Thermal Ablation for Hepatic Epithelioid Hemangioendothelioma

Image-Guided Thermal Ablation for Hepatic Epithelioid Hemangioendothelioma: A Multicenter Experience

Clinical question

Is image-guided thermal ablation safe and effective in patients with hepatic epithelioid hemangioendothelioma?

Take away point

Based on this retrospective multicenter review of 18 patients with 31 ablations, image-guided thermal ablation is a feasible and safe treatment option for patients with HEHE that resulted in local tumor control and a favorable long-term prognosis

Reference

Zeng, Q., Luo, Y., Yu, J., Li, X., Jiang, T.A., Xie, X., Dong, G. and Liang, P., 2024. Image-Guided Thermal Ablation for Hepatic Epithelioid Hemangioendothelioma: A Multicenter Experience. Journal of Vascular and Interventional Radiology.

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Study design

Retrospective, observational, descriptive study

Funding Source

None

Setting

Academic

Figure

Summary

Hepatic epithelioid hemangioendothelioma (HEHE) is a rare vascular neoplasm with an incidence of less than 1 per million people and constitutes under 1% of hepatic malignancies. Despite its low-to-intermediate malignant potential, HEHE often necessitates treatment due to its multifocal presentation, potential for aggressive progression, and tendency for recurrence and metastasis. The European Society for Medical Oncology recommended surgical resection for stable unifocal or locoregional disease and liver transplantation for unresectable HEHE without extrahepatic disease. For patients ineligible for surgery, alternative treatments such as chemotherapy, radiation, immunotherapy, and antiangiogenic therapy are considered, albeit with varying outcomes. Image-guided thermal ablation has emerged as a potential treatment, particularly for those not suitable for surgery or as a bridge to transplantation. This retrospective study aims to evaluate the feasibility, safety, and effectiveness of thermal ablation for HEHE based on a multicenter experience.

The study involved a retrospective investigation across four hospitals. Informed consent was obtained from 18 patients with pathologically proven HEHE who underwent microwave or radiofrequency ablation between January 2013 and February 2023. Surgical treatment was initially recommended, but ablation was performed on patients ineligible for surgery due to contraindications such as low platelet counts, high international normalized ratios, severe organ dysfunction, or refusal of surgery. Procedures were performed under general anesthesia. Technical success and adverse events were evaluated with contrast-enhanced imaging three days post-ablation, with longer-term follow-ups approximately every three months to monitor intrahepatic distant metastasis, extrahepatic metastasis, local tumor progression, and progression-free survival. Post-ablation adverse events were categorized using the Clavien-Dindo classification within one month of the procedure.

22.2% of the included patients had extrahepatic involvement at diagnosis. Prior treatments included hepatic resection, transcatheter arterial chemoembolization, and systemic therapy. A total of 51 tumors, with a median size of 23.2 mm, were treated with image-guided thermal ablation in 31 sessions, resulting in a 93.5% technical success rate. The median hospitalization was 7 days, with no major adverse events reported. Over a median follow-up of 37.2 months, the median overall survival (OS) was 90.5 months, with OS rates at 1, 3, and 5 years estimated at 87.6%, 75.5%, and 75.5%, respectively. Recurrence occurred in 10 patients, with a median progression-free survival (PFS) of 23.8 months. Larger tumor size was significantly associated with decreased PFS. Patients without extrahepatic involvement had better PFS rates, and early-stage patients had higher PFS rates compared to intermediate-to-advanced-stage patients, although this was not statistically significant.

This multicenter investigation demonstrated that image-guided thermal ablation is a safe and effective treatment for patients with HEHE, achieving a 93.5% technical success rate and manageable minor adverse events. The 1-, 3-, and 5-year OS rates for ablation patients were comparable to those for hepatic resection or liver transplantation, although PFS rates were shorter, likely due to the higher tumor burden and aggressive disease progression in the ablation cohort. Extrahepatic involvement was associated with poorer outcomes, and larger tumor size was a predictor of decreased PFS. Despite these challenges, the repeatability of ablation sessions contributed to favorable OS rates, underscoring its potential as a treatment option. The study's limitations include its retrospective design, potential selection bias, and small sample size due to the rarity of HEHE. Further research is needed to evaluate the benefits of combining ablation with neoadjuvant therapies for larger or multifocal tumors and to determine its role on the HEHE treatment management pathway. In summary, thermal ablation offers favorable local tumor control and long-term effectiveness for HEHE patients ineligible for surgery or transplantation.

