WCIO

Abstracts

SIR assumes no legal liability or responsibility for the completeness,accuracy, and correctness of the information presented in the abstracts.Abstracts will be published in the Journal of Vascular and InterventionalRadiology as submitted by the authors, except for minor stylistic adjustmentsto ensure consistency of format and adherence to abstracts style.

Additional WCIO and CIO abstracts are available online at www.jvir.org

©SIR, 2013

DOl: 10.1016/j.jvir.2013.03.027

ABSTRACTS FROM WCIO

World Conference on Interventional Oncology

(WCIO) 2013

May 16-19, 2013, New York, New York

Paper 2: Superselective Transarterial Chemoembolization for

Hepatocellular Carcinoma in Liver Transplantation Candidates with

Bilirubin ≥ 2.5

D.S. Wang, E.A. Davalos, G.L. Hwang, J.D. Louie, L.V. Hofmann,D.Y. Sze, N. Kothary

Objectives: To determine whether superselective transarterial chemoembolization

(TACE) can be safely performed to bridge hepatocellular carcinoma (HCC) patients

at high risk for post-TACE liver failure, as indicated by a baseline serum bilirubin

(TBili) ≥ 2.5mg/dL, towards liver transplantation (LT).

Methods: Patients with unresectable HCC on the LT wait-list who underwent high

risk (defined as pre-TACE TBili ≥ 2.5mg/dL, without biliary obstruction) superselec-

tive TACE (defined as delivery of chemoembolic agents at the segmental level or

greater order) from 2005 to 2012 at our institution were retrospectively evaluated. LT

wait-list outcomes, change in medical MELD score, and 30-day and 90-day procedure-

related mortality were assessed.

Results: Forty-seven patients underwent 96 superselective TACE procedures, of

which 62 were high risk with a pre-TACE TBili ≥ 2.5mg/dL (mean 3.6mg/dL, range

2.5-10.1mg/dL). Mean medical MELD was 15.9 (range 5.8-31.5) with 18 classified as

Child-Pugh C, 13 as B9, 12 as B8, and 4 as B7. Of these 47 patients, 34% were trans-

planted, 8.5% remained on the LT wait-list, 14.9% dropped off the list due to malignant

disease progression, 10.6% were removed due to liver failure, and 31.9% were active

on the list but were removed for other reasons. Average time from first high risk TACE

to LT wait-list outcome was 223 days. Mean change in medical MELD score after high

risk TACE was +1.4. Thirty and ninety day procedure-related mortality were 1 (2.1%)

and 4 (8.5%) patients, respectively.

Conclusions: Particularly applicable in regions with long wait-list times, superselec-

tive TACE may be performed safely in HCC LT candidates conventionally rejected for

treatment because of poor baseline hepatic reserve, as indicated by an elevated TBili,

in order to bridge them to transplantation.

Paper 3: Survival, Efficacy and Safety after Doxorubicin Drug Eluting

Beads Transcatheter Chemoembolization (DEB TACE) for Patients with

Unresectable Hepatocellular Carcinoma (HCC) with 100-300 μm versus

300-500 and 500-700 μm Eluting Beads

H.J. Prajapati, J.R. Spivey, S.I. Hanish, B. El-Rayes, J. Kauh, H.S. Kim

Objectives: To investigate the survival, efficacy and safety of 100-300 μm versus

300-500 and 500-700 μm LC (low compression) beads used for doxorubicin drug elut-

ing beads transcatheter chemoembolization (DEB TACE) in patients (pts) with

unresectable hepatocellular carcinoma (HCC).

Methods: A total of 323 consecutive pts (mean 61.1 years, SD 10.4) with unre-

sectable HCC who underwent 736 embolizations from January 2006 to September

2012 were reviewed. This is a single institutional correlative retrospective analysis of

a prospective study with patient’s consent. The pts who underwent liver transplantation

were excluded. The HCC tumors were sub selectively treated with 100-300 μm LC

beads (Biocompatibles, Farnham, Surrey, UK) from July 2008 to 2012 (Group A) and

with mixed 300-500 and 500-700 μm LC beads before July 2008 (Group B). There

were 285 pts in group A and 38 pts in group B. Survivals were analyzed according to

different parameters from the time of 1st DEB TACE. Kaplan Meier estimator by log

rank test and Cox Proportional Hazard model were used for survival analysis. A Chi-

square test and t-test were used to compare categorical and continuous variables

accordingly.

Results: The overall medial survivals (OS) of 323 pts were 18.8 months (m). The OS

in group A and B were 20.2 m and 13.3 m respectively (p=0.005). The Kaplan Meier

survival graph of both groups is shown in figure 1. The both groups were similar in

age, sex, race, Child Pugh class, Okuda staging, BCLC staging, ECOG performance

status, portal vein thrombosis (PVT), extra hepatic metastasis and tumor burden

(p>0.5) (table 1). The OSs by different parameters in both groups are shown in table

1. The 30 day mortality was 0.35% (n=1) in group A and 13.1% (n=5) in group B. The

CTCAE grade III or worse adverse events were present in 3.9 % (n=11) in group A

and 18.4% (n=7) in group B. The CTCAE grade I or II adverse events were present in

27.3 % (n=78) in group A and 31.6 % (n=12) in group B.

Paper 1: An Initial Experience with Drug-eluting Microsphere Transarterial

Chemoembolization (DEM TACE) for the Treatment of Unresectable

Hepatocellular Carcinoma (HCC) using Doxorubicin Loaded 30-60 μQuadrasphere Microspheres

K. Maglione, R. Khanna, A.M. Fischman, R. Patel, F.S. Nowakowski,E. Kim, R. Lookstein

Objectives: We report an initial single-centre experience with drug-eluting micros-

phere transarterial chemoembolization (DEM TACE) for the treatment of unresectable

hepatocellular carcinoma (HCC) using doxorubicin loaded 30-60 μ Quadrasphere

microspheres.

Methods: Over a 9 week period, 21 patients with unresectable HCC underwent DEM

TACE using 50 mg doxorubicin per vial of 30-60 μ Quadrasphere microspheres (Merit

Medical, South Jordan, UT). Mean follow up time was 30 days (range 15-90 days).

Primary endpoints included safety and efficacy. Safety was assessed by National Can-

cer Institute Common Terminology Criteria for Adverse Events (NIC CTCAE, version

4.0) using total bilirubin and aspartate aminotransferase (AST). Significant clinical

toxicities were defined as abdominal pain, nausea, fever, and encephalopathy requiring

medical attention. Post-procedure hospitalization and mortality were also assessed at

30 days. Efficacy was evaluated by radiologic tumor response on imaging (CT or MRI)

per modified response evaluation criteria in solid tumors (mRECIST) criteria approx-

imately 1 month after treatment. Serum alpha-fetal-protein (AFP) measurements were

also used to assess efficacy.

Results: A total of 31 tumor nodules (mean size 2.3 cm, range 1.0 cm to 4.9 cm) were

evaluated in 21 patients (17 male and 4 female, mean age 63.4). Etiology of HCC

included HCV (n=9), HBV (n=7), alcoholic (n=3) and cryptogenic (n=2). All patients

were naïve to trans-arterial therapy. Six patients (28.6%) had undergone prior hepatic

resection. The Child’s Pugh classification was A in 14 patients (67%) and B in 7

patients (33%) at the time of treatment. Barcelona Clinic staging was A in 17 patients

(81%) and B in 4 patients (19%). Mean dose of Doxorubicin administered was 50mg

(range 25-75 mg). Technical success was achieved in 100% of patients. There were no

post procedure major adverse events. Survival at 30 days was 100%. Post-embolization

syndrome occurred in 3 patients (14.3%). No significant clinical toxicities were

observed in the follow-up period. One patient (4.8%) demonstrated a class 1 rise in

total bilirubin and 1 patient (4.8%) demonstrated a class 1 rise in AST. There was 1

(4.8%) hospital admission within 30 days following treatment for presumed sponta-

neous bacterial peritonitis. Follow-up cross-sectional imaging (contrast-enhanced CT

or MRI) was evaluated using mRECIST criteria at 30 days. Response rates included:

32 % complete response (n=6), 42% partial response (n=8), 21% stable disease (n=4)

and 5% progression of disease (n=1). Two patients were excluded from mRECIST cal-

culations due to tumor hypovascularity. Treated tumors demonstrated a mean decrease

in contrast enhancement of 55%. In those patients who had elevated AFP and in whom

follow up was available (n=8), the mean decrease in AFP was 32.8 ng/dL. Ten patients

(47.6%) required re-treatment within the follow-up period for stable or progressive

disease.

Conclusions: Our initial single centre experience demonstrates that TACE using dox-

orubicin-loaded 30-60 μ Quadrasphere microspheres is feasible, well-tolerated with a

low complication rate, and is associated with promising tumor response. Longer fol-

low-up on larger series is mandatory to confirm these preliminary results.

759.e2W

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Table 1. There were no statistically significant differences for the variables presented

in Table 1 between the patients who were downstaged and those who were not down-

staged.

Conclusions: This is the first study to assess downstaging of HCC patients to within

Milan criteria using DEB-TACE. The data presented from this small series of patients

suggest that DEB-TACE offers UNOS stage T3 HCC patients a good chance of down-

staging to within transplant criteria.

Table 1. Demographic and Clinical Data for Patients Overall, Downstaged Patients,

and Not Downstaged Patients.

SD = Standard Deviation

Paper 5: Comparison of Survival and Toxicity in Patients with

Unresectable Hepatocellular Carcinoma: Drug Eluting Beads Leads to

Longer Survival than Yttrium-90 Radioembolization and Conventional

Chemoembolization

A. Faramarzalian, N. Obuchowski, G. McLennan, G. Cheah, C. Lance,J. Spain, A. Levitin, A. Gill, M. Sands, F.N. Aucejo, N. Menon, R. Pelley,B. Estfan

Objectives: To compare survival and toxicity after chemoembolization with drug

eluting beads (DEB) versus Yttrium-90 radioembolization (90Y) versus conventional

chemoembolization (TACE) in patients with unresectable hepatocellular carcinoma

(HCC).

Methods: In generating an interdisciplinary single-center database, data was prospec-

tively collected from consecutive patients who underwent trans-catheter therapy from

March 2007 to February 2013. Data was then retrospectively filtered for all patients

with HCC who received chemoembolization or radioembolization therapy without

crossover and were ineligible for resection or transplantation. Response rate was eval-

uated by the modified Response Evaluation Criterion in Solid Tumors. Toxicity was

graded according to the National Cancer Institute Criterion for Adverse Events v 4.0.

Hospitalization rates and duration of stay were tabulated. Median overall survival from

treatment, overall survival from diagnosis, and time to progression were assessed by

the Kaplan-Meier method. Survival outcomes were compared by the Log-rank test.

Chi-square and Wilcoxon signed rank tests were used to assess differences in disease

characteristics, response rate, toxicities, and hospitalizations.

Results: This study included 122 patients with unresectable HCC treated by DEB (n

= 48), 90Y (n = 43), or TACE (n = 31). Patients were predominantly Caucasian (78%),

male (75%), and with BCLC stage C tumors (78%). Cohorts did not differ significantly

in baseline demographics, ECOG status, hepatic function, imaging characteristics,

Childs, Okuda, CLIP, or BCLC tumor stage. DEB led to longer overall survival from

treatment (12.7 vs. 7.9 vs. 10.2 months; p = .008) and diagnosis (18.4 vs. 10.8 vs. 13.5

months; p = .009) than 90Y or TACE, though time to progression (5.6 vs. 4.1 vs. 4.0

months; p = .85) did not differ significantly by treatment modality. However, this insti-

tution uses the presence of main portal vein occlusion as an indication to select 90Y

over DEB or TACE (25% vs. 2% vs. 10%; p = .005). Stratifying for patients without

main portal vein occlusion, DEB continued to offer improved survival from treatment

(12.7 vs. 8.6 vs. 10.3 months; p = .03) and diagnosis (19.3 vs. 11.8 vs. 14.9 months; p

= .03) over 90Y or TACE. Response to treatment was marginally greater following

DEB than 90Y or TACE (53% vs. 33% vs. 36%; p = .10). Abdominal pain was more

frequent following DEB or TACE than 90Y (67% vs. 65% vs. 36%; p = .01). There

were otherwise no significant differences in clinical or laboratory toxicities. TACE led

to longer mean initial (2.1 vs. 1.2 vs. 0.0 days; p < .001) and total hospital stay (4.0 vs.

2.3 vs. 1.9 days, p < .001) than DEB or 90Y therapy. Frequency of patients needing

re-hospitalization did not differ significantly between the TACE, DEB or 90Y cohorts

(26% vs. 25% vs. 30%; p = .86).

Conclusions: DEB therapy resulted in improved survival and marginally greater

response over 90Y radioembolization or conventional TACE in patients with unre-

sectable HCC. Time to progression did not differ significantly by treatment modality.

Toxicity was similar among cohorts, despite abdominal pain being greater after

chemoembolization. Initial and total hospital stay per-patient was longest after con-

ventional TACE and shortest after 90Y radioembolization. Though limited by size,

retrospective design, and the inclusion of patients with vascular occlusion, this study

demonstrates therapy with DEB to provide favorable survival outcomes for patients

with unresectable HCC. Prospective trials are recommended to further explore this sur-

vival benefit.

Conclusions: DEB TACE with 100-300 μm eluting beads is an effective and safe

treatment method and demonstrates higher OS in pts with unresectable HCC as com-

pared to DEB TACE with 300-500 and 500-700 μm eluting beads.

The Kaplan Meier survival graph demonstrating survival difference between group

A (100-300 μm eluting beads) and group B (300-500 and 500-700 μm eluting

beads).

Table 1 Demographics, Clinical and Imaging Characteristics of Patients Treated with

DEB TACE with 100-300 Micron (Group A) versus 300-500 and 500-700 Micron

eluting beads.

BCLC* -Barcelona Clinic Liver Cancer (BCLC)

Paper 4: Downstaging HCC to Within Milan Criteria Using Doxorubicin-

eluting Bead TACE

T.J. Green, P.J. Rochon, S. Chang, C.E. Ray, A. Brown, H. Winston,B.C. Shulman, J. Durham

Objectives: To assess downstaging rates in HCC patients treated with doxorubicin-

eluting (DEB)-TACE, from UNOS stage T3 disease to within Milan criteria.

Methods: Single center retrospective study of patients treated with DEB-TACE

between September 1, 2008 and December 21, 2011. Twenty-two consecutive patients

with UNOS stage T3 HCC (one nodule >5 cm or up to 3 nodules with one >3 cm), no

extrahepatic disease (distant metastases or regional lymph nodes >2 cm short axis),

and no imaging evidence of vascular invasion, meeting diagnostic criteria for HCC as

defined in the updated AASLD guidelines, were included in the study. Patients were

treated with DEB-TACE using variable technique (bead size, dose, degree of arterial

selectivity, etc) according to operator preference. Baseline and follow-up CT or MR

imaging performed prior to first DEB-TACE and at least 28 days after each DEB-

TACE treatment was assessed by an abdominal radiologist, who recorded the longest

enhancing diameter of each HCC, according to EASL recommendations and the mRE-

CIST system.

Results: Seventeen of 22 (77%; 95% confidence interval = 55-92%) patients were

downstaged to within Milan criteria. At the time of this submission, of the 17 down-

staged patients, seven eventually underwent transplantation; one remains active on the

transplant list; one is undergoing transplant evaluation; five eventually progressed

beyond Milan criteria; two were censored at the time of subsequent non-LC bead

TACE; and one was censored at the time of subsequent radiofrequency ablation. Mean

time from first DEB-TACE to downstage (N=17) was 98 days (standard deviation =

63 days). Mean time from first DEB-TACE to transplant (N=7) was 228 days (standard

deviation = 106 days). Of the seven transplanted patients, all are still living, though

two have developed metastatic HCC. Of those downstaged but not transplanted (N=6),

mean time from downstage to progression beyond Milan criteria was 149 days (stan-

dard deviation = 69 days). Baseline demographic and clinical characteristics of our

patients overall, and according to whether or not they were downstaged are given in

759.e3W

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Results: Overall survival mean in the measured population was 548.8 +/- 327 days

Of the predictor variables measured for significance in survival, Child’s score (A vs.

B-C) approached significance, which was confirmed with a Student’s T-test (p=0.10).

No other predictor variables demonstrated trends towards significance. Regression

analysis results are pending.

Conclusions: Patients with advanced hepatocellular carcinoma demonstrated

improved survival over reported historical controls when treated with DEB TACE

compared to those observed or treated solely with sorafenib. Larger studies are needed

to confirm the increased survival benefit.

Paper 8: Characteristics of Primary and Secondary Hepatic Malignancies

that Accurately Predict Hepatopulmonary Shunting

S. Zivin, M.S. Dikopf, L. Casadaban, J. Minocha, M. Knuttinen, J.T. Bui,Y. Lu, R.C. Gaba

Objectives: The current protocol for yttrium-90 radioembolization (Y90 RE) includes

technetium-99m macroaggregated albumin (Tc-99m MAA) lung shunt fraction (LSF)

calculation for quantification of non-target pulmonary radiation. Parameters that might

accurately predict high or low LSF could allow early identification of patients who are

not treatment candidates or who need measures to reduce LSF during planning angiog-

raphy (e.g. bland embolization), or could in theory allow deferral of planning

angiography entirely. This study aimed to identify characteristics of hepatocellular car-

cinoma (HCC) and liver metastases that accurately predict low (<10%), intermediate

(10-20%), and high (>20%) LSF.

Methods: In this single center retrospective study, 82 patients (37 HCC, 45 LM,

M:F=54:28, mean age 62 years) who underwent mapping angiography with Tc-99m

MAA LSF calculation prior to Y90 RE from 2007-2011 were identified. Tumor char-

acteristics, such as size and morphology (circumscribed, infiltrative) of index lesion,

focality (uni-, oligo-, multi-nodular), hepatic lobe involvement (left, right, both), dis-

ease burden (<50%, >50%), macrovascular invasion (present, absent), and arterioportal

shunting (present, absent) were correlated with Tc-99m MAA scan calculated LSFs.

Results: Mean LSF for all tumors was 10.5±6.5%. Higher LSF was associated with

larger index tumor size for HCC (mean 6.9, 7.1, and 12.1 cm for LSF <10%, 10-20%,

and >20%; P=0.049) and liver metastases (mean 5.1 and 7.8 cm for LSF <10% and

10-20%; P=0.008). However, linear regression showed no predictable relationship

between individual tumor size and LSF. Other tumor characteristics showed no pattern

that accurately predicted LSF. Patients underwent median 1.6±0.7 Y90 sessions, and

mean per treatment lung dose was 8.2±6.9 Gy. Overall median survival was 521 (range

25-1603) days.

Conclusions: Tumor characteristics do not show a significant relationship with LSF.

While index lesion size has a statistical relationship with broad LSF categories, LSF

is not predictable in individual cases. If radiation pneumonitis is felt to be a clinically

significant adverse event within the anticipated life expectancy of Y90 patients, then

Tc-99m MAA scanning remains a necessary component of Y90 pre-procedure plan-

ning.

Paper 9: LI-RADS: Initial Experience in Multidisciplinary HCC Tumor Board

M.A. Sultenfuss, K. Hussain, M. Hanif, K. Kobayashi, D. Anaya,R. Matejowsky

Objectives: To evaluate our initial experience of categorizing untreated liver lesions

by LI-RADS criteria during multidisciplinary HCC tumor board.

Methods: The Liver Imaging Reporting and Data System (LI-RADS) was developed

to standardize liver lesion interpretation and reporting in cirrhotic patients, as well as

facilitate treatment. We implemented the LI-RADS system at our institution’s multi-

disciplinary HCC tumor board prior to January 2012. All patients presented in tumor

board since implementing LI-RADS criteria were reviewed from January 2012 through

December 2012. LI-RADS categories assigned to each untreated lesion were evalu-

ated, excluding any previously treated lesions. Pathologic confirmation of the

diagnosis, if available, was also reviewed.

Results: Over 336 untreated lesions in 156 patients were categorized by LI-RADS

criteria. There were 14 LI-RADS (LR) category 1 lesions (4.1%), 16 LR2 lesions

(4.8%), 139 LR3 lesions (41.4%), 101 LR4 lesions (30.0%), and 66 LR5 lesions

(19.6%). Treatment recommendations after assigning a LI-RADS category ranged

from no-follow-up needed or observation in LR1-LR3 lesions. Biopsies were recom-

mended in some LR3 lesions, based on additional clinical concern for HCC. LI-RADS

4 and 5 category lesions were referred for loco-regional therapy, surgical resection,

and/or chemotherapy. Two LR3 category lesions were downgraded to LR1 at follow-

up imaging. A third LR3 lesion was downgraded to LR1 after core biopsy

demonstrated fatty change. Two lesions were upgraded in LR category after follow-

up imaging: One LR2 lesion was upgraded to LR4, and one LR3 lesion was upgraded

to LR5. Two non-HCC lesions were mistakenly assigned LI-RADS 5B category. One

was determined to be a neuroendocrine tumor after biopsy, while the other was deter-

mined to be an FNH after additional imaging.

Conclusions: LI-RADS categorization of untreated lesions in our HCC tumor board

has successfully standardized lesion interpretation and reporting, and facilitated deci-

Paper 6: Longitudinal Quality of Life Assessment in Patients with

Unresectable Advanced Infiltrative Hepatocellular Carcinoma with Portal

Vein Thrombosis Post Yittrium-90 Radioembolization

M. Xing, N. Kokabi, J.C. Camacho, J.R. Spivey, S.I. Hanish, B. El-Rayes,J. Kauh, X. Wang, H.S. Kim

Objectives: To evaluate the effects of Yittrium-90 (Y-90) rediombolization on health-

related quality of life (HRQOL) in patients with advanced infiltrative hepatocellular

carcinoma (HCC) and portal vein thrombosis (PVT).

Methods: Single-center, IRB-approved, HIPPA compliant, prospective HRQOL

scores were obtained through Short-Form 36 (SF-36) assessment tool. Regular assess-

ments were performed at baseline and monthly after Y-90 therapy. Twelve consecutive

patients (10 males; mean age 59 (range 35-80)) with advanced (Barcelona Liver Can-

cer stage C) infiltrative HCC (geographic high T2 signal conspicuous tumor on MR)

and PVT are presented in this midterm report. All patients underwent baseline HRQOL

assessment and were at least 3 months post Y-90 therapy. Longitudinal analysis was

performed by evaluating baseline HRQOL scores for significant change (p <0.05) at

1, 2, and 3 months post Y-90 therapy. Statistical significance was analyzed using paired

t-test, with significance level set at 0.05. SPSS software v20.0 (IBM, Armonk, NY)

was used for all data management and analysis.

Results: Patients showed decreased pre-treatment baseline scores within all 8 domains

of the SF-36 compared to age-adjusted controls. One patient expired within 1-month

post therapy. Eleven patients completed HRQOL questionnaires at 1, 2 and 3 months

post Y-90 therapy. At 1 month, there were statistically significant negative trends in

physical functioning (RF) (score change, -21.8; p= 0.026; n=9), role physical (RP)

(score change, -29.5; p= 0.029; n=5), and social functioning (SF) (score change, -18.2;

p= 0.034; n=9) domains. No significant change in any HRQOL domain, including SF,

RF, and RP, was observed at 2 and 3 months post treatment when compared to the base-

line. Figure 1 illustrates longitudinal trends of each of 8 domains evaluated by SF-36

in the cohort.

Conclusions: Midterm analysis of standardized HRQOL survey indicates that while

patients with advanced-stage infiltrative HCC with PVT undergoing Y-90 therapy may

perceive short-term (~1 month) temporary decline in PF, RP and SF domains post ther-

apy, these changes appear to be transient with returning back to baseline within

2-months after therapy.

Paper 7: Post DEB TACE Survival Outcomes in Patients with Advanced

Hepatocellular Carcinoma

A.C. Brown, C.E. Ray, J. Durham, H. Winston, T.J. Green, P.J. Rochon

Objectives: To determine if there is a survival benefit in patients with advanced hepa-

tocellular carcinoma treated with DEB TACE.

Methods: A database of 239 patients treated with DEB TACE was assembled from

the institutional medical record and retrospectively reviewed after IRB approval was

obtained. 43 patients met the inclusion criteria of advanced HCC (BCLC > C) who

were treated with DEB TACE between September, 2008 and December, 2011. Patients

concomitantly treated with sorafenib were excluded. The primary outcome was sur-

vival from date of first TACE treatment to date of death. Patients who were still alive

had their most recent encounter date recorded. For patients who underwent liver trans-

plantation, the date of transplant was used as last encounter. Survival data was

measured with Kaplan Meier. Secondary outcome predictors for survival including

bilirubin, ECOG score, albumin, MELD score, and AFP were assessed by Wilcoxon

Rank Sum analysis to determine their significance on overall survival rate in this

patient population. Variables that approached significance were further evaluated with

Fisher’s exact or students t-test.

759.e4

sion making for these patients. There is a learning curve in applying this system into

daily practice, and a firm understanding of the criteria for each lesion category is crit-

ical. Pitfalls include mimics of HCC, which should always be considered when

utilizing this system.

Paper 10: Comparative Study of Staging Systems for Hepatocellular

Carcinoma in 428 Patients Treated with Radioembolization

R. Salem, M. Vouche, R. Lewandowski

Objectives: During the last decade, Yttrium-90 radioembolization has emerged as a

treatment option for hepatocellular carcinoma (HCC). We aimed to compare the utility

of different staging systems and analyzed independent predictors of survival in patients

with HCC treated with 90Y radioembolization.

Methods: 428 HCC patients were treated with 90Y at our institution from 2004-2011.

All patients were staged prospectively by Child-Turcotte-Pugh [CTP], United Network

for Organ Sharing, Barcelona Clinic Liver Cancer [BCLC], Okuda classification, Can-

cer of the Liver Italian Program [CLIP], Groupe d`Etude et de Traitement du

Carcinome Hepatocellulaire, Chinese University Prognostic Index and the Japan Inte-

grated System; their ability to predict survival was assessed. Staging systems were

compared using cox-regression model, linear trend test, Akaike information criterion

(AIC) and Concordance Index (C-index). Uni/Multivariate analyses were employed to

assess independent predictors of survival.

Results: When tested independently, all staging systems provided significant ability

to discriminate early (long survival) from advanced disease (worse survival). CLIP

provided the most accurate information in predicting survival outcomes (AIC=2993,

C-index=0.8503); CTP was least informative (AIC=3074, C-index=0.6445). Independ-

ent predictors of survival included ECOG 0 (HR:0.56, CI:0.34-0.93); non-infiltrative

tumors (HR:0.62, CI:0.44-0.89); absence of portal venous thrombosis (HR:0.60,

CI:0.40-0.89); absence of ascites (HR:0.56, CI:0.40-0.76); albumin ≥2.8 g/dL

(HR:0.72, CI:0.55-0.94); alkaline phosphatase ≤200 U/L (HR:0.68, CI:0.50-0.92); and

AFP ≤200 ng/mL (HR:0.67, CI:0.51-0.86).

Conclusions: CLIP was most accurate in predicting HCC survival. Given that not all

patients receive the recommended BCLC treatment strategy, this information is rele-

vant for clinical trial design and predicting long-term outcomes following 90Y.

Paper 11: Minimizing Radiation Dose in CT-guided Lung Biopsies: Are

Operator Choices or Nodule Characteristics More Important?

R.C. Valentin, M. Shamis, J.P. Erinjeri, L.T. Dauer, M. Maybody,J. Durack, W. Alago, K. Brown, S. Solomon, R.H. Thornton

Objectives: To evaluate radiation dose variability from CT-guided lung biopsy and

to determine what factors were associated with lowest-dose procedures.

Methods: 50 consecutive CT-guided lung biopsies performed in 2012 by 13 inter-

ventional radiologists (range 1-9; median 3 biopsies each) were retrospectively

reviewed. Effective dose estimates were calculated using an effective dose/dose length

product conversion factor of 0.017. Procedures with total effective dose ≤ 25th per-

centile were compared to those with a dose ≥ 75th percentile. Nodule characteristics

(size, needle trajectory length, location, and morphology), mode of CT guidance, scan

lengths and technical factors were evaluated for association with dose.

Results: Overall, estimated effective dose varied 147-fold from 0.21-31.3 mSv

(median 2.6 mSv). 14 doses were ≤ 25th percentile (mean 1.04 mSV, range 0.21-

1.66mSv); 13 doses were ≥ 75th percentile (mean 8.74mSv, range 4.5-31.3 mSv).

Nodule characteristics were similar between groups, with no significant difference

in nodule size (p=0.09), needle trajectory length (p=0.35), location (central vs

peripheral, p=0.68; lower lobe vs other lobe, p=1.0), or morphology (solid vs sub-

solid, p=0.22). Compared to the highest dose quartile, procedures with lowest doses

had significantly shorter scan lengths for both lesion localization (p=0.0007) and

post-procedure evaluation (p=0.01); lower tube currents (<=60 mA; range 10-60 mA,

p=0.006); and fewer procedural scans (p=0.01). Use of helical CT vs CT-fluoroscopy

for procedure guidance was not different between groups (p=0.38). Contributing fac-

tors to high dose procedures included use of tube currents > 60 mA (54%);

dose-escalating changes to pitch and/or gantry rotation speed (32%); and operator-

specific factors (14%).

Conclusions: Operator choices, not lesion characteristics, determined whether

patients received lower or higher radiation doses from CT-guided lung biopsy.

Paper 12: Radiofrequency Ablation as a Primary Therapy for Lung

Carcinoma: Effectiveness and Survival

C.A. Ridge, M. Silk, E.N. Petre, J.P. Erinjeri, W. Alago, C.T. Sofocleous,R.H. Thornton, S.B. Stephen

Objectives: To report patient outcomes following radiofrequency (RF) ablation of

early stage primary lung carcinoma.

Methods: 31 patients (12 men and 19 women; median age, 74 years, range 51-92)

with 23 T1a and 9 T1b primary lung tumors were included in this retrospective study

approved by the institutional review board. Median tumor diameter was 15 mm (8-30).

RF ablation was performed using computed tomographic (CT) guidance. Follow-up

CT or positron emission tomography (PET)-CT studies were obtained immediately

after treatment and every 4-6 months during a median surveillance period of 21 months

(5-59) thereafter to assess for complications and tumor recurrence. Technical success

and effectiveness rates were calculated and disease free survival and overall survival

were modeled using Kaplan-Meier analysis.

Results: 32 primary lung tumors were treated by RF ablation between May 2006 and

September 2010. One patient developed a metachronous lung tumor during surveil-

lance which was also treated with RFA. For T1a tumors, technical success and

technical effectiveness were 100% (23/23) and 82% (19/23), respectively. However,

for T1b tumors, technical success and technical effectiveness were 100% (8/8) and

63% (5/8), respectively. Local recurrences occurred in 4 of 24 patients with T1a tumors

(20%) and 5 of 8 patients with T1b tumors (63%). For all patients with T1 tumors,

median survival was 48 months (5-90). Estimated 1 and 3 year survival was 100%

(95% CI, 100) and 69% (95% CI, 42-85), respectively. Estimated 1 and 3 year disease

free survival was 88% (95%, CI, 67-96) and 80% (CI, 58-91), respectively. Pneumoth-

orax requiring chest tube occurred in 7 of 32 ablations (22%).

Conclusions: RF ablation for T1 primary lung tumors has a high technical effective-

ness, can provide good local tumor control, and may prolong survival of patients with

primary lung carcinoma that cannot undergo curative resection.

Paper 13: Complications of Computed Tomography-guided Placement of

Lung Fiducials for the Purpose of Stereotactic Body Radiation Therapy

P. Reeves, M. Abramson, M. Mete, F. Banovac

Objectives: To investigate the complication rates associated with percutaneous com-

puted tomography (CT)-guided placement of lung fiducials for the purpose of

stereotactic body radiation therapy of lung lesions.

Methods: We conducted a retrospective review of CT scans, follow-up chest radi-

ographs and medical records for 162 patients with single or multiple lung lesions who

underwent percutaneous CT-guided placement of lung fiducials between 9/2003 and

7/2012 at an academic medical center. Patients who underwent repeat percutaneous

CT-guided placement of lung fiducials were excluded. Presence of pneumothorax,

placement of thoracostomy tube, and presence parenchymal hemorrhage were evalu-

ated. The effects of age, gender, size of lesion, number of fiducials placed, and

performance of concomitant biopsy on the complication rates were analyzed.

Results: Of 162 patients with a total of 541 fiducials placed, 79 patients (49%) expe-

rienced a procedure-related pneumothorax and 31 patients (19%) required

thoracostomy tube placement. Patients who experienced pneumothorax had a higher

average age, 74, than those who did not, 70 (p = 0.02). Occurrence of pneumothorax

was associated with a smaller average lesion diameter, 2.7 cm, than no pneumothorax,

3.2 cm (p = 0.05). There was no significant effect of gender, number of fiducials

placed, or performance of concomitant biopsy on pneumothorax incidence. Postpro-

cedural or intraprocedural CT demonstrated significant parenchymal hemorrhage in

18 patients (11.0%). Five patients experienced intraprocedural hemoptysis, with pre-

mature termination of the procedure in 2 of the 5 cases. There was no significant effect

of age, gender, size of lesion, number of fiducials placed, and performance of concomi-

tant biopsy on incidence of parenchymal hemorrhage.

Conclusions: We found that approximately one half of patients develop pneumoth-

orax, and approximately one fifth of patients develop pneumothorax requiring

thoracostomy tube placement. Smaller lesion diameter and older age are associated

with an increased risk of pneumothorax. Concurrent biopsy at the time of fiducial

placement was not associated with an increased risk of pneumothorax. Clinically sig-

nificant hemorrhage occurs infrequently.

Paper 14: Safety of Same Day Discharge After Renal Tumor Thermal

Ablation

M. Galfione, C. Farrelly, M. Soulen, T. Clark, T. Guzzo, A. Wein,B. Malkowicz, S. Stavropoulos

Objectives: Overnight hospital admission of patients after percutaneous renal abla-

tion remains standard practice for many institutions. The aim of this study is to evaluate

the safety of same day discharge of patients who undergo percutaneous CT-guided

radiofrequency ablation (RFA) and cryoablation of renal tumors.

Methods: An IRB approved retrospective analysis was conducted of patients with

renal tumors treated with percutaneous CT-guided RFA and cryoablation between Jan-

uary 2004 and June 2012. Ablation method, tumor size, complications and rates of

hospital admissions were analyzed.

Results: A total of 153 procedures were performed on 134 patients including 82

cryoablations and 71 radiofrequency ablations. All patients were planned to be dis-

charged the same day as their procedure following a standard 4 hour observation

period. Overall, five of 153 encounters (3.3%) resulted in patients being admitted

overnight. All five admissions occurred because of a complication detected during the

first 4 hours after the procedure. Hospital admission was required in 4/71 (5.6%) RFA

encounters and in 1/82 (1.2%) cryoablation encounters (p=0.28). Admission was

required because of pneumothorax (n=2, one each group) and bleeding (n=3, all in the

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RFA group). There were no procedure related readmissions after same day discharge

however 2/71 (2.8%) RFA encounters had perinephric hematomas detected after dis-

charge but the patients did not require admission .There was no significant difference

in mean tumor size between the RFA (3.1cm) and cryoablation (3.3cm) groups (p=0.4).

Conclusions: Planned same day discharge after renal cryoablation and RFA is safe

with no significant difference detected between the two procedures. Complications

requiring admission are low and were detected in the immediate post-procedure obser-

vation period.

Paper 15: Long-term Outcomes Following Percutaneous Radiofrequency

Ablation of Renal Masses ≤ 4 cm

A.N. Kurup, G. Schmit, A.J. Weisbrod, M.R. Callstrom, T. Atwell

Objectives: To assess the long-term efficacy of percutaneous radiofrequency ablation

(RFA) in the treatment of small renal masses ≤ 4 cm.

