Image-guided interventions: a key pillar in cancer care

Watch this session on ECR Live: Wednesday, March 1, 16:00–17:30, Room F2

 There is hardly any area of hospital medicine where interventional radiology (IR) has not had some impact on patient management. The range of conditions that can be treated using interventional radiology techniques is continually expanding.

In today’s session, experts will provide an insight into image-guided interventions in oncology with a particular focus on illustrating the importance of quality assurance in image-guided oncological interventions and their effect on treatment outcomes.

In recent years, IR has played a vital role in the field of oncology, and alongside medical, surgical and radiation oncology it constitutes a key pillar in cancer care. Vascular and non-vascular procedures such as transarterial chemoembolisation, radiofrequency ablation (RFA), microwave ablation, radioembolisation, cryoablation and high-intensity focused ultrasound (HIFU) are delivered locally, minimise damage to nearby tissue and avoid the systemic side effects of chemotherapy.

Colorectal lung metastasis before CT – guided microwave ablation.

For the interventional radiologist providing oncologic therapies it is essential to understand the rapidly changing field of oncology and to have a broad knowledge of oncologic diseases and available therapies to treat them. Radiologists providing image-guided interventions in oncology have an outstanding understanding of imaging as well as a diversity of interventional skills. However, they lack formal training in oncology and an understanding of chemotherapy and radiotherapy, according to Prof. Andy Adam from the Department of Radiology at Guy’s and St. Thomas’ Hospital in London. Read more…

ECR 2013 Rec: Detection of HCC and liver metastases with BR14: final results of a multicentre phase IIA study #SS201b #B0232


B-0232 Detection of HCC and liver metastases with BR14: final results of a multicentre phase IIA study

J. Hohmann, A. Müller, J. Skrok, K.-J. Wolf, A. Martegani, C.F. Dietrich, T. Albrecht | Thursday, March 7, 14:00 – 15:30 / Room I/K

Purpose: The study was primarily designed to find the optimal dose range of BR14 to detect malignant focal liver lesions. Secondary objectives were the evaluation of the safety profile and comparison with contrast-enhanced MRI (CE MRI).
Methods and Materials: 25 patients (9f, 16m, mean age: 66y) with known HCC or liver metastases were examined in three centres during a time period of three months. Each patient underwent a baseline and at least three contrast-enhanced US (CEUS) with ascending dose levels (0.25ml, 1.0ml, 4.0ml) of BR14. CE MRI was done 4 weeks prior or post-study examination. Lesions were recorded in on a liver map, with respect to localisation, size and suggested lesion type. Examination quality was documented and safety parameters were assessed.
Results: The number of lesions detected with BR14 CEUS increased with dose, while the number of missed lesions and the lesion size decreased. Despite the increasing contrast enhancement no other image quality parameter showed a substantial difference. No significant changes were found for the analysed safety parameters and no serious adverse events were reported.
Conclusion: We finally conclude that the recommended dose level of BR14 is between 1.0 ml and 4.0 ml for which the lesion detection was comparable to the CE MRI. In addition, we found a higher number of especially small lesions with higher doses of BR14 which might be due to a higher sensitivity of CEUS for the detection of liver metastases. However, this is an interesting and debatable finding.

ECR 2013 Rec: A. RF ablation #RC709 #A187


A-187 A. RF ablation

 J. del Cura | Friday, March 8, 16:00 – 17:30 / Room N/O

RF ablation is currently indicated in HCC as curative treatment in Child-Pugh A-B patients with: single <2 cm nodule and not candidates for transplation, 1-3 nodules <3 cm and not candidates for resection or transplantation. RF can be also performed in patients waiting for liver transplantation. Some studies suggest that survival does not differ between RF ablation and resection in 5 cm because of the high possibility of recurrence. Different types of electrodes can be used: internally cooled, cluster, expandable, with saline instillation. Although results can be good with any of them, every type of device requires a different technique of ablation. Obtaining a margin of at least 0.5 cm of ablated tissue around the tumour is key to avoid recurrences. Combined treatments like combining chemoembolization or PEI with RFA can be useful to increase the ablation volume. Published data show a pooled 5-year survival of 48-55%, with better outcomes in Child-Pugh A patients. In candidates for surgery, 5-year survival is similar to resection: 76 %. RFA is safe: major complications appear in 10 % and reported mortality is 0.15%. Tumours located subcapsular or near major vessels, biliary tree or bowel are more prone to complications. Laparoscopic ablation can be an alternative in these cases. Imaging follow‑up with CT, MRI or CEUS is performed to assess the outcome and detect recurrences, new lesions or complications. Although not well established, most protocols include an immediate post-procedure imaging, 1-month follow-up and explorations every 3 or 6 months for 2-3 years.

ECR 2013 Rec: Biliary procedures #SF14a #A445


A-445 Biliary procedures

M. Krokidis, A.A. Hatzidakis | Sunday, March 10, 14:00 – 15:30 / Room F1

Palliative Percutaneous Transhepatic Biliary Drainage (PTBD) is a therapeutic procedure leading to drainage of the obstructed bile duct system. If endoscopy is not possible and if patient is inoperable, then the percutaneous treatment is indicated. Drainage of the bile ducts is performed with a small plastic multiple hole pigtail catheter. Self-locking catheters are preferred in order to minimize the dislocation risk. The percutaneous catheter is pushed through the malignant stricture, so that bile is draining through the catheter towards the bowel loops. Technical success rate of percutaneous biliary drainage can reach nearly 100 % in experienced hands, while the major complications rate is usually lower than 5 %. Clinical efficacy is usually lower, but still over 90 %. The drainage procedure can be extended with the placement of a permanent metallic stent, which keeps the stenosed biliary duct patent, without need for a catheter. Metallic biliary stents have been proved as the best palliative treatment of non-resectable malignant obstructive jaundice, allowing longer patency rates than plastic endoprostheses. The technique is safe, with low-complication rate and procedure-related mortality between 0.8 and 3.4%. Still controversial remains in the timing between initial drainage and metallic stent placement, as well as the question of balloon dilatation before stent insertion. There is evidence that if the initial transhepatic drainage is completed without causing any severe complications, especially bleeding in form of haemobilia, primary metallic stenting can follow as a single-step procedure.