Commentary

The use of image-guided thermal ablation for patients with unresectable hepatic epithelioid hemangioendothelioma represents a promising and viable treatment option, as evidenced by the findings of this multicenter, albeit small, investigation. This study highlights the procedure’s safety and effectiveness, showcasing a high technical success rate of 93.5% and favorable overall survival rates comparable to those achieved through more invasive treatments like hepatic resection and liver transplantation.

One significant advantage of thermal ablation is its minimally invasive nature, which makes it suitable for patients who are not candidates for surgical management due to various contraindications. The repeatability of ablation also stands out, allowing for multiple sessions to manage recurrences effectively, potentially contributing to sustained overall survival rates.

However, the shorter progression-free survival rates observed in this study, compared to more invasive treatments, underscore the need for careful patient selection, intra-procedural ablation confirmation software, and potentially the integration of ablation with other therapies. The study's identification of larger tumor size as a predictor of worsened progression-free survival suggests that combining ablation with therapies such as chemoembolization could enhance outcomes for patients with larger or multifocal tumors.

In conclusion, this study provides preliminary evidence that image-guided thermal ablation is a valuable treatment for patients with unresectable hepatic epithelioid hemangioendothelioma, offering a balance of efficacy and safety. Further research will optimize its clinical utility and potentially expand its role in the management of hepatic epithelioid hemangioendothelioma.

DCB versus PTA in AVF

Comparison of Clinical Effectiveness and Safety of Drug-Coated Balloons versus Percutaneous Transluminal Angioplasty in Arteriovenous Fistulae: A Review of Systematic Reviews and Updated Meta-Analysis

Clinical question

What does the most updated meta-analysis say about the safety and clinical effectiveness of drug-coated balloons versus percutaneous transluminal angioplasty for arteriovenous fistula stenosis?

Take away point

Drug eluting ballons have been shown to have consistent benefits in treating arteriovenous fistulae compared to percutaneous transluminal angioplasty in both primary patency and target lesion revascularization at 6 and 12 months, without increased mortality.

Reference

Lee, H., Choi, H., Han, E. and Kim, Y.J., 2024. Comparison of Clinical Efficacy and Safety of Drug-Coated Balloons versus Percutaneous Transluminal Angioplasty in Arteriovenous Fistulas: A Review of Systematic Reviews and Updated Meta-Analysis. Journal of Vascular and Interventional Radiology.

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Study design

Systematic review and meta-analysis

Funding Source

None reported

Setting

Academic

Figure

Figure 3. Forest plot of primary patency at 12 months. Pooled effect with 95% CI were estimated using a Mantel–Haenszel (M-H) random-effects model. DCB = drug-coated balloon; df = degree of freedom; PTA = percutaneous transluminal angioplasty.

Summary

Arteriovenous fistulae are primarily created for hemodialysis in patients with end-stage renal disease due to their lower infection risk and better maintenance compared to other types of access. However, they are usually plagued by stenosis and an eventual loss of patency. Percutaneous transluminal angioplasty is the conventional treatment, with drug-coated balloon emerging as a promising treatment option recently. Despite several systematic reviews and meta-analyses assessing the clinical effectiveness and safety of drug-coated balloons for arteriovenous fistulas and arteriovenous grafts, the results remain controversial. A comprehensive review of existing evidence and an updated meta-analysis were conducted to evaluate the clinical effectiveness and safety of drug-coated balloons compared to percutaneous transluminal angioplasty for arteriovenous fistula stenosis.