Methods: After institutional review board approval, 315 renal tumors treated in 286

RFA procedures among 271 patients at our institution between May of 2000 and

December of 2011 were retrospectively identified for study. Technical success (absence

of tumor enhancement or growth within 3 months of treatment) and local tumor control

(absence of new nodular enhancement within the ablation zone or ablated tumor

growth at 3 months or later following treatment) were assessed. Time to recurrence

was assessed for the subset of 265 (84%) tumors that were followed for at least three

months. 18 of the 271 patients were missing information regarding vital status or dura-

tion of follow up, leaving 253 patients for survival analyses. Recurrence-free, overall,

and cancer-specific survival was estimated using the Kaplan-Meier method. The dura-

tion of follow-up for recurrence-free survival was defined from the date of RFA to the

date of last tumor follow-up. The duration of follow-up for overall and cancer-specific

survival was defined from the first date of RFA for each patient to the date of death or

the date the patient was last known to be alive. Complications were graded using the

Clavien-Dindo classification with grades ≥ 3 considered major complications.

Results: Median patient age was 70 years (range 25-91), and 199 (63%) patients were

male. Median tumor size was 1.8 cm (range 0.6-4.0). There were 4 (1.3%) technical

failures observed. Among the 265 tumors that were followed for at least three months,

8 (3.0%) tumors recurred at a mean of 4.1 years following RFA (range 0.8-8.0). The

mean duration of follow-up for the 257 tumors that did not recur was 3.6 years (median

2.6; range 0.3 – 11.2). Estimated recurrence-free survival rates (95% CI; number still

at risk) at 1, 3, 5, and 7 years following RFA were 99.6% (98.7 – 100; 223), 97.8%

(95.6 – 100; 131), 96.9% (94.1 – 99.7; 78), and 94.8% (90.1 – 99.8; 39), and 87.1%

(76.5 – 99.1; 6), respectively. Among the 265 tumors with adequate follow up, 93

(35%) contained RCC at biopsy. Three (3.2%) of these 93 tumors recurred at 0.8, 2.5,

and 8.0 years following RFA, respectively. The mean duration of follow-up for the 90

RCCs that did not recur was 3.3 years (median 2.9; range 0.3 – 8.4). Estimated recur-

rence-free survival rates at 1, 3, 5, and 7 years following RFA for the subset of

biopsy-confirmed RCC tumors were 98.8% (96.4 – 100; 77), 96.8% (92.5 – 100; 44),

96.8% (92.5 – 100; 24), and 96.8% (92.5 – 100; 10), respectively. These were not sig-

nificantly different from the overall cohort. Of the 253 patients with follow up for

survival analysis, 61 (24%) died at a mean of 3.4 years following the first RFA (median

2.8; range 0.2 – 9.9). Estimated overall survival rates at 1, 3, 5, and 7 years following

RFA were 98.7% (97.3 – 100; 214), 82.0% (76.7 – 87.7; 134), 69.1% (62.2 – 76.7; 81),

and 65.3% (57.7 – 73.8; 44), respectively. Estimated cancer-specific survival rates at

1, 3, 5, and 7 years following RFA were 100% (100 – 100; 102), 98.6% (96.1 – 100;

69), 96.3% (91.2 – 100; 40), and 96.3% (91.2 – 100; 22), respectively. Among the 286

procedures, 32 (11%) resulted in a complication, including 6 (2%) major complica-

tions.

Conclusions: Percutaneous RFA provides durable local control in the treatment of

small renal masses ≤ 4 cm, equivalent between non-biopsied solid renal masses and

biopsy-proven RCC. However, imaging surveillance must be long term given late

tumor recurrences.

Paper 16: Image-Guided Cryoablation (CRYO) of Renal Cell Carcinoma

(RCC): The Mid-term Result

T.M. Wah, W. Gregory, J.T. Smith, J.M. Cartledge, A.D. Joyce, P.J. Selby

Objectives: This aims to evaluate our mid-term clinical experience with percutaneous

image-guided cryoablation (CRYO) of renal cell carcinoma (RCC) at a single tertiary

university teaching institution.

Methods: Percutaneous image guided cryoablation was performed on 77 renal tumors

in 70 patients from May 2008 to November 2012 in a single institution. Prospective

data documentation for the tumor ablation database included patient’s demographics,

clinical details, treatment parameters, imaging characteristics and clinical/imaging fol-

low up outcome were reviewed. All treatments were performed using CT-guidance

under general anaesthesia. Warm pyeloperfusion was used when treating centrally

located tumors or tumors sited close to the ureter. CT-guided pneumo-dissection with

carbon dioxide/ sterile air or CT-guided hydro-dissection with 5% Dextrose fluid tech-

nique was used accordingly to protect the surrounding vital structures when they were

in close proximity to the treatment margin. Treatment response was examined with

contrast enhanced CT or MRI. Technical success was defined by absence of contrast

enhancement within the tumor on CT or MRI. All technical success (primary and over-

all), complications (major and minor) and management and outcomes of the

complications were prospectively documented. The mid-term treatment outcomes such

as the local disease and distant metastasis progression rates were also examined.

Results: A total of 77 renal tumors with a mean tumor size of 2.8cm (range 0.9- 5.5

cm) in 70 patients (45 male and 25 female patients) were treated with image guided

cryoablation. The mean patient age was 67.9 years (age range 21.6 to 86.2 years). The

primary and overall technical success rates were 93.5% vs. 97.4% respectively. A total

of 75 renal tumors were completely ablated (72 during a single session, 2 after a second

session and 1 after a third session) with a mean imaging follow-up period of 20.4

months (range from 1-56 months). All residual disease requiring repeated treatment

(n=5) occurred when performed by operators with less than 12 months image guided

cryoablation experience. One patient declined re-treatment and another patient is cur-

rently awaiting repeat treatment. The pre- and post-treatment eGFR were 65.3 +/- SD

25.6 ml/min/1.73m2 vs. 63.4 +/- SD 28.6 ml/min/1.73m2. There was no significant

difference between the eGFR measurements before and after treatment (p=0.11). Our

minor and major complication rates were: 3% and 1.2% respectively. There were 5

minor complications including small pneumothorax that was managed conservatively

(n=1), small subcapsular haematoma (n=2) and transient lumbar plexus injury (n=2).

One predicted ureteric injury occurred while treating a centrally RCC adjacent to the

renal pelvis without warm pyeloperfusion during our initial experience. At our mid-

term follow up, we have no local disease progression or distant metastasis progression

related to primary RCC to date following image guided cryoablation treatment.

Conclusions: Percutaneous image-guided cryoablation of RCC is a safe, effective

and minimally invasive treatment. This treatment offers preservation of renal function

and has good mid-term treatment outcome results. However, there is a definite learning

curve for cryo-needle placement and residual disease should improve with operator’s

experience. Warm pyeloperfusion should be considered for treating tumors close to the

collecting system/ureter.

Paper 17: Ultrasound-guided Transhepatic Radiofrequency Ablation of

Renal Tumors: A Safe Alternative Approach

R. Hegg, T. Atwell, A. Kurup, G. Schmit

Objectives: To determine the feasibility and safety of ultrasound-guided transhepatic

radiofrequency ablation (RFA) of masses in the right kidney.

Methods: Between June 2001 and December 2011, 122 separate RFA procedures

were performed on right kidneys in 120 different patients. Of these procedures, 18 were

performed via transhepatic approach on 18 patients. Complications (Clavien-Dindo

classification system), local control, and changes in renal function were evaluated for

all patients.

Results: Median maximal diameter of the treated renal tumors was 1.9 cm (range 1.1

– 4.3 cm). Complications developed in 1 of the 18 patients (5.6 %). No patients devel-

oped tumor seeding of the ablation tract. No peri-procedural mortality, kidney loss,

peri-procedural dialysis or long term dialysis occurred in any of the patients. Median

drop in patient estimated glomerular filtration rate (eGFR) following renal ablation

was 1.0 ml/min (mean = -4.6 ml/min; range -29.0 – 20.0 ml/min). At median follow-

up of 26 months, 18/19 (93%) tumors show no local recurrence.

Conclusions: Percutaneous transhepatic RFA of renal neoplasms is technically fea-

sible and is associated with a low rate of complications. Transhepatic RFA provides an

additional approach which may allow safe ablation of tumors that would be difficult

to treat by standard RFA approach.

Paper 18: The Role of 3D Image Segmentation in Planning

Radiofrequency Ablation (RFA) of Renal Cell Carcinoma

T.M. Wah, D.M. Magee, D.L. Buckley, P.J. Selby

Objectives: Planning image-guided RFA of RCC is usually performed on 2D slices

of CT or MRI, but treatment strategy can be difficult based on 2D visualisation as the

interventional radiologist (IR) has to create a mental 3D image to assist planning, this

usually requires a lot of clinical experience. We aim to evaluate the feasibility of man-

ual segmentation of contrast-enhanced (CE) MRI of RCC and adjacent vital organs

pre-RFA to create a 3D volume dataset using the offline in-house built interactive com-

puter software. In addition, to compare the shortest distance (SD) between RCC and

vital organs measured by the automatic analysis of segmented 3D volume with the rou-

tine 2D clinical measurement measured by the experienced (IR and Senior Fellow-SF)

and inexperienced readers (medical student-MS).

Methods: Twenty patients with 21 RCCs underwent RFA and had pre-treatment CE-

MRI. The images with the tumour and vital organs were segmented manually offline

by the experienced IR to create the 3D volume using the computer software in two dif-

ferent sittings to test for intra-observer variability. The SD between two points (renal

tumour and vital organs) is calculated by taking the 3D distance transform of the seg-

mentation of one structure and determining the minimum value of this transform over

all voxels in the other structure. For the 2D manual clinical measurement, the SD was

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performed on the routine clinical reporting workstation. This was measured on single

slice axial 2D-images where the distance was deemed shortest by IR, SF and MS.

Results: The segmentation of renal tumor vs. vital organ was measured twice by the

experienced IR in two different sitting shows low intra-observer variability (r ≥ 0.99,

p < 0.0001). In this cohort, the vital organ that was close to the treatment margin and

was segmented: colon (n=9), muscle (n=8), pancreas (n=1), adrenal (n=1) and spleen

(n=1). One renal tumor had no vital organ at risk in close proximity. The mean SD

measured using the 3D volume dataset vs. 2D axial dataset by the experienced IR, was

not statistically different 7.6 +/- 6.1 mm (3D) vs. 8.7 +/- 6.3 mm (2D) (p< 0.59). For

the 2D axial dataset, the mean SD for the experienced IR vs. senior fellow vs. medical

student were, 8.7 +/- 6.3 mm, 9.4 +/- 6.7 mm and 12.9 +/- 8.5 mm respectively. The

measurement between the experienced observers, IR and SF has good correlation R2

= 0.97 and there is poor correlation between the IR and SF with the MS with R2 =0.46

and 0.44 respectively.

Conclusions: It is feasible to segment the pre-treatment CE-MRI of RCC off line to

create a 3D volume dataset using the in-house built computer software which provides

automatic analysis of the SD between RCC and vital organ, which is highly correlated

with IR 2D clinical measurement. However, a semi-automated segmentation algorithm

that could be incorporated into the scanner software would be useful as this allows real

time segmentation into 3D volume dataset and the treatment planning may be less

reliance on the clinical experience of the operator.

Segmentation of the renal tumor using the computer aided analysis program (Volume

Viewer)

A 3D volume dataset of the anterior and posterior located renal tumors and its rela-

tionship with the surrounding structures

Paper 19: Cryoablation vs. Microwave Ablation of Small Renal Masses:

Is There a Difference in Outcome?

J. Martin, F. Magistris, S. Athreya

Objectives: There are various treatment options for small renal tumors,raning from

nephron sparing surgery to percutaneous ablation techniques. However, their effect on

the biology of small renal masses (SRMs) have yet to be characterized. The objective

of the current study was to analyze and compare the published data regarding cryoab-

lation and microwave ablation as primary treatments of SRMs.

Methods: A search of the MEDLINE, CINAHL, and PUBMED databases was per-

formed in October 2012 to review the literature regarding the treatment of suspected

renal malignancies by means of renal cryoablation or microwave ablation. This meta-

analysis was limited to series that analyzed clinically localized, sporadic renal tumors

that were managed by open, laparoscopic, and percutaneous cryoablation or microwave

ablation. Series that included only patients with hereditary or metastatic RCC were

excluded. Prospective and retrospective series were included in the study, although sin-

gle case reports were excluded. In the case of multiple series from an institution or

overlapping patient cohorts with potentially redundant data, only the most recent series

or the series with the largest study population was selected to avoid double counting

of patients. In total, 51 met inclusion criteria and were analyzed.

Results: Fifty-one studies representing 1942 kidney lesions treated by cryoablation or

microwave ablation were analyzed. No differences were detected between ablation

modalities with regard to mean patient age (P = 0.15), or duration of follow-up (P =

0.07). Mean tumor size was significantly bigger in the microwave ablation group (P =

0.03). There was no difference in primary effectiveness (93.75% vs. 91.27%, P = 0.40),

cancer-specific survival (98.27% vs. 96.8%, P = 0.47), local tumor progression (4.07%

vs. 2.53%, P = 0.46), or progression to metastatic disease (0.8% vs. 0%, P = 0.12). The

higher incidence of local tumor progression with cryoablation was found to be corre-

lated significantly with mean follow-up duration on univariate (P = .009) and on

multivariate regression analysis (P = 0.003). Cryoablation usually was performed evenly

laparoscopically (49.17%) and percutaneously (49.79%). Microwave ablation was per-

formed more frequently with laparascopy (50.61%) relative to percutaneously (37.20%).

Open access was used more frequently in microwave ablation (12.20% vs. 1.04%).

Conclusions: Although the long term survival remains to be established for ablation

modalities, the current data suggest that there is no difference in local tumor control

or metastatic spread with cryoablation compared with microwave ablation, even with

significantly larger tumors in the microwave ablation group.

Table 1 - Patient Tumor Characteristics and Outcome According to Ablation

Modality

Table 2 – Univariate and multivariate regression analysis of factors postulated to

influence local and metastatic tumor progression in patients treated with

cryoablation.

Paper 20: Percutaneous Microwave Ablation of Renal Tumors:

Multicenter Evaluation of Safety and Efficacy

A.J. Moreland, T.J. Ziemlewicz, A.M. Fischman, J. Hinshaw, E. Abel,M.G. Lubner, S.L. Best, M.L. Center, C.L. Brace, F.T. Lee Jr.

Objectives: To evaluate the feasibility, safety, and preliminary effectiveness of a high-

powered, gas-cooled microwave ablation system for treatment of renal tumors.

Methods: Between 1/2011 and 12/2012, 35 renal tumors in 35 patients were treated

at two medical centers using ultrasound and CT-guided microwave ablation with a

high-powered, gas-cooled microwave ablation system (NeuWave Medical, Madison,

WI). Tumors included biopsy-proven renal cell carcinoma (n=26; grade 1=6; grade

2=15, ungraded=5), angiomyolipoma (n=4, diagnosis made by imaging), oncocytoma

(n=2), glomerulosclerosis (n=2), and insufficient tissue for diagnosis (n=1). Mean

patient age was 63 years, with 26 males and 9 females. Post-procedure imaging was

performed by CECT or MRI to evaluate for enhancement in the ablation zone at target

intervals of 3, 6, and 12 months post-ablation.

Results: Mean pre-treatment tumor diameter was 2.9 cm (range: 1.0-5.4). Tumor

diameter decreased by a mean of 13% (range: -30 to +30%; SD = 15%) on immediate

post-ablation CT. An average of 1.5 antennae were used per tumor, and the mean dura-

tion of power application was 6.5 minutes (range: 3-12). Mean generator power was

76.7 W (range: 52.5-140). No residual enhancing tumor was observed on immediate

post-procedure CT for all tumors. There was one major complication (3%, n = 1/35;

renal artery aneurysm and AVF caused by immediate pre-procedure biopsy with active

extravasation requiring coiling) and one minor complication (3%, n = 1/35; urinary

retention requiring discharge with Foley catheter). Serum creatinine as measured in 31

patients pre- and post-ablation demonstrated a mean percent change of -0.1% (range:

-24.3 to +47.9). Hospital stay was 1 day for all patients, with a 30-day readmission rate

of 3% (n=1; readmitted on post-operative day 4 for shortness of breath secondary to

fluid overload). Median length of clinical follow-up was 8.0 months. All patients are

currently alive and without evidence of metastatic disease, with the exception of one

death occurring approximately 6 months post ablation and unrelated to either the pro-

cedure or the malignancy. 22 patients have had follow-up imaging at a mean of 5.7

months status post ablation (range: 2-19 months), with enhancement in the ablation

zone identified in one case (a 3.0 cm centrally-located clear cell RCC). One additional

case of a 2.8 cm papillary RCC demonstrated post-ablation histologic evidence of

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viable tumor, but without enhancement on follow-up MRI. Retreatment of this tumor

with percutaneous microwave ablation has been performed. Overall, the procedure

demonstrated 91% primary treatment effectiveness (n = 20/22) and a 95% secondary

treatment effectiveness (n = 21/22), with one tumor yet to be retreated.

Conclusions: Utilizing a high-powered, gas-cooled percutaneous microwave ablation

system for the treatment of renal masses appears feasible, safe, and efficacious at short

term follow-up. Further studies are warranted to demonstrate long-term oncologic out-

comes.

Paper 21: Vessel-Dependent Thrombotic Events during Microwave Tumor

Ablation of an in-Vivo Porcine Liver Model: A Pilot Study

J. Chiang, B. Willey, C.L. Brace

Objectives: Microwave tumor ablation systems are capable of heating tissue to higher

temperatures compared to radiofrequency systems, thus overcoming heat sink effects

and creating a more homogenous ablation zone. However, there is limited information

on the risks of blood vessels acting as a heat conduit and thrombosing near microwave

ablation zones. In this preliminary study, we performed microwave ablations near

major vasculatures in an in-vivo porcine liver model and monitored the rate of throm-

botic events as a function of vessel size and velocity.

Methods: Microwave antennas (Neuwave Medical Inc, WI) were placed in 9 in-vivo

porcine lobes. Under ultrasound guidance, the nearest portal vein, hepatic artery and

hepatic vein around each antenna was identified. Vessel size, blood flow velocity and

transverse spacing from the antenna were measured under ultrasound and Doppler

imaging. Microwave ablations were performed at 100 W for 5 minutes. Post-ablation

vessel flow was measured under Doppler to detect thrombotic events.

Results: Within 27 vessels, we found separability between thrombosed and un-throm-

bosed vessels in terms of vessel size and velocity. Hepatic arteries, spaced up to 26

mm away from the antenna, remained patent after the ablation. Hepatic veins and por-

tal veins, spaced up to 32 mm away from the antenna, were observed to be both patent

and thrombosed. The main differentiating variables between patent hepatic arteries and

thrombosed portal vein/hepatic veins were the size (2.03±0.7 vs 6.43±3.22 mm,

p=<0.01) and velocity (100.11±19.90 vs 17.43±10.5 cm/sec, p<0.00001). There was

no significant difference between the antenna spacing of the hepatic arteries and por-

tal/hepatic veins.

Conclusions: The results suggest that vessel size and velocity influence thrombotic

risk when antenna spacing is normalized between vessels. High flow rates and smaller

vessel size associated with hepatic arteries appear to confer a protective “heat-sink”

effect to the vessel patency. Slower flow rates and larger vessels that characterize

hepatic and portal veins are more susceptible thrombosis during high-temperature heat-

ing associated with microwave ablations. Antenna spacing was expected to be a

determining factor in thrombotic events, but our limited sample size currently does not

support this. Additional animal studies are underway to confirm these results and clar-

ify the effect of antenna spacing.

Paper 22: Subclinical Breast Cancer: Minimally Invasive Approaches. Our

Experience on Percutaneous Radiofrequency Ablation vs Cryotherapy

G. Manenti

Objectives: To compare the efficacy of radiofrequency ablation and cryoablation in

the treatment of sub clinical invasive breast cancers, based on tumor necrosis, clinical

and cosmetic outcome.

Methods: Eighty post-menopausal women with a mean age of 73±5 years with small

(≤2 cm) invasive breast cancer were retrospectively evaluated. We had 2 groups, forty

underwent cryoablation with a double 17-gauge probe procedure under US-guidance,

associated with intra-procedural lymph node mapping and excision of the sentinel node

and forty underwent radiofrequency ablation using a 25-mm 15-gauge monopolar cool-

tip needle electrode by using a temperature-controlled mode with the same protocol.

Tumor volume and histopatologic data were compared by means post-procedural 3.0-

T magnetic resonance imaging (MRI). 30-45 days after the percutaneous ablation all

patients underwent surgical resection.

Results: Both techniques allow to obtain a good correlation with histopathological

data. The general shape of the ablated area was close to a sphere in all cases. In 75

(93,8%) patients we observed a complete necrosis of the lesion, in five cases there was

residual disease in post-procedural MRI and postoperative histological examination.

There was a good correlation between MRI volume and histologic samples. Cosmetic

results were good in all the patients but two.

Conclusions: Both percutaneous radiofrequency ablation and cryotherapy are mini-

mally invasive techniques with a good clinical and cosmetic outcome on selected cases.

MRI examination is an ideal method to qualify and quantify breast neoplasm and resid-

ual tumor extent after percutaneous ablation. Cryotherapy is preferred because of

analgesic effect of freezing with better patients compliance in offsetting.

MRI evaluation

One-week post-ablation MRI showed no residual enhancement in 71 (88,7%) of 80

lesions (36 for cryoablation and 35 for RF ablation). The 4 week post-ablation MRI

showed increasing enhancement in 5 (6,25%) (2 for cryotherapy and 3 for RF abla-

tion) of the 9 areas of residual enhancement suggesting residual tumor tissue, which

was confirmed by results of NADH-diaphorase assessment

Cosmetic evaluation

Cosmetic evaluation was performed at the end of the ablation (Time 0) and at 4

weeks from the procedure (Time I), prior to the surgical excision. The absence of

skin pigmentation was considered excellent cosmetics as grade 1, breast with slight

texture changes or mild pigmentation was index of good cosmetics as grade 2, breast

with moderate texture or pigmentation was acceptable cosmetics as grade 3, the

presence of marked texture or pigmentation changes was considered a poor cosmet-

ics as grade 4.

Paper 23: Seeding: Unreasonable Fear? Needle Track Seeding Post CT

Guided Radiofrequency Ablation for Hepatocellular Carcinoma and Liver

Colorectal Metastases

V. Demers, T. Cabrera, R. Lindsay, D. Valenti

Objectives: Hepatocellular carcinoma (HCC) and metastatic colorectal liver cancer

(mCRC) are the two most common malignant liver tumors worldwide (El-Serag et al,

1999). While surgical resection remains the gold standard therapy, only 15-30% of

HCC patients (Poon et al, 2001; Poon et al, 2004) and 10-15% of mCRC patients

(Fong, 1999) are resectable. Percutaneous ablation using radiofrequency (RFA) is one

of the leading alternative treatments to control and potentially cure malignant liver

tumors, whether primary or metastatic, in patients unsuited for surgical resection.

Malignant seeding is a dreaded, but not well documented, complication after percuta-

neous RFA in patients with HCC and liver colorectal metastases. Needle tract seeding

following RFA of a liver tumor is defined as the development of new neoplastic disease

outside the liver capsule, either in the subcutaneous soft tissues of the abdomen, inter-

costal muscles or peritoneum, long the path f the needle used to perform the ablation

procedure. Its real incidence is difficult to assess and has been demonstrated to range

from 0.72% to 0.95% in HCC and from 0.9% to 12.5% in mCRC (Stigliano et al,

2009). The aim of this study is to determine and compare the risk of seeding, defined

as new neoplastic lesions in subcutaneous tissue or peritoneal cavity post ablation, for

HCC and mCRC.

Methods: A review of our prospective database of patients treated by CT guided RFA

for HCC or mCRC, from January 2008 to September 2012, was performed. A total of

57 patients underwent RFA for HCC and a total of 60 patients underwent RFA for

mCRC. All patients were followed with CT scan or MRI at 6 weeks after the procedure

and 6 months later. Short and long term imaging was reviewed retrospectively for

assessment of needle tract tumor seeding. Risk factors like postprocedure hematoma,

use of multiple needles, or pre-ablation biopsy were analyzed.

Results: A total of 182 of lesions were treated in total, with an average of 1.6 lesions

per patient. Multiple lesions treated in the same session was common in the colorectal

cancer group. Various ablation devices are used at our Institution, including Radionics

Cool Tip, single or three needles; Boston Scientific Le Veen needle from 3 to 5 cm, or

microwave ablation, Evident, Covidien one, two or three antennas. In every case, cau-

terization of the track was performed. The mean follow up time was 325 days with a

max of 1758 days. Among the 57 patients who underwent CT guided RFA for HCC

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and the 60 patients who underwent CT guided RFA for mCRC at our institution from

January 2008 to September 2012, 3 suspicious case for malignant seeding detectable

on imaging (CT or MRI) were reported.

Conclusions: Although tumor seeding along the needle track has been reported, its

incidence is not known and reports are variable. In our study, only 3 cases of suspected

seeding were reported among 182 treated lesions, for a risk of 1.65% per lesion. We

consider the risk to be very low when compared with other complications and that it

is an acceptable clinical risk after a percutaneous thermal ablation procedure.

Paper 24: A Short Microwave Ablation Zone is Possible: In Vivo

Experience with Single and Multiple Modified Triaxial Antennas

M. Lubner, T. Ziemlewicz, L. Hinshaw, F. Lee, L. Sampson, C.L. Brace

Objectives: Microwave ablation allows for faster heating, hotter temperatures, and

larger ablation zones. In addition to larger ablation zones, microwaves often generate

elongated ablation zones with lengths ranging from 4.9 to 8.5 cm reported in the liter-

ature. However, this increased ablation zone length may at times lead to unique

challenges, particularly in patients with small tumors, tumors at the periphery of the

liver, poor liver function or closely adjacent vulnerable structures. This has been one

of the main limitations of microwave to date. To combat this problem, a modified tri-

axial antenna was made to create shorter, rounder ablation zones. The purpose of this

study was to evaluate the ability of single and paired modified triaxial microwave

antennas to produce precise, spherical ablation zones.

Methods: A total of 50 single-antenna and 11 paired-antenna ablations were per-

formed in an in vivo porcine liver model. Ablations were performed using 17 gauge

gas cooled modified triaxial antennas powered continuously at 65W from a 2.45 GHz

generator. Single antenna ablations were performed at 2 (n=16), 5 (n=21), and 10

(n=13) minutes. Paired antenna ablations were performed with 2 antennas spaced 1 cm

apart for 5 (n=7) and 10 minutes (n=4). Following ablation, animals were euthanized,

ablation zones excised en bloc and sectioned along the antenna tract. Mean transverse

width, length, area and aspect ratio (width:length) were obtained. Results were com-

pared to a conventional triaxial microwave antenna used in a similar in vivo model.

Results: For single antennas, mean ablation zone length was 2.9±0.45, 3.5±0.55 and

4.2±0.40 at 2, 5, and 10 minutes respectively. Mean width was 1.8±0.3, 2.0±0.32,

2.5±0.25 at 2, 5, and 10 minutes. For paired antennas, mean length (cm) at 5 and 10

minutes respectively was 4.2±0.9 and 4.5±0.32. Mean width was 3.0±1.0 and 3.8±0.9

cm at 5 and 10 minutes. Single antenna aspect ratios of 0.57 and 0.59 were calculated

at 5 and 10 minutes, compared to aspect ratios for paired antennas of 0.72 and 0.83 at

5 and 10 minutes. Single and paired antenna ablation zones remain shorter and are

rounder than those produced by single conventional triaxial antennas where mean

lengths of 5.3 and 5.8 cm were seen at 5 and 10 min respectively in a prior study in a

similar model.

Conclusions: Microwave ablations using single and paired modified triaxial antennas

can generate relatively short, spherical ablation zones which may enable microwave

treatment of tumors in patients with tenuous liver function or tumors abutting vulner-

able structures. This warrants further evaluation of additional spacing combinations

for paired antennas to help guide clinical use.

Paper 25: Single Center Experience with Percutaneous Irreversible

Electroporation (IRE) for Down Staging and Control of Unresectable

Pancreatic Adenocarcinoma

G. Narayanan, K.J. Barbery, R. Suthar, N. Zamora, R. Fourzali, T. Froud,E. Perez-Rojas, J. Yrizarry

Objectives: To evaluate the overall median survival in the group of patients with

locally advanced pancreatic cancer (LAPC) treated with irreversible electroporation

(IRE). Irreversible electroporation (IRE) is a non-thermal ablative modality that uses

high voltage DC current to cause cell death.

Methods: Pancreatic cancer carries a dismal prognosis with just 8% of newly diag-

nosed patients having localized disease (1). Nearly 40% of the patients are inoperable

due to vessel encasement and fall in the LAPC category. Treatment options include

chemotherapy and/or radiation, but outcomes remain poor. IRE has been used in a sur-

gical setting to treat pancreatic cancer, and we present a single center experience with

the percutaneous use IRE in the treatment of LAPC. IRE was performed in patients

with pancreatic cancer whose tumors remained unresectable after, or who were intol-

erant of standard therapy. The procedures were all done percutaneously, under general

anesthesia. Patients were then followed for adverse events, and tumor response. Over-

all median survival was calculated using the Kaplan Meier curve.

Results: Twenty nine IRE procedures were performed in 27 patients (2 patients were

treated twice). Nine patients were excluded from the analysis as 7 had metastatic dis-

ease and 2 had recurrence in the pancreatic bed. Eighteen patients in the LAPC group

were analyzed for overall median survival. All patients had received chemotherapy

previously, and 12 had received radiation. The median tumor size was 3.5 cm (range

1.2-8 cm). Immediate and 24-hour post-procedural scans demonstrated patent vascu-

lature in the treatment zone in all patients. Two patients underwent surgery 4 and 5

months after IRE, respectively. Both had margin-negative resections, and one had a

pathologic complete response; both remain disease-free after 17 and 14 months,

respectively; the latter patient is currently lost to follow up. Complications included

pancreatitis (n = 3), abdominal pain (n=3) and hematoma (n=3). Six patients died from

progression of disease and no deaths were directly related to the procedure. Overall

median survival was 16.2 months (95% CI: 8.1-24.3 months).

Conclusions: Percutaneous IRE for pancreatic adenocarcinoma is feasible with care-

ful patient selection and workup. The median survival 16.2 months warrants further

evaluation of the role of IRE in the management of pancreatic cancer.

1.Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA CancerJ Clin.

2012;62:10Y29.

Overall survival: total patients- 18; total pts died-6

Overall median survival: 16.2 months (95% CI: 8.1-24.3 months)

Paper 26: Impact of Hepatic Blood Flow on the Size of MW Ablations at

2.45 GHz and 915 MHz

G.D. Dodd, A.C. Lanctot, S.M. Kreidler, D.H. Glueck

Objectives: Prior work has shown that the size of hepatic lesions produced by RF

ablation (RFA) is inversely affected by changes in hepatic blood flow while the size

of lesions produced by MW ablation (MWA) at 915 MHz are unaffected by change in

hepatic blood flow. In this study we investigate the impact of changes in hepatic blood

flow on the size of lesions produced by MWA at 2.45 GHz and compare it to those pro-

duced by MWA at 915 MHz.

Methods: 120 ablations (6 at 2.45 GHz [140W, 5min, Certus 140TM, NeuWave Med-

ical] and 3 at 915MHz [60W, 10min, MTX-180, BSD Medical] per liver) were

performed in 25 bovine livers perfused with autologous blood via the portal vein at 60,

70, 80, 90, and 100 ml/min/100g liver. Length and width were measured, and volume

and sphericity index (SI) were calculated for each ablation. Size and SI of ablations were

compared across flow rates while controlling for lobe and correlation within livers.

Results: Hepatic blood flow was not a significant predictor of volume (p=0.12),

length (p=0.37), width (p=0.20), or SI (p=0.99) for either 2.45 GHz or 915 MHz

MWA. 2.45 GHz produced larger volume ablations than 915 MHz (p<0.0001). The

average lesion volume at 2.45 GHz was 30.72 cm3 (95% CI: 29.44 to 32.00 cm3), and

at 915 MHz was 23.66 cm3 (95% CI: 22.18 to 25.13 cm3). Variation in ablation vol-

ume was greater at 2.45 GHz than 915 MHz (p=0.002). Both devices produced oblong

ablations. On average, the ablation volume was 33.1% (95% CI: 30.7% to 35.4%) of

the volume that would have been achieved with a perfectly spherical ablation.

Conclusions: Ablation size and shape do not change with flow for MWA at 2.45 GHz

and 915 MHz. The volume of ablations produced at 2.45 GHz is both larger and more

variable than 915 MHz. In comparison to prior work, it appears that both MWA fre-

quencies are less susceptible than RFA to changes in flow rate.

Paper 27: Analysis of Tissue Contraction during Microwave Ablation with

CT Imaging

D. Liu, C.L. Brace

Objectives: Tissue contraction is an important factor affecting device characterization

and clinical treatment assessment post ablation. The objective of this study was to eval-

uate radial and longitudinal contraction over time during high temperature liver

ablation using CT.

Methods: A total of 46 aluminum fiducial markers were positioned in a 60mm x

80mm grid, in a single plane, around a microwave ablation antenna in ex vivo liver.

The liver was then placed onto the bed of a CT scanner. A 3-4cm diameter ablation

zone was created by applying 100W for 10min. During each ablation, the entire liver

volume was imaged using CT (0.625mm slices, 15cm field of view) every 30 seconds.

A total of 8 ablations were performed to allow statistical analysis of CT images using

the following procedure. Maximum intensity projection was used to generate a two

dimensional image of the markers, antenna and liver. Marker displacement between

time frames was determined using a custom block-matching algorithm. Displacement

vectors were then split into radial (towards the antenna) and longitudinal (along the

antenna) components, which represented radial contraction and longitudinal contrac-

tion, respectively. Contraction maps were then generated by interpolating the

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displacement from all of the markers onto a rectangular grid. The final dataset was

compiled by averaging the displacement maps over all samples at each time point.

Results: Total radial and longitudinal contraction (displacement maps), and contrac-

tion over time are shown in Fig.1 and Fig.2. Mean total radial contraction 5mm, 10mm

and 15mm from the antenna were 1.4mm, 2.5mm and 3.1mm, respectively. These rep-

resent relative contractions of 27%, 25% and 20%, respectively. Total displacement

decreased exponentially over time, with approximately 63% of the total radial contrac-

tion occurring within the first 5 minutes. Mean total longitudinal contraction was

negligible in the region distal to the antenna’s radiating segment. Longitudinal con-

tractions were 1.4 mm, 2.4 mm and 3.4 mm, representing relative contractions of 28%,

24% and 23% at 5 mm, 10 mm and 15 mm proximal to the radiating segment, respec-

tively. Longitudinal contraction followed a similar trend as radial contraction over time.

Approximately 63% of the longitudinal contraction occurred in the first 4minutes of

heating. .

Conclusions: Tissue contraction can reduce the measured diameter of microwave

ablations by approximately 25%. An irregular spatial pattern of contraction follows

the heating pattern of the microwave antenna. Both radial and longitudinal total con-

traction increases with increasing of radial and longitudinal distances respectively, but

the greatest relative contraction occurs near the center of ablation zone. Contraction

slows over time, with the greatest effect occurring in the first 4minutes of heating.