ECR 2013 Rec: Chairman’s introduction #A339 #RC1109


A-339 Chairman’s introduction

M. Krokidis, A.A. Hatzidakis | Saturday, March 9, 16:00 – 17:30 / Room N/O

There are some basic IR techniques everybody needs to know before starting to treat biliary diseases. Τhese are Percutaneous Transhepatic Cholangiography (PTC) and Percutaneous Transhepatic Biliary Drainage (PTBD). These basic procedures are essential first for opacification and then for getting access into the biliary tree. After accessing the biliary system, decisions must be made about the need for further interventional procedures. Presence of benign or malignant strictures, stones or other kind of disease are leading us to the necessary actions, such as dilatation, stenting or lithotripsy. Dilatation of stenosed parts of the biliary system is performed after negotiation of the stricture or occlusion with help of high-pressure angioplasty balloons of variant sizes. Balloons of 8-14 mm width can be used alone or two parallel to each other. Stenting is rarely needed in benign biliary disease and usually in cases where multiple dilatations are not responding. Percutaneous lithotripsy with or without cholangioscopic assistance is a wide-used technique for clearance of biliary stones or fragments. Extraction balloons or baskets and special lithotripsy devices are commonly used for impacted or large calculi.

ECR 2013 Rec: Hepatic parenchymal and vascular contrast improvement in super-delayed phase images of Gd-EOB-DTPA-enhanced MRI #B0984 #SS1801b


B-0984 Hepatic parenchymal and vascular contrast improvement in super-delayed phase images of Gd-EOB-DTPA-enhanced MRI

S. Kobayashi, O. Matsui, T. Gabata, W. Koda, T. Minami, K. Kozaka, A. Kitao | Monday, March 11, 14:00 – 15:30 / Room I/K

Purpose: To elucidate the parenchymal and vascular contrast improvement effect of super-delayed phase (SDP) images of Gd-EOB-DTPA (EOB)-enhanced MRI in poor hepatobiliary phase (HBP) image cases special focus on Child-Pugh (CP) classification.
Methods and Materials: 76 cases, who have examined EOB-enhanced MRI for closer examination of hepatic lesions, and taken SDP images approximately 90 minutes after iv administration of EOB because of poor HBP image are subjected to this study. 20 hepatobiliary disease cases who had also taken SDP images which show normal HBP images were used as control. Hepatic vascular/parenchymal enhancement ratios (ER) were defined as signal intensity (SI) of intrahepatic vessel / SI of liver. ER of HBP and SDP were calculated and compared between each CP class liver damage groups. Chi square test was used for statistics and p<0.05 was considered statistical significant.
Results: In poor HBP cases (n=76), ER of HBP and SDP were 0.88±0.16 and 0.64±0.16. In control cases (n=20), ER of HBP and SDP were 0.54±0.08 and 0.39±0.06. ER of HBP and SDP in CP-A poor HBP (n=27), CP-B poor HBP (n=47), CP-C poor HBP (n=2) were 0.83±0.14 and 0.60±0.13, 0.90±0.16 and 0.65±0.16, 1.03±0.16 and 0.99±0.19, respectively (all combinations except CP-C showed significance difference).
Conclusion: In most of the poor HBP image cases, SDP image improve parenchymal and vascular contrast except CP-C liver damage cases.

ECR 2013 Rec: Pre-therapeutic radiological evaluation #A245 #RC809


A-245 Pre-therapeutic radiological evaluation

J. Raupach, O. Renc, P. Hoffmann, J. Zizka; | Saturday, March 9, 08:30 – 10:00 / Room N/O

Endovascular abdominal aortic aneurysm repair (EVAR) was introduced over 20 years ago to primarily treat old and sick patients. Due to technical improvements and satisfactory clinical results of this technology, the number of patients treated with stent-grafts is steadily increasing. There is also tendency to use this therapy for ruptured abdominal aortic aneurysms. Pre-operative assessment of aortic morphology regarding suitability for stent-graft implantation is, therefore, an important challenge for every radiologist now. Main limitation of EVAR is unfavourable anatomy of landing zones and access vessels. Gold standard for EVAR planning is contrast-enhanced CTA. Alternative modality for patients with contraindications for CT, such as renal impairment, is unenhanced MR with steady-state free precession sequence. A number of 2D or 3D reconstructions are generated to provide information about the aneurysm morphology. Dedicated vessel analysis and planning software can be applied. Usually, axial images and thin MPR reconstructions are sufficient in emergent cases. Proper stent selection is a domain of operator and is still matter of his/her experience. The planning procedure can be subdivided into 4 different sections: infrarenal neck, aneurysmal sac, aortic bifurcation and access vessels. There are several critical and rules which must be obeyed during the evaluation process and general radiologists should be aware of. The presentation will review main inclusion and exclusion criteria for EVAR.