This study conducted a systematic review and meta-analysis following PRISMA guidelines, with a protocol registered in PROSPERO. An extensive search of MEDLINE, Embase, and Cochrane Library databases up to April 2023 used keywords related to "arteriovenous fistula," "drug-coated balloon," "angioplasty," and "hemodialysis." Studies were included if they involved patients with arteriovenous fistula stenosis, compared drug-coated balloon to standard or high-pressure percutaneous transluminal angioplasty, and reported primary patency, target lesion revascularization, or mortality. Only systemic reviews of randomized controlled trials, nonrandomized studies, or cohort studies were considered, excluding low-quality studies. Quality was evaluated using AMSTAR and appropriate bias assessment tools for original studies. Data synthesis involved narrative and quantitative analyses, with subgroup and sensitivity analyses to address heterogeneity and potential biases, using Revman 5.4 for meta-analysis and funnel plots for publication bias.

The results of this systematic review and meta-analysis are based on an extensive literature search that identified 257 systematic reviews, of which 11 were included. These reviews, published between 2019 and 2022, focused on patients with arteriovenous fistula stenosis undergoing angioplasty, comparing drug-coated balloon to standard or high-pressure balloon treatments. The primary outcome, primary patency, was assessed in 9 reviews, showing a general trend favoring drug-coated balloon at 6 and 12 months, with significant results in 7 outcomes and nonsignificant differences in 3 outcomes. Target lesion revascularization was reported in 3 reviews, indicating significantly lower target lesion revascularization rates for drug-coated balloon at 6 months and mixed results at 12 months. Mortality was reported in 4 reviews, showing no significant difference between drug and percutaneous transluminal angioplasty at 6 and 12 months. A meta-analysis update included 23 studies, revealing significantly more favorable primary patency for drug-coated balloon at 6 and 12 months but not at 24 months, and a lower risk of target lesion revascularization at 6 and 12 months. Mortality rates showed no significant difference at any time point. Subgroup analyses confirmed favorable primary patency for drug-coated balloon at 12 months across various device brands, study funding sources, and designs, with no evident publication bias.

The study highlighted the variability in outcomes due to heterogeneity among included studies, differences in study design, and various methodological factors. Despite these inconsistencies, the overall findings suggest that drug-coated balloon is more effective than percutaneous transluminal angioplasty in maintaining arteriovenous fistula patency without increasing mortality risk, although further well-designed studies are needed to confirm these results and address long-term outcomes and cost-effectiveness.

Commentary

This article provides a comprehensive and meticulous synthesis of current evidence on the use of drug-coated balloons compared to percutaneous transluminal angioplasty for treating arteriovenous fistula stenosis. By analyzing multiple systematic reviews and updating previous meta-analyses, the authors highlight the clinical benefits of drug-coated balloons, particularly in improving primary patency and reducing target lesion revascularization rates at 6 and 12 months. However, the study also underscores the variability and heterogeneity among the included studies, which pose challenges in drawing definitive conclusions. Notably, the review confirms that drug-coated balloons do not increase mortality risk, aligning with previous findings. Despite some limitations, including the need for more long-term data and consideration of cost-effectiveness, this article provides updated level 1 (SIR-A) evidence for drug-coated balloon’s efficacy and safety in the context of arteriovenous fistula stenosis. Further well-designed research may resolve existing discrepancies and provide better insights regarding longer-term clinical outcomes.

Predictive factors of Splenic Artery Aneurysm Growth

The Natural History of Splenic Artery Aneurysms: Factors That Predict Aneurysm Growth

Clinical question

What factors predict splenic artery aneurysmal growth?

Take away point

A larger baseline splenic artery aneurysm, the presence of a mural thrombus and low amounts of rim calcification translated to increased overall growth rate

Reference

An, T. J., Chen, X., Omar, O. M., Sutphin, P. D., Irani, Z., Wehrenberg-Klee, E., Iqbal, S., & Kalva, S. P. (2024). The natural history of splenic artery aneurysms: Factors that predict aneurysm growth. Journal of Vascular and Interventional Radiology, 35(7), 972–978. https://doi.org/10.1016/j.jvir.2024.04.007

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Study design

Retrospective

Funding Source

None

Setting

Single academic institution-Mass General Hospital

Figure

Plots of the mean growth rate of splenic artery aneurysms (SAAs) based on different aneurysm characteristics. (a) SAAs with greater than 50% mural thrombus were associated with an increased rate of growth (0.65 mm/y). (b) SAAs with greater than 50% rim calcification were associated with a decreased rate of growth (0.14 mm/y). (c) SAAs greater than 2 cm in diameter cm were associated with an increased rate of growth (0.41 mm/y). (d) There was no significant difference in SAA growth rate based on aneurysm location. Error bars on the graphs denote the standard error of the mean. Double asterisks (∗∗) denote statistical significance (P < .05).