Displacement map

Plot of contraction vs time

Paper 28: Percutaneous Microwave Ablation of Hepatocellular Carcinoma

with High-Powered, Gas-Cooled Antennas: 24-Month Experience in 63

Patients

T. Ziemlewicz, L. Hinshaw, M. Lubner, C.L. Brace, M. Alexander,L. Sampson, F.T. Lee Jr.

Objectives: Microwave (MW) ablation is a promising technology that offers several

advantages over radiofrequency (RF) ablation including: faster heating, higher (more

lethal) tissue temperatures, improved consistency in different tissue types, and poten-

tially greater ablation zone sizes. The purpose of this study was to retrospectively

review the results in the first 63 patients with hepatocellular carcinoma (HCC) treated

with a high-power, gas-cooled MW device at a single center.

Methods: Between December 2010 and December 2012 we treated 91 hepatocellular

carcinomas in 63 patients via a percutaneous approach utilizing US and/or CT guid-

ance. There were 54 male and 9 female patients with mean age of 61 years (range

44-83). All procedures were performed with a high-powered, gas-cooled microwave

system (Certus 140, Neuwave Medical, Madison, WI) utilizing 1-3 (mean 1.7) 17-

gauge antennas. Antenna power and ablation time was determined by the performing

physician based on lesion size, location, and imaging findings. Mean power was 78 W

(range 35-140 W) and mean ablation time was 5.7 minutes (range 1-15 minutes). 12

tumors in 10 patients were treated with chemoembolization at the time of or within 3

weeks preceding microwave ablation (7 patients with tumors >4 cm and 3 patients

where the tumor(s) could not be identified by ultrasound). Follow-up imaging was per-

formed immediately post-ablation and at 1, 3, 6, 9, and 12 months with

contrast-enhanced CT or MRI.

Results: Tumors ranged in size from 0.5 to 6.0 cm (mean 2.5 cm) and median follow-

up was 10 months. All treatments were considered technically successful with no

evidence of residual tumor at immediate post-procedure CECT. Primary treatment

effectiveness was 89.0% (80/91) for all tumors, 94.7% (74/79) for tumors < 4 cm, and

58.3% (7/12) for tumors > 4 cm. Primary treatment effectiveness for tumors > 3 cm

and < 4 cm was 100% (9/9). Secondary effectiveness via local regional therapy (LRT)

was 98.8% (85/86), with one patient awaiting repeat microwave ablation. 5 tumor pro-

gressions were excluded from secondary effectiveness analysis as they were noted only

at explant pathology and therefore there was not opportunity for retreatment. Of the

tumor progression in lesions <4 cm (n=5); 3 were treated with little or no margin due

to compromised hepatic function or proximity to a critical structure and 2 were iden-

tified as only microscopic foci at explant pathology (by H&E staining, no viability

staining was performed). A single minor complication occurred (1.6%), a main portal

vein thrombus following ablation of a caudate lobe lesion which was noted at 1 month

follow-up and resolved with anti-coagulation. There were no major complications. A

patient died 8 days following the procedure secondary to a pneumonia for which he

refused treatment. There was no procedure related mortality. Overall survival is 85.7%

at median 10 month follow-up with deaths related to end stage liver disease (n=4), mul-

tifocal HCC/ESLD (n=3), transplant complications (n=1), or pneumonia (n=1).

Conclusions: 24 month experience treating hepatocellular carcinoma using a high-

powered, gas-cooled microwave ablation system is safe with excellent local control.

Prior RF studies have noted a substantial drop in efficacy when tumors exceed 3.0 cm

in diameter. In this study local control of HCC by MW ablation was excellent in tumors

up to 4.0 cm in size. Continued study is warranted to determine durability of treatment

and survival with longer follow-up.

Paper 29: Microwave Ablation of Focal Hepatic Malignancies Regardless

of Size: Short-Term Safety and Efficacy

E.S. Alexander, F.J. Wolf, J.T. Machan, K.P. Charpentier, J. Iannuccilli,R.A. Haas, D.E. Dupuy

Objectives: To retrospectively evaluate the safety and efficacy of microwave ablation

(MWA) as a treatment for single, focal hepatic malignancies.

Methods: Institutional review board approval was obtained for this HIPAA-compliant

retrospective study. From December 2003 to May 2012, 66 patients (42 men, 24

women; mean age 69.3±12.5) were treated with MWA for a single hepatic lesion, in

66 sessions (intra-operative, n=14; percutaneous, n=52), with the intent to treat all

known disease. Hepatocellular carcinoma (HCC) was treated in 25 patients (mean

tumor size, 3.8±2.2 cm; range, 1.0-12.0 cm) and metastatic disease was treated in 41

patients (mean tumor size, 3.5±1.9 cm; range, 0.8-8.0 cm). Kaplan-Meier (K-M)

method was used to analyze time event data. Chi-square and correlation were used to

examine the relationship between tumor size and treatment parameters.

Results: Technical success rate was 95.5% (63/66). Treatment parameters were tai-

lored to tumor size; as size increased more antennae were used (p = <.0001), the

likelihood of treatment in a single activation decreased (p = <.0001), and treatment

time increased (p = <.0001). To test the adequacy of our treatment parameters tailored

to tumor size we tested the time to recurrence as a function of tumor size, number of

activations, number of antennae, and treatment time, none of which were statistically

significant. Additionally, tumor histology and receipt of adjuvant chemotherapy

showed no evidence of earlier time to recurrence. At one-year follow-up, K-M analysis

predicted a likelihood of recurrence of 39.8% in patients with HCC and of 47.9% in

patients with metastatic disease at the site of the previously ablated lesion. Analysis

yielded median cancer specific survivals of 38.3 months for HCC patients and 35.9

months for hepatic metastases patients. Complications occurred in 21.2% (14/66) of

sessions, and included, nausea, pain requiring analgesics, pneumothorax, pneumonia,

bradycardia, skin burn, somnolence, UTI, and presyncope.

Conclusions: MWA appears to be a safe and effective treatment option for patients

with single, focal hepatic malignancies, especially in non-surgical patients.

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Paper 30: Cetuximab Plus Chemoembolization Adopting Drug-eluting

Beads Preloaded with Irinotecan (DEBIRITUX) as Second-line Treatment

for Metastatic Colorectal Cancer to the Liver: Results of a Clinical Phase

II Study

G. Fiorentini, C. Aliberti, M. Tilli, P. Coschiera, F. Gomez Munoz,R. García Marcos, L. Mulazzani

Objectives: Transarterial chemo embolization (TACE) adopting DEBIRI has demon-

strated manageable toxicities and a favorable response rate. The addition of cetuximab

to DEBIRI can increase treatment efficacy. We evaluated the efficacy and safety of

cetuximab plus DEBIRI, the DEBIRITUX regimen, as second-line treatment in

patients with liver metastases (LM) not resectable from colorectal cancer (CRC).

Methods: In a phase II study, treatment consisted of weekly cetuximab for 12 admin-

istrations plus two cycles of DEBIRI. Tumor response was evaluated monthly for three

months than every 3 months. The primary efficacy criterion was the complete response

(CR) rate and the response rate (RR).

Results: From April 2008 to April 2010, 20 patients were enrolled ( 12 KRAS wt and

8 mutated). The median age was 64 years (range, 35-75 years). The median duration

of DEBIRITUX was 2.9 months ( range 2.5-3.2), and a median of 10 cycles of cetux-

imab was given per patients (range 8-12). All Patients received 2 sessions of DEBIRI.

Two Patients (10%) showed a CR, with a duration of 7.3 and 10.2 months . Sixteen

patients presented responses with an objective response rate of 80% (95% CI 66%-

91%).The responses were not related to KRAS status confirming the hypothesis of

activity of DEBIRI. The median overall and progression free survival times were 14.7

months and 6.5 months, respectively. The most frequent grade 2 adverse events were

post embolization syndrome ( 30%), diarrhea 35%, skin rushes (30%) and fatigue

(25%).

Conclusions: The DEBIRITUX regimen appears to be effective and feasible in sec-

ond line treatment of liver metastases (LM) from CRC in patients KRAS wt. In the

sub set of patients KRAS mutated only DEBIRI is suggested.

Paper 31: Radioembolization with Yttrium 90 Microspheres as a Salvage

Therapy for Heavily Pretreated Patients with Hepatic Colorectal

Metastases

E. Violari, C.T. Sofocleous, W. Shady, N. Pandit-Taskar, A.R. Garcia,E.N. Petre, L. Brody, W. Alago, R. Siegelbaum, J. Durack, J.P. Erinjeri,S. Solomon, K. Brown, A. Covey, R.H. Thornton, G. Getrajdman,M. Maybody, A. Aguado, J. Carrasquillo, N. Kemeny

Objectives: To evaluate the efficiency of Yttrium 90 selective internal radiation ther-

apy (SIRT) in heavily pretreated patients, with colon cancer liver metastases (CLM)

and identify factors affecting patient survival.

Methods: SIRT dose was calculated using the body surface area (BSA) method as

described in the device insert. Following IRB waiver of approval, review of a HIPPA

registered clinical database was performed. Kaplan Meier methodology was employed

to calculate Overall Survival (OS) and Liver Progression Free Survival (LPFS). Demo-

graphics (Age, sex), extend of hepatic replacement by tumor, extrahepatic disease,

bilobar or unilobar disease, prior Hepatic Arterial Chemotherapy (HAC), prior system-

atic chemotherapy with more than 3 lines, prior biologic chemotherapy with

bevacizumab, prior liver surgery, full dose delivery before stasis, time from primary

diagnosis to liver metastases (DFI1), time from liver metastases to SIRT (DFI2) and

additional therapies after SIRT (systemic chemotherapy, HAC and thermal ablation)

were assessed as factors affecting oncologic outcomes. CEA levels before and after

treatment at 6 and 12 weeks were compared.

Results: From September 2009 to November 2012, 48 patients (25 males and 23

females), median age 56 (range 24-86) years received SIRT for CLM at a median of

38 months from initial diagnosis and 33 months since the development of CLM.

Thirty-three out of 48 patients received additional therapy after SIRT: 30 had systemic

chemotherapy, 12 had hepatic arterial chemotherapy (HAC) and 5 had liver thermal

ablation. Median overall survival (OS) from the time of initial SIRT was 9 (95% CI:

6-18) months. One, 2, and 3 year survival probabilities were: 45% (95% CI: 3%-29%),

19% (95% CI: 30-59%) and 13%,( 95% CI: 8-34%), respectively. Median total sur-

vival from the initial diagnosis of the primary colorectal tumor was 46 (95% CI:

34-111) months. At univariate analysis age <60 (p=0.03), bilobar disease (p=0.01), and

a shorter DFI1 (p=0.02) were factors associated with decreased OS. Regarding addi-

tional therapies after SIRT, HAC (p=0.02) was associated with increased OS. Patients

that were treated with HAC after SIRT had a median OS of 17 months compared to 8

months for those who didn’t receive HAC (p=0.02). Median OS for patients who were

treated with systemic chemotherapy after SIRT was 15 months compared to 8 months

for those who didn’t receive additional chemotherapy (p=0.52). Patients with bilobar

disease had a median survival of 7 months and patients with unilobar disease had a

median survival of 17 months. At multivariate analysis age <60 (p=0.02), shorter DFI1

(p=0.05), and bilobar disease (p=0.002) retained significance. Sex (p=0.93), extrahep-

atic disease (p=0.87), percentage of liver replacement by tumor (p=0.17), DFI2

(p=0.07), prior SIRT HAC (p=0.79), prior SIRT systemic chemotherapy > 3 lines

(p=0.61), prior SIRT biologic chemotherapy with bevacizumab (p=0.56), prior SIRT

liver surgery (0.07), administration of full dose before stasis (0.52), post SIRT systemic

chemotherapy (p=0.53) and post SIRT ablation (p=0.09) did not influence the survival

after SIRT. Median LPFS was 5 (95% CI: 3-7) months. A shorter DFI2 (p=0.05), and

age <60 (p=0.05) were factors associated with shorter LPFS, however, none of the fac-

tors reached significance at multivariate analysis. CEA levels before and at 6 and 12

weeks after treatment were not significant.

Conclusions: Salvage SIRT for CLM in heavily pretreated patients may help extend

OS. Given that this population was treated with Yttrium 90 for persistent metastases

after multiple lines of chemotherapy and several other treatment modalities the onco-

logic outcomes are encouraging. SIRT did not impede additional treatments and the

combination with systemic and HAC shows promising results even at this advanced

salvage setting.

Paper 32: Percutaneous Microwave Ablation of Hepatic Metastases with

a High-powered, Gas-cooled Antennae: 24 Months Experience in 29

Patients

L. Hinshaw, T. Ziemlewicz, M. Lubner, C.L. Brace, M. Alexander,L. Sampson, F.T. Lee Jr.

Objectives: Oligometastic disease is a leading indication for thermal ablation.

Microwave (MW) ablation offers several advantages over radiofrequency (RF) abla-

tion that make it well suited for this indication including: faster heating, higher (more

lethal) tissue temperatures, improved consistency in different tissue types, and poten-

tially greater ablation zone sizes. The purpose of this study was to retrospectively

review the results in the first 29 patients with hepatic metastatic disease treated with a

high-power, gas-cooled MW device at a single center.

Methods: Between December 2010 and December 2012 we treated 66 hepatic metas-

tases (Primary: 26 colon, 13 carcinoid, 11 melanoma, 7 sarcoma, 3 renal cell

carcinoma, 3 neuroendocrine tumor, and 1 each endometrial cancer, breast cancer, and

squamous cell carcinoma) in 29 patients via a percutaneous approach utilizing US

and/or CT guidance. There were 19 male and 10 female patients with mean age of 61

years (range 35-84). All procedures were performed with a high-powered, gas-cooled

microwave system (Certus 140, Neuwave Medical, Madison, WI) utilizing 1-3 (mean

= 2.3) 17-gauge antennas. Antenna power and ablation time was determined by the

performing physician based on lesion size, location, and imaging findings. Mean power

was 77 W (range = 55 – 140 W) and mean ablation time was 5.5 min (range = 2-17

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min, SD = 3.3 min). Follow-up imaging was performed immediately post-ablation and

at 1, 3, 6, 9, and 12 months with contrast-enhanced CT or MRI.

Results: Tumors ranged in size from 0.6 to 6.0 cm (mean = 2.1 cm, SD = 1.5 cm) and

median imaging follow-up was 5 months with a mean imaging follow-up of 7.3

months. All treatments were technically successful with no evidence of residual tumor

at immediate post-procedure CECT. Local tumor progression occurred in 4.5% of

treated lesions (3/66), two of which have undergone successful repeat treatment with

microwave ablation, and one of which developed brain metastasis in the interval and

has gone on systemic therapy. This gives a primary technique effectiveness of 95.5%

and a secondary technique effectiveness of 98.5%. A single minor complication

occurred (3.4%) (significant pain at site) and a single major complication occurred

(3.4%) (right sided pleural effusion requiring two throacenteses). There were no pro-

cedure related mortalities and all patients are currently alive with an Overall Survival

of 100% at a mean of 8.9 months. In the 21 patients who have had at least 6 months

of follow up, 14/21 (67%) have developed other sites of metastatic disease for a Pro-

gression Free Survival rate of 33% at a mean of 11.3 months.

Conclusions: Microwave ablation of metastatic disease to the liver is safe and in our

experience associated with a very high local control rate (98.5%) and all oncologic

failures were associated with progression of systemic disease. Continued study is war-

ranted to determine efficacy and survival with longer follow-up.

Paper 33: A Single Center Experience in 127 Consecutive Patients with

Metastatic Uveal Melanoma (UM) Treatment

C. Aliberti, A. Mantoan, S. Valpione, R. Carandina, M. Veronese,G. Ramondo, V. Chiarion

Objectives: We retrospectively reviewed the medical records of 127 consecutive

patients (M/F:61/65) with metastatic UM treated at our institution from September

1990 to February 2012. We collected: gender, age, TNM stage, data and site of primary

UM and metastases; LDH, alkaline phosphatase, gGT, transaminases; treatments and

outcome.

Methods: Ninety-nine (77.95%) patients had liver metastasis (LM), 28 (22%) had

local or nodal involvement, 9 (7.1%) had lung metastases and 13 (10.2%) had SNC or

other visceral metastases (kidney, spleen, adrenal gland, bone), 30 (23.6%) patients

had multiple sites of disease. Lung metastases were more frequent in females (OR 9.17,

95% C.I. 1.11-75.96, p=0.037). LDH and gGT levels at recurrence, or at first diagnosis

in the case of metastatic onset, were inversely correlated with survival (p<0.05). Sur-

vival was significantly poorer in LM bearers (13% versus 55% 1 year survival,

p<0.01). Longer DFI was a prognostic factor for not hepatic recurrence and better

prognosis (logistic regression, OR 0.88, 95% C.I. 0.78-0.99, p<0.05). Age at diagnosis

correlated with age at recurrence and with longer DFI (p<0.05).

Results: Considering all treatments, almost always combining loco regional to sys-

temic therapy with fotemustine, [hepatic intra-arterial fotemustine, radiofrequency,

alcholization, surgery, intra-arterial hepatic chemoembolization with Irinotecan Drug

Eluting Beads (DEBIRI) TACE, only DEBIRI TACE was associated with an improved

prognosis (OR 0.17, 95% C.I. 0.06-0.46, p<0.001) and with a longer survival after

metastasis diagnosis (p= 0.024).

Conclusions: DEBIRI TACE can be safely combined with systemic therapy and

seems to provide a clinical benefit in UM metastases; this encourages prospective stud-

ies also combining anti angiogenic drugs to systemic chemotherapy.

Paper 34: Response to Radioembolization Associated with Improved

Overall Survival in Mixed Histology Cohort

J. Meyer, A. Shahkarami, S. Li, K. Devarajan, D.S. Ball

Objectives: Radioembolization (RE) permits the delivery of high doses of radiation

to liver tumors, minimizing dose to the normal liver. This can be performed with two

commercially available products: SIR-Spheres and Therasphere, and on a variety of

primary and metastatic tumors. While numerous retrospective studies have been per-

formed on patients treated by radioembolization, the impact of histology on response

has not been fully evaluated. Our institutional experience was reviewed in order to bet-

ter answer this question.

Methods: Medical records from all patients treated with RE between 2002 to 2012

were examined for relevant clinical data as part an Institutional Review Board-

approved retrospective investigation. Clinical data were collected, including primary

histology, lobe treated, number of chemotherapy regimens completed before RE, and

RE dose delivered. All patients without at least one follow-up imaging study were

excluded. All remaining patients were evaluated based upon RECIST criteria for radi-

ographic response, and dichotomized into stable disease versus progressive disease.

Time to progression (TTP) and overall survival (OS) were calculated from the date of

first radioembolization treatment. Kaplan-Meier survival analysis was performed, and

multivariable analysis was pursued using the Cox proportional hazards model. A p

value of 0.05 was considered significant.

Results: A total of 150 patients had been treated with radioembolization. Of these, 71

patients had adequate follow-up imaging for analysis. Male patients made up 58 per-

cent of the cohort, and the mean age was 64 (range: 44-87). The most common

histology was colorectal (31) followed by neuroendocrine (15) and hepatocellular (9).

The remaining patients included: cholangiocarcinoma, sarcoma, breast cancer and

esophageal cancer. Disease was confined to the liver in 17 patients, and the remaining

patients had disease classified as liver dominant. The median number of chemotherapy

regimens was 2 (range: 0-6). Initial treatment was to the right lobe in 56 patients, the

left lobe in 12 patients and both lobes in 3 patients. Forty-two patients had stable dis-

ease or response on imaging, while 29 patients had progressive disease on follow-up

imaging. Median OS was 574 days and survival was increased in patients without pro-

gression (p=0.01, relative risk (RR)=2.43). Time to progression was decreased with

increasing numbers of chemotherapy regimens used (p=0.044, RR=1.29). Colorectal

histology was associated with decreased TTP (p=0.04, RR 2.17). A trend toward

improved TTP was seen with neuroendocrine histology (p=0.07, RR=3.8). After con-

trolling for lobe treated, there was no association of dose and TTP. There was no

significant difference in OS between liver-confined and liver-dominant disease.

Conclusions: This retrospective study finds that response to RE is associated with

increased OS in this mixed population. The association of increasing numbers of

chemotherapy regimens with decreased TTP suggests that RE may be more valuable

earlier in a patient’s course. Given the predominance of metastatic colorectal patients

in the literature, the decreased TTP in these patients suggests that the focus on these

patients may underestimate the utility of RE for patients with liver tumors.

Paper 35: Factors Affecting Peri-procedural Morbidity and Mortality and

Long-term Patient Survival after Arterial Embolization of Hepatic

Neuroendocrine Metastases

E.N. Petre, C.T. Sofocleous, M. Gonen, D. Reidy-Lagunes, I. Ip, W. Alago,A. Covey, J.P. Erinjeri, L. Brody, M. Maybody, R.H. Thornton,G. Getrajdman, K. Brown, S. Solomon

Objectives: To identify factors affecting peri-procedural morbidity and mortality and

long term survival following hepatic artery embolization (HAE) of hepatic neuroen-

docrine tumor (NET) metastases.

Methods: From 08/09/1996 to 09/01/2007 we performed 320 HAEs to treat hepatic

metastases in 137 patients with carcinoid (78) or pancreatic neuroendocrine tumor

(PNET) (59). Forty-seven of the 320 HAEs were performed in patients admitted to the

hospital with symptoms refractory to medical care (urgent group), while 273/320 were

performed on an elective basis (elective group). Complications were categorized using

the Common Terminology Criteria for Adverse Events (CTCAE) v 4.0 . Survival was

calculated by Kaplan-Meier methodology. Univariate and multivariate analyses were

performed in order to identify independent predictors for overall survival, complica-

tions and 30-day mortality. The independent factors were combined to develop clinical

risk score patient groups.

Results: Urgent HAE (p=0.007), liver involvement by metastases greater than 50%

by volume (p<0.0001), and concomitant extrahepatic disease (p=0.007) were inde-

pendent predictors for shorter survival. The risk of death was more than triple for

patients with > 50% metastatic burden (HR=3.27 95% CI: 2.13 – 5.01, p<0.0001), and

double for those with extrahepatic disease (HR= 1.89 95% CI: 1.25 – 2.88, p=0.0028)

as well as for patients treated urgently (HR= 2.08 95% CI: 1.30 – 3.33, p=0.0023).

Patients with all three risk factors (risk score 3) had a very short survival compared to

those with no risk factors (8.5 vs. 86 months; p<0.001). Thirty-day mortality was sig-

nificantly lower in the “elective” (1%) versus the “urgent” group (8.5%) (P= 0.0009).

There were 8/273 (3%) complications of greater than grade 1 severity in the elective

vs. 5/47 (10.6%) in the urgent group (p=0.03). Male sex and urgent referral were inde-

pendent factors for higher rate of peri-procedural death (p=0.023 and 0.016,

respectively) and complications (p=0.012 and 0.001, respectively).

Conclusions: Urgent HAE, replacement of >50% of liver by tumor and concomitant

extrahepatic disease are strong independent predictors of shorter overall survival. Male

sex and urgent HAE carry higher 30 day mortality and periprocedural morbidity.

Overall survival by risk score groups

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Table 1. Multivariate analysis on risk factors for OS: final model after backwards

selection

Paper 36: Quality of Life Assessment after Yittrium-90 SIR-Spheres

Therapy in Patients with Neuroendocrine Tumor Hepatic Metastases

H.H. Park, A.F. Morales, S. Prater, M. Rivas, J. Kang, H.S. Kim

Objectives: To investigate the effects on Health Related Quality of Life (HRQOL)

of patients with neuroendocrine tumor hepatic metastases after undergoing Yittrium-

90 (Y-90) SIR-Spheres therapy.

Methods: Single-center IRB-approved prospective HRQOL study with analysis of

the Short-Form 36 (SF-36) assessment tool before and after Y-90 radioembolization.

The SF-36 questionnaire is used to quantify a person’s health in regards to 8 categories

including: Physical-Functioning (PF), Role-Physical (RP - problems with work or daily

activities as a result of physical health), Role-Emotional (RE), Vitality (VT), Mental

Health (MH), Social Functioning (SF), Body-Physical (BP) and General Health (GH).

A total of 14 patients (5 males, 9 females; average age 61.1 years; range 53-75) with

neuroendocrine tumor hepatic metastases were enrolled in the study. HRQOL scores

were obtained prior to and after Y-90 Sir-Spheres therapy and were compared in two

groups - short-term follow-up (initial treatment to 90 days) and long-term follow-up

(90 days to 1 year after initial treatment). The mean follow-up in the short-term group

was 50.1 days. In the long-term group the average follow-up occurred at 216 days post

initial treatment. The results were analyzed with the paired t-test. Significance levels

were set at p=0.05 for all tests. Age-adjusted norms for the SF-36 questionnaire were

also used for comparison.

Results: Compared to the age-adjusted norms, patients with neuroendocrine tumors

with hepatic metastases experienced decreased raw scores in the areas of RP, RE, VT,

and GH. In the short-term, there was no significant change in each of the domains of

PF (47.5 vs. 42.5, p=0.44), RP (25.0 vs. 37.5, p=0.37), RE (36.1 vs. 38.9, p=0.89), VT

(34.3 vs. 27.1, p=0.16), MH (60.3 vs. 62, p=0.83), SF (53.1 vs. 52.1, p=0.92), BP

(56.25 vs. 63.5 p=0.21) and GH (39.8 vs. 40.7, p=0.87) after initial therapy. Patients

did, however, experience a significant improvement in the RP score in the long-term

after initial treatment (47.7 vs. 70.4, p=0.04). There was no significant change in each

of the other domains of PF (59.5 vs. 58.2, p=0.73), RE (60.6 vs. 72.7, p=0.10), VT

(51.8 vs. 50.5, p=0.66), MH (75.3 vs. 79.8, p=0.09), SF (67.0 vs. 76.1, p=0.14), BP

(73.9 vs. 68.2 p=0.45) and GH (49.3 vs. 54.5, p=0.26) in the long-term. Compared to

the age-adjusted norms increased raw scores were seen in the PF, RP, RE, MH, SF and

BP categories in the long-term.

Conclusions: Compared to the age-adjusted norms patients with neuroendocrine

tumors with hepatic metastases received lower raw scores for Role-Physical, Role-

Emotional, Vitality, and General Health prior to treatment with Y-90 Sir-Spheres. In

the short-term there was no significant change in any category following the initial

treatment. In the long-term, patients experienced improvements in the raw score for

the Physical-Functioning, Role-Physical, Role-Emotional, Mental Health, Social Func-

tioning, and Body-Physical categories. As reflected in this patient population, patients

with neuroendocrine tumors are likely to experience significant improvements in work

or daily activities as related to physical health in the long-term after initial treatment

with Y-90 Sir-Spheres therapy.

Paper 37: Targeted Radiofrequency Ablation (t-RFA) of Spinal Tumors

Using a Novel Bipolar Navigational Device: Multicenter US Initial Clinical

Experience

J. Jennings, B. Georgy, D. Coldwell, B. Zablow, C. DePena, A. Brook,N. Rutledge, K. Conrad, J. Yung-Hung Chang, N. Tran, F. Vrionis

Objectives: Report initial clinical experience and determine the efficacy and safety

of targeted radiofrequency ablation (t-RFA) of malignant spinal lesions using a novel

bipolar RF ablation system. Demonstrate the use of temperature monitoring of ther-

mocouples (TC) on an articulating electrode to determine ablation size and morphology

with use of post-ablation magnetic resonance imaging (MRI) and comparison with pre-

clinical thermal distribution curves.

Methods: 168 lesions in 132 procedures were treated at nine centers. The STAR

Tumor Ablation System includes a robust articulating, navigational bipolar electrode

containing two active TCs positioned to permit real time monitoring of the peripheral

edge of the ablation zone to determine size of ablation. Treatment was controlled by

adjusting power while monitoring TC temperature in-situ. Access and number of abla-

tions were based on lesion size and location, and ability to articulate the bipolar

electrode. Cement augmentation via the same guiding cannula was performed when

required. In some cases not augmented with cement, sequential post-procedural MRI

allowed assessment of ablated area up to one year. Pain was assessed pre and post-pro-

cedurally.

Results: Lesion etiology included a wide variety of metastatic lesions from T2 to S2

and ilium. No complications or thermal injury occurred. Cement augmentation follow-

ing t-RFA was efficient and resulted in predictable cement filling. Post-ablation MRI’s

demonstrated discrete ablation zones with 3:2 length to width aspect ratio consistent

in size with thermal monitoring by TCs during the ablation. Nearly all patients reported

pain relief. Post contrast MRI and histopathology confirmed tumor necrosis.

Conclusions: The STAR device was safely and effectively used in the navigation and

targeted RF ablation of spinal malignant lesions. Post-ablation MRI’s confirmed

lesions were included in the ablation zone with necrosis of the lesion. The ablation

zone was consistent in size with that measured by the TCs and similar in morphology

to that extrapolated from thermal distribution curves. The STAR navigational ability

allowed for easy access to posterior vertebral body lesions, previously difficult to

access with other ablation devices. In many cases, this technique allowed for treatment

of individual lesions not controlled by systemic or radiation therapy.

Paper 38: Percutaneous Vertebroplasty in Treatment of Painful Vertebral

Compression Fractures in Multiple Myeloma

S.S. Patil, S. Kulkarni, N. Shetty, T. Dharia, A. Polnaya, R. Gandhi,H.A. Pendse, M. Thakur, H. Menon, A. Puri, A. Gulia, M. Sengar

Objectives: Percutaneous vertebroplasty is a minimally invasive image guided pro-

cedure used to stabilize vertebral compression fractures & to alleviate pain in

osteoporotic patients in whom conservative management is failed. However only lim-

ited data is available in the literature documenting its use in the treatment of

compression fractures in Multiple Myeloma patients. In this retrospective analysis of

prospective data, we evaluate the efficacy of percutaneous vertebroplasty in the relief

of pain and improvement in quality of life in patients of Multiple myeloma at our insti-

tute.

Methods: We analysed clinical outcome data of vertebroplasty treatment performed

at our institute from May 2007 to May 2012 over a period of 5 years. 67 procedures

of vertebroplasty performed in 40 cases of multiple myeloma patients were included

in the study. . Plane X-rays, computed tomography (CT) scan, and magnetic resonance

imaging (MRI) scan were performed on all patients. With a reflex hammer, percussion

pain was correlated to the imaging abnormalities. The preplanning CT scan was used

to calculate the exact entry point and angle of the bone-biopsy needle. Pain score and

quality of life was assessed pre and post operatively to assess quantitative outcome.

10 points Visual Analog Scale was used for quantification of pain levels and improve-

ment in quality of life was assessed using EORTC QLQC-30 (Vers3.0) questionnaire.

Subjective outcomes included self-reported pain and mobility. The data was collected

preoperatively, next postoperative day and follow up at 3 weeks, 3 month and 6 month

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after treatment. Outcomes assessed includes comparing pre and post procedural pain,

quality of life and change in mobility.

Results: We found out significant improvements in all of the outcome measures post-

operatively and the follow-up period. Quantitative outcome measures (visual analog

pain scale 0–10) improved by 2.6, and 3.6 points, respectively in next post operative

day and in 3 weeks post procedure, with persistent improvement was noted in the fol-

low up period. Quality of life was improved by 2.2 and 2.5 points in 3 weeks and 3

months respectively post procedure, with persistent improvement in the follow up

period. 80% patients treated with vertebroplasty experienced improved mobility in the

follow up interval. Only two patients had mild haemorrahge during the procedure

which was controlled with conservative management. None of the patient developed

any major procedure related complication.

Conclusions: Percutaneous vertebroplasty is thus safe procedure and provides sig-

nificant pain relief for multiple myeloma patients with intractable pain due to vertebral

compression fractures.

Pain score on 10 point Visual Analogue Scale

Mean Pain score on VAS before treatment- 6.97

Mean Pain score Next Post procedure day- 4.4

Mean Pain score 3weeks post procedure- 3.4

Paper 39: Targeted Radiofrequency Ablation (t-RFA) of Malignant Spine

Lesions Before Cement Augmentation Using Novel Bipolar Navigational

Device

B. Georgy

Objectives: Report early clinical experience of t-RFA followed by cement augmen-

tation in malignant lesions of the spine using a novel bipolar RF ablation system,

purpose built for minimally invasive procedures in the axial skeleton.

Methods: 25 spinal lesions in 15 patients with different malignant etiologies were

included after IRB approval. The STAR Tumor Ablation System includes a robust,

articulating, navigational osteotome, containing an extensible electrode. The device is

bipolar and contains two thermocouples (TC) positioned at 10 and 20 mm from center

of the ablation zone to permit real-time monitoring of the ablation zone. RF warmed

cement augmentation via the same guiding cannula was performed after lesion abla-

tion.

Results: All procedures were performed safely with no complications or thermal

injury. Ablation time ranged from 1.5-6 minutes. Maximum recorded temperature was

65 °C at the distal TC and 50 °C at the proximal TC (10 and 20 mm from the center of

the ablation zone, respectively). TCs on the electrode were used to confirm re-estab-

lishment of core temperature prior to cement augmentation. Post procedure CT showed

no significant cement leakage. Average VAS scores dropped from 7 pre-procedure to

4.7 post-procedure. Average ODQ scores improved from 25.8 to 18 post-procedure.

Decreased tumor volume and decreased metabolic activity was confirmed by MRI and

PET scan, respectively.

Conclusions: Targeted RF Ablation followed by RF warmed high viscosity cement

augmentation was performed successfully in this series of malignant spinal lesions.

Improvement in pain and functional status was noted in all patients. The STAR Tumor

Ablation System permitted minimally invasive access to all lesions, regardless of loca-

tion. Proximal and distal TCs allowed accurate monitoring of the temperature inside

the vertebral body to avoid complications of nearby vital structures. Targeted delivery

of high viscosity cement following ablation via the same guiding cannula provided

vertebral stability.

Paper 40: Outcome of Endovascular Treatment for Aneurysmal Bone

Cysts

R. Shaikh, H. Padua

Objectives: Surgical management of aneurysmal bone cysts (ABCs) is associated

with perioperative morbidity, mortality and high recurrence. In addition, some ABCs

are inoperable. We evaluated the presentation, morphology, technique and outcome of

percutaneous image guided sclerotherapy for ABCs.

Methods: We retrospectively reviewed the medical records and imaging studies of

patients with ABCs who underwent percutaneous sclerotherapy at our institution. Age,

location, size, symptoms, image guidance, agents used and outcomes were docu-

mented. Symptomatic and radiological changes were evaluated and compared pre and

post sclerotherapy

Results: 27 pts (5-18 yrs; mean age 11.5 yrs) including 20 non-spinal ABCs (5-18

yrs; mean age 11.5 years) and 7 spinal ABCs (8-18 yrs; mean age 13 yrs) underwent

percutaneous sclerotherapy. Most common symptoms were pain, swelling and neuro-

logical. 21 pts had biopsy proven ABCs. Sonographic, fluoroscopic or C-arm

flat-detector CT (dynaCT) as well as combinations of these modalities was used for

guidance. The sclerosant agents were sodium tetradecyl sulfate (n=23), ethanol (n=12)

and doxycycline (n=8); either singly or in combinations. In 7 pts (4 non-spinal, 3

spinal) sclerotherapy was combined with transarterial embolization.1-9 sclerotherapy

sessions were performed (mean: 5). Range of follow-up was 2-69 (mean: 35.5) months.

In 17 (85%) non-spinal and 4 (71%) spinal lesions, pain resolved, completely in 16 pts

(14 non-spinal and 2 spinal) and partially in 10 pts (5 non-spinal and 5-spinal). Radi-

ological regression was noted in 14 (70%) non-spinal and 3 (43%) spinal lesions. 3

other pts with spinal ABCs showed radiological progression and spinal instability.6 pts

(5 spinal, 1 non-spinal) required further operative interventions but with significantly

lesser blood loss. There were no complications related to sclerotherapy.

