 y; range, 0–14.2 y). Primary technical success rate was 95.8% with conversion rate to open surgery of 4.2% (all in the emergency group). In-hospital mortality rate was 1.4%. Total of 17 endoleaks were observed (6 type I, 10 type II, 1 type IIIa). Overall re-intervention rate was 16.7%. Primary patency rate was 98.6%. 22 deaths occurred (30.6%), but only 2 aneurysm-related deaths (2.8%). The authors concluded that primary endovascular repair of IIAAs shows excellent results and should be considered the first-line therapy for IIAAs. Surgical backup should be available in emergent cases. 

Fig: Anatomic classification of IIAA.

Commentary

This paper reinforces the important role of endovascular approach for arterial aneurysms, specifically for rare cases of isolated iliac artery aneurysms. The low incidence of this entity should not undermine its significance since it can lead to major complications such as rupture, which is associated with high morbidity and mortality. Therefore, it is recommended to treat aneurysms > 3cm. However, even for elective cases, surgical repair can have up to a 10% mortality rate, given the deep location of the iliac arteries within the pelvis. The present retrospective study demonstrated that endovascular repair was safe and effective for both elective and emergent cases even after long term follow-up (median of 4.3 years). There was a low conversion rate (4.6%) to open repair and they all occurred in emergent cases. This is not surprising given the severe clinical presentation of this patient population. Therefore, surgical back up is definitely recommended in these cases as mentioned by the authors. The initial critical presentation also explains the higher incidence of in-hospital major complications and increased length of admission for those emergent cases presenting with rupture. The standardized endovascular way to treat those aneurysms according to the location as performed by the research definitely helps replication of the results and solidification of the endovascular approach as the first line treatment for this condition.

Click here for abstract

Post Author:
Ricardo Yamada, MD
Assistant Professor
Department of Radiology
Division of Vascular and Interventional Radiology
Medical University of South Carolina

Endovascular Denervation: a new approach for cancer pain relief 

Summary

Debilitating pain is a common issue that affects cancer patients, and while medical treatment may improve the symptoms, there are significant side efectssuch as nausea, addiction, constipation etc. Celiac pleuxus neurolysis (CPN) has been performed by percutaneously injecting ethanol or phenol around the celiac plexus, however complications such as nerve damage, pneumothorax, hematoma, etc. More recently Endoscopy has been used to guide celiac plexus neurolysis and while it has been effective there have been major side effects such as bleeding, abscess, bowel perforation etc.

The authors sought out toe evaluate the feasibility of patients Endovascular denervation (EDN) to treat pain caused by pancreatic cancer, cervical cancer, cholangiocarcinoma and esophageal cancer. The authors included patients with abdominal cancer that had a VAS >6, ages 25-75 and had a greater than 1 month survival expectation. The primary end point was pain relief as measured with VAS, secondary end points included, QOL assesment, narcotic intake and safety. During the procedure the patient has a surface electrode placd on the back, an aortogram is performed and through an 8 French sheath a 6 electrode catheter is placed proximal to the celiac artery and close to the SMA. The procedure was done under moderate anesthesia, and the denervation was performed for 120 seconds and 60 degrees. Six different points of ablation were treated in that region.

The seven patients included had a VAS score greater than 7 and experienced pain relief at 1, 2 , 4, 8 and 12 weeks. The average VAS score was reduced by greater than 3 points in all patients. The average QOL score increased by 25, with improvement in sleep and more enjoyment in activities. Narcotic use also decreased after EDN, and no major complications were observed.

The authors hypothesize that the radiofrequency energy delivered through the aorta may cause celiac plexus block and improve abdominal pain. The authors mention that the results are similar to CT or EUS guided CPL and quote pain relief in 10-24% when used alone and 80-90% when used in combination with other options. In the group presented by the authors pain relief lead to significant increase in QOL scores, with decreased narcotic use and improved sleep, with no major complications.

The study is limited by the small sample size, the lack of a control group and the difficulty in quantifying a subjective measure like pain.



Figure- Anortogram showing the origin of the celiac and SMA(a), followed by deployment of the electrode near the celiac (b) and the SMA (c)

Commentary

The authors show that endovascular CPN might be an alternative to CT CPL and potentially technically easier and with less complications. Technically the procedure seems straight forward and the results promising. Patients had a decrease in pain scores, improved QOL scores and decreased narcotic intake. The discussion mentions similar outcomes when compared to CT and EUS CPN, however the data presented for the other studies (pain relief efficacy) is not similar to what the authors presented, similar to the pain relief duration. The study could benefit from a longer follow up, and to compare it to a group of patients that were treated either with CT or EUS CPN.

Click here for abstract

Zhang Q, Guo JH, Zhu HD, Zhong YM, Pan T, Yin HQ, Dong YH, Teng GJ. Endovascular Denervation: A New Approach for Cancer Pain Relief? J Vasc Interv Radiol. 2018 Nov 7. pii: S1051-0443(18)31415-5. doi: 10.1016/j.jvir.2018.08.008. [Epub ahead of print] PubMed PMID: 30414719.

Post Author
Carlos J. Guevara, MD
Assistant Professor
Department of Radiology, Interventional Radiology Division
University of Texas Health Sciences, Houston
@UTHouston_IR
@CarlosGuevaraIR