Summary

Splenic artery aneurysms (SAAs) are the third most common type of abdominal aneurysm, and represent up to 60% of visceral artery aneurysms. Despite their low incidence (0.8% at arteriography and 0.04%-0.1% at autopsy), increased use of cross-sectional imaging has led to more frequent incidental detections of splenic artery aneurysms. Higher incidences are noted in women and patients with conditions such as atherosclerosis, vasculitis, vasculopathy, and portal hypertension. Although typically asymptomatic, splenic artery aneurysms can rupture and cause life-threatening hemorrhages, with increased rupture risks associated with pregnancy, portal hypertension, pseudoaneurysm, and concurrent vasculitis. Both endovascular and surgical treatments for SAAs show high success and low mortality rates, particularly for asymptomatic aneurysms larger than 2 cm.

This study was done to look at progression of splenic artery aneurysms to ascertain any predictive factors for increased growth which may ultimately lead to life-threatening rupture. This retrospective study used 30 years of patient imaging from 1990-2020 encompassing 132 patients with median age of 66.6 years who had multiple cross-sectional CT and/or MR studies. Patients were excluded if they were under 18, those who had previous correction by endovascular or surgical intervention, and those with splenic pseudoaneurysms or false aneurysms. Multivariable linear regression was performed using aneurysm growth rate as a continuous dependent variable.

In the study, 89% of the patients had a history of hypertension, 64% history of smoking, 31 % with a history of diabetes and 11% with a history of portal hypertension. Most splenic artery aneurysms (61%) remained stable, with a low median growth rate of 0.60 mm/year. Splenic artery aneurysms with >50% of mural thrombus, and a baseline size greater than 2 cm, had increased rates of splenic artery aneurysmal growth. Splenic artery aneurysms with greater than 50% rim calcifications were negatively correlated with aneurysm growth rates. 88% of patients were managed conservatively.

Overall, the authors conclude that there is a trend toward nonoperative surveillance and increased endovascular intervention in the management of splenic artery aneurysms. Formal published guidelines were based on retrospective data, recommending treatment for nonruptured splenic artery aneurysms greater than 3 cm, those increasing in size, or in high-risk patients. Based on the data presented in the current series, for patients with positive predictive factors including baseline size > 2 cm and > 50% mural thrombus, preventive interventions may be warranted. Limitations include the retrospective design, non-standardized protocols, low incidence of adverse events, and potential imaging modality discrepancies.

Commentary

The authors initially found large proportion of the cohort to have existing comorbid conditions of smoking, diabetes, and hypertension with known involvement in aneurysmal formation and growth. Nevertheless, statistical analyses revealed that the factors associated with aneurysmal growth, specifically in the context of splenic artery aneurysm, were mural thrombus, baseline size, and rim calcifications. These new predictors can guide procedural timing in those with increased risks of life-threatening rupture.

It is often informative to utilize large amounts of data obtained over time to uncover obscure trends; but this approach can also carry significant bias and blind us from evolving environmental factors that could have influenced these patients’ disease course. In addition, it may overlook technological advances in diagnostic imaging in the long timespan, which could have implications in aneurysmal diameter measurements and growth rate calculations. To expand on the current study design would entail prospective data and diverse patient populations. Optimal timing for referral to endovascular or surgical intervention, and follow-up interval estimation, will be the next steps.

Post Author
Christopher Loiselle, DO, MS
PGY-1 General Surgery
Rutgers-Robert Wood Johnson Medical School
@Caloiselle