Conclusions: Endovascular treatment is a safe and effective treatment for aneurysmal

bone cysts. It can be used as definitive treatment or as a bridge to elective surgical

operation. This approach provides symptomatic relief and regression of the size of most

ABCs, with more favorable outcome in non-spinal lesions.

Paper 41: Lipiodol™ Tumor Uptake Ratio as an Imaging Biomarker of

Tumor Targeting after Chemoembolization in the Liver VX2 Model: A

Histopathologic-radiologic Correlation of Vascular and Cellular

Parameters of Tumor Uptake

J.H. Geschwind, S. Mirpour, V. Tacher, S.M. Hussain, N. Bhagat,A. Gholamrezanejhad, E. Liapi

Objectives: To prospectively evaluate whether Lipiodol™ tumor uptake ratio can be

used as an imaging biomarker of tumor targeting after chemoembolization (TACE) in

the liver VX2 model.

Methods: 31 liver VX2 bearing rabbits were scanned in a 320-detector row volumet-

ric CT scanner (Acquilion One, Toshiba, Japan) before and at 24 hours (n=6), 7(n=10),

14(n=6), and 20 (n=5) days following TACE. Four other rabbits were followed without

treatment and euthanized at 20 days. For each time point, Lipiodol™ tumor uptake

was defined as the ratio of each tumor volume with Lipiodol™ retention (L) to the

total volume of each tumor (T) after treatment (L/T). The volumetric (non-helical)

scanning parameters were: FOV=22 cm, kV=120, mA=80, slice thickness=0.5 mm,

scan delay=6 sec, intermittent scanning for 67 sec (arterial phase every 2 sec, portal

venous phase every 3 sec). Rabbits were injected with 1.5 ml/kg of isoosmolar CM at

1 ml/sec, followed by a saline flush. CT data were analyzed using the Toshiba CT body

perfusion software and calculated tumor perfusion, as well as ipsilateral and contralat-

eral to tumor hepatic perfusion using the maximum slope model. All rabbits were

euthanized after the final CT scan and tumor samples were evaluated for percentage

of tumor necrosis per tumor slide. Lipiodol™ tumor retention and tumor cell viability

were also assessed by TEM.

Results: Lipiodol™ tumor uptake was high at 24 hours (L/T=0.91, SD=0.11) and

remained high at 7 (L/T= 0.93, SD=0.04) and 14 days (L/T=0.92, SD=0.06). Changes

in perfusion index (PI) values were evident as early as 24 hours after treatment (PI

pre=62.25, PI post=4, p=0.04), and persisted at 7 and 14 days (p=0.0002 and p=0.0001,

respectively), but were normalized at 20 days (p=0.35, compared to baseline, and

p=0.62 compared to controls). A statistically significant reduction in hepatic portal

flow PF and hepatic PI was seen at 14 days (p=0.004 and p=0.002, respectively for the

left lobe, and p=0.01 and p=0.008, respectively for the right lobe). On pathology, tumor

necrosis was significantly increased at 7 days compared to 24 hours (p=0.0001) but

significantly decreased from 7 days to 14 days (p<0.0001), suggesting tumor recur-

rence. Lipiodol™ retention was evident in vessels, as well as viable and necrotic tumor

cells on TEM for all time points, with droplet size ranging from 3-17μm at 24 hours

after TACE to 0.5-5μm at 14 days following TACE. There was a statistically significant

correlation between tumor PI and lipiodol tumor uptake at 24 hours after TACE. There

was no statistically significant correlation between tumor necrosis and Lipiodol™

tumor uptake at 24 hours, 7 and 14 days after TACE.

Conclusions: Lipiodol™ tumor uptake ratio can be used as an imaging biomarker of

tumor targeting after TACE. Accumulation of lipiodol occurs in viable and necrotic

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tumor cells and early decrease in tumor CT perfusion index correlates with increased

lipiodol tumor retention.

Paper 42: Robotic Navigation and Guidance for Percutaneous CT-guided

Interventions

Y. Koethe, S. Xu, G. Velusamy, B.J. Wood, A.M. Venkatesan

Objectives: Computed-tomography (CT) guided needle placement is frequently used

in medicine, but its success often depends on physician experience and a series of men-

tal estimations with potential for targeting error. Challenging targets may mandate

frequent trajectory adjustments and serial imaging that may prolong procedure and

increase risk for radiation exposure. We hypothesized improved needle placement

accuracy compared to conventional technique via use of a mobile interventional radi-

ology (IR) assistance platform (MAXIO, Perfint, Chennai, India) that may be readily

incorporated into standard workflow without repeated platform-to-CT registration, and

which obviates the need for special needles. This platform has an electromechanical

guide arm with 5 degrees of freedom and 180 degrees range of motion, a computer

console for calculating coordinates on CT images, and an RS232 interface for DICOM

data communication. This study evaluates needle placement accuracy with use of this

integrated assistance platform compared to conventional technique.

Methods: 12 pairs of virtual point target and skin entry points requiring multi-angle

insertion with mean entry-to-target distance 11.1 ± 0.4 cm were selected on pre-pro-

cedural CT. For each target/entry pair, single-pass needle insertions using an 18 Gauge,

15 cm needle (Biomedical SRL, Firenze, Italy) were first performed by an attending

interventional radiologist into an abdominal phantom (CIRS, Norfolk, VA) with free-

hand technique, then with use of the IR assistance platform. No intra-operative CT

scans and needle adjustments were permitted for either approach. All needle insertions

were single-pass. Post-procedural CT datasets after each needle insertions were ana-

lyzed using research software to determine needle tip-to-target distance and the shortest

projected needle path to target distance.

Results: Greater mean tip-to-target distance was observed with freehand technique

(13.71 ± 9.82 mm) than with use of the IR assistance platform (5.92 ± 2.68 mm)

(P=0.015, paired t-test) (Figure 1A). Greater mean projected needle path to target dis-

tance was observed with freehand technique (13.71 ± 9.24 mm) than via the IR

assistance platform (5.71 ± 2.73 mm (P = 0.017, paired t-test) (Figure 1B). Variability

in tip-to-target distance and mean projected needle path to target distance was also

greater with freehand technique.

Conclusions: Percutaneous needle placement with use of a novel robotic interven-

tional radiology assistance platform is feasible, easy to integrate into standard

workflow without the need for registration with each use, and does not require needle

modifications. This platform can improve the accuracy, precision, and reproducibility

of first-pass needle placement. Future clinical trials will determine clinical impact, in

terms of risk, procedure time, safety and outcomes.

Figure 1. Scatter plots demonstrate distribution of tip to target distance (1A) and

needle path to target distance (1B) for freehand and IR-assistance platform-guided

needle insertion.

Paper 43: Defining a Safe Distance from the Nearest Non-target Vessel

for Delivery of Radioembolization in Treatment of Hepatic Tumors

Alleviating the Need for Pre-treatment Coil Embolization

T. Caridi, M. Soulen, A. Shahkarami, J. Mondschein, M. Dagli

Objectives: To evaluate the safety of yitrium-90 radioembolization at a defined dis-

tance away from a non-target vessel.

Methods: Retrospective analysis of 78 patients (113 procedures) treated with

radioembolization for primary or secondary hepatic malignancy was performed. Fifty-

one of these patients did not have coil embolization prior to radioembolization.

Non-target branches were defined as those supplying the stomach, bowel, or gallblad-

der. Angiography from each radioembolization procedure was reviewed and distance

to the nearest non-target vessel from the point of yitrium-90 delivery was measured.

Follow-up was based on clinical signs of non-target embolization and further imaging

as needed.

Results: Of the 51 patients and 74 procedures not coiled, the GDA was the most fre-

quent (n = 38) nearest non-target vessel, followed by RGA 10, cystic 7, and LGA 5.

Two non-coiled patients experienced non-target embolization to the stomach. In the

first patient, treatment was through the left hepatic artery 16.11 mm from the right gas-

tric artery. The second patient had unexplained gastric ulceration following treatment

via a replaced right hepatic artery off the SMA. For the remaining 49 patients without

adverse effects, the mean and median distance from the radioembolic delivery point

to the nearest non-target vessel was 44.24 mm and 42.5 mm, respectively, with a range

of 0 – 98.28 mm. Of the 27 patients and 39 procedures where coil embolization was

employed prior to radioembolization, there was one non-target event. For the coiled

group the distance to the Y-90 delivery point was 0 – 90.2 mm (mean 31.21mm/median

22.77mm). There were eleven instances (28%) where the distance to the nearest non-

target vessel was greater than 42.5 mm.

Conclusions: Delivery of yitrium-90 microspheres at a distance greater than 4.3 cm

beyond the non-target vessel is safe and should not require pre-treatment coil emboliza-

tion.

Paper 44: Penumbral Staining: The Role of a Completion C-arm CT in

Evaluating Treatment Adequacy Following Transarterial Chemo -

embolization of HCC Located in the Watershed Region of the Liver

V. Sidhar, P. Sullivan, R. Popat, D.S. Wang, N. Kothary

Objectives: Tumors located in Coinaud segment IV and adjacent VIII (watershed

region) often have dual arterial supply from adjoining segments, resulting in incom-

plete treatment and residual disease. In this retrospective study, we evaluated the

presence of incomplete circumferential staining of the parenchyma surrounding the

tumor (penumbra) on completion non-contrast C-arm CT (CACT) imaging as a fore-

caster of residual disease, following lipiodol-based transarterial chemoembolization

(TACE) for hepatocellular carcinoma (HCC) in the watershed region of the liver.

Methods: Between January 2008 and December 2011, patients with <3 tumor(s) in

the watershed region, <4 cm in size and with adequate completion CACT images were

included. Completion CACT images were reviewed to determine whether the treated

tumor showed complete, circumferential ethiodol staining of the tumor itself as well

as the penumbra. The frequency of residual disease following complete and incomplete

staining was compared using a chi-square based test. Further, time to progression

(TTP) for both groups was determined by serial follow-up cross-sectional imaging.

Results: Of the 50 watershed tumors subjected to TACE, 22 were found to have

incomplete tumoral or penumbral staining on a completion CACT and 28 tumors had

circumferential tumor and penumbral staining. 19 tumors (86%) with incomplete

penumbras, 19 had residual disease on follow up, yielding a median TTP of 144 days

in this cohort; Only 6 tumors (21%) of the cohort with complete penumbral staining

demonstrated residual disease on follow up imaging (p<0.0001). TTP in this cohort

was 306 days.

Conclusions: Circumferential tumor and parenchymal staining on completion CACT

imaging is a strong predictor of disease response and adequacy of treatment in water-

shed tumors. As HCC in these regions are more likely to have more than one arterial

supply, completion CACT after TACE can aid the interventionalist in ensuring com-

plete treatment of target lesions.

Paper 45: Modified mRECIST Criteria Responses at an Early Time Point

by Contrast Enhanced Imaging Predicts Survival in Patients with

Unresectable Intrahepatic Cholangiocarcinoma (ICC) Refractory to

Standard Chemotherapy Following Intra-arterial Yttrium-90 (Y-90) Resin-

based Radioembolization

J.C. Camacho, N. Kokabi, H.J. Prajapati, B. El-Rayes, H.S. Kim

Objectives: Criteria for following unresectable intrahepatic cholangiocarcinoma

(ICC) following intra-arterial therapy administration have not been established in the

literature. Response evaluation criteria in solid tumors (RECIST) and modified

response evaluation criteria in solid tumors (mRECIST) were assessed and correlated

with survival analysis after resin-based radioembolization therapy (Y-90).

Methods: IRB approved prospective correlative study in which 21 consecutive

patients with ICC refractory to standard chemotherapy underwent resin-based Y-90

therapy. Target and overall treatment response was assessed. The mRECIST criteria

were modified to be applied on delayed phases of dynamic contrast-enhanced cross

sectional imaging studies. Definition of response included disappearance of all enhanc-

ing lesions (CR) or ≥ 30% decrease in the sum of the greatest one-dimensional

diameter of the enhancing component when compared to baseline (PR). Objective

response included PR and CR. Restaging imaging was obtained at 1 and q3-month

intervals until deceased. Two fellowship-trained radiologists provided imaging inter-

pretation. Survival analyses by Kaplan–Meier and Log-Rank proportional models were

performed using SPSS software v20.0 (IBM, Armonk, NY) and significance set at

<0.05.

Results: Median period between the baseline pre-treatment contrast-enhanced scan

and Y90 therapy was 35.3 days (range 6 –97). Average period of time between Y-90

therapy and the first and second imaging assessment was 43 (range 15 - 86) and 94

days (range 29 -177), respectively. CT was used in 21% of patients to assess response

and MR in 79 %. Overall median survival (OS) was 16.3 months (95% CI 7.2-25.4

months). When determining response, statistically significant differences between

modified mRECIST and RECIST were found (p-value <0.001). No correlation

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between OS and target or overall mRECIST criteria was seen on 1-month follow-up

scan. However, based on mRECIST criteria on 3-month scan, statistically significant

prolonged OS was observed for patients with targeted objective response (p-value =

0.005). RECIST does not correlate with OS neither at 1 or 3-month follow-up.

Conclusions: Target modified mRECIST criteria at 3-months following Y-90

radioembolization therapy for ICC predicted OS.

Survival in responders vs. non-responders based on target modified mRECIST crite-

ria on 1-month (Rigth) and 3-month (Left) imaging follow-up

Paper 46: SMA Arteriogram for TACE: Is it Really Necessary?

N.J. Weisman, M. Itkin

Objectives: Purpose: Superior mesenteric arteriography (SMA) and portography are

part of the mapping arteriogram protocol prior to transarterial chemoembolization

(TACE). The goal of this study is to establish if there is any added benefit to SMA/por-

tography prior to TACE in patients who have undergone pre-procedure contrast

enhanced MRI given the anatomic information provided by this non-invasive study.

Methods: 110 consecutive patients (M/F-86/24, mean age 62.4 yrs) undergoing first

time chemoembolization with pre-procedure contrast-enhanced multiphase MRI

between 1/29/2006 and 9/13/2011 were retrospectively reviewed by two independent

interventional radiologists. The average time between MRI and TACE was 68 days.

The MRI and arteriogram findings with regards to portal vein patency as well as supe-

rior mesenteric artery and celiac anatomy were assessed and compared using Cohen’s

kappa coefficient.

Results: There was complete agreement between MRI and arteriography with regards

to SMA anatomy (kappa = 1.00, 100% sensitivity and specificity) with pre-procedure

MRI accurately identifying all 27 arterial variants encountered. MRI proved less reli-

able in terms of predicting celiac arterial anatomy (kappa = 0.58, 54% sensitivity),

identifying 23/43 celiac arterial variants present on DSA. Portography was found to

be inferior to MRI in terms of assessing portal venous patency (kappa = 0.67, 54%

sensitivity). Despite an average of 68 days between the two studies, no interval portal

venous clot was encountered.

Conclusions: Superior mesenteric arteriography and portography were found to pro-

vide no new information with regards to SMA variants or portal veinous patency in

the setting of pre-procedure contrast enhanced multiphase MRI. The utility of routine

mapping superior mesenteric arteriography/portography in TACE patients must there-

fore be questioned.

Paper 47: Biodistribution of Polylactide-Co-Glycolide Sorafenib-eluting

Microspheres in Rodent HCC Model

J. Chen, D. Kim, R. Salem, R. Lewandowski, R. Omary, L. Shea,A. Larson

Objectives: Sorafenib is a multi-kinase inhibitor against angiogenesis and cell pro-

liferation proven to extend life in patients with advanced hepatocellular carcinoma

(HCC). The current oral tablet formulation is associated with side effects and low

serum levels may suggest delivery of insufficient doses to tumors. An embolic con-

trolled drug release formulation for transcatheter, intra-arterial delivery would increase

the dose at tumors and reduce side effects. Therefore, we recently developed polylac-

tide-co-glycolide (PLG) microspheres co-encapsulating sorafenib for transcatheter

intra-arterial delivery as well as an iron-oxide ferrofluid to allow MRI of in vivo biodis-

tributions. The purpose of this study was comparing intra-hepatic distributions of PLG

sorafenib-eluting microspheres produced with difference sizes.

Methods: In this study, two sets of PLG microspheres were fabricated to co-encap-

sulate sorafenib and iron oxide ferrofluid via a double emulsion/solvent evaporation

method. The microsphere sizes were determined from transmission electron

microscopy. Further microsphere characterization for sorafenib and iron content was

performed via high performance liquid chromatography (HPLC) and inductively cou-

pled plasma mass spectroscopy (ICP-MS). McA-RH7777 rat hepatoma cells were

implanted in the livers of 4 Sprague Dawley rats (400-450 g). A week later, the proper

hepatic artery in each rat was catheterized via the gastroduodenal artery with a 24

gauge catheter. Pre and post-procedural MRI was performed using a 7 Tesla MRI scan-

ner (Bruker Clinscan, Billerica, MA, USA) with T2-weighted sequences to visualize

microsphere delivery. The rats were sacrificed after post-procedural MRI and the tissue

harvested for histologic staining with Prussian blue for iron identification.

Results: The PLG, sorafenib-eluting microspheres were 1-5, and 10-20 microns in

diameter (Fig. 1), respectively and included sorafenib percentages of roughly 19.7%

and 11.3% (w/w) and iron oxide percentages of roughly 2.8% and 0.5% (w/w), respec-

tively. Each rat had a tumor over 5 mm in diameter after 1 week and was successfully

catheterized. Prussian blue staining analysis indicated that larger 10-20 micron micros-

pheres distributed around tumor borders and adjacent normal liver tissues while smaller

1-5 micron microspheres distributed more distally into tumor tissues (Fig. 2).

Conclusions: This study demonstrated that varying the size of the microspheres

impacts the resulting sorafenib and iron oxide encapsulation as well as microsphere

biodistributions in the liver (most likely due to vessel sizes). Further studies are needed

to further enhance PLG microsphere characteristics and investigate the effect of

microsphere size and associated biodistribution upon therapy response.

Fig. 1: (a) Microspheres imaged using a Leica DM IL inverted contrasting micro-

scope (Leica Microsystems, Wetzlar, Germany) at 200x magnification as well as

Transmission Electron Microscopy with a FEI Tecnai Spirit G2 microscope (Hills-

boro, OR, USA) (b) indicates that the microsphere diameters were 1-5 microns (a)

and 10-20 microns (b).

Fig. 2: Prussian blue histology images acquired at 200x magnification using the Tis-

sueFAXS microscope (TissueGnostics GmbH, Vienna, Austria) show that a) the

smaller 1-5 micron microspheres (indicated by the Prussian Blue staining)distributed

in the tumor tissue, while b) the larger 10-20 micron microspheres distributed in the

normal tissue near the tumor border that is outlined by the arrows. The scale bars in-

dicate 50 microns.

Paper 48: Targeting the Metabolic Stress Response in Hepatocellular

Carcinoma Through Inhibition of Autophagy

T.P. Gade, S. Hunt, L. Tucker, J. Oh, T. Clark, M. Soulen, C. Simon,M. Schnall

Objectives: Autophagy is one of several metabolic stress response pathways which

enable tumor cell survival under ischemia. (HCC). We hypothesized that hepatocellular

carcinoma (HCC) cells under ischemia activate an autophagic sress response that (1)

contributes to their survival under transarterial chemoembolization (TACE)-like

ischemia and (2) renders these cells less susceptible to conventional TACE agents but

sensitive to inhibition of autophagy.

Methods: HepG2 human HCC cells were studied under 21%, 3% and 0.5% O2 with

replete (10% serum, 11 mM glucose) or depleted (1% serum, 1 mM glucose) media.

Growth kinetics were measured every 48 hours for one week. Cells incubated under

severe ischemia (0.5% O2¬, depleted media) were then incubated for 168 hours under

standard conditions (21% O2, replete media). Cellular viability and cell cycle kinetics

were measured by flow cytometry. Protein expression of molecular mediators of meta-

bolic stress was measured by Western blot. Cytotoxicity profiles for cells treated with

doxorubicin (DOX) or chloroquine (CHL, inhibitor of autophagy) were measured

using the WST-1 spectrophotometric assay.

Results: Ischemia resulted in reduced cellular viability (p≤0.039), but even cells incu-

bated under severe ischemia remained viable with imperceptible growth and a

concomitant reduction in cells in S phase (p=0.01). Upon subsequent incubation under

standard conditions, these cells demonstrated more advanced growth kinetics

(p<0.001). Cells incubated under ischemia demonstrated activation of metabolic stress

response pathways including hypoxia-inducible factors, the unfolded protein response,

and autophagy. Incubation of cells with CHL under severe ischemia resulted in reduced

viability (p=0.006). Under ischemic stress the half-maximal inhibitory concentration

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(HMIC) for cells treated with DOX increased 44%. The cytotoxicity of CHL was

potentiated under ischemia with a 50% decrease in HMIC.

Conclusions: Autophagy enables the survival of HCC cells under TACE-like

ischemic stress. While the cytotoxicity of DOX is reduced under ischemic stress, tar-

geted inhibition of autophagy results in reduced viability that is potentiated by

ischemia.

Paper 49: Comparison of Serum Doxorubicin Levels Following Different

DEB Chemoembolization Techniques as well as Systemic Administration

in the Same Canine Patients with Naturally-occurring Hepatocellular

Carcinoma

C. Weisse, A. Berent, M. Soulen

Objectives: The most recent recommendations for performing DEB chemoemboliza-

tion suggest delivering the beads as a drug delivery system and maintaining tumor

perfusion rather than continuing to complete tumor stasis that may induce further

angiogenesis. It is unclear how intratumoral and systemic doxorubicin levels are

affected by DEB delivery performed with or without vascular stasis. Avoiding

embolization may facilitate drug washout, reduce tumor doxorubicin concentrations,

and increase systemic exposure to chemotherapy. We hypothesized there would be a

decrease in systemic doxorubicin exposure following DEB versus systemic chemother-

apy and chemoembolization to stasis versus delivery without stasis.

Methods: Dogs diagnosed with naturally occurring nonresectable HCC were sched-

uled to receive three separate treatments ~5 weeks apart containing the same systemic

dose of doxorubicin; 1) 100-300 DEB delivered without stasis, 2) 100-300 DEB deliv-

ery followed by Beadblock to stasis, and 3) intravenous doxorubicin. Serum

doxorubicin levels were measured.

Results: Serum doxorubicin levels were detectable for a median of 180, 30, and 1080

minutes following delivery without stasis (5 dogs), with stasis (7 dogs), and intra-

venously (4 dogs), respectively. Median maximum serum doxorubicin levels, median

area-under-the-curve systemic doxorubicin levels, and median relative systemic dox-

orubicin exposures are reported in TABLE 1.

Conclusions: Different DEB chemoembolization techniques may achieve different

serum doxorubicin concentrations and therefore different intratumoral drug concen-

trations. When performing DEB chemoembolization in dogs with naturally occurring

hepatocellular carcinoma, delivery to stasis results in the lowest systemic doxorubicin

exposure (and presumably higher intratumoral concentrations) than when embolization

to stasis in not performed.

TABLE 1

Paper 50: A Novel Method for Estimating Dose Delivered to Hepatocellular

Carcinoma after Yittrium-90 Glass-based Radioembolization Therapy

N. Kokabi, D. M. Schuster, J. R. Galt, J. C. Camacho, H. S. Kim

Objectives: Yittrium-90 (Y-90) radioembolization is a treatment option for patients

with unresectable hepatocelluar carcinoma (HCC). Despite efforts made to personalize

the administered dose, the actual dose delivered to target tumor(s) and survival corre-

lation is not well understood. A novel method to estimate Y-90 dose delivered to

advanced HCC tumor is investigated in this study.

Methods: A prospective single-center, IRB approved, HIPPA compliant, safety/feasi-

bility study currently enrolls patients with advanced (Barcelona Liver Cancer Stage C)

HCC and PVT for Y-90 glass-based therapy. Liver to lung shunt was evaluated pre-ther-

apy by lobar hepatic intra-arterial delivery of microalbumin aggregate albumin (MAA)

injection followed by SPECT/CT. Patients with >20% shunts were excluded. Individu-

alized dose of Y-90 was calculated based on proprietary formula suggested by the

manufacturer. Following catheter directed angiography of the targeted region and

administration of pre-planned Y-90 dose, bremsstrahlung SPECT/CT was obtained to

ensure delivery to the target region. The baseline MRI was fused with post MAA and

Y-90 SPECT/CT separately. Tumor and liver volumes, respective radioactive counts,

and ratio of count in tumor relative to the entire liver was calculated using a medical

image processing software MIM v5.6.1(MIM Software Inc, Cleveland, OH). Using the

count ratio, unit tumor dose (dose/volume, MBq/cm3) was estimated based on dosime-

try to the entire liver. Correlation between MAA and Y-90 proportions delivered to the

tumor was analyzed using Pearson’s r and Spearman’s Rho methods. Survival analysis

was performed using Kaplan-Meier estimations. Log-rank test for several unit tumor

doses was performed. SPSS Statistics software v20.0 (IBM, Armonk, NY) was used for

all data managements and analyses. Significance levels were set at .05 for all tests.

Results: Of 27 screened patients, 3 were excluded (>20% shunts), and 18 have under-

gone Y-90 therapy to date (median age 55.3 years (range 32-80.3) and mean tumor

volume 1249cm3). For a desired dosimetry of 120Gy to the entire liver, the adminis-

tered Y-90 dose was calculated based on target tumor/liver volume, time of

administration, lung shunt fraction, and previous dose to the lungs. Median survival

was 7.4 months, calculated from the day of the first Y-90 therapy. Patients were fol-

lowed up either monthly or 3-monthly based on disease stability. Mean dose of 2.8

GBq (76.7 mCi) of Y-90 was administered through a lobar hepatic artery for a mean

dose of 116.4 Gy delivered to the liver. Based on our proposed method, mean unit dose

of 1.22 MBq /cm3 was estimated to be delivered to the tumor(s). Unit dose of >1.30

MBq/cm3 was found to be predictor of survival based on log-rank and univariate

analysis (p-values <0.05). Based on the calculated count ratio, mean of 49.9% of

administered Y-90 dose was delivered to the targeted tumor(s). Likewise, mean of

69.8% of MAA was delivered to the corresponding lesion(s). There is statistically sig-

nificant correlation between the proportion of MAA and Y-90 dose delivered to

targeted tumor(s) based on Pearson’s r= 0.698 (p-value = 0.001) and Spearman’s

Rho=0.690 (p-value= 0.002).

Conclusions: Preliminary findings based on correlative study to a prospective phase

II investigation suggest that approximately 50% of Y-90 dose is delivered to the tar-

geted infiltrative HCC tumors with PVT. Delivering unit tumor dose of >1.30

MBq/cm3 to advanced unresectable HCC tumor may be a positive prognostic factor

for survival.

This paper is scheduled to be presented in Session 1.

Poster 1: Endoluminal Radio Frequency in Portal Vein Percutaneous

Recanalization: An Early Experience

M. Mizandari, N. Habib

Objectives: To present the technique of the portal vein recanalization using a novel

endovascular radiofrequency (RF) catheter for portal vein thrombosis

Methods: The recanalization procedure was performed to 6 patients with liver cancer

and portal hypertension due to tumour thrombus in the portal vein. Percutaneous

thrombodestruction was attempted using an endovascular bipolar radiofrequency

device under combined real-time ultrasound-fluoroscopy guidance. Using both seda-

tion and local anaesthesia, an 18G puncture needle accommodating a 0.035 inch

guidewire was introduced into a tributary of the portal vein through which the guide

wire was introduced through the thrombus into the portal vein confluence/SMV after

careful manipulation by 5G guide catheter under the guidance of digital subtraction

angiography (DSA). The endovascular radiofrequency device was inserted into the

thrombus. The device was then connected to a radiofrequency generator for radiofre-

quency ablation (RFA) at 10 watts for a duration of 2 minutes followed by immediate

balloon angioplasty for another 2 minutes for each application. The whole procedure

was repeated twice.

Results: Post RFA portography showed significant improvement of the portal vein

patency with restoration of blood flow to the liver; no intra- or postprocedure compli-

catiopns were observed

Conclusions: The endovascular RFA is a safe and efficient technique, which may be

used for percutaneous thrombodestruction as an alternative approach to recanalize ves-

sels. This new technique may have a wider clinical application in the management of

vascular thrombosis.

Patient B. Portography - The thrombus is seen in the left PV; the right PV is ab-

solutely ocluded

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Patient B. Portography - After the stent placement - restored PV patency is docu-

mented

Poster 2: Percutaneous Endobiliary RFA with Subsequent Stenting for

Biliary and Pancreatic Duct Patency Restoration

M. Mizandari, N. Habib, T. Azrumelashvili

Objectives: This abstract reports the early experience of a new technique of percu-

taneous recanalization of biliary&Wirsung duct using endobiliary radiofrequency

ablation (RFA), followed by stenting.

Methods: Percutaneous endobiliary RFA was performed after preliminary percuta-

neous drainage to 35 patients with unresectable malignant biliary and Wirsung duct

block; among them simultaneous double (CBD&Wirsung duct or left&right hepatic

duct) procedure was performed in 3 cases, triple (right, 4-th segment and 2-3rd segment

duct) - 1 case. Patients’ age - 31 to 82 years (13 pancreatic cancer, 10 cholangiocarci-

noma, 7 metastatic invasion, 4 hepatocellular carcinoma and 1 gallbladder cancer), RFA

ablation was performed under intravenous analgesia and deep sedation using10 Watts

of power for 2 minutes using bipolar RF catheter (diameter - 8Fr for biliary and 5 Fr

for Wirsung duct), placed in block manipulating by guiding catheter and guidewire

using drainage fistula. RFA application was immediately followed by stenting; stent

diameter – 8 to 10 mm for biliary and 5-6 mm for Wirsung. Procedures finish with

drainage catheter reposition in order to maintain access to the duct.

Results: Percutaneous endobiliary RFA with subsequent stenting restored bile

duct&Wirsung patency in all cases as assessed by contrast injection. No intraproce-

dural complications were observed on RFA&stenting procedures;. There was no 30

day mortality, haemorrhage or pancreatitis following RFA. The mild bile leakage and

restenosis (tumour overgrowth in 1 case of GB tumour) were observed in 2 cases.

Conclusions: Endobiliary RFA with subsequent stenting is effective and safe tech-

nique, enabling to restore the biliary&Wirsung duct patency. RFA processing may offer

additional palliative (tumour killing) potential.

Patient C. Contrast is injected via PTC and Wirsung duct drainage catheters - the

block is caused by pancreatic tumor

Patient C. After Simultaneous CBD and Wirsung duct recanalization procedure by

endoluminal RFA&stenting - stents are positioned in CBD and Wirsung duct

Poster 3: Spectrum of Interventional Procedures for Vertebral Tumors:

An Up-to-Date Review of Techniques and Imaging Findings

J. Park, A.J. Lee, S. Cho, C. Loh, A. Gomes, S.T. Kee, E. Lee

Objectives: 1. To provide a comprehensive review of interventional management

techniques for vertebral tumors 2. To demonstrate the imaging findings of vertebral

tumor interventions including fluoroscopy, MRI, and CT

Methods: A 5 year search through our database is performed to obtain high resolution

fluoroscopic, MRI, and CT images of vertebral tumor interventions. We also perform

an extensive literature review and report our own institutional experiences for each

intervention (transarterial embolization, nerve block, radiofrequency ablation, cryoab-

lation, vertebroplasty, kyphoplasty)

Results: The following are presented in didactic format: 1. Review of indications,

optimal techniques, and complications of various interventions . 2. Pictorial presenta-

tion of interventions with multi-modality images

Conclusions: Interventional procedures for vertebral tumors are promising therapeu-

tic tools in the comprehensive care of cancer patients. These procedures offer

minimally invasive alternatives to traditional open surgery, which is often not an option

for patients with advanced disease. Continued development of future therapeutic

approaches to vertebral tumors offers the promise of improved care of the cancer

patient

28-year-old male with metastatic testicular cancer to the spine presented for pre-op-

erative spinal embolization. Pre-operative angiogram of the right L1 radicular artery

demonstrates hypervascular tumor blush

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Post-embolization angiogram of the right L1 radicular artery demonstrates signifi-

cant decrease in tumor blush (following embolization of bilateral T12 and L1 radicu-

lar arteries using a combination of PVA particles (250-350μm) and coils)

Poster 4: Interventions for Thoracic Metastases: Review of Current

Strategies for Treatment of Pulmonary, Pleural, and Chest Wall Disease

Q. Al-Tariq, F. Abtin

Objectives: To review current treatment strategies for thoracic metastases. Various

forms of thermal ablation therapies will be discussed for management of pulmonary

and chest wall disease including microwave, cryo-, laser, and radiofrequency ablation.

Topics to be covered for management of pleural disease include chemical pleurodesis

and indwelling catheter placement.

Methods: Each modality of thermal ablation will be closely examined, including rel-

ative strengths/weaknesses. Case examples will be used to discuss the management of

pleural disease, specifically malignant effusions. Adjunctive techniques will be

included as needed.

Results: Ablation therapies provide a quality alternative to metastatectomy in patients

who are poor surgical candidates. The main goal of ablation treatment for chest wall

lesions is to provide local palliation of painful lesions. Management of pleural effu-

sions is accomplished through the use of temporary and/or indwelling catheters with

or without chemical pleurodesis.

Conclusions: Management of thoracic metastatic disease is complex and involves

the use of multiple modalities and treatment strategies. To achieve total treatment in

this location, the interventionalist should not only address metastases to the lung

parenchyma, but also the pleural space and chest wall.

Poster 5: Safety, Efficacy and Prognostic Factors of Survival for Yittirium-

90 Radioembolization Therapy in Unresectable Advanced Hepatocellular

Carcinoma with Portal Vein Thrombosis: A Midterm Report from a Single

Center Prospective Feasability Study

N. Kokabi, J.C. Camacho, M. Xing, J.R. Spivey, S.I. Hanish, B. El-Rayes,J. Kauh, H.S. Kim

Objectives: Yittirium-90 (Y-90) radioembolization has shown objective response as

locoregional therapy for patients with hepatocellular carcinoma. Safety profile, effi-

cacy, and prognostic factors of Y-90 therapy in the subset of patients with advanced

unresectable HCC requires further evaluation.

Methods: Prospective, single-center, IRB approved, safety/feasibility study currently

enrolls patients with unresectable aggressive (Barcelona liver cancer stage C) HCC

and PVT with infiltrative features (geographic high T2 signal conspicuous tumor on

MR). Safety was assessed at 1 week following treatment and in monthly intervals after

therapy, along with efficacy, with clinical/laboratory and imaging data. Therapy

response was evaluated by contrast enhanced MRI applying targeted and overall

Response Evaluation Criteria in Solid Tumors (RECIST) and modified RECIST. Sur-

vival analysis was performed using Kaplan-Meier estimations. Survival curves were

compared using log-rank test and univariate analysis for plausible prognostic factors.

Significance levels were set at .05 for all tests. SPSS Statistics software v20.0 (IBM,

Armonk, NY) was used for all data managements and analyses. Tumor volume was

estimated based on baseline MRI of abdomen using 3D-volume rendering software

(MIM v5.6.1, MIM Software Inc, Cleveland, OH).

Results: Of 24 enrolled patients, to date 18 have undergone Y-90 therapy. Patient

demographics include median age 55.3 years (range 32-80.3), 84% male, and mean

tumor volume 1249cm3 (range 250-2650). No immediate complications, related ER

visits or hospitalizations were reported. Additionally, no lung, liver, renal or bone mar-

row toxicity was documented. Two patients expired before the first imaging and

laboratory follow up. ALT, AST, serum bilirubin or albumin showed no statistically

significant differences at baseline and at follow-ups. Upon short-term imaging follow

up (mean 36 days post Y-90), 84% of patients were found to have complete (15%) or

partial (69%) response based on targeted mRECIST criteria. Table 1 summarizes short-

term follow up image based response evaluation. Survival was calculated from the day

of the first Y-90 therapy. Median survival was 7.4 months with overall survival rates

of 89%, 78% and 58% at 1, 3, and 6 months respectively. Tumor volume, Child-Pugh

score, and ascites were found to be significant prognostic factors affecting survival (p-

values <0.05).

Conclusions: In patients with aggressive infiltrative HCC and PVT, Y-90 radioeb-

molization therapy is a viable and safe treatment option with low morbidity and

mortality following treatment. Large tumor volume, baseline Child-Pugh score of B

or C, and ascites were found to be independent negative prognostic markers of survival

after the treatment.

Table 1: Y-90 therapy response based on short-term image follow up

Table 1 summarizes proportion of various targeted and overall short-term image based

response in patients post Y-90 therapy based on RECIST and mRECIST criteria.

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Poster 6: A Novel Approach to Superselective DEB TACE; Using the

Isoflow Infusion Catheter to Improve Delivery While Safeguarding

Against Reflux

W.L. Monsky, S.A. Padia, A.H. Hardy

Objectives: A novel infusion microcatheter ( 2.3 fr) for superselective isolated

chemoembolization, IsoFlow (Vascular Designs, San Jose, CA), is described and initial

assessment of safety and technical efficacy made. The catheter design allows isolation

of target arteries, supplying the tumor, between two balloons (4 to 6 mm) for isolated

lateral infusion of therapeutics under pressure generated by the operator, without reflux

and with maintained perfusion of vasculature distal to the infusion port.

Methods: 17 superselective DEB chemoembolizations were performed in patients

with hepatocellular carcinoma ranging in size from 4 to 9 cm. 100-300 micron LC

Beads, containing 50-120 mg doxorubicin was delivered. Rotational c-arm CT was

performed following delivery and follow-up multiphase CT was obtained three months

following the procedure for initial assessment of response. Technical performance

including placement/tracking, dose delivery, and procedure time was evaluated. Device

safety, evidence of reflux, non-target embolization and vascular injury were evaluated.

Results: In 11 of 17 cases the entire dose was delivered without evidence of reflux.

In 3 cases, 80-90% was delivered with stasis, but no reflux occurred. There were no

cases of non-target embolization. In all cases the catheter tracked well to the segmental

or sub-segmental target vessel. No evidence of isoflow catheter related vessel injury .

In one case there was spasm at the guide catheter tip which resolved with 100 mcg

nitroglycerine. Rotational c-arm CT suggested good initial intratumoral delivery. Three

month follow–up CT demonstrated 3 complete and 6 partial responses, as well as 4

patients with disease progression and one with stable disease by EASL Criteria. Three

patients were lost to follow up.

Conclusions: Initial clinical evaluation of this novel catheter for superselective

chemoemboliztion suggests excellent technical performance, efficacy and safety. Pro-

tected superselective, isolated delivery of the entire dose is usually obtained. No reflux,

non-target embolization or related vascular injury occurred.

Poster 7: Protective Effect of Metformin on Tumor Recurrence in Patients

Previously Treated for Hepatocellular Carcinoma

M.C. Peterson, E. Cressman, C. Pocha

Objectives: To evaluate the survival times of diabetic patients who have been treated

for HCC and are on metformin versus those who are not, in order to determine if met-

formin has an effect on tumor recurrence and survival.

Methods: With IRB approval, a retrospective chart review of patients treated for HCC

over the last ten years was performed, with treatments including TACE, radiofrequency

ablation, and sorafenib therapy. We compared the survival time of patients who were

on metformin with those who were not. Survival times were calculated from the time

of first treatment (or diagnosis) for HCC, with subset analysis based on severity of

underlying liver disease, etiology of liver disease, tumor burden (solitary, multifocal,

size, PV involvement), mode of treatment, and comorbidities.

Results: 155 patients with a diagnosis of HCC were reviewed, of which 9 were on

metformin. Survival times appear to be modestly increased in patients who are on met-

formin versus those who are not.

Conclusions: Metformin may improve overall survival in those treated for HCC, and

therefore may be a beneficial medication in the treatment algorithm for these patients.

Larger studies are needed to confirm this result.

Poster 8: Tumor Response Assessment: Automated Tumor Volume vs.

Standard RECIST Criteria

J.D. Elbich, S.B. White, E.M. Weil, P.J. Patel, E.J. Hohenwalter, R.A. Hieb,S.M. Tutton, M.D. Hohenwalter, W. Rilling

Objectives: Evaluating tumor response to therapy has been an ongoing challenge.

Unidimensional and bidimensional measurements have been used as surrogates for

tumor volume in the RECIST criteria. In this study, novel software was used to perform

3D true volume measurements of tumors to determine if this is more accurate and/or

specific than diameter.

Methods: A retrospective analysis of 85 CT scans in 20 patients who underwent Y-

90 therapy was performed. RECIST criteria measurements (as made by a radiologist)

were documented in 4 or 5 reference lesions per patient and followed chronologically,

resulting in a total of 408 hepatic lesions. Prototype software was employed to re-eval-

uate these lesions using Hounsfield unit data to define the tumor in all dimensions.

Additionally, the longest axial diameter of each lesion was determined.

Results: Of the 408 lesions, 238 were excluded due to confluence of multiple lesions,

lesions <0.9 cm or poorly defined tumor boundaries. Therefore, 174 were evaluated

by the software. Of the 174 evaluated, the software measured diameters to be larger in

127/174 (73%), smaller in 25/174 (14.4%) and equal in 22/174 (12.6%) when com-

pared to the radiologist interpretation. The average difference in diameter was 15.9%,

which was not significantly different (F-Test, p=0.4). In terms of RECIST criteria, 110

data points were obtained by comparison at sequential time points. Using the radiolo-

gist diameters, each lesion categorized as: Stable Disease (SD) 60, Partial Response

(PR) 23, Progressive Disease (PD) 27. The RECIST results using volume from the

software revealed: SD 84, PR 12, PD 14 (Chi sq p=0.00003). RECIST results of the

software calculated diameters were not significantly different than those of the radiol-

ogist SD 66, PR 22, PD, 22 (Chi sq p=0.456).

Conclusions: When novel software was used to compare 3D volume measurement

to tumor diameter, 3D volumes were found to be a less specific measurement of tumor

progression (more tumors were found to have SD). The novel software does however

show utility in lesion diameter measurements, which are similar to those of the radi-

ologist.

Poster 9: Use of Internal Pair-production Y-90 PET-CT after

Radioembolization of Primary or Metastatic Liver Tumors: Our Early

Experience and Review of the Literature

M.L. ONeill, S. Williams, J. Salsamendi, M. Georgiou, R. Kuker,G. Narayanan

Objectives: Introduce the technique of Internal Pair Production Y-90 PET CT in the

context of post-radioembolization imaging. Review the available literature regarding

this technique Contrast this technique with SPECT and SPECT CT, including potential

advantages and disadvantages Review our institutional experience with regard to the

use of SPECT and PET CT in the setting of post Y-90 radioembolization in the patients

imaged thus far. Suggest potential future areas of study and implications regarding Y-

90 PET CT

Methods: IRB approval and informed consent was obtained. A prospective case series

of a total of 4 patients with primary or metastatic liver tumors thus far have been

imaged, with additional cases pending at this time. A Tc-99m SPECT study and diag-

nostic angiogram were obtained as per institutional standard of care, and vessels were

coiled as needed at the time of diagnostic arteriography. The patient returned 1-3 wks

later to receive Y-90 resin treatment, which was followed in all cases by a

Bremsstrahlung SPECT scan and then by a PET/CT scan without the use of FDG. The

PET/CT study was performed either the same day of treatment or the day immediately

following. All images were then reviewed. Using the angiography images obtained at

the point of treatment as a reference standard, the SPECT and the PET/CT images

obtained were reviewed for diagnostic accuracy with respect to dose distribution. All

images were also analyzed for presence of extrahepatic localization. The administered

activity was logged. The TN ratio (tumor to normal liver) in the injected portion of

liver were obtained and correlated with administered activity. Absolute counts in tumor

vs. normal liver and count statistics were also tabulated.

Results: PET/CT was successfully performed either the day of, or the day following

therapy. The administered activities were generally lower than those administered in

previously published case reports and case series. PET/CT was successfully obtained

with administered activities ranging from 13.24-45.95 mCi. Total acquisition time for

2 bed positions ranged from 20-40 min. TN ratios ranged from 3.3-10.6. There was

suggestion of an early trend towards a positive relationship between administered

activity and TN ratio in the first 4 patients studied. Mean counts in the gross tumor

area (as judged by CT) were highly variable within and across individual patients

(Mean counts 106-356, std dev. 30-99). Mean counts in the grossly uninvolved areas

(as judged by CT) of the injected lobe (s) were lower and less variable. (12-108, std.

dev. 8-13) The intrahepatic dose distribution was complementary to SPECT alone in

our estimation. We observed a variable amount of extrahepatic signal in all cases.

Conclusions: Internal pair production Y-90 PET/CT is readily achievable, with

potentially important advantages and disadvantages. It was feasible to acquire at lower

doses than those previously reported, with acquisition times of 40 minutes. Useful

images were acquired within 2 days of therapy. Potential advantages include a higher

resolution and potentially more accurate intrahepatic dose distribution. Disadvantages

include longer acquisition time, on average, than SPECT or SPECT/CT and also the

frequent observation of extrahepatic signal. The etiology and significance of the latter

is as yet unclear, although it is conceivable that it may in part be due to the known low

level background counts from the LYSO crystal and/or other factors. In conclusion, as

PET technology evolves and as our collective experience with this technique improves,

strategies to circumvent the disadvantages can potentially be developed. The higher

intrahepatic resolution may enable this infrequently utilized technique to become a

useful tool or complementary alternative to SPECT or SPECT/CT in the future.

(Left to Right) DSA image obtained at time of treatment, with corresponding axial

SPECT, Y-90 PET/CT, and Diagnostic CT images (middle), followed by sagittal

SPECT and Y-90 PET/CT images. Note the improved anatomic and spacial resolu-

tion of the PET/CT compared to the SPECT images of the same area.

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Example of a Y90 PET/CT image demonstrating a representation of the counts in

tumor and normal liver, respectively, from which TN ratios were also derived.

Poster 10: Quality of Life Assessment after Percutaneous Cryoablation in

Patients with Renal Cell Carcinoma

A.F. Morales, H. Park, M. Rivas, P. Nieh, J. Pattaras, V. Master, Z. Chen,X. Wang, H.S. Kim

Objectives: To investigate the effects on quality of life (QOL) of percutaneous

cryoablation in patients with renal cell carcinoma (RCC)

Methods: A single-center, IRB-approved, prospective, health-related quality of life

(HRQOL) study was performed using the Short Form-36 (SF-36) health survey assess-

ment tool. Baseline scores in the eight QOL domains were obtained prior to the renal

cell carcinoma cryoablation procedure. These scores were then compared to and ana-

lyzed with post-treatment score(s) using the paired t-test. The significance levels were

set at 0.05 for all tests. The SAS statistical package V9.3 (SAS Institute, Inc., Cary,

North Carolina) was used for all data management and analysis.

Results: Nine patients with renal cell carcinoma (5 males, 4 females; median age 66;

age range 48-77) were enrolled into the study. Each patient was treated with percuta-

neous cryoablation between 02/2012 and 08/2012. All procedures were performed on

an outpatient basis. The mean length of time from the procedure date to the first fol-

low-up survey was 47 days. Of note, the patients’ pretreatment baseline HRQOL mean

scores were similar to or higher than those of the age-adjusted norms for the general

U.S. population in all health domains except vitality. There were no significant differ-

ences in the 8 health domains (physical functioning, role-physical, bodily pain, general

health, vitality, social functioning, role-emotional and mental health) between the pre-

procedure and post-procedure surveys. Positive trends were seen in General Health

(66.7 vs. 68.3, p = 0.66) and Role-Emotional (70.8 vs. 81.5, p = 0.56), however these

were not statistically significant. There were no significant differences in Physical

Functioning (74.4 vs. 70.7, p = 0.35), Role-Emotional (70.8 vs. 81.5, p = 0.56), Vitality

(48.7 vs. 48.3, p = 0.93), Mental Health (80 vs 76.9, p = 0.26), Social Functioning (83.3

vs. 75, p = 0.14), or Bodily Pain (77.8 vs. 76.4, p = 0.87).

Conclusions: Patients with renal cell carcinoma demonstrated no significant change

or decrease in health-related quality of life after percutaneous cryoablation when com-

pared to baseline.

Poster 11: The Multidisciplinary Treatment of Colorectal Cancer Liver

Metastases (CRLM): Role of Thermal Ablation - A Retrospective Analysis

from a Single Institution

L. Carmignani, M. Fedi, M. Ricasoli, M. Lupi, A. Pagliari, S. Riccadonna,M. Iannopollo, L. Vannucchi, M. Di Lieto, S. Giannessi, P. Pacini

Objectives: Liver is a common site of metastatic disease in colorectal cancer (CRC)

and surgical resection is the gold standard therapy. Unfortunately only 15%-20% of

CRLM are eligible to surgery alone at the time of diagnosis. For this reason, multidis-

ciplinary protocols are increasingly recommended, in an attempt to prolong the

disease-free interval and to ensure a good quality of life for patients. We report our

experience about the feasibility and effectiveness of thermal ablation joined with sur-

gery and chemotherapy in the multidisciplinary treatment of CRLM.

Methods: From January 2010 to June 2012 we treated 34 patients (15 male, 19

female), with a median age of 68 years (56-82) with a total of 112 CRLM (1 cm – 12

cm in maximum diameter/1 – 11 lesions per patient). Treatment plan consisted of peri-

operative chemotherapy, surgical resection and intraoperative/percutaneous thermal

ablation (Radiofrequency Ablation/RFA and Microwave Ablation/MWA). For each

patient at least one liver lesion was biopsied with outcome of CRLM; all patients were

studied with contrast CT and assessed with CEUS immediately before and after the sur-

gical/ablative treatment. Ablation was performed during surgery in 19 cases, after

surgery in 15 cases, during and after in 12 cases, always making use of ultrasound guid-

ance. Depending on the circumstances, the intraoperative ablation was performed to

treat unresectable deep metastases, to clear the left hepatic lobe in preparation for resec-

tion of the right lobe (after ligation of the right portal branch) or to coagulate the zone

of resection in order to minimize bleeding. All procedures were discussed and endorsed

in the Domestic Tumor Board and each patient gave written informed consent.

Results: No major complications occurred; no procedure-related deaths. Follow-up

was performed with contrastographic CT examinations at a distance of 1, 3, 6, 9, 12

months after treatment and then on a yearly basis. The 1 month follow-up demonstrated

total necrosis (referred as absence of contrast enhancement) in 89/112 CRLM (79,5%)

and partial necrosis (referred as residual contrast enhancement) in 23/112 CRLM

(20,5%). Fifteen CRLM denoting partial necrosis at 1 month immediately underwent

a second percutaneous RFA/MWA session. Overall Survival Rate (OSR) and Disease-

Free Survival Rate (DFSR) were considered in a median 14 month follow up (6 – 30).

Two patients died due to disease progression for a OSR = 94%. At present 11 patients

(32,4%) have recurrent disease (1 after 6 months, 3 after 9 months, 3 after 12 months,

2 after 18 months, 2 after 24 months) with resultant 1 year DFSR = 79,4% and 2 year

DFSR = 67,6%.

Conclusions: The multidisciplinary approach may play an important role in the man-

agement of CRLM. Our experience demonstrates that liver surgery and liver ablation

are complementary and not mutually exclusive. Ablation improves resection rates for

CRLM and is able to clear tumor(s) in the future liver remnant. Pre-coagulation with

ablation minimizes blood loss in selected cases. Percutaneous ablation provides also

a minimally invasive, therapeutic option to observe tumor biology and can be consid-

ered the treatment of choice for relapses after surgery. Further studies are necessary to

define patient setting, ablation timing and best combination with surgery and systemic

therapies.

Poster 12: CT-fluoroscopy Guided Thermal Ablation of Liver, Renal and

Adrenal Tumors Through a Transpulmonary Approach

W. Prevoo, M. Meier

Objectives: We retrospectively evaluated the transpulmonary approach treating

tumors of the liver, kidney and adrenal gland with thermal ablation

Methods: From dec 2011-dec 2012, 24 patients (18 male, 6 female, mean age 61,8

years) with liver tumors (18), renal cell carcinoma (4) and metastases in the adrenal

gland (2) underwent deliberately a transpulmonary RFA, or MWA under CT-fluoro-

scopic guidance. In total 40 transpulmonary approaches were evaluated. 22 times a

single RFA needle and 6 times a RFA cluster needle was used (Cool-tip RFA system

E-series, Covidien, MA, USA), and 12 times a microwave antenna (Evident

Microwave system, Covidien, MA, USA)

Results: In 11 of 40 sessions a small pneumothorax occurred which needed no further

treatment. In 1 session a haematothorax occurred which also didn’t need any further

treatment. In 7 patient more than 1(2-3) needle, or antenna was inserted through a

transpulmonary approach during the same treatment session, resulting in a small pneu-

mothorax in 3 cases. No pneumothorax was seen using cluster needles. Hospital stay

for 22 patients was 1 day and 2 patients were admitted for 14 days because of liver

bleeding. One patient developed an empyema 31 days after treatment.

Conclusions: No serious short term complications occurred treating patients with

thermal ablation for liver, renal and adrenal tumors through a transpulmonary approach

Poster 13: Ablation Zones and Weight Bearing Bones, Points of Caution

for the Palliative Interventionalist

J. Buethe, I. Patel, J.D. Prologo

Objectives: Percutaneous image guided cryoablation has recently emerged as an

effective palliative therapy for management of painful metastatic disease involving soft

tissue and bone. We report adverse outcomes encountered during the implementation

of this service that are instructive for patient selection.

Methods: Following IRB approval, we retrospectively collected and analyzed data

on seven patients that experienced adverse events following CT guided percutaneous

palliative cryoablation for painful osseous metastatic disease. The events were classi-

fied 1) according to the SIR Classification System for Complications by Outcome, 2)

as anticipated or unanticipated events, and 3) according to underlying mechanism of

the complication.

Results: Two patients developed complete fracture following ablation of proximal

femoral lesions (grade D). Two patients developed neuropraxia related to damage of

nerves adjacent to the predicted ablation zone: one followed ablation of a supraclav-

icular lymph node with involvement of the scapular nerve and subsequent muscle

atrophy (grade D), and one involved sciatic nerve involvement following ablation of

an intragluteal metastatic deposit (grade B). Two patients incurred damage to adjacent

osteocartilagenous structures (grade B): meniscus and distal femoral involvement fol-

lowing a proximal tibial lesion ablation and proximal femoral involvement following

a supra-acetabular ablation. One patient had residual pain related to incomplete abla-

tion of a sternal metastatic deposit. Three of seven were classified as anticipated, the

remaining 4 were unanticipated.

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Conclusions: Consideration of potential predictable adverse events related to percu-

taneous image guided palliative cryoablation is important for patient selection as the

procedure is implemented to evolving interventional oncology services.

Poster 14: Safety and Efficacy of Superselective Bland Embolization as a

Palliative Treatment of Bone and Soft Tissue Metastatic Tumors: A Single

Center Experience

I.N. Dedes, A. Drevelegas

Objectives: The basic purpose of this study is to present an evaluation of safety and

efficacy of superselective bland embolization in the management of bones and soft tis-

sue metastases.

Methods: In a 94 month period, 8 men and 3 women that underwent 16 sessions of

bland embolization to manage bone and/or soft tissue metastatic tumors were included.

Median age was 59 years. In three of these cases soft tissue metastases were developed

without bone involvement. Primary tumors included hepatocellular carcinoma (2),

rhabdomyosarcoma (2), melanoma, neurofibrosarcoma, renal cancer, breast cancer,

stomach cancer, adenoid cystic carcinoma and anaplastic carcinoma. Sites of metas-

tases included the ischium, humerus, groin, axilla, maxilla and mediastinum. The mean

pre-embolization tumor size was 13,2 cm. All patients underwent at least one supers-

elective bland embolization.

Results: All procedures were generally well tolerated. No major complications

occurred. Minor complications included palpable hardness in 10 out of 11 patients,

rubor in 8 patients and sensitivity in 3 patients. In 9 patients there was a mean reduction

of 20% or more in the tumor diameter on CT and MRI after an average of 1,45

embolization session per patient. All patients reported a significant reduction in pain

within two weeks, according to Numeric Rating Scale-11 (NRS-11). The average pain

score before treatment was 8,3 and after treatment was 5,1 and pain relief was

achieved, in all patients, within 96 hours following treatment. Eight patients reported

significantly increased mobility in a 3 months follow up. Average length of hospital-

ization was 1,6 days. Mean overall survival from the first embolization was 10 months.

Conclusions: Superselective bland embolization is an effective and safe palliative

treatment for bone and soft tissue metastatic tumors. Large trials are needed to assess

the long term effects including any overall survival benefit.

Huge metastases in humerus in a patient with HCC. Image before superselective

bland embolization.

After superselective bland embolization.

Poster 15: Evaluation of YO-PRO-1 as an Early Marker of Irreversible Cell

Death Immediately After Radiofrequency Ablation of Colon Cancer Liver

Metastases

S. Fujisawa, C.T. Sofocleous, M. Turkekul, N. Fan, Y. Romin, A. Barlas,L. Petrovic, A.R. Garcia, S. Monette, D. Klimstra, J.P. Erinjeri,S.B. Stephen, N. Kemeny, K. Manova-Todorova

Objectives: Radiofrequency ablation (RFA) is a minimally invasive treatment for

colorectal-cancer liver metastases (CLM) in selected nonsurgical patients. Unlike sur-

gical resection, RFA is associated with no routine pathological examination capable of

confirming either cell death or the presence of residual, viable tumor cells. This NIH

supported study sought to develop and evaluate a method of immediate assessment of

tumor apoptosis after RF ablation.

Methods: Specifically, we evaluated YO-PRO-1, a green fluorescent DNA marker

for dying cells with compromised plasma membrane, as a potential, early marker of

apoptosis to be used immediately after RFA. In human CLM and in normal pig and

mouse liver, YO-PRO-1 was used to stain ablated CLM tissues adherent to the elec-

trode used in the RFA procedure and biopsy samples from central and marginal regions

of the ablation zone as depicted by dynamic CT. These tissues were also immunos-

tained for fragmented DNA (TUNEL assay) and for active mitochondria (anti-OxPhos

antibody).

Results: Following RFA of human CLM, more than 90% of cells were positive for

YO-PRO-1. In nonablated pig and mouse liver tissues, we found a YO-PRO-1 signal

of 93.1% and 65% respectively. When however, the surrounding liver parenchyma was

kept intact during staining, significantly smaller proportion of cells was YO-PRO-1

positive (22.7%).

Conclusions: Results suggest that manipulation of the tissue is sufficient to cause

widespread plasma membrane injury that allows YO-PRO-1 penetration in live cells.

As a consequence, we conclude that live staining with YO-PRO-1is not a reliable

marker of early cell death specifically attributed to hepatic ablation.

Fig 1: Human & pig RFA liver tissues exhibit ubiquitous YO-PRO-1 staining. Im-

ages from confocal z-stacks of human liver sections stained live with YO-PRO-1

(green, right panel) & Hoechst (blue, center panel). (a)Electrode, prominent heat ar-

tifact seen, some nuclei unnaturally elongated (arrows). Distinct nuclear & cytoplas-

mic regions not well discernible, decompartmentalization of cells (arrowhead).

(b)Center of ablated region, morphologically intact hepatocytes seen. A high propor-

tion is positive YO-PRO-1. (c)Margin, area expected for cell survival, high YO-

PRO-1 positivity seen. (d & e)Subset of margin sample fixed & stained with TUNEL

(d) & anti-OxPhos antibody (e). Significantly less TUNEL compared to YO-PRO-1,

& abundant OxPhos compared to YO-PRO-1. Despite YO-PRO-1 positivity, margin

tissue contained metabolically active cells with intact DNA. (f & g) YO-PRO-1

staining of ablated (f) & nonablated (g) pig liver-RFA does not influence the amount

of YO-PRO-1 positivity. Scale: a=25 μm, all others=100 μm.

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Fig 2: YO-PRO-1 positivity in adult mouse liver tissue influenced by amount of

physical damage inflicted during dissection. (a)Liver section from adult mouse

stained with YO-PRO-1 & Hoechst. Similarity to what was seen with human sam-

ples, majority of liver cells YO-PRO-1-positive. (b)Higher magnification reveals

nonhepatic cells with elongated nuclei seem to avoid YO-PRO-1 penetration (ar-

rows). (c)TUNEL staining mouse liver tissue shows cells near sites of physical dam-

age are particularly susceptible to apoptosis. Know this is not an edge effect since

TUNEL positivity is not observed near intact edge of tissue (asterisks).( d & e)Entire

lobe of liver dissected gently & stained & imaged while intact. Proportion YO-PRO-

1-positive cells significantly less & these cells formed small clusters (arrows).

(f)TUNEL staining intact liver lobe shows minimal apoptosis. Scale: a=100 μm,

b=40 μm, c=500 μm, 50 μm, d=100 μm, e=50 μm, f=1 mm, 100 μm

Poster 16: Prospective Study Comparing the Use of Catheter-directed

Contrast-enhanced Ultrasound and Catheter-directed Computed

Tomography Arteriography in Transarterial Chemoembolization for

Intermediate Stage Hepatocellular Carcinoma

M. Burgmans, A.R. van Erkel, C. Too, R.H. Lo, B. Tan

Objectives: Transarterial chemoembolization (TACE) is the treatement of choice in

patients with hepatocellular carcinoma (HCC). TACE is guided by digital subtraction

angiography (DSA), but DSA only provides two-dimensional imaging. The use of

catheter-directed cone beam computed tomography (CBCT) or catheter-directed com-

puted tomography arteriography (CCTA) in addition to DSA allows more accurate

tumor targeting. Yet, CBCT and CCTA are not widely available and are associated with

significant radiation. Catheter-directed contrast-enhanced ultrasound angiography

(CCEUSA) is widely available, not associated with radiation and may provide similar

information as CBCT and CCTA. In this prospective study, patient underwent TACE

with the combined use of DSA, CCEUSA and CCTA. The objectives were to evaluate

the feasibility and safety of CCEUSA and to compare the information provided by each

imaging modality on tumor enhancement and arterial supply.

Methods: From December 2010 to December 2011, 9 patients (mean age 67 years

(range 58-79 years; male = 7) with unresectable HCC were included in the study. All

patients underwent ultrasound with intravenous injection of sulphur hexafluoride

micro-bubbles (SonoVue) before and after the TACE procedure. Tumor vascularity

was studied with the use of DSA and a treatment plan was formulated. Both CCEUSA

with SonoVue and CCTA were then performed with selective injections into the proper

and (sub-)segmental hepatic arteries. Images were analysed to see how both imaging

modalities altered the treatment plan. TACE was then performed as selective as possi-

ble using 100-300μm and 300-500μm drug-eluting beads loaded with a total of 150mg

Doxorubicine. Adverse effects were classified according to CTCAE v3. All patients

underwent triphasic CT of the liver at 6 weeks. Tumor response was assessed according

to mRECIST and RECIST 1.1.

Results: A total of 19 tumors were identified with an average of 2.1 (range 1-5)

tumors per patient. The mean maximal tumor size was 45.3 mm (range 10-145mm).

Fifteen of the 19 tumors (78.9%) were demonstrated with the use of DSA. CCEUSA

was able to demonstrate 14 of the 19 (73.7%) tumors. All tumors were visualized on

CCTA images. The detection rate for tumors with a diameter of ≥ 2cm was 100% for

all three modalities. In 44.4% of patients (n=4), the use of CCEUSA provided infor-

mation that was not evident on DSA and let to a change in treatment plan. CCTA

provided the same information as CCEUSA, but also allowed detection of an additional

feeding artery in one patient that was not evident on DSA and CCEUSA images. No

complications occurred as a result of the use of CCEUSA. Overall tumor response

according to mRECIST criteria was 100% at 6 weeks. The mean follow-up was 19.6

months (range 12.8-24.0 months). Overall 1 year survival was 66.7%.

Conclusions: CCEUSA can be safely performed in combination with DSA to guide

TACE. Combined DSA and CCEUSA improves the identification of tumor feeding

arteries and the accuracy of tumor targeting compared to DSA alone, but is slightly

inferior to combined DSA and CCTA.

Poster 17: Evolution of the Ablation Zone Following Irreversible

Electroporation of Liver Tumors on Computed Tomography and Possible

Predictors of Recurrence

M.T. Silk, K. Lee, T. Wimmer, J. Durack, J.P. Erinjeri, C.T. Sofocleous,S.B. Solomon

Objectives: To study the evolution of the ablation zone following irreversible elec-

troporation (IRE) of hepatic metastases on CT imaging and to identify indicators

related to tumor recurrence.

Methods: We performed an Institutional Review Board approved retrospective

review of all liver metastases treated by percutaneous IRE from January 2011 to Octo-

ber 2012 at our institution. Ablation zones on post-procedural CT imaging were

analyzed according to largest single dimension on axial images and contrast enhance-

ment obtained immediately, one month, and four months after intervention. Residual

or recurrent tumor was defined by biopsy or FDG avidity on PET/CT. Characteristics

of ablation zones were compared between tumors showing recurrence and those that

did not.

Results: Twenty-seven hepatic metastases in 15 patients were treated with percuta-

neous IRE during the period of review. Ten tumor ablations were excluded from the

study due to CT imaging artifacts (n=3), concomitant alternative treatments (1 RF abla-

tion, 1 arterial embolization) or overlapping ablation zones from adjacent tumors (n=5).

Seventeen tumors with a mean largest dimension of 2.3 ± 0.5 cm were included. The

mean largest axial diameter of the hypodense ablation zone was 4.2 ± 0.7 cm (214%

± 44 % of initial tumor size, n=17) immediately after treatment, 3.1 ± 0.6 cm (156%

± 29 % of initial tumor size, n=16) after one month, and 2.4 ± 0.4 cm (130% ± 13 %

of initial tumor size, n=10) after four months. In cases suggestive of recurrence on PET

imaging, we observed a larger pre-ablation tumor size, a relatively smaller ablation

zone, CT contrast enhancement within the ablation zone and a reduced involution of

the ablation zone over time (Table 1).

Conclusions: Similar to thermal ablation in the liver, the ablation zone following

hepatic IRE typically maintains low attenuation relative to liver and decreases in size

over time. Tumor recurrence based on PET imaging was correlated with CT contrast

enhancement, associated with larger tumor sizes, smaller relative ablation zones, and

less reduction in size of the ablation zone over time.

Comparison of pre-treatment tumor size, ablation zone size and contrast enhance-

ment following IRE for all tumors, tumors that showed recurrence and tumors that

did not show recurrence. Mean values and standard errors are given.

Poster 18: Infectious Complications of Y90 Radioembolization in Patients

with Surgical Bilioenteric Anastamosis or Compromised Sphincter of

ODDI: Our Experience

A. Mahvash, S. Gadani, R. Avritscher, R. Murthy, B. Odisio

Objectives: Pyogenic hepatic abscess is a known complication of transarterial

embolotherapies for primary or secondary liver malignancies in patients with history

of bilioenteric anastomosis or incompetent sphincter of Oddi. Safety of Y90 radioem-

bolization (RE) in such patients is unknown. We present our experience at a single

institution.

Methods: Between November 2009 and June 2012, total 10 patients with either bil-

ioenteric anastomosis (n=6) or biliary stents (n=4) were treated with Y90 RE. Liver

tumors treated were neuroendocrine tumors (n=6), hepatocellular carcinoma (n=2) and

cholangiocarcinoma (n=2). Whole liver was treated in 9 and the left lobe was treated

in 1 patient. All patients were treated with prophylactic pre and postprocedure antimi-

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crobial therapy. Clinical and laboratory follow up was performed at 1, 3 and 6 months

while imaging follow up was performed at 1-3 months and every 3 months thereafter.

Results: Median follow up was 315 days (62-1079 days). Median activity delivered

was 54.6 mci (38.2-73.7). Total 5 patients were hospitalized within 30 days of Y90 RE

therapy. One patient was admitted with pancreatitis and other patient was admitted

with fever without imaging evidence of abscess. The remaining three patients were

admitted for nausea/vomiting and unrelated medical issues. Two patients were admitted

(NCI-CTCAE grade 3) between 30-90 days post Y90 RE therapy. One patient admitted

on day 71 with imaging evidence of liver abscess that was drained percutaneously and

other patient admitted on day 89 for cholangitis without evidence of abscess. No grade

4 / 5 NCI-CTCAE occurred in any patient.

Conclusions: Our preliminary data suggests that risk of infectious complications fol-

lowing Y90 RE therapy of the liver is similar to other transarterial embolotherapies in

patients with bilioenteric anastamosis or compromised sphincter of Oddi.

Poster 19: Multiple-antenna Microwave Ablation: High-power

Modulation Increase Ablation Zone Size

M. Bedoya, C.L. Brace

Objectives: Microwave ablation has proven to be an effective tumor ablation modal-

ity. Pulsing high powers has been shown to create larger ablations than continuous

lower powers, even when delivering the same total energy. Larger ablations have also

been demonstrated when utilizing multiple antennas. However, the combination of

multiple antennas and pulsing has yet to be evaluated. The objective of this study was

to compare the performance of multiple antenna arrays utilizing conventional contin-

uous power delivery to experimental pulsed power delivery algorithms.

Methods: A total of seven different power delivery protocols were evaluated (n=5

each) in ex vivo bovine liver and (n=3 each) in vivo porcine liver using a 2.45GHz

clinical microwave ablation system. Protocols were divided into three groups: in Group

A, power was delivered continuously using conventional settings (140W for one

antenna, 95W each for two antennas, 65W each for three antennas); in Group B, the

maximum allowed power (195W) was modulated between two or three antennas every

15sec (140W to one antenna, the remainder split between the rest); in Group C, the

maximum channel output (140W) was switched between two or three antennas every

15sec. All ablations were conducted for 5min total. Antennas were spaced approxi-

mately 1.5-2cm apart. Ablation zones were then thinly sliced transverse to the antenna

tract and analyzed for maximum and minimum diameter, final distance between

antenna probes, length, volume, and circularity. Comparisons of size and shape were

made between groups based on the number of antennas, power delivery protocol, aver-

age power applied, and peak power.

Results: In the ex vivo ablations, difference in length were found in two and three

antenna ablations both the continuous group A and the pulsed group B produced larger

ablation diameter. Overall group B3 has the largest volume with 52.7±11.8cm^3.

Group C in the three antennas produced smaller volumes. It appears as if multiple

simultaneous applicators greater impact the ablation size compared to one applicator

at the time. Group A2 formed the most spherical ablation with an aspect ratio of 1.48.

Overall differences in length were found (P<0.002) (Table 1). A total of seven different

power delivery protocols were evaluated (n=5 each) in ex vivo bovine liver and (n=3

each) in vivo porcine liver using a 2.45GHz clinical microwave ablation system. Pro-

tocols were divided into three groups: in Group A, power was delivered continuously

using conventional settings (140W for one antenna, 95W each for two antennas, 65W

each for three antennas); in Group B, the maximum allowed power (195W) was mod-

ulated between two or three antennas every 15sec (140W to one antenna, the remainder

split between the rest); in Group C, the maximum channel output (140W) was switched

between two or three antennas every 15sec. All ablations were conducted for 5min

total. Antennas were spaced approximately 1.5-2cm apart. Ablation zones were then

thinly sliced transverse to the antenna tract and analyzed for maximum and minimum

diameter, final distance between antenna probes, length, volume, and circularity. Com-

parisons of size and shape were made between groups based on the number of

antennas, power delivery protocol, average power applied, and peak power.

Conclusions: Ablation size may be influenced by power delivery algorithm. Lower

power and lower total energy produced smaller ablations. Modulating greater powers

between multiple antennas can increase ablation zone size; however, idle antennas in

the array can negatively impact ablation size. More study is needed to optimize the

power delivery algorithm for multiple-antenna microwave ablations.

Poster 20: Advanced Glycation Endproducts are Responsible for the

Development of Drug Resistance in Hormone-refractory Prostate Cancer

C. Wu, S. Hsia, S. Hsu

Objectives: Advanced glycation end products (AGEs), also known as glycotoxins,

are a diverse group of highly reactive compounds with pathogenic significance in dia-

betes and in several other chronic diseases. The pathologic effects of AGEs are related

to their ability to promote oxidative stress and inflammation by binding with the recep-

tor for AGEs (RAGE) or crosslinking with body proteins, altering their structure and

function. In addition to AGEs that form within the body, AGEs also exist in foods.

Modern diets are largely heat-processed and as a result contain high levels of AGEs.

Because dietary AGEs are poorly absorbed, their potential role in human health and

disease was largely ignored. However, the findings from animal and human studies

suggest that avoidance of AGEs exposure helps delay cancer malignancy in animals

and possibly in human beings. Dietary factors are important for the development of

prostate cancer and AGEs formation, and RAGE has aggressive roles related to metas-

tasis and invasion in some cancers. Nevertheless, the involvement of AGEs-RAGE

interaction in prostate cancer’s drug resistance has not been fully elucidated. The aim

of this study was to investigate the role of AGEs-RAGE on the development of drug

resistance in hormone-refractory prostate cancer.

Methods: Prostate cancer cell viability in response to chemodrugs was evaluated

using the MTT assay.Autophagy and apoptosis associated protein expression were

eveluated by western blotting.The RAGE-shRNA, Beclin-1-shRNA, ATG5-shRNA,

or pUNO1-RAGE were transfected into cells using Lipofectamine 2000 reagent. To

generate murine subcutaneous tumors,DU145 wild type, RAGE overexpression, or

RAGE-knockdown cells were injected subcutaneously to the right of the dorsal midline

in non-SCID mice. Tumors were measured by IVIS imaging system. Theexpression of

RAGE in prostste cancer tissues were identified by immunofluorescence analysis.

Results: We now report a novel role for the AGEs-RAGE interaction in prostate can-

cer cell response to stress.The chemotherapy resistance of DU 145 and PC-3 prostate

cancer cells is enhanced by AGEs treatment. Targeted knockdown of RAGE in the

tumor cells, leads to increased apoptosis, diminished autophagy and decreased tumor

cell survival. In contrast, overexpression of RAGE is associated with enhanced

autophagy, diminished apoptosis and greater tumor cell viability. Mechanistic studies

show that RAGE sustained autophagy is associated with decreased phosphorylation of

mammalian target of rapamycin (mTOR) and increased Beclin-1/VPS34 autophago-

some formation.

Conclusions: AGEs-RAGE interaction correlates with tumor cell survival following

cytotoxic insult. RAGE-mediated tumor cell survival is associated with increased

autophagy and decreased apoptosis. Our data might provide insight into the develop-

ment of novel clinical therapies targeting AGEs-RAGE pathway.

Poster 21: Microwave Ablation with Uncooled Single-antenna for

Metastatic Liver Cancers: Pilot Clinical Experience in the Asia

K. Huang

Objectives: Microwave ablation (MWA) is the most recent development in the field

of local ablative therapies. The aim of this study was to evaluate the efficacy and safety

of a new generation of Un-cooled single-antenna microwave to ablate large metastatic

liver tumor larger than 4 cm in diameter.

Methods: An uncooled single-antenna microwave system (Avecure Microwave Gen-

erator; MedWaves, San Diego, CA) was used. 14 consecutive patients (7 men and 7

women) with liver cancers were recruited. 6 (29 %) of the patients had metastatic liver

cancers. MWA was performed using a percutaneous (n=12) or open approach (n=2)

for 16 tumors with larger than 4 cm in diameter. All tumors were ablated by applying

temperature control (ablation temperature set point at 110°C, time set point at 900 sec-

onds).

Results: The median tumor diameter was 5.4 cm (range, 4.0-6.3 cm). Duration of the

ablation time was 1780 ± 225 seconds. The mean ablation session is 1.2 (range, 1-2).

Long axis diameter of ablation zone was 5.2 ± 1.2 cm. Short axis diameter was 4.8 ±1.2 cm. Complications occurred in 1 (7%) of the patients with wound pain and there

was no operative mortality. 2 (14%) of the patients experienced incomplete ablation.

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Local recurrent was noted in 2 (14%) of the patients after a median follow-up of 4

(range, 2-6) months.

Conclusions: This new-generation microwave technique is safe and effective for

local ablation of lager liver cancers. The ablation size is large and ablation duration is

short by using only single antenna. It will be a valuable option for patients who are not

candidates for liver resection.

Poster 22: Emergent Embolization of Ruptured Hepatocellular Carcinoma:

A Single Center Experience

E.J. Monroe, S.A. Padia, S. Bastawrous, S.W. Kwan, W.L. Monsky,M.J. Kogut

Objectives: Tumor rupture with hemorrhage is a catastrophic complication and major

cause of death in patients with hepatocellular carcinoma (HCC). We sought to evaluate

our experience with catheter-based management of this entity.

Methods: 26 patients treated with transarterial embolization for ruptured HCC were

identified between 2000 and 2012. Retrospective chart and imaging review was per-

formed. 6 patients were excluded due to incomplete data. Demographics, baseline liver

function, embolization methods and technical success, complications, length of hos-

pital stay, and 30-day mortality were assessed for each patient.

Results: Mean patient age was 55 (range 31-74). 17/20 (85%) were male. Etiology

of cirrhosis included hepatitis C in 10 (50%), hepatitis B in 8 (40%), alcohol in 6

(30%), cryptogenic in 2 (10%), nonalcoholic steatohepatitis in 1 (5%), and alpha 1-

antitrypsin deficiency in 1 (5%). Degree of cirrhosis was classified as Child’s A in 13

(65%), Child’s B in 4 (20%) and Child’s C in 3 (15%). 13 (65%) of patients did not

have a diagnosis of HCC prior to rupture. Hemorrhagic shock was present in 8 (40%).

Embolization was performed with coils in 3 (15%), polyvinyl alcohol in 4 (20%), gel-

atin slurry in 5 (25%), or a combination of embolics in 8 (40%). Chemoembolization

was performed in 2 patients. Two of the patients had recent prior chemoembolization

procedures. Technical success of embolization was 100%. Most frequent complications

included transient transaminitis in 9 (45%) and pleural effusion in 7 (35%).

Encephalopathy occurred in one patient and resolved following medical treatment.

There were no cases of abscess, biloma, or pancreatitis. Of the patients who survived

to discharge (14/20), average length of hospital stay was 9 days (range 1-37 days). 30-

day mortality is summarized in Table 1.

Conclusions: Transcatheter embolization for ruptured HCC is safe and has a high

technical success rate at achieving hemostasis in patients with ruptured HCC. Decom-

pensated liver function (Child’s C) and the presence of hemorrhagic shock are

associated with increased 30-day mortality.

Table 1

Poster 23: Locoregional Therapy Algorithm for Unresectable Intrahepatic

Cholangiocarcinoma: What the Interventional Oncologist Needs to Know

A.F. Morales, H. Park, B. El-Rayes, D. Kooby, H.S. Kim

Objectives: 1. To review the classifications of cholangiocarcinoma: intra-hepatic,

hilar, and distal. 2. To identify appropriate surgical candidates 3. To review the indi-

cations/contraindications and efficacy of interventional oncology (IO) treatments in

unresectable disease including: intra-arterial therapies (TACE, DEB-TACE, TACI,

Radioembolization) and thermal ablation (radiofrequency, microwave). 4. With mul-

tidisciplinary input, offer an institution-specific treatment algorithm for managing

patients with ICC.

Methods: Background: Cholangiocarcinomas are subdivided into three subtypes:

intrahepatic, hilar, and extrahepatic distal. Intrahepatic cholangiocarcinoma (ICC)

remains among the most difficult tumors to manage and carries a dismal prognosis.

Surgical resection and orthotopic liver transplantation can be definitive cures in care-

fully selected patients; however, only 20-30 % of patients will meet criteria for surgical

resection at initial presentation, and the recurrence rate after surgery is high. The vast

majority of patients will present as nonoperative candidates secondary to late diagnosis

and/or advanced disease. In these patients, the disease is uniformly fatal with a median

survival time of several months to 1 year.

Results: Literature Review: Traditional systemic chemotherapy regimens (5-FU,

gemcitabine) for ICC have not been efficacious resulting in a median survival of 6 to

12 months. The chemotherapy combination of gemcitabine and cisplatin has however

shown a significant survival advantage in one phase III trial. Radiotherapy as a primary

treatment for unresectable ICC is associated with poor outcomes because of the poor

radiation tolerance of the liver and adjacent organs (stomach, duodenum, spinal cord).

Adjuvant radiotherapy has been used with limited success for palliative measures.

Accordingly, there is great interest in IO locoregional therapies as a means of improv-

ing treatment outcomes in those patients without surgical options. Multiple

single-institution studies have demonstrated significantly increased survival times and

progression free survival with intra-arterial chemotherapy-based regimens (TACE,

DEB-TACE, TACI). More recently, published data from several institutions using

radioembolization with yttrium-90 microspheres for unresectable ICC have all shown

encouraging results. When tumor size, number, and location are favorable, thermal

ablation may be an effective and potentially curative option with the 5-year survival

similar to that of surgical resection.

Conclusions: Unresectable intrahepatic cholangiocarcinoma remains among the most

difficult tumors to manage. Locoregional therapies are being increasingly pursued over

traditional treatments secondary to their higher tumor response rates, increased survival

times, and overall lower systemic toxicities. In this report, in conjunction with our insti-

tution’s surgical and medical oncologists, we will attempt to critically review and

comprehend the current role and future potential of present-day and experimental ther-

apies for ICC. Additionally we will offer our institution-specific multidisciplinary

algorithm for the management of ICC.

Poster 24: To Evaluate the Role of Radio Frequency Ablation in Treatment

of Liver Metastases

H.A. Pendse, S. Kulkarni, N. Shetty, T. Dharia, A. Polnaya, R. Gandhi,S. Patil, M. Thakur, S. Shrikhande, M. Goel

Objectives: 1. To evaluate the role of radio frequency ablation in treatment of liver

metastases 2. To evaluate the role of CEA as a tool to evaluate response to RFA

Methods: 29 patients who have undergone radiofrequency ablation for liver metas-

tases during the period of 2009-2012 are included in the study. PET-CT was done in

all patients to document the activity of the tumor and to delineate any other metastatic

lesion. RFA was performed using RITA STARBURST Probe. Pre and post RFA FDG

uptake on PET- CT study was noted after 6 weeks of patients to assess response to

treatment. Patients were later followed up every three months for a year and later fol-

lowed every six months for a year. The percentage decrease in tumor marker (CEA for

colorectal metastases) and decrease in SUV was calculated to assess the response to

treatment.

Results: 29 patients were recruited for the study comprising of 12 males and 17

females. 19 cases with metastasis from colorectal primary were assessed. The 6 week

follow-up demonstrated total necrosis in 16/19 lesions and partial necrosis in 3/19. The

3 month PET-CT demonstrated recurrence of lesion at same site as previous RFA in 2

patients while 2 patients had a second lesion at a site different from the treated lesion

6 month follow-up showed recurrence of tumor at the treated site in 3 patients with 4

patients having recurrence at a distant site from the treated lesion. The pre RFA CEA

levels were compared with the post RFA CEA levels done at 6 weeks by Student’s

Paired T Test which showed fall in the CEA levels to be significant at p value less than

0.05. The pre-procedure FDG uptake of the lesions was also compared with the post-

RFA FDG uptake at 6 weeks scan. . 3/19 patients showed residual FDG uptake in the

lesion suggesting residual tumor while rest of the 16 patients showed complete absence

of FDG uptake. 5 cases with single liver from Breast primary were treated. The 6 week

follow-up demonstrated total necrosis in all lesions. The 3 month PET-CT demon-

strated recurrence of lesion at same site as previous RFA in 1 patients while 1 patient

developed extra-hepatic metastasis 6 month follow-up showed recurrence of tumor at

the treated site in 2 patients with 2 patients having recurrence at a distant site. 2 cases

with renal cell carcinoma primary, single case of adrenal primary and single case of

liver metastases from endometrial carcinoma were also treated.

Conclusions: RFA has shown good efficacy in ablation of liver metastasis.

Poster 25: Endobiliary Brush Cytology During Percutaneous Transhepatic

Biliary Drainage for Suspected Malignant Biliary Obstruction

R. Gandhi, T. Dharia, S. Kulkarni, N. Shetty, A. Polnaya, S. Patil,H.A. Pendse

Objectives: To emphasize the role of PTBD brush cytology to diagnose the etiology

of obstructive jaundice. To evaluate the efficacy and safety of brushing.

Methods: Fifty seven patients (30 men and 27 women; mean age, 54.5 years) with

obstructive jaundice underwent endoluminal brush cytology during or after percuta-

neous transhepatic biliary drainage in the presence of on-site cytologist. The lesions

involved the upper common bile duct (n _ 7), lower common bile duct (n_4), common

hepatic duct (n _ 15) and hilum with right or left intrahepatic ducts (n_31). In each

patient, three (mean-2 specimens) were taken from the lesion with 8F cook brush.

Results: 40 out of 57 brush biopsies resulted in correct diagnoses of malignancy. 2

biopsy diagnoses proved to be true-negative. There were 15 false-negative diagnoses

which were proved by USG/CT biopsy, tumour markers, radiological diagnosis or clin-

ical suspicion and no false-positive diagnoses. The diagnostic performance of

endoluminal brush cytology in malignant biliary obstructions was as follows: sensi-

tivity – 72.7%, specificity - 100%, positive predictive value - 100%, negative

predictive value – 11.8% and accuracy – 73.7%. Sensitivity of cytology in the 36

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patients with cholangiocarcinoma was 68.6%. The sensitivity of brushing with cholan-

gioca was more with respect to noncholangioca. The sensitivity of brush cytology was

highest in type II (83.3%) obstruction and lowest in type I (55.6%).

Conclusions: Percutaneous endoluminal brush cytology is a safe and relatively

highly accurate procedure that is easy to perform through a transhepatic biliary

drainage tract.

Poster 26: Withdrawn

Poster 27: Magnetic Resonance-guided Focused Ultrasound (MRGFUS)

for the Treatment of Osteoid Osteoma – Brazilian Initial Experience

E.P. Anastacio, C. Cavalcanti, F. Barbosa, M. Moura, P. Viana, E. Garcia,M. Menezes

Objectives: Osteoid osteoma are benign small size tumors that can affect any bone

in the body but are most common in long bones, such as the femur and tibia. They

account for around 12 percent of all benign bone tumors and are most common in

patients between the ages of 4 and 25 years old. Males are more affected (3 M : 1F).

The most common symptoms are: pain that escalates to severe at night, swelling, limp-

ing, bowing deformity and muscle atrophy. It has greater importance because

determines a functional limitation in economically active population. The lesion can

easily be detected on CT scan. Osteoid osteoma typically show a round lucency, con-

taining a dense sclerotic central nidus surrounded by sclerotic bone. The classic

modalities of treatments are non-steroidal anti-inflammatories, surgical or percutaneous

ablation. Recently, percutaneous radiofrequency ablation is the preferred treatment

option because it is a minimally invasive procedure, the recovery time is shorter and

it does not weaken the bone as much as surgery does. MRI guided high-intensity

focused ultrasound is a non-invasive and highly precise hyperthermia therapy that

applies high-intensity focused sonic energy to locally heat and destroy diseased or

damaged tissue through ablation under magnetic ressonance guindance. In this context,

thermal ablation of osteoid osteomas using high intensity focused ultrasound under

MRI guidance emerged as a new modality of non-invasive treatment option. The aim

of our study was to demonstrate Brazilian first and initial experience of MRGFUS as

a non invasive method for the treatment of pain caused by osteoid osteoma.

Methods: We selected three patients with osteoid lesion and limited reduced quality

of life due to painful osteoid lesion associated to mild joint function, confirmed at MR

and CT. MRGFUS (ExAblate 2100, InSightec, Haifa, Israel) housed into a 1,5T MR

system (GE) was performed. Each patient was planned with multiple sonications to

complete nidus ablation. Clinical and imaging (MRI) follow-up was performed 1, 3

and 6 months after treatment.

Results: After treatment, all patients refered complete disappearance of painful symp-

toms. There was a self-limited small focal skin burn in one patient. There were no

treatment-related complications peri and post procedure

Conclusions: In our experience, osteoma can be noninvasively treated with high

intensity focused ultrasound under MR guidance. MRGFUS represents a safe and

effective treatment for the ablation of osteoid osteoma.

Poster 28: Pathology Examination of 64 Consecutive Specimens Obtained

Using a Powered Biopsy Device at a Community Based Hospital

K. Symington, F. Martinez, T. Philbeck

Objectives: In 2010, a new battery/rotary powered biopsy device was introduced for mar-

row sampling and examination of focal lesions of bones. A retrospective examination was

conducted to determine the characteristics of pathology specimens using the new device.

Methods: For this IRB-approved study, records at Spokane Holy Family Hospital

from Mar 2010 to Jul 2012 were examined for patients who had undergone biopsy pro-

cedures using the powered device (OnControl, Vidacare Corp, Shavano Park, TX) with

focus on pathology data including specimen size, grading for crush/thermal artifact,

hemorrhage, quality, and ability to provide a definitive/descriptive diagnosis.

Results: 64 patients had biopsy procedures using the powered device by 11 interven-

tional radiologists. 84% of patients received targeted bone biopsy for focal lesions; the

remainder received marrow aspiration and biopsy for hematological disorders. Proce-

dures were performed on vertebrae and the ilium in 39% and 38% of the cases,

respectively. Other bones: sacrum, femur, pubis, humerus, rib, and tibia.

Conclusions: The powered biopsy device is especially useful for hard bones and dif-

ficult to reach lesions. Shorter procedures and less physician effort using the new

system improves ergonomics. For bone marrow sampling and focal lesions, these

advantages result in larger/higher quality specimens, a broader spectrum of potential

users, and reduced radiation exposure to patients and clinicians. The system also turns

previously inaccessible focal lesions into potential biopsy targets.

OnControl Biopsy System Powered Driver and Needleset

Study Results

Poster 29: A Single Device for Percutaneous Tissue Ablation Using

Irreversible Electroporation and Subsequent Core Biopsy in a Swine

Model

T. Wimmer, N. Gutta, S. Monette, S. Solomon, C.T. Sofocleous,G. Srimathveeravalli

Objectives: Percutaneous ablation techniques are clinically used to treat tumor tissue

locally without tissue removal. We studied the feasibility of a combined device for tis-

sue ablation using irreversible electroporation (IRE) and for subsequent core biopsies

from the ablation zone and evaluated the predictive value of core biopsy samples taken

from ablation zones in two different porcine tissue models.

Methods: 12 ablations in porcine skeletal muscle and 12 ablations in porcine kidneys

were performed using hybrid ablation-core biopsy probes and a range of treatment set-

tings for IRE (including monopolar and bipolar arrangements). Complete treatment

was simulated through application of a high voltage setting (1725 V/cm), and incom-

plete treatment through reduced voltages (1250 V/cm and 500 V/cm). Core biopsy

samples were taken from the zone of ablation using the probe in the same location IRE

was performed as well as from untreated tissue for control. Histopathologic analysis

was performed on muscle biopsy samples stained with hematoxylin and eosin (H&E)

and on kidney biopsy samples stained with nicotinamide dinucleotide diaphorase

(NADH) and compared to necropsy tissue samples harvested acutely from the ablation

zone and stained with H&E.

Results: 23 IRE treatments were successfully completed while one treatment in mus-

cle tissue at 1725 V/cm was aborted due to high current. The hybrid probe for ablation

and biopsy did not impact the delivery of IRE as confirmed by histopathologic

necropsy specimen. Muscle core biopsy samples taken directly after treatment with

low voltage settings appeared normal whereas muscle biopsy samples taken after treat-

ment with the high voltage setting showed moderate to marked myofiber degeneration

and necrosis on H&E stains. Kidney biopsy samples showed no NADH staining after

treatment with the high voltage setting but moderate to strong staining after treatment

with the low settings and on the untreated control group indicating incomplete cell

death in the low settings.

Conclusions: A single applicator device can be used to perform tissue ablation using

IRE and to take core biopsy samples from the ablation zone. Biopsy specimens taken

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from the ablation zone immediately after treatment may indicate incomplete ablation

when using lower voltage settings.

Poster 30: Interventional Oncology: Collaborative Practice to Develop a

Concurrent Nursing Conference

G. Deitrick, D. Fleischer, D. VanHouten, M. Kennedy

Objectives: Interventional oncology (IO) is a subspecialty important to the collabo-

rative care of oncology patients. Nursing practice in interventional oncology

incorporates surgical, radiological and general oncology nursing knowledge and skills.

IO nurses and advanced practitioners serve as experts in IO/IR patient care. Patients

undergo procedures including venous access placement, embolization, chemoem-

bolization, radioembolization and ablative therapy for solid tumors and bony

metastases. Attendees will be able to describe the development of the first concurrent

nursing interventional oncology conference, including development of nursing objec-

tives, opportunities for nursing research and integration into the annual WCIO

conference.

Methods: A collaborative team was formed with interventional radiology (IR) nurse

practitioners (NPs) and nurse leaders at the University of Pennsylvania Health System

and Memorial Sloan-Kettering Cancer Center with the assistance of the WCIO Board

of Directors. Discussions of common questions and concerns related to oncology pop-

ulations were held via email and teleconferencing.

Results: The top four topics identified were: tumor ablation, tumor embolization,

venous access and irreversible electroporation. Content outlines were developed, and

NP and physician networks were used to select and invite expert presenters for the con-

ference. There were two expert nurse practitioner speakers invited from outside of the

planning panel to speak on irreversible electroporation and venous access devices.

Both of these speakers are well known in the IO field as experts in their practice. The

remainder of the topics including post-embolization syndrome pathophysiology and

management, the basics of ablation, and the intricacies of post-procedural vs. post-

anesthesia monitoring by IR nurses will be discussed by the nurse practitioners on the

planning committee, as well as expert practitioners from their associated IO practices.

Session evaluations, using a Likert scale rating system will be collected. Also, written

comments and verbal feedback will be collected and analyzed, including topic ideas

for future conferences.

Conclusions: IR and IO are important aspects of oncology care that require an expan-

sion of scientific- and practice-based knowledge, and engagement of experts to direct

future work in nursing research, standardization of nursing practices, and strategies to

improve patient outcomes. This conference is a major step in defining competencies

and scope of practice for IR/IO nurses and advancing subspecialization within oncol-

ogy nursing. Moreover, this conference and future meetings serve as a foundation for

building special interest groups within other professional organizations, specifically

the Oncology Nursing Society (ONS), for IR and IO nurses.

Poster 31: Percutaneous Cryoablation for Renal Cell Carcinoma (RCC)

Therapy: A Pilot Study of Mean MR Apparent Diffusion Coefficient (ADC)

to Assess Early Tumor Response

J.C. Camacho, N. Kokabi, V. Master, J. Pattaras, P. Nieh, H.S. Kim

Objectives: To evaluate changes in mean ADC values to assess early response to

treatment in RCC following percutaneous cryoablation therapy

Methods: Prospective IRB approved HIPPA compliant study with 11 patients and 12

biopsy proven RCCs that underwent cryoablation in a 3-9 months period. Dynamic

MR imaging to assess therapy response was completed 1, 3 and 6 months post-therapy.

Early imaging was defined as < 45 days. DWI respiration triggered fat-suppressed sin-

gle-shot echo-planar sequence with tri-directional diffusion gradients and b values of

50, 400 and 800 s/mm2 was used. Pixel-based ADC maps were generated and mean

values were calculated after drawing ROI at tumor center, periphery and peritumoral

region. Complete response (CR) was defined as no contrast-enhancement within the

treated lesion as primary outcome. Paired t-test was used to compare different tumor

ADC values before and after 45 days post-procedure. Significance levels were set at

.05 and data was analyzed using SAS statistical package v9.2

Results: All patients had CR to treatment. Average tumor size was 2.6 cm (1.4-4.4

cm) pretreatment and 3.0 cm (1.8-5.9 cm) after (p = 0.06). Mean ADC value was 1.010

× 10−3 mm2/sec in the center of the lesion, 1.272 × 10−3 mm2/sec at the periphery

and 1.410 × 10−3 mm2/sec peritumoral. The difference between central and periphery

ADC was statistically significant (p= 0.004) as well as the difference between central

- peritumoral ADC (p=0.017). Peritumoral - periphery ADC difference was not statis-

tically significant (p=0.331). Mean ADC value in lesions evaluated < 45 days was

0.880 × 10−3 mm2/sec at the center, 1.039 × 10−3 mm2/sec at periphery and 1.409 ×10−3 mm2/sec peritumoral. Mean ADC value in lesions evaluated > 45 days was 1.048

× 10−3 mm2/sec at center, 1.260 × 10−3 mm2/sec at periphery and 1.350 × 10−3

mm2/sec peritumoral. When comparing ADC values of images < and > 45 days post-

treatment, difference of central – periphery ADC was statistically significant (p= 0.020

and p=0.038 respectively). Qualitative restriction was observed < 45 days after treat-

ment with subsequent signal increase of ADC on images > 45 days

Conclusions: Restricted diffusion can be observed in the early post-procedure period

(<45 days) and if ADC value increases (>1.0 x 10−3 mm2/sec) after 45 days potentially

predicts positive or favorable cryoablation outcome

Poster 32: CT-Guided Biopsy of FDG-avid Lesions Without Tomographic

Abnormality: Feasibility and Diagnostic Accuracy

V.G. Sahani, K. Kobayashi, K. Sam, M.A. Sultenfuss, D. Smith, N.R. Patel

Objectives: Because F-18 FDG PET-CT can demonstrate malignancy before mor-

phologic changes are evident, biopsy of FDG-avid lesions without tomographic

abnormality can theoretically facilitate early histologic diagnosis and staging. How-

ever, such lesions may be difficult to target under CT-guidance alone. The purpose of

this study is to retrospectively evaluate the feasibility and diagnostic accuracy of CT-

guided biopsy of FDG-avid lesions at PET-CT without tomographic abnormality.

Methods: A review of 819 consecutive CT-guided biopsies between 4/01/09 and

11/30/12 identified 13 biopsy cases of a focal FDG-avid lesion at PET-CT without

tomographic abnormality. Anatomic landmarks were used to guide a needle to the focal

area of FDG uptake seen on PET-CT. Medical records were reviewed for a history of

previous malignancy, pathology results and any complications occurred related to

biopsy. For cases with negative pathology, nature of the lesion was determined based

on clinical and imaging follow-up. The size and standard uptake value (SUV) of the

focal FDG-avid lesions were measured.

Results: Of the 13 patients included, 9 had a history of malignancy including lung

(n=5), leukemia (n=1), bladder (n=1), esophagus (n=1), and malignant fibrous histio-

cytoma (MFH) (n=1). The locations of the focal FDG-avid lesions biopsied were bone

(n=8), soft tissue (n=3) and pleura (n=2). The mean size of FDG-avid area was 1.7 cm

and SUV ranged from 4.7 to 12.7 (average 6.9). 12 biopsies were technically feasible

and the needle was placed within the FDG-avid area. One biopsy was aborted because

of difficulty in placing the needle into a small area of FDG uptake within muscle. Of

the 12 biopsies, 8 were positive for malignancy (metastasis from lung cancer (n=3),

bladder (n=1) or esophagus (n=1), malignant fibrous histiocytoma local recurrence

(n=1) and plasmacytoma (n=2)). The positive biopsy sites included bone (n=7), and

soft tissue (n=1). Of 4 cases with negative biopsy, one (pleura) was diagnosed with

metastasis from lung cancer by subsequent biopsy via pleuroscopy and one (bone) was

considered to be metastasis by clinical follow-up. The remaining 2 negative biopsy

cases (pleura and muscle) confirmed stability of the lesion on follow-up imaging. No

biopsy-related complications occurred. The sensitivity and accuracy of CT-guided

biopsy were 80% and 83%, respectively.

Conclusions: CT-guided biopsy of FDG-avid lesions without tomographic abnor-

mality was technically feasible and yielded relatively high accuracy by using anatomic

landmarks for needle placement. However, full PET-CT guidance may result in a

higher biopsy yield.

Poster 33: Withdrawn

Poster 34: Cisplatin Microspheres Demonstrate Improved Cytotoxicity

Profile Against 6 Cancer Cell Lines

B. Mishra, S. Dhokai, R. Verma, P. Blaskovich, X. Guan, A. Mathur,H. Sard, M. Jaggi, A. Singh, R. Ohri

Objectives: Cisplatin has been classified as one of the most potent anticancer agents

for many solid tumours, including liver tumours. However, the efficacy of cisplatin is

limited due to serious side effects and resistance phenomena associated with its admin-

istration. We have developed a microsphere based sustained-release formulation of

cisplatin, with the goal of preserving its efficacy, while mitigating side-effects and

drug-resistance.

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Methods: Our lead microsphere based formulation, called “Cis-MS-30”, contains

cisplatin at 27% (w/w) and was prepared with PLGA as the encapsulating polymer

[PLGA i.e. poly (D,L-lactide-co-glycolic acid with a 75:25 ratio between lactide and

glycolide], and with a size range of 105 μm – 150 μm in diameter. The in-vitro release

profile achieved with this formulation in ideal sink conditions is represented in Figure

1. The anti-proliferative potential of Cis-MS-30 microspheres was evaluated using a

panel of six human cancer cell lines for different durations of treatment ranging from

5 h – 168 h, over a wide concentration range (1nM - 100μM), and was directly com-

pared with the effects of un-encapsulated, free cisplatin using the same cell-lines,

durations of treatment and concentrations. The human tumor cell-lines used in this

evaluation were those corresponding to hepatocellular carcinoma (Hep G2), urinary

bladder carcinoma (5637), cervix squamous cell carcinoma (SiHa), lung carcinoma

(A549), ovary teratocarcinoma (PA-1) and pancreas adenocarcinoma (AsPc-1).

Results: As summarized in Figure 2, the Cis-MS-30 microsphere formulation for cis-

platin demonstrated decreased in vitro cytotoxicity profile as compared to free cisplatin

for the same dosage, as evident by 1.5-3.0 log higher IC50 values in target cancer cell

lines for shorter durations of exposure. At the same time, the data suggests that by later

time-points, the efficacy achieved with the Cisplatin microspheres is similar to that of

free Cisplatin given that the IC50 values achieved with Cisplatin microspheres are at

the same order of magnitude compared to those achieved with free cisplatin at later

time points, reflecting the gradual and sustained release of cisplatin from PLGA

microspheres. Hence there exists a proportional and cumulative correlation between

the release of cisplatin and the cytotoxic activity exerted by the cisplatin microspheres.

Conclusions: The data suggests that the Cis-MS-30 formulation of cisplatin micros-

pheres is capable, over-time, of demonstrating anti-tumor efficacy similar to a single

administration of free cisplatin at the same dose. At the same time, the cisplatin micros-

pheres offer the potential of reduced side-effects and drug-resistance by virtue of the

slow-release at a lower concentration of the cisplatin for the same dose spread over a

longer period of time, rather than a high concentration from the dose that would result

with free cisplatin administration. Significant advantages could therefore be offered

for interventional oncology applications.

Poster 35: Investigation into Shapes and Volumes of Ablated Tissue with

Bipolar Radiofrequency Ablation Using a Monopolar Generator in an

Agar Liver Model

A. Rezvani, J.K. Tun, T. Fotheringham

Objectives: Solid tumours can be treated using radiofrequency ablation (RFA). Most

of generator needle combinations use monopolar RFA and aim to produce a roughly

spherical burn, typically 5cm or less. The majority of generators and needles available

are intended for monpolar use however, monopolar radiofrequency generators can be

used without modification for bipolar RFA. Bipolar RFA can treat larger lesions and

also be used to create non spherical burns. The purpose of this study was: to demon-

strate that a monoploar generator can by used for bipolar treatment, to confirm that

larger volumes of ablation can be achieved and to show the shape of burns that result

from different needle positions. Additional tests are being performed with different

needles sizes at different distances to develop a more complete view of the bipolar

ablation shapes and volumes.

Methods: An agar liver phantom was used as a medium to determine the shape and

volume of the ablation. An RF 3000 generator (Boston Scientific, MA), delivering up

to 200W was used with 4cm LeVeen RFA needles (Boston Scientific, MA) to perform

the ablations. The endpoint for both monpolar and bipolar ablations was determined

by an impedance-based feedback system. The agar model was sectioned and the size

and shaped of the ablation recorded. The volume of ablated tissue was calculated. A

monopolar ablation was performed as a control with a 4cm needle. Bipolar ablations

were performed with 7 different deployments each using two 4cm needles. The needles

were placed in parallel with the arrays ranging from 2-10cm apart.

Results: The monopolar ablation was spherical, 5cm in diameter, volume=65ml. The

shape of the bipolar ablations varied with the distance between the two arrays. At 2cm

the ablation was spherical, 5cm diameter, volume=65ml. The shape was ovoid (3-6cm)

volumes ranging from 113-163 ml. The ablation was dumbbell shaped (arrays 8 and

10cm apart) volumes=286 and 754 ml. There results show larger volumes can be

ablated with a bipolar technique. The shape of the ablation is predictable and with

wider separation of the two arrays the ablation is non spherical.

Conclusions: The findings support the hypothesis that monopolar RFA generators

and needles can be used as bipolar systems, without modification, and may facilitate

ablation of large or irregular lesions.

Poster 36: Percutaenous Cryoablation a Novel Method for Rapid Palliation

for Severely Symptomatic Osteoid Osteoma Patients

T. Dean, R.S. Williams, D. Yim, D. Monson

Objectives: The purpose of this study was to evaluate the safety, efficacy and utility

in rapid palliation following CT-guided percutaneous cryoablation in opioid requiring

severely symptomatic osteoid osteoma patients.

Methods: Over a 12-month period (11/2011-11/2012), four patients mean age of 17.5

± 8.2 years old under went CT-guided percutaneous cryoablation for painful osteoid

osteomas. Lesion locations included two mid shaft tibia, one lesser trochanter and one

femoral neck. Three procedures were performed under general anesthesia and one

patient with moderate sedation. Under CT guidance a 15-gauge bone drill was used to

core the approach. Subsequently, a 17-gauge cryoablation probe was placed within the

lesion and ablation performed. Each ablation included two 10-minute freezes inter-

spaced by an 8-minute thaw cycle. Post ablation CT was performed for evaluation of

hazy disruption of lesion nidus. Follow-up was performed to assess clinical outcome

for a minimum of 1 month. A visual analog scale (VAS) and pain episodes requiring

oral opioids per week (PEOA), 24-hour post-ablation and 1 month post-ablation pain

scales were assessed.

Results: Cryoablation was clinically successful for all patients. No fractures or other

adverse events were observed. Complete (100%) pain relief was observed in all

patients at one month. Mean VAS were 6.25 ± 1.2 @ pre-procedure, 1.0 ± 0.82 @ 24-

hours post procedure and 0.25 ± 0.50 @ 1 month follow-up. The PEOA pre procedure

was 5.8-± 1.71 and at 0 @ 1 month post procedure. All patients were allowed return

to unrestricted activity within 10 days after the procedure without incident.

Conclusions: Percutaneous image-guided cryoablation is a safe, effective and rapidly

palliating method for severely symptomatic patients with osteoid osteoma.

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16 year old male with severely symptomatic OO in the mid-tibia. Cryoabaltion

probe was placed in the central aspect of the nidus.

Poster 37: Withdrawn

Poster 38: The Use of Skin Dosimetry as an Adjunct Measure of Patient

Exposure During Hepatic Chemoembolization

B.D. Hammelman, S. Richard, M. Watts, M. Itkin

Objectives: To assess the use of skin dosimetry as a measure of patient peak skin

exposure during transarterial hepatic chemoembolizations, and compare its utility to

more commonly used measures provided by modern fluoroscopic equipment.

Methods: We placed skin dosimeters (Microstar, Landauer, Glenwood Illinois) on

the backs of patients prior to transarterial hepatic chemoembolizations (TACE). On the

vast majority of these patients, three skin dosimeters were placed. We recorded the cor-

responding dose area product (DAP), reference air kerma, and fluoro times as reported

by our fluoroscopy unit for each of the procedures. The highest reading from the

dosimeters placed was used as a measure of peak skin dose. Pearson’s correlation coef-

ficients were calculated comparing this maximum dosimeter reading to reference air

kerma and DAP.

Results: Skin dosimeters were placed under 87 supine patients undergoing hepatic

transarterial chemo-embolizations. For all but five of these procedures, the maximal

dosimeter measurement was less than the reference air kerma. In six of our TACE pro-

cedures a skin dosimeter recorded an exposure higher than 2 Gy, a commonly accepted

threshold for radiation changes to the skin. Pearson’s correlation coefficients compar-

ing the hightest dosimeter reading for a given exam with the reported reference air

kerma and reported dose area product were low (0.18 and 0.29 respectively).

Conclusions: Skin dosimetery demonstrated a poor correlation with metrics supplied

by fluoroscopy equipment commonly used as a surrogate for peak skin dose. While

skin dosimetry is a direct measurement of skin dose at a given point, sampling error

(the inability to position the dosimeter at the location of the actual peak dose) limits

their clinical relevance when used as a predictor of deterministic radiation effects on

the skin. While skin dosimetry can be used as an adjunctive quality assurance measure

in clinical practice, it has the potential to underestimate the peak skin dose, and in most

cases reference air kerma will remain a more conservative, if less accurate estimate of

peak skin dose. Recently described methods for skin dose mapping through computer

modeling will likely provide the best estimate of peak skin dose as they become com-

mercially available.

Poster 39: Microwave Ablation of Symptomatic Hepatic Cavernous

Hemangiomas

M. Lubner, T. Ziemlewicz, A. Cohn, M.L. Center, S. Wells, C.L. Brace,L. Hinshaw, F. Lee

Objectives: Hepatic hemangiomas are common, benign hepatic neoplasms that gen-

erally follow an indolent course. However, approximately 20% of hemangiomas are

large (greater than 4 cm in diameter) or progressively increase in size. Large heman-

giomas can result in symptoms including abdominal/ epigastric pain resulting from

capsular distention or mass effect on adjacent organs. Historically, large, symptomatic

hemangiomas were treated surgically; however, surgery is associated with a significant

morbidity and prolonged recovery. Microwave (MWA) offers several advantages,

including large ablation zones and rapid ablation times compared to radiofrequency

ablation. We describe the use of MWA in the minimally invasive management of large,

symptomatic hepatic hemangiomas.

Methods: A total of 6 patients and 7 hemangiomas (5 female, 1 male, mean age 46

yrs) were treated. All lesions were peripheral in location and abutted/stretched the liver

capsule. One replaced nearly the entire right hepatic lobe. Mean largest dimension was

7.0 cm (range 3.4-12.2 cm), mean volume was 278 cm3 (range 21-951 cm3). Patient

symptoms consisted of right upper quadrant pain, bloating, early satiety and two

patients had intermittent vomiting. All patients were treated with microwave ablation

using 17-gauge gas cooled antennas for a mean ablation time of 10.8 minutes and mean

power of 67 W. Three patients received hydrodissection to protect adjacent structures

(5% dextrose in water, mean volume 550 mL). Mean clinical and imaging follow was

8.4 months, with immediate post ablation imaging in all patients and two patients with

delayed follow up imaging.

Results: All procedures were technically successful with no major or minor compli-

cations by SIR criteria. Immediately post-ablation, mean tumor diameter decreased

19% (from 7.0 cm pre to 5.4 cm post, p<0.05), and mean volume decreased 48% (from

277 to 83 cm3, p<0.05). Three patients are now pain free, two report abdominal pain

dissimilar to preprocedure pain, and one was treated in the last month.

Conclusions: Microwave ablation is a safe, well-tolerated minimally invasive

method for treating symptomatic benign lesions such as cavernous hemangiomas. In

this series, symptom improvement and significant lesion size reduction was seen. In

addition, the mean ablation time of 10.8 min

Hepatic hemangioma pretreatment with a largest diameter of 12.2 cm and a volume

of 951 cm3.

Same hemangioma 13 months post treatment, now 7.7 cm in greatest diameter and

151 cm3, an 84% reduction in volume. Note how the kidney has ascended as the

tumor continues to shrink.

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Poster 40: Illustration of a Novel Cryoablation Technique in the Treatment

of Osteoid Osteomas of the Spine: A Safer Alternative to Radiofrequency

Ablation?

D. Yim, R. Williams, H. Park, D. Monson

Objectives: The purpose is to illustrate a unique application of Cryoablation technol-

ogy distinct from Radiofrequency ablation to more safely treat Osteoid Osteomas of

the spine.

Methods: The efficacy of cryoablation and RFA for palliative treatment of painful

osseous lesions is well documented. However, RFA needle placement technique has

focused on penetrating cortical bone into the lesion, potentially leading to iatrogenic

fracture and injury to adjacent neural elements. We illustrate a new technique of plac-

ing a cryoablation needle parallel and adjacent to the bony cortex, allowing lethal ice

to grow across the bone into the targeted lesion.

Results: Two pediatric patients were referred for RFA of osteoid osteoma lesions.

RFA was considered too risky due to proximity to neural elements. One lesion was

located in the left L3 pars interarticularis and the other adjacent to the left S4 neuro-

foramina, respectively. So, a single 17G “Ice Rod” Cryoneedle (Galil Medical, Arden

Hill, MN) was placed under CT guidance within 1 mm tangent to the bony cortex such

that the “iceball” migrated across the bone through the tumor nidus as seen on CT.

Both patients experienced complete resolution of pain and stopped taking NSAIDs

immediately post procedure. During serial follow up to 1 year, the VAS for each patient

remained 0. Both patients did not resume taking NSAIDs at any time. The only minor

complication occurred in the patient with the sacral lesion, as she experienced some

mild numbness in the left inner thigh near the perineum that shortly resolved within 1

month.

Conclusions: Due to the inherent technology of cryoablation, the cryoneedle can be

placed parallel to the bony cortex because lethal ice can cross cortical bone which acts

as a barrier to thermal energy. Therefore, RFA probes must penetrate the bony cortex

and seat into the nidus. This unique feature of cryoablation eliminates the need to dis-

rupt the integrity of the bony spine which could result in fracture and other skeletal

complications. Additionally, neural elements are more resistant to cold injury than ther-

mal injury making cryoablation a more attractive treatment modality in the axial

skeleton. As more cases are performed using this technique, cryoablation has the poten-

tial to become the preferred modality in the treatment of spinal osteoid osteoma.

Poster 41: Prediction of Tumor Response and Patient Outcome of

Radioembolization for Hepatic GI Metastases

B. Baigorri, N. Jain, C. Arsene, R. Patel, J. Critchfield

Objectives: Radio-embolization has shown promising results in the treatment of unre-

sectable metastatic gastrointestinal cancer to the liver, however the tumor response is

unpredictable. The importance of predicting the outcome of selective internal radio-

therapy (SIRT) in these patients cannot be over emphasized. This retrospective review

was conducted to determine if the CEA levels, number of lesions, metastasis to other

organs, size of the lesion, age at diagnosis and gender can predict the outcome in these

patients treated with Yttrium-90 glass microsphere radio-embolization.

Methods: Patients with known history of SIRT for hepatic metastasis from colorectal

tumors were included in the study. All these patients received baseline CT scans and

CT scans at 1 month, 3 months and 6 months post SIRT. We collected demographic

data and other variables like CEA levels, number of lesions, metastasis to other organs,

and size of the lesion. Descriptive statistics and survival analyses were conducted.

Results: Twenty-three patients (61% males; average age of 60 years) were included

in the study. 65% of the patients had three or more lesions, only 26% had metastasis

to other organs besides liver, the mean CEA value was 196.5, the mean size of the

lesion by RECIST 1.1 criteria was 12.02, and the mean overall survival was 313 days

(the median was 750 days).

Conclusions: There was no statistical significant association between the observed

variables and the overall survival at one year. The size of the lesions was not a good

predictor of survival and nor was the metastasis to other organs outside liver. Many

lesions demonstrated an increase in the size after one month of therapy, though many

of these patients had overall survival rates comparable to or even less than the patients

with decreased size, and therefore indicating that the RECIST 1.1 criteria may not be

self sufficient to access tumor progression in these patients.There is no statistical sig-

nificant correlation between the variables observed and the overall survival at one year.

The size of the lesions was not a good predictor of survival and nor is the metastasis

to other organs outside liver. Many lesions demonstrated increase in the size after one

month of therapy though many of these patients had overall survival comparable to or

even less than the patients with decreased size, thus indicating that the RECIST 1.1

criteria may not be self sufficient to access tumor progression in these patients.

Poster 42: Safety and Efficacy of Combined Treatment with

Radiofrequency Ablation Followed by Hepatic Arterial Chemo -

embolization for the Treatment of Primary and Secondary Malignant

Hepatic Neoplasm: A Retrospective Evaluation

S. Gadani, T. Dawson, P. Lertdilok, J. Ensor, A. Tam, K. Ahrar,M. Wallace, S. Gupta

Objectives: Locoregional therapies like radiofrequency ablation (RFA) and transar-

terial chemoembolization with drug-eluting beads (DEB-TACE) for liver malignancies

can have limitations, especially when used in isolation. While combination therapies

are widely accepted, there is controversy regarding how best to combine these tech-

niques to optimize the clinical outcome. The objective of this study was to

retrospectively review the safety and efficacy of RFA followed by DEB-TACE for the

treatment of primary and secondary hepatic malignancies.

Methods: Total 23 patients with 25 liver lesions were treated with RFA followed by

DEB-TACE. Ablations were performed using single or multiple RF probes (Cool-tip,

Covidien). RFA was followed within one day by DEB-TACE using 100-300 micron

DC beads (Biocompatible UK Ltd) loaded with doxorubicin or irinotecan. Technique

effectiveness as well as time-to-progression (TTP) of the treated lesion and liver as a

whole were evaluated.

Results: Of the 25 treated liver lesions, there were 2 hepatocellular carcinomas and

23 metastatic lesions from various primary malignancies. Lesion sizes ranged from 1.5

cm to 5.0 cm in maximum dimension. On angiography, 22 lesions showed reactive

hyperemia in the periablation zone. Mean dose of chemotherapy administered was 20

mg. Major complication rate was 4.3%; one patient with prior history of Whipple’s

surgery developed liver abscess one week after treatment. Complete ablation was

achieved in 22 lesions. Median TTP of index lesion and whole liver were 15.1 and 6.2

months respectively.

Conclusions: Our preliminary data suggests that combination therapy (RFA followed

by DEB-TACE) for liver malignancies is safe and well tolerated. RFA created periab-

lation reactive hyperemia in majority of the patients facilitating localization of

hypovascular tumors, selective catheterization and drug delivery during DEB-TACE.

Prospective randomized control trials are indicated to evaluate the treatment response

and survival benefit with this approach for various liver malignancies.

Poster 43: Very Late Complications of Percutaneous Thermal Ablation

Treatment of Malignant Liver Tumors and Renal Tumors: A Series of

Unexpected Cases

V. Demers, T. Cabrera, R. Lindsay, M. Aanidjar, P. Metrakos, D. Valenti

Objectives: Thermal ablation has become a common treatment for patients with unre-

sectable primary or secondary hepatic malignancies and selected cases of renal

malignancies. its use has gained widespread popularity immediate complications have

been well described, however long term complications associated with thermal ablation

have been only rarely reported. Only a few isolated case reports of seeding, capsular

necrosis, intraperitoneal hemorrhage, pleural effusion, hemothorax and hepatic

abscesses have been documented in RFA treatment series. We are presenting a series

of four cases with significant long term complications following percutaneous RFA

treatment: a colo-hepatic fistula, a diaphragm perforation with bilio-bronchial fistula,

a duodenal perforation and a vascular fistula with gross hematuria.

Methods: We are presenting a series of four cases with significant long term compli-

cations following percutaneous RFA treatment: a colo-hepatic fistula, a diaphragm

perforation with bilio-bronchial fistula, a duodenal perforation and a vascular fistula

with gross hematuria.

Results: Case 1: 75 yo man presenting with large liver abscess secondary to colo-

hepatic fistulisation 5 years post percutaneous radiofrequency ablation treatment of a

liver metastatis from colorectal cancer. The abscess was treated with percutaneous

drain and to date, there is no evidence of recurrent disease. Case 2: 59 yo man present-

ing with a diaphragmatic tear after a golf swing complicated by a pleuro-biliary fistula

and thoracobilia 6 months after a microwave ablation treatment. Patient died with mul-

tifocal pneumonia. Case 3: 67 yo man presenting a pyelonephritis complicated by a

duodenal perforation 6 months after an RFA treatment for RCC of the right kidney,

mid and anterior segment developed a pyelonephritis 6 months after the treatment,

extending to the duodenum presenting duodenal perforation. Surgical duodenal recon-

struction and right nephrectomy were required. 57 months after the RFA the patient is

now disease free. Case 4: 58 yo woman presenting with gross hematuria related to an

arterio-venous fistula at the site of ablation 2 years post RFA of a right sided RCC.

Embolisation was required.

Conclusions: Percutaneous thermal ablation allows treatment of otherwise unre-

sectable primary and secondary hepatic and renal malignancies. Immediate

complications are well known and multiple techniques have developed to avoid them

as much as possible. However, late complications are still unexpected in the majority

of cases. Although it is generally considered to be a relatively safe technique, it is cru-

cial to be aware of the potential serious morbidity and mortality resulting from its use.

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Poster 44: New Frontiers in CT-guided Interventions: How Optical

Guidance Can Get You Where You Want to Go

V. Demers, T. Cabrera, R. Lindsay, D. Valenti

Objectives: 1.To explain optical navigation and its advantages when used in chal-

lenging CT guided interventions 2.To review the safe use of such a system and its

limitations 3.To present cases demonstrating anatomically challenging and innovative

interventions using this system

Methods: Among the various guiding modalities for percutaneous interventions,

computed tomography (CT) is widely used because of its many advantages such as

accurate localization and targeting of small lesions. Image guided navigation systems

are already an integral part of the neurosurgical and orthopedics operating room, but

few systems have yet been proven useful for anatomically challenging body interven-

tional radiology. The ActiSight Needle Guidance System (Activiews) is an optical

navigation system designed to assist imaged guided interventions by displaying, in real

time, the simulated needle and its planned path. Although this navigation system has

already been demonstrated to be effective, accurate and safe in lung biopsy and a few

anatomically challenging biopsies and interventions, its use in innovative interventions

has not been addressed.

Results: Via a series of cases, we will demonstrate the benefits and safety of using an

optical navigation device in CT guided interventions. In most of these cases, given the

target location, a hands-free procedure would be very difficult and/or imply a high risk

of crossing non-target organs, cavities or anatomic compartments. Case 1: Targeting

multiple lesions in liver RFA from a single access point Case 2: Reaching stealth

lesions: achieving precision despite targets showing up only on arterial phase CT phase

Case 3: Dangerous needle positioning: getting close to the heart Case 4: Redefining

challenging anatomical access: adrenal gland, parathyroid and paraspinal retroperi-

toneal lymph node biopsies

Conclusions: Optical navigation is an emerging technique that allows innovative CT

guided interventional approaches. It is useful to target lesions in challenging anatomic

locations requiring off-axial needle paths, for lesions visible only solely after contrast

enhancement and for situations where 2 or more lesions can be targeted from one cap-

sule puncture.

Poster 45: The Pilot Experience of Irreversible Electroporation for

Medium-size Liver Cancers in the Asia

K. Huang

Objectives: Irreversible electroporation (IRE) is a novel, non-thermal ablation tech-

nique that uses high-voltage DC current to induce irreversible disruption of cell

membrane integrity. We present the initial safety and efficacy experience with IRE in

the treatment of Liver cancers with medium tumor size.

Methods: The prospective study was performed at National Taiwan University Hos-

pital in 2012. 7 consecutive patients (4 male, 3 female), age 43-77, with liver cancers(4

hepatocellular carcinoma, 3 liver metastasis of colon cancer) of 3-6 cm in diameter(3.8

cm in mean), were treated by IRE under general anesthesia with complete muscle

relaxation and then tumors were resected 2-4 hours later. Average Eastern Cooperative

Oncology Group grade was 0.6 (range 0-2). American Society of Anesthesiology class

was 3 in all patients. All procedures were performed with ultrasound guidance. Clinical

examination and laboratory assay were performed at baseline, 6 hours, 1st to 7th day

after procedure. The ablation effect of tumor specimen was evaluated by 2,3,5-Triph-

enyltetrazolium chloride (TTC) staining. Any adverse effect was recorded intra- and

post-operatively.

Results: 9 technically successful ablations were performed in the 7 patients. The abla-

tion methods include 2 laparoscopic approaches, 2 percutaneous approaches and 5

laparotomic approaches. No mortalities occurred at 30 days. Intraoperative transient

hypertension occurred with 1 treatment (1/9). No patients had prolonged hypertension

after completion of IRE. No intra-operative arrhythmia occurred in these patients, and

there was no other evidence of adjacent organ damage related to the procedure. Com-

plete target tumor ablation verified by TTC staining of resected tumors was achieved

in all tumors. Pathologic examination all showed nonspecific change in the regions

treated by IRE. R0 resection was confirmed in all cases. During 6 months follow-up

in mean, no local recurrence was noted.

Conclusions: IRE is a feasible and safe modality for treating medium-size HCC by

laparotomic, laparoscopic or percutaneous approach in our experience. Further larger

scale, prospective randomized trials are needed to confirm our findings.

Poster 46: Patency of Transjugular Intrahepatic Portosystemic Shunt

(TIPS) Following Radiofrequency Ablation in Patients with Hepatocellular

Carcinoma

J. Park, S. Raman, M. Price, S. Siripongsakun, J. McWilliams, D. Lu

Objectives: Patients with portal hypertension and transjugular intrahepatic shunts

(TIPS) presenting for radiofrequency (RF) ablation of hepatocellular carcinoma (HCC)

are commonly encountered. However, to our knowledge no current studies have

assessed the effect of RF ablation on TIPS patency. The aim of our study was to assess

the patency of TIPS in patients who underwent RF ablation for HCC. Potential imme-

diate post-procedural complications of RF ablation in this patient population were also

reviewed. A brief review is also performed on the physical properties of currently avail-

able TIPS materials.

Methods: An extensive retrospective database review of patients with pre-existing

TIPS who underwent RF ablation of HCC was conducted over a 147 month period

ending in November 2012. The patency of TIPS prior to and after RF ablation was

assessed by ultrasound, angiography or contrast-enhanced CT or MRI. CT and/or MRI

were performed within 1 day following RF ablation. Clinical notes were also reviewed

for post-procedural symptoms of TIPS occlusion, such as increasing ascites. Patient

demographics and immediate post-RF ablation outcomes and complications were also

reviewed.

Results: 19 patients (15 men, 4 women; mean age 62.2 years, range 51-73 years)

undergoing a total of 25 RF ablations were included in our series. Child-Pugh class A,

B, and C scores were seen in 1, 13, and 5 patients, respectively. 11 patients ultimately

underwent liver transplantation. Of the patients who did not undergo transplantation,

1 died of metastatic disease, 2 were alive at the time of data review, and 5 were lost to

follow-up. Mean time period from initial RF ablation to either transplantation or last

clinical visit was 13.2 months (range 1-37 months). Of the 9 patients who had TIPS

placed at our institution, 6 patients had Gore Viatorr endoprostheses and 3 had Schnei-

der Wallstent endoprostheses. Pre-ablation TIPS patency was demonstrated in 22/25

ablation cases (88%). In 7 cases the lesions ablated directly abutted the TIPS. Of the

22 cases with patent TIPS prior to ablation, post-ablation patency was demonstrated

in 22/22 (100%) on immediate post-ablation imaging and in 21/22 (95%) at last fol-

low-up. The 1 patient with subsequent TIPS occlusion was clinically asymptomatic

and incidentally identified while undergoing chemoembolization (30 months post-abla-

tion). His ablated tumor was not adjacent to the TIPS, and given his extensive disease

progression at that time his TIPS occlusion was thought to be secondary to tumor

thrombus. No immediate complications following RF ablation were observed.

Conclusions: TIPS patency was preserved both immediately and in the delayed

period following RF ablation for HCC in our study, even in cases where the ablation

zone was directly adjacent to the TIPS. Based on our results we postulate that the phys-

ical properties of currently available TIPS stents do not significantly increase the risk

for occlusion following RF ablation. Patients with both portal hypertension and HCC

are commonly encountered in clinical practice, and a pre-existing TIPS does not appear

to be a contraindication for RF ablation.

RF ablation probe visualized immediately adjacent to the medial TIPS, which re-

mained patent before and after the procedure. An additional lateral TIPS placed in

the past is visualized, which became occluded prior to placement of the medial TIPS.

Color doppler ultrasound of TIPS in a different patient 2 months after RF ablation

demonstrates patency.

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Poster 47: Selective Portal Vein Embolization in the Treatment of Liver

Cancer

J. Sun, Y. Zhang, C. Nie, J. Li, W. Wang, S. Zheng

Objectives: To evaluate the clinical feasibility and effectiveness of transcatheter por-

tal vein embolization (PVE) and transcatheter arterial chemoembolization (TACE) in

the treatment of hepatocellular carcinoma.

Methods: PVE was performed in 22 patients with unresectable advanced hepatocel-

lular carcinoma. Right portal vein were embolized with percutaneous transhepatic

approach through the ultrasound guidance. Left hepatic lobe volume was measured

with CT scans before and after PVE. Liver function, and coagulation function were

also measured before and after PVE.

Results: Right portal vein was embolized successfully in all patients. Right liver

resection was performed in 12 patient. The left hepatic lobe volume was (315 ±101)

cm3 before PVE, and (628 ±121) cm3, (740 ±103)cm3 and (678 ±132) cm3, respec-

tively 2 weeks, 4 weeks, and 8 weeks after PVE. Left hepatic lobe volume increased

(44.1±21.1) %, ( 47.1 ±22.1) % and (49.3 ±23.1) %, respectively. There was statistical

difference in left hepatic lobe volume before and 2 weeks after PVE (P <0.05). Liver

function damage after PVE was minimal. No patient had complication after PVE.

Conclusions: PVE is clinically feasible, safe and effective in inducing the compen-

satory hypertrophy of the remnant liver. It can increase the resection rate and safety of

operation.

Right portal vein were embolized with coils.

Poster 48: Safety and Efficacy of Radiofrequency Ablation in Hepatic

Metastases from Gastrointestinal Stromal Tumor

H. Won, P. Kim, Y. Shin

Objectives: The aim of this study was to evaluate the safety and efficacy of radiofre-

quency ablation (RFA) in hepatic metastasis from gastrointestinal stromal tumor

(GIST).

Methods: Between February 2002 and Aug 2010, we retrospectively reviewed our

prospectively maintained database and found 29 GIST patients (M:F = 18:11, age

range 35-77 years, median age 61 years) who had undergone US-guided RFA for

metastasis in the liver. RFA was done in percutaneous (n= 24) or intraoperative man-

ners (n=5). The average number of target lesions per procedure was 2.3; the mean

lesion size was 1.3 cm (Range 0.4-3.6 cm). All patients were treated with imatinib

mesylate.

Results: In 10 patients, RFA was not performed in all hepatic metastasis due to poor

visibility or possible collateral damage of adjacent organs. One patient developed

bleeding at RFA site and recovered with transfusion. One patient developed peritoneal

seeding near RFA tract. The median follow-up of the patients was 33.1 months (Range

12.2 ~ 108.6 months). Seven of the 29 treated tumors (10.1%) developed local recur-

rence (median 3.2 months, range 0.7-10.5 m). 18 patients (62%) developed new

metastasis at other site. Five patients died. Only one of five patients has local tumor

recurrence. Median overall survival was 90.2 months. The 1-, 3-, and 5-year survival

rates were 100%, 41%, and 10%.

Conclusions: In this small cohort, RFA appears to be a safe and effective treatment

for hepatic metastasis of GIST.

Poster 49: Evaluating the Safety and Efficacy of Radiofrequency Ablation

for the Treatment of Both Primary Hepatocellular Carcinoma and

Metastases within the Caudate Lobe of the Liver

Q. Al-Tariq, S. Siripongsakun, S. Raman, S. Bahrami, J. McWilliams,M. Douek, D. Lu

Objectives: Radiofrequency ablation (RFA) provides a viable alternative to surgical

resection for patients with both primary and secondary hepatic neoplasms. However,

may interventionalists are wary when considering using this technique for caudate lobe

lesions due to issues of access given their deep, posterior location and heat sink effects

owing to proximity to either the IVC, left branch of portal vein, or both. The purpose

of this project is to evaluate the efficacy and safety of radiofrequency ablation in the

treatment of caudate lobe lesions, whether they be hepatocellular carcinoma in origin

or metastases from various primaries.

Methods: From a database of over 1,000 patients, a case control study comparing 14

patients with caudate lobe lesions (HCC or metastasis including neuroendocrine, col-

orectal, and endometrial) and 25 patients with size matched lesions (HCC or

metastasis) in segment 4 was performed. Differences in morbidity/mortality, recurrence

rates, and time to recurrence were assessed. Further sub-group analysis within the cau-

date lobe group was performed to evaluate the role of needle number, tumor histology,

technical approach (subxiphoid via segment 4 or right intercostal), and perivascular

location in predicting tumor recurrence. All patients received RFA therapy under com-

bination CT/US guidance using between 1-3 application needles. Technical approaches

were differentiated as being right intercostal and sub-xiphoid. A post-procedure con-

trast enhanced MRI was performed on the day of the ablation to verify adequate

ablation zone and exclude any serious complication, vascular or otherwise. Patients

then received follow-up examinations at near 3 month regular intervals to assess for

recurrence. Recurrence was established by the presence of new enhancement within

or along the ablation zone margin following initial therapy, which was defined as ther-

apies conducted within 6 months of the initial ablation for the treatment of a specific

lesion. This was done to take into consideration cases of staged ablations. Numerical

data was assessed using Fisher exact test while chi-squared analysis was used for cat-

egorical data. A P <0.05 was taken to be significant.

Results: There was no statistically significant difference in recurrence rate between

the caudate group (14%) versus the segment 4 group (26%) P = 0.45. The average time

to recurrence was shorter in caudate lobe lesions (3.5 months vs. 17.3). Adequate abla-

tion zones were achieved in all cases. Significant complications were not seen in either

treatment group. Within the caudate lobe group, no statistically significant differences

were seen based on the technical approach used (P = 0.45), the histology of the target

lesion (P= 0.80), the number of needles used (P = 1.0), or the lesion having a perivas-

cular location (P = 0.60).

Conclusions: When compared to radiofrequency ablation of liver lesions elsewhere,

treatment within the caudate lobe has a comparable safety profile and efficacy with no

significant difference in recurrence after an average of 19.8 months of follow-up. Fac-

tors that do not appear to impact local recurrence within caudate lobe lesions include

the technical approach used, histology of target lesion, and a perivascular location.

Comparison of Caudate Lobe and Segment 4 Groups

Poster 50: Fixation of the Hepatic Artery Infusion Catheter Tip in the

Gastroduodenal Artery using the Amplatzer Vascular Plug

Y. Kim, H. Ko, D. Goo

Objectives: To evaluate the feasibility of fixation of the tip of an infusion catheter in

the gastroduodenal artery using the Amplatzer Vascular plug.

Methods: Twentythree (20 men; age, 46-73 years; mean, 56.6 years) underwent

implantation of a 5.8-F chemotherapeutic infusion catheter via the common femoral

artery, positioned so that the tip was in the gastroduodenal artery and a side hole was

in the common hepatic artery. The Amplatzer Vascular plug fixed the tip in the gastro-

duodenal artery. The purposes of using the Amplatzer Vascular plug were prevention

of a catheter migration and occlusion of the gastroduodenal artery.

Results: Catheter placement via the femoral route was successful in all patients. Mean

catheter indwell durations were 121 days (range, 6-327 days). The sizes of the

Amplatzer Vascular plug were 3 mm (n=1), 4 mm (n=11), 6 mm (n=10), and 8 mm

(n=1). Catheter migration during treatment occurred in one patient who was deployed

3mm sized Amplatzer vascular plug. One patient had epigastric pain during infusion

chemotherapy. Endoscopy revealed duodenal ulcer. We removed the infusion catheter

in two patients without complications.

Conclusions: Fixation of the infusion catheter using the Amplatzer vascular plug is

safe and feasible and reduces infusion catheter migration rate.

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Poster 51: An Overview of Imaging Biomarkers of Treatment Response

in Liver-Directed Therapies

P. Rezai, T. Folan

Objectives: Surgical resection remains the treatment of choice for hepatocellular car-

cinoma (HCC) and metastatic liver cancer (MLC). However, only up to 25% of the

patients are surgical candidates. Consequently, the majority of these patients are treated

with systemic chemotherapeutic agents or locoregional therapies. The objective of this

poster is to discuss different imaging biomarkers of treatment response evaluation in

HCC and MLC.

Methods: Treatment response monitored by the evaluation of change in size

(Anatomical biomarkers), function (Functional biomarkers) and liver-specific biomark-

ers will be discussed.

Results: An overview of anatomical imaging biomarkers such as WHO, RECIST and

volumetric evaluation will be provided. Biomarkers that monitor alterations in function

of neoplastic cell in response to treatment such as EORTC and DWI MR will be dis-

cussed. Eventually, liver-specific biomarkers of treatment response such as mRECIST,

EASL and Choi criteria will be discussed.

Conclusions: The reader will get familiarized with the latest methods of treatment

response evaluation of liver-directed therapies.

Poster 52: Combination Therapy Consisting of Ethanol and Radiofrequency

Ablation for Predominantly Cystic Thyroid Nodules

E. Ha, J. Baek, J. Shin

Objectives: To evaluate the feasibility and safety of ethanol and radiofrequency (RF)

ablation combination therapy for predominantly cystic thyroid nodules

Methods: Between September 2010 and August 2011, 40 cases of predominantly cys-

tic nodules were treated by internal fluid aspiration, followed by RF ablation. Among

them, 11 cases showed the internal bleeding during the fluid aspiration. To control the

internal bleeding, 99% ethanol was injected to the nodules and RF ablation was fol-

lowed. The efficacy of ethanol in controlling bleeding was assessed. Nodule volume,

cosmetic, symptomatic scores and complications were determined.

Results: Ethanol controlled the internal bleeding well and followed RF ablation was

feasible in all patients. The mean follow-up duration was 11.4±6.7 months (range, 6-

24 months). It was possible to treat 10 patients (91%) in one session and no recurrences

were observed. The mean nodule volume dropped from 17.1 to 4.3 ml at the last fol-

low-up (P = .018), and the mean cosmetic and symptom scores dropped from 4.0 to

2.8 (P = .01) and from 2.6 to 1.1 (P = .011), respectively. There were no major com-

plications.

Conclusions: Ethanol and RF ablation combination therapy is feasible and safe for

predominantly cystic thyroid nodules that exhibit internal bleeding during the treat-

ment.

Poster 53: Superparamagnetic Iron Oxide Nanoparticles-embedded

Chitosan Microsphere for MRI-traceable Embolic Material in Rabbit

Uterus

S. Choi, B. Kwak, H. Shim, S. Hong, B. Kang

Objectives: To compare standard embolization polyvinyl alcohol particles with cal-

ibrated SPIO-loaded chitosan microcapsules in rabbit models in relative distribution

of the embolic agents within the uterus and correlate this with Magnetic Resonance

and pathologic findings.

Methods: Twelve New Zealand white rabbits were divided into four groups according

to the materials used for embolization of the uterine artery; standard polyvinyl alcohol

particles (PVA, 45-150μm and 350-500μm) and calibrated SPIO-loaded chitosan

microsphere (45-150μm and 300-500μm). T1-weighted images (T1WI), T2-weighted

images (T2WI), and Gadolinium-enhanced T1WI (Gd-T1WI) of the rabbits were

obtained with a 3T clinical MR scanner 1 week after embolization. Histopathologic

analysis was performed with focus on the localization of the embolic materials within

the different vascular zone of the uterine organ tissue, and was correlated with MR

images.

Results: MR images showed that calibrated SPIO-loaded chitosan microsphere size

of 45-150μm was detected on T2WI. At histologic analysis, calibrated SPIO-loaded

chitosan microsphere was found at uterine myometrium or endometrium but PVA was

found at the perimyometrium. Inverse relationship was seen between the calibrated

SPIO-loaded chitosan microsphere size and the size of the lumen filled by this embolic

agent.

Conclusions: Calibrated SPIO-loaded chitosan microspheres permit more segmental

arterial occlusion than do PVA particles, and have great potential as a new embolic

material since it travels into blood vessels more distally. The level of arterial occlusion

was correlated with the size of the microsphere size. MR imaging studies can be used

to evaluate treatment response after embolization as this material can also be detected

on T2-weighted MR imaging.

Poster 54: Development of a Y90 Radioembolization Program in a

Community Hospital Setting For Treatment of Metastatic and Primary

Liver Tumors

B.K. Martinez, V. Flanders, N.K. Gupta, K. Natarajan, M.P. Underhill,J. Cooke

Objectives: To detail the development of a sustainable yttrium-90 community pro-

gram that will result in improved liver outcomes, patient quality of life, and growth of

a dynamic multidisciplinary approach to treatment of liver tumors.

Methods: Development of an yttrium-90 community program begins with a group

of physicians dedicated to improving outcomes of liver cancer. Team members include:

Medical, surgical and radiation oncology, interventional radiology, radiology and

oncology mid-levels, and the physics department. The physician authorized user appli-

cation (Code of Federal Register 10, Part 35.390 or 35.490) are submitted and close

adherence to NRC rules and regulations are essential. Multidisciplinary tumor board

conferences are essential for appropriate patient selection and treatment discussion.

Radiology and oncology mid levels work with physicians to organize clinic visit and

follow up to assess for treatment toxicities. Through a business agreement with the

hospital patients are collaboratively pre determined with Sirtex business office for all

ICD codes immediately following initial IR clinic visit. All patients at our institution

are seen in clinic by one of 4 interventional radiologists in consultation prior to treat-

ment. Mapping angiography with embolization of extra-hepatic collaterals is

performed as an outpatient procedure. Fractional tumor, liver flow characteristics, and

lung shunt fractions are determined using hepatic arterial Tc-99m MAA imaging. Pre-

scribed activity is calculated by BSA and volumetric analysis methods. All patients at

our institution have been treated with Y-90 Resin microspheres, SIR-Spheres® (Sirtex

Medical Inc, Lake Forest, IL). Imaging responses are reviewed by RECIST criteria.

Treatment related toxicities are assessed using National Cancer Institute Common Ter-

minology Criteria v3.0.

Results: Since April 2012 there have been 27 patients treated in our community hos-

pital with 46 doses delivered. Tumor types included 11 (40%) colon, 2 breast, 2

cholangiocarcinoma, 2 carcinoid, and 2 HCC with 1 patient each of ovarian, cervical,

gastric, GIST, undifferentiated NET, urothelial, uveal melanoma and pancreatic ade-

nocarcinoma. Patient median age was 58. ECOG status of most patients was 0-2

however 5 patients with ECOG 3 were treated. 25 patients were treated successfully

without procedural complications. Early imaging on 18 patients reveals 84% imaging

response rate (PR+SD). 1 patient presented with unresectable cholangiocarcinoma and

was downstaged to surgical resection for cure and demonstrates no evidence of recur-

rent or residual disease. There has been 1 major complication of death in a patient with

Childs class B cirrhosis and multifocal HCC that declined into liver failure following

single right lobe treatment and subsequently died. A total of 5 deaths related to pro-

gression of disease have occurred, the majority of whom were referred with known

extrahepatic disease and were treated in the salvage setting. There have been 2 patients

with minor complications of coil migration during mapping angiography, none of

which resulted in inability to treat or organ ischemia due to intrahepatic collateral for-

mation. A total of 6 grade 3 toxicities, significant fatigue, nausea and vomiting resulted

in admission, in 46 delivered doses.

Conclusions: The development of a community based radioembolization program,

although challenging, can be successfully accomplished when the appropriate team

members are involved and dedicated to the program. The treatment can be provided in

a safe and successful manner integrated into an oncology treatment plan.

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a. gastrohepatic trunk with gastric branches and arteries to segments 2, 3, and 4

b. selection of gastric branch for embolization

c. gastrohepatic trunk with embolization of extrahepatic collaterals

d. right hepatic injection with arterioportal shunting from tumor

a. CT shows large central cholangiocarcinoma extending along portal venous branch

to segment 3

b. Liver SPECT following TcMAA showing distribution predominantly in vascular

tumor

c. Image from lung shunt calculation

d. Post radioembolizatrion CT showing tumor shrinkage along with hypertrophy of

the left lobe. Patient went to full resection with extended right and negative margins

Poster 55: Shear Wave Elastography in the Evaluation of Porcine Liver

Treated with Radiofrequency Ablation in vitro Experiment

X. Xie

Objectives: Objective To evaluate the stiffness of porcine liver in vitro treated with

the radiofrequency ablation (RFA) using shear wave elastography (SWE).

Methods: Methods A total number of 24 pieces of porcine livers were randomly

divided into 4 groups, which were treated with RFA for 6 min or 12 min, and 15 ml

ethanol injection combined with RFA for 6 min or 12 min, respectively. The Young

modulus were measured before ablation,after ablation immediately and 30 min after

ablation when the gas disappeared in ablation zone.

Results: Results SWE imaging can clearly delineate the boundary of the stiffness

changes in the RFA ablation zone, even that part was difficult to display in baseline

ultrasound due to the gas hyperechogenicity reflection. The mean Young modulus

before ablation,after ablation immediately and 30 min after ablation without gas reflec-

tion were 14.90 kPa ± 4.04 kPa,94.31 kPa ± 23.03 kPa,89.32 kPa ± 20.77 kPa,

respectively. Both the mean Young modulus of after ablation immediately and 30 min

after ablation were significantly different from that of before

ablation(P<0.001,P<0.001),but there was no significant difference between the mean

Young modulus of after ablation immediately and 30 min after ablation (P=0.385). The

Young modulus changes of ablation zone of RFA 6 min,12 min,15 ml ethanol injection

combined with RFA 6 min or 12 min were 81.29 kPa ± 9.19 kPa,84.88 kPa ± 9.89

kPa,97.27 kPa ± 16.20 kPa,103.82 kPa ± 22.04 kPa, respectively. The ethanol injection

combined with RFA could make the ablation zone stiffer than only RFA did (P=0.009),

whereas prolonging ablation duration would make no change of stiffness in ablation

zone (P=0.275).

Conclusions: Conclusion SWE can quantitatively monitor the elasticity changes of

porcine liver during RFA treatment in vitro, no matter the gas exists in the ablation

zone or not. The changes of stiffness in ablation zone were different when ethanol was

injected pre-ablation.

Before ablation

After ablation

Poster 56: Doxorubicin Drug-eluting Beads Transcatheter Arterial

Chemoembolization (DEB TACE) in Patients with Recurrent Unresectable

Hepatocellular Carcinoma (HCC) After Orthotopic Liver Transplantation

(OLT): Survival, Efficacy, and Prognostic Factors Determining Survival

P.K. Kavali, H.J. Prajapati, J.R. Spivey, S.I. Hanish, B. El-Rayes, J. Kauh,H.S. Kim

Objectives: To investigate the survival, efficacy and prognostic factors following

DEB TACE in patients with recurrent hepatocellular carcinoma (HCC) status post

orthotopic liver transplantation (OLT).

Methods: Consecutive patients with unresectable HCC who underwent OLT from

December 2005 to September 2012 were reviewed. Patients who developed recurrent

HCC after OLT were identified. Patients that did not undergo DEB TACE were

excluded (n=2). A total of 7 patients met the inclusion criteria. Five patients were alive

at the end of the study. One of the patients received a second OLT within 6 months of

TACE and censored from the data of OLT for survival analysis. Routine MRI of the

abdomen is performed every 6 months for surveillance after OLT. Histopathologic

results of the HCC after OLT were correlated with survivals. 1, 6 and 12 month sur-

vivals were analyzed according to different parameters from the time of OLT, diagnosis

of recurrent HCC, and from first DEB TACE. Univariate and multivariate survival

analyses could not be performed due to lack of adequate number of deceased patients.

Results: 43 patients underwent OLT after downsizing of the HCC with DEB TACE

treatment. Recurrence of HCC was identified in 9 patients; of those, 7 patients under-

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went a total of 14 DEB TACE treatments (range 1 to 4) after recurrence. Mean age at

diagnosis of HCC was 54.1 years. The imaging, staging and survival characteristics of

the patients are shown in tables 1 and 2. Mean recurrence free survival from OLT was

50.6 months. 1, 6 and 12 month survivals from diagnosis were 100% (7/7), 83% (5/6),

and 60% (3/5) respectively. 1, 6 and 12 month survivals from DEB TACE were 100%

(7/7), 83% (5/6), and 60% (3/5) respectively. Two patients had poor overall survival

from DEB TACE (9.3 and 3.4 months) and both showed elevated serum alpha feto-

protein (AFP) levels (>2400 ng/mL) and extrahepatic metastases. The shortest survival

from DEB TACE was 3.4 months and the patient had hepatitis B, > 12 HCC tumors,

extrahepatic metastasis, and AFP >2400 ng/mL. All other patients had hepatitis C.

Histopathologic results after OLT were available in 5 of the 7 patients. Patients with

moderately differentiated multifocal HCC on histopathology had poor overall tumor

free survival (table 2).

Conclusions: DEB TACE showed promising survival in patients with recurrence

after OLT. Patients with multifocal HCC with moderate differentiation on histopathol-

ogy report, elevated serum AFP (>2400 ng/mL), and extrahepatic metastases at the

time of TACE had a poor overall prognosis.

Demographics, clinical, survival, and imaging characteristics of HCC patients

Recurrence free survival and histopathologic results of native explant

Poster 57: Contrast Enhanced Ultrasound-guided Percutaneous Thermal

Ablation in Treatment of Solid Organ Bleeding: Preliminary Clinical

Results

X. Xie, M. Kuang, M. Lu

Objectives: To preliminarily evaluate the application of contrast enhanced ultrasound

(CEUS) guided percutaneous thermal ablation (PTA) in assessing and treatment of

solid organ bleeding in clinical practice.

Methods: Methods: Six patients who underwent CEUS guided PTA for treatment of

solid organ bleeding (5 in liver, 1 in spleen) from Desember 2005 to Desember 2008

were included in this study. The clinical information, the CEUS image before and after

ablation, the ablation method were retrospectively collected and analysed.

Results: Results: Of all six patients, the location of bleeding lesion were clearly

shown in five. Hemostasis was successfully reached in four of them, one by radiofre-

quency ablation (RFA), three by microwave ablation (MWA). The PTA for hemostasis

was failed in one patient with postbiopsied spleenic arterial bleeding because the bleed-

ing vessel were a thick branch of spleenic artery. The other one patients with

postbiopsied liver active bleeding were failed because CEUS did not precisely locate

the bleeding lesion and hence the ablation zone did not cover the whole lesion.

Conclusions: Conclusion: CEUS guided PTA is a precise, effective and micro-inva-

sive method to treat solid organ bleeding. However, it should be carefully investigated

for those whose bleeding lesion could not be located by CEUS or those whose bleeding

vessel were thickened.

Poster 58: Trans Arterial Chemoembolization with Irinotecan Loaded DC

Beads (DEBIRI) for Symptomatic and Intractable Colorectal Cancer (CC).

Phase I Study

S. Comelli, R. Bini, G. Gallo, D. Savio, T. Viora, R. Leli, G. Vaudano

Objectives: The aim of this study is to evaluate feasibility, safety and efficacy of

TACE performed using irinotecan loaded microparticles for treatment of complications

in patients treated on a compassionate use basis. The second part is to investigate a

possible volume reduction of the target lesion.

Methods: We have been considering patients with CC not eligible for conventional

treatment, according to international guidelines, and presenting rectal bleeding needing

blood transfusion, colon obstruction and pain. Multidisciplinary evaluation was per-

formed before every enrollment by senior colorectal surgeon, radiologist and

oncologist. Specific informed consent was obtained by every patient according to our

institutional guidelines for the off label use of therapeutic agents. Selected patients

underwent an abdominal quadriphasic CT scan (64 slices GE CT), in order to obtain a

preliminary arterial mapping of the tumour lesion and to preoperatively stage the can-

cer. Under local anaesthesia a diagnostic angiography of superior and inferior

mesenteric arteries (SMA and IMA) was performed to define tumour vascularization

and main feeding arteries, in order to recognize the best target vessels for the treatment.

Using a microcatether a solution of 1 up to 2 ml of irinotecan drug-eluting beads (DC-

Bead, Biocompatibles, UK Ltd) was injected into the main feeding arteries to the

lesions. All treated patients underwent an unenhanced CT study at 24-48 hours, in order

to exclude peri and immediate postprocedural complications. A quadriphasic CT study

with the same scan was performed one month later in order to obtain a restaging of the

treated lesion. We used 3 well known and worldwide accepted criteria for solid tumor

evaluation as MASS, RECIST and mChoi. We propose a 3D method to evaluate the

magnitude of the tumor. On an Aw Volume share 2 (work station) we obtained a 3D

reconstruction of the tumors (slice thickness 5 mm) that allowed us to compare pre and

post treatment volume of the mass.

Results: 10 patients (9 male and 1 female) were enrolled for the study according to

above mentioned inclusion criteria. Technically the procedure was successfully per-

formed in all clinical settings (also in AMI ligature and radiotherapy). All patient

experienced a clinical improvement such as stop bleeding and reduced pain in a week.

Not major complications were observed and no one patient died after the procedure.

Fever lasting one or two days and procedure related pain were observed in the first two

days. Persisting muchorrea and tenesm were reported by 4 patient. No systemic

adverse effects were also observed. Due to the particular clinical condition of our

patient, the follow up was only clinical. After 4 months of follow up all treated patient

were alive without pain or recurrence of bleeding . Concerning the secondary end point

the main results are summarized in Table 1.

Conclusions: Despite a small serie of patients, TACE with debiri as shown to be safe

and feasible in a wide range of clinical oncologic patient. No major adverse events

were recorded. Relieve of symptoms was also achieved. Volume mass reduction has

been observed in almost all patients.

Poster 59: Percutaneous Ablation of Small Hepatocellular Carcinoma:

Comparison of 3 Commercially Available Microwave Devices

L. Tarantino

Objectives: To compare the effectiveness of 3 microwawe devices for percutaneous

treatment of small hepatocellular carcinoma (HCC).

Methods: between march 2009 and march 2012, 24 consecutive patients with Child-

Pugh A5 HCV related Cirrhosis and a single intraparenchymal small HCC nodule

(diameter <2 cm) located al least 2 cm far from large hepatic vessels, were treated with

MW ablation with one of the following devices : 1) 10 patients with 14G - 915 MHz

antenna with 45 watt MW generator (Vivawawe, Covidien, USA) ; 2) 5 patients with

14G - 2450 MHz antenna with 100 W generator (AMICA, Hospital Service, Italy) ; 3)

9 patients with 13G – 2450 MHz antenna with 180 W generator (Acculis, Microsulis

Medical Ldt, England). The choiche of a specific MW device was not randomly

assigned, but based on the availability of that device in our unit at the time of treatment.

For each treatment we used the ablation parameters suggested from the manufacturers

and from their product specialists operating on the generator during the procedures.

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Therapeutic efficacy in terms of size of the ablation areas were evaluated with contrast

enhanced ultrasound (CEUS) at 48 hours from the ablation time. We compared the

transverse diameter of the areas of necrosis as measured on CEUS scan in venous

phase.

Results: The diameter of HCC nodules ranged 11 - 20 mm (mean : 15 mm) . At CEUS

evaluation, complete necrosis was observed in all cases.. At CEUS examination the

following sizes of ablation areas were obtained with the different devices : 1)

Vivawawe Covidien : Ablation parameters : 40W – 10 minutes ; mean longitudinal

diameter : 4.7 + 1.2 cm; mean max. transverse diameter : 3.0 + 0.6 cm ; Mean volume

: 16.9 + 2.8 ml 2) Amica HS : ablation parameters : 60 W 10 minutes ; mean longitu-

dinal diameter : 5.1 + 1.4 cm; mean max. transverse diameter : 3.4 + 0.7 cm ; Mean

volume : 18.3 + 2.8 ml 3) Acculis Microsulis : 120 W 6 minutes ; mean longitudinal

diameter : 4.9 + 1.5 cm; mean max. transverse diameter : 3.5 + 0.9 cm ; Mean volume

: 19.0 + 2.4 ml Difference in transverse diameter of the area of necrosis between the

Covidien device and the other two devices was statistically significant (p=0,01). There

was no statistically significant difference between AMICA HS and Acculis devices.

Howewer the time of application to obtain a similar result was consistently low with

Acculis device than with AMICA HS. No complication occurred in all treated patients.

Conclusions: All tested devices seems to be effective and safe . Howewer, the

Acculis system is faster than the other two devices. Furthermore, in our experience in

vivo and in cirrhotic patients, the sizes of necrosis obtained were quite lower than what

reported from manufacturers (expected transverse diameter of necrosis area : Covidien

: 3,2 cm ; AMICA HS : 4.0 cm: Acculis : 4.5 cm) .

Poster 60: Transcatheter Arterial Embolization with Gelfoam for Ruptured

Hepatocellular Carcinoma

T. Seo, I. Cha, M. Song, Y. Kim, S. Cho, H. Chung, S. Lee

Objectives: Rupture of hepatocellular carcinoma (HCC) is a life-threatening condi-

tion accompanied by hemorrhage. The purpose of this study is to evaluate usefulness

of transcatheter arterial embolization (TAE) for ruptured HCC as a treatment option

for initial hemostasis.

Methods: We retrospectively reviewed the medical record of 23 patients (18 men and

5 women) who underwent TAE with Gelfoam for ruptured HCC. Rupture of HCC was

diagnosed by RBC count > 10,000 microliter on analysis of ascites and abdominal CT

scan. We evaluated clinical factors including demographic data, past medical history,

physical and laboratory examinations, abdominal CT, angiographic findings, and final

results of TAE.

Results: Types of the HCC on CT were diffuse (n=10), multiple (n=6), exophytic

(n=4), and nodular (n=3) and mean diameter of ruptured HCC was 9.5cm. Ruptured

sites were hepatic angle (n=10), dome (n=5), lateral segment (n=4), and right lobe

(n=4) and portal vein thrombosis was associated in 10 patients. The lowest systolic

and diastolic pressures before embolization were under 90 and 60 mmHg in 12

patients. Child-Pugh classes were A in 1 patient, B in 14 patients and C in 8 patients.

Mean amount of packed RBC transfusion was 4.2 pint between 1 day before and 3

days after TAE. Hepatic arteriograms revealed no active leakage of contrast media in

all patients and collapsed artery by hypovolemic shock in 8 patients. Embolized arter-

ies were proper hepatic artery (n=1), lobar artery (n=13), segmental artery (n=4),

subsegmental artery (n=3) and extrahepatic feeder because of obliteration of hepatic

artery by previous repeated chemoembolization (n=2). Median duration from TAE to

discharge was 11 days (0~44 days). Five patients expired within 2 days because of

hypovolemic shock and 18 patients recovered from hypovolemia and their mean sur-

vival period was 44 days (7-225 days).

Conclusions: TAE for ruptured HCC was good treatment method to recover the

patients from hypovolemic shock and to expect increase of their survival.

Poster 61: Preoperative Transcatheter Arterial Chemoinfusion in Patients

with Osteosarcoma

T. Seo, I. Cha, M. Song

Objectives: The purpose of this study is to report experience of the preoperative tran-

scatheter arterial chemoinfusion (TACI) for treatment of the patients with osteosarcoma

Methods: We performed preoperative TACI in 3 patients (1 boy and 2 girls, mean

age 16 years) with osteosarcoma. Locations of osteosarcoma were fibular head in 2

patients and proximal tibia in one patient. After angiography of the femoropopliteal

artery with 4F headhunter catheter by puncturing the contralateral common femoral

artery, catheter tip fixation was done at proximal to origin of all tumor feeders. TACI

was performed with two different chemotherapeutic agents (adriamycin and cisplatin)

on the same day. TACI was done twice in 2 patients and three times in one patient with

one month interval between the procedures. MR images were obtained after the second

TACI. Tumor resection was done 3~4 weeks after the last TACI. We evaluated the

changes of the tumor on follow-up angiogram, MRI and clinical outcomes.

Results: Vascularity of the tumor was decreased on angiograms obtained during sec-

ond and third TACI in all patients. Compared to the MRI taken before TACI, tumor

size decreased to 67% and 77% in two patients and no significant change was noted

in one patient because of hemorrhagic necrosis of the tumor. Tumor resection was pos-

sible in all patients. They underwent adjuvant intravenous chemotherapy with various

regimens and have survived without recurrence for 3 to 6 years.

Conclusions: Preoperative TACI seems to be a new option in treatment for the

patients with osteosarcoma.

Poster 62: Severe Hepatic Abscess after Radiofrequency Ablation of Liver

Metastases in Patients with Entero-biliary Anastomosis: Our Experience

L. Tarantino, V. Nocera, C. Ripa

Objectives: Percutaneous radio-frequency (RF) ablation is a relatively safe procedure

with a very low death rate of 0.2% and a major complication rate of 2.2%. Hepatic

abscess is a relatively rare complication after RF treatment. Howewer, several authors

reported that entero-biliary anastomosis (EBA), biliary stents o biliary obstruction rep-

resents high risk factors for hepatic abscess complicating the RF procedure. We

retrospectively reviewed our series of patients treated with RF for hepatic metastasis,

including patients with EBA, in order to report the rate of hepatic abscess complication

after the procedure and to assess if EBA is really correlated with this major complica-

tion of RF procedure.

Methods: We retrospectively reviewed the records of 45 patients (25 males,48-

82years) treated with RFA for hepatic metastasis from cancer of colon (23), breast (11),

stomach (4), biliary tract (3), pancreas (2), bladder (2). The overall number of metasta-

tic nodules was 81. The number of lesion per patients ranged 1 to five (mean=1.8); the

diameter of nodules ranged from 0.8 to 6.5 cm (mean 2.3 cm). 2/45 patients had a sur-

gical EBA. None of the patients had biliary stents. One patients had a sfinterotomy

performed 5 years before during an endoscopic retrograde colangio pancreatography.

All patients underwent RF with a commercially available expandable-saline-enhanced

electrode-needle (Starbust XLi, Angiodynamics,USA). 13 patients underwent intraop-

erative RFA, with synchronous resection of colonic or gastric primitive tumor in 7 out

13 cases. 32 patients underwent percutaneous RFA of metachronous metastasis . All

patients treated percutaneously left the hospital within 1 – 3 days after procedure and

were advised to make a phone call in case of fever, pain or other significant symptoms

. Patients treated with open surgery had a post procedural hospital stay ranging from

5 to 38 days (mean = 11 days). Control of efficacy of the procedure entailed contrast

enhanced ultrasound (CEUS) and enhanced MDCT within 4 - 5 weeks after procedure.

Scheduled follow-up included US control every 3 months and enhanced MDCT every

6 months.

Results: Minor complications (pain, skin burn, self-limiting peritoneal effusion)

occurred in 7/45 (15.5%) cases. 5/45 (6.6%) major complications occurred: In 2 cases,

duodenal perforation and severe refractory ascites occurred as complication from open

surgery rather than from RFA procedure. The damage of duodenal wall occurred during

removal of hard post surgical adhesion between stomach and liver as preparation for

intraoperative RFA. Refractory ascites occurred in a patient with HCV related hepatitis

operated on for synchronous colonic cancer and metastasis. The control of ascites

required 6 weeks The complication was treated with 3 large volume paracentesis, albu-

min infusion and diuretics. Patients 2 and 3 had an EBA, so that 2/2 (100%) patients

with this condition showed a severe abscessual complication, while only 1/43 (2.3%)

patients without EBA showed hepatic abscess. Difference between the two groups was

highly statistically significant.

Conclusions: Patients with surgical EBA are at very high risk for severe hepatic

abscess as complication of RFA treatment. These patients should be excluded from

RFA treatment.

.Female 63 years . Previous Hepatico-jejunostomy for Cholangiocarcinoma of Main

biliary tract . After 8 months, CT shows aerobilia and 2 mestasis in the IV and the

VIII segments. The patients was treated with RF within one month. Four days after

treatment the patient presents with septyc fever, unconsciousness, tense abdomen.CT

shows a large gas containing hepatic abscess communicating with intrahepatic bil-

iary ducts.

JVIR � WCIO AbstractsW

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759.e36

The patient was successfully treated with percutaneous long-lasting (5 weeks)

catheter drainage.

Poster 63: Fast and Complete Single-session Ablation of Large

Hepatocellular Carcinoma by Simultaneous Insertion of Multiple

Microwave Antennas and Intraoperative CEUS

L. Tarantino, C. Ripa, V. Nocera

Objectives: A single insertion of radio-frequency (RF) or Microwave (MW) device

into the tumor, is able to produce “in vivo” a necrotic area rarely exceeding 3.0-3.5 cm

in diameter.In order to obtain large ablation volumes, simultaneous insertion of multi-

ple MW antennas in the tumor has been proposed One of the main problem of thermal

ablation for large HCC is the assessment of efficacy at the end of the treatment before

to let the patient to leave the operatory room. This problem have been partially solved

with intraoperative contrast enhanced ultrasound (CEUS) control . Detection of resid-

ual viable tumor tissue after ablation session entails the possibility of performing

additional antennas insertions in order to complete the treatment of large lesions in a

single session. we investigate the efficacy and safety of 915-MHz- MW ablation of

large HCC by simultaneous activation of intratumoral multiple antennas and intraop-

erative CEUS .

Methods: From January 2008 to June 2009, 12 consecutive cirrhotic patients (8 men,

4 women; age range, 58 - 79 years) underwent MW ablation for a single HCC nodule

> 3 cm in diameter (range : 3.2-6 cm; mean 4.3 cm). From january 2008 to June 2009,

12 consecutive cirrhotic patients (8 men, 4 women; age range, 58 - 79 years) underwent

MW ablation for a single HCC nodule > 3 cm in diameter (range : 3.2-6 cm; mean 4.3

cm). All patients underwent a single session percutaneous MW ablation with 14 G

antennas and a commercially 915 MHz MW generator with 45 W output power (Evi-

dent™, Covidien LDT, USA) session was planned according with the following

treatment schedule : a) nodules >3cm < 4 cm : simultaneous insertion of two antennas

; nodules >4cm : simultaneous insertion of three antennas; b) activation of MW gen-

erator for 10 minutes after insertion of antennas; c) intraoperative CEUS evaluation

(Sonovue, Bracco, Milan, Italy) of ablation within 3-10 minutes after switching off the

MW generator, according with gas artifacts fading in the US image; d) In case of resid-

ual hypervascular HCC tissue at CEUS, additional insertion of 1-3 antennas according

with the size of residual viable tumor. Treatments were performed in deep sedation

without intubation in all patients. Treatment efficacy was assessed by three-phase-

enhanced-CT performed within 1 month after MW, bimonthly US follow-up and yearly

follow-up with CT. In case of suspect tumor progression at US follow-up control,

CEUS was performed.

Results: The first step MW ablation was performed with two antennas in 6 nodules

and with three antennas in 4 nodules.Intraoperative CEUS showed residual tumor in

6 patients. 5 out of these patients underwent a second insertion of two antennas and 1

patient of three antennas. Intraoperative CEUS at the end of the procedure showed

complete necrosis of the tumor in all patients. One-month CT control showed complete

necrosis in all patients. Non major complication was reported. Follow-up ranged from

8 to 24 months (median : 14 months) At CT and US follow-up controls we observed :

- no local progression of the treated tumor - 6 new HCC nodules in different segments

than treated one in 3 patients at 6, 10 and 18 months follow-up respectively. New

lesions’ size ranged from 12 to 20 mm. The diagnosis of HCC recurrences have been

assessed with charachteristic enhancement at CT and CEUS. All 3 patients have been

successfully retreated with a single insertion of MW antenna per nodule.

Conclusions: Simultaneous insertion of multiple MW antennas can realize a very

fast and safe ablation of large HCC . Intraoperative CEUS at the end of multiple anten-

nas’ application can detect incomplete ablation and address retreatment of residual

viable tumor in the same session. With this schedule we obtained 100% complete

necrosis of medium-large HCC nodules at post-treatment CT and absence of local pro-

gression at post-treatment follow-up.

CT scan shows complete necrosis of the large tumor aftera single sssion of MW ab-

lation .

Intraoperative CEUS scan after ablation with simultaneous insertion of 3 MW anten-

nae shows a large but incomplete necrosis of the tumor, with persistence of residual

active tumor . A second application of 2 MW antennae into that protion of the mass

was performed .

Poster 64: The Effect of DynaCT on Radiation Dose of Transcatheter

Arterial Chemoembolization for Hepatic Tumors

S. Hur, H. Jae, H. Kim, J. Chung

Objectives: To evaluate the radiation dose of transcatheter arterial chemoemboliza-

tion (TACE) using DynaCT for hepatic tumors in comparison with that of conventional

TACE.

Methods: Radiation dose reports of 369 patients who underwent TACE on Flat panel

angiography system (Axiom Artis zee, Siemens Healthcare, Forchheim, Germany)

from August to September 2012 were retrospectively reviewed. According to our insti-

tutional TACE protocol, patients with less than 4 tumor nodules on preprocedural CT

or MR images underwent DynaCT for superselective TACE. DynaCT technique was

used for depicting the tumors and feeding arteries. Those who have more than 5 tumor

nodules underwent conventional TACE without the use of DynaCT. DynaCT was per-

formed at common hepatic artery level after conventional celiac arteriography. If there

was a variation of hepatic artery anatomy, each variant hepatic artery was selected and

both angiography and DynaCT was taken. The number of DynaCT, dose-area product

(DAP) of DynaCT, the number of digital subtraction angiography (DSA) images, flu-

oroscopy time, and total DAP were recorded automatically by the angiography system.

These data were compared between DynaCT TACE group and conventional TACE

group using student T-tests.

Results: Among 175 patients who underwent DynaCT TACE, DynaCT was per-

formed once in 134 patients, twice in 32 and three times in 9 patients. Conventional

TACE was performed in the other 194 patients. The average weight of entire patients

was 63.4kg. Average fluoroscopy time was 13.7% longer in DynaCT TACE group

(19.8 min vs. 17.4 min, P<0.05) than in conventional TACE group. DAP by a single

WCIO Abstracts � JVIRW

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759.e37

DynaCT was 60.3 Gy cm2 in average, which consists of 54.9% of total DAP during

the TACE. There was no significant difference in total DAP between patients who

underwent DynaCT once and those who underwent conventional TACE (131.2 Gy cm2

vs. 125.1 Gy cm2, P=0.401). On the contrary, 41 patients in whom DynaCT was per-

formed more than twice were exposed to mean 228.3 Gy cm2 of DAP, which is 82%

higher than the conventional TACE group. The average number of DSA images of

DynaCT TACE group was 54.2, which was significantly less than 79.2 images of the

conventional TACE group (P<0.05).

Conclusions: The total DAP of TACE using single DynaCT examination was similar

with that of conventional TACE, because DynaCT technique can reduce the require-

ment of additional DSA. However, additional DynaCT examinations due to anatomic

variations caused markedly increased DAP.

Poster 65: Early Cryoablation Experience of Six Patients with Recurrent

Desmoid Tumors

R.S. Williams, D. Monson, T. Dean, D. Yim

Objectives: Desmoid tumors are rare benign neoplasms with known high recurrences

rates, as high as 50%, and limited consensus on definitive management. The purpose

of this article is to describe our early experience using cryoablation, at times utilizing

a novel multi disciplinary approach, with surgically persistent and/or recurrent desmoid

tumors for local control

Methods: Over an 18-month period (6/2011-12/2012), 6 patients with desmoid

tumors were referred to interventional radiology clinic. Median age was 37 years (26-

71yo); patients were predominantly female 5 out of 6 (83 %). The lesions in the cohort

most commonly arose in extremities (83 %) with one lesion located along the abdom-

inal wall (17 %). The tumor mean size was 10.8 cm (6.1-19 cm) and volume= 700.1 ±834 cc. Most patients under went R0 resections at the margins; one patient (size/vol-

ume = 7 cm/140 cc) was referred due aborted resections secondary to intra-operative

bleeding. Five patients were referred for local control only. However due to the aggres-

sive locoregional behavior of desmoids two of these patients had lesions in close

proximity to major peripheral nerves (sciatic and posterior tibial nerves); therefore the

potential for post-surgical major nerve injury was anticipate. Both of these patients

were treated in conjunction with neurology that performed real-time neural monitoring.

The final patient (abdominal wall lesion) was treated for both local control and pain.

All patients were asked to identify their greatest symptom and were asked to describe

it as improved, unchanged or worsened on 6-month follow-up.

Results: The patients referred for local control demonstrated no interval tumor pro-

gression. The two patients with lesions adjacent to vital structures demonstrated

decrease in mean tumor size 4.5 to 3.4 (Δ=25%) at 6-month follow-up. Despite neural

monitoring both cases had mild to moderate neural deficient to secondary branches of

major peripheral nerve. Both were evaluated with follow-up MRI-Neurography

demonstrating neuropraxia of the adjancent nerve. One patient of these patients par-

ticipated in aggressive physical therapy resulting in improved accompanying muscular

activity. Improved symptomology was noted in five of the six patients at six months.

As a corollary, all of these patients in additionally noted improved range of motion,

likely secondary to decreased tethering on adjacent muscle, tendons and connective

tissue. The patient with abdominal wall lesion had complete tumor coverage of ablated

region and reported complete absence of pain at 6 months.

Conclusions: Cryoablation appears to be a safe and effective option for patients with

both extra-abdominal and abdominal desmoid tumors with improved pain and range

of motion. In patients with lesions near or adjacent to vital structures a multidiscipli-

nary approach appears to show promise, as a percutaneous treatment option but

requires further investigation.

Image-guided cryoablation of lesion interposed between lesser trochanter and pubic

ramus

Three month post ablation follow-up MRI demonstrates moderate decrease in size of

lesion

Poster 66: Combination TACE and Microwave Ablation Therapy in

Intermediate Sized HCC: Preliminary Results

P. Dalvie, T. Ziemlewicz, P. Sonntag, N. Gutta, A. Cohn, O.S. Ozkan,F. Lee

Objectives: The aim of this study was to assess the safety and efficacy of a combi-

nation of transcatheter arterial chemo-embolization (TACE) and percutaneous

microwave ablation (MWA) in the treatment of intermediate sized (between 2.1 to 6

cm) hepatocellular carcinoma (HCC).

Methods: From March 2011 to October 2012, 10 patients (9 male and 1 female; with

mean age of 60.6 years, range 44-72 years) with a total of 11 HCC lesions underwent

combination therapy of TACE followed by USG/CT guided MWA treatment within 0-

4 weeks. Patients were followed up with CECT or CE-MRI at 1 month, 3 month, 6

month, 12 month, and 18 months post-procedure.

Results: The treated HCC lesions (N=11) had a mean diameter size of 4.2 cm with a

range of 2.6 to 6.0 cm. Eight out of 11 HCC lesions (72.7%) showed primary treatment

effectiveness in the form of local tumor control on follow-up imaging (median follow

up of 7.5 months). Of the remaining 3 lesions, 2 lesions showed local tumor progres-

sion on imaging within 2 months and 1 lesion showed residual tumor cells in the

explanted liver specimen after liver transplant at 3 months post therapy. The 2 lesions

with local progression, were successfully re-treated - 1 with combination TACE and

MWA and 1 with TACE alone due to proximity to the colon. Our secondary effective-

ness is 10/10= 100% at 7.5-month median clinical follow-up. Two deaths, unrelated

to combination therapy, were noted at 8 and 15 months of clinical follow-up, both were

due to development of newer overwhelming multifocal HCC disease burden. No

immediate or delayed, major or minor, complications were noted except for mild pain

in one patient, which resolved with conservative treatment.

Conclusions: Our preliminary results suggest combination therapy with TACE and

MWA is a safe and effective treatment for intermediate sized HCC.

JVIR � WCIO AbstractsW

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bstracts

A

Aanidjar, Maurice - Poster 43

Abel, E. Jason - Paper 20

Abramson, Michael - Paper 13

Abtin, Fereidoun - Poster 4

Aguado, Alisson - Paper 31

Ahrar, Kamran - Poster 42

Al-Tariq, Quazi - Poster 4, Poster 49

Alago, William - Paper 11, Paper 12,

Paper 31, Paper 35

Alexander, Erica S - Paper 29

Alexander, Marci - Paper 28, Paper 32

Aliberti, Camillo - Paper 30, Paper 33

Anastacio, Eduardo Pinheiro Zarattini -

Poster 27

Anaya, Daniel - Paper 9

Arsene, Camelia - Poster 41

Athreya, Sriharsha - Paper 19

Atwell, Thomas - Paper 15, Paper 17

Aucejo, Federico N - Paper 5

Avritscher, Rony - Poster 18

Azrumelashvili, Tamta - Poster 2

B

Baek, Jung Hwan - Poster 52

Bahrami, Simin - Poster 49

Baigorri, Brian - Poster 41

Ball, David S - Paper 34

Banovac, Filip - Paper 13

Barbery, Katuzka Jemima - Paper 25

Barbosa, Felipe - Poster 27

Barlas, Asfar - Poster 15

Bastawrous, Sarah - Poster 22

Bedoya, Mariajose - Poster 19

Berent, Allyson - Paper 49

Best, Sarah L - Paper 20

Bhagat, Nikhil - Paper 41

Bini, Roberto - Poster 58

Blaskovich, Phillip - Poster 34

Brace, Christopher L - Paper 20,

Paper 21, Paper 24, Paper 27,

Paper 28, Paper 32, Poster 19,

Poster 39

Brody, Lynn - Paper 31, Paper 35

Brook, Allan - Paper 37

Brown, Anthony - Paper 4

Brown, Anthony C - Paper 7

Brown, Karen - Paper 11, Paper 31,

Paper 35

Buckley, David L - Paper 18

Buethe, Ji - Poster 13

Bui, James T - Paper 8

Burgmans, Mark - Poster 16

C

Cabrera, Tatiana - Paper 23, Poster 43,

Poster 44

Callstrom, Matthew R - Paper 15

Camacho, Juan C - Paper 6, Paper 45,

Paper 50, Poster 5, Poster 31

Carandina, Riccardo - Paper 33

Caridi, Theresa - Paper 43

Carmignani, Luca - Poster 11

Carrasquillo, Jorge - Paper 31

Cartledge, Jon M - Paper 16

Casadaban, Leigh - Paper 8

Cavalcanti, Conrado - Poster 27

Center, Marci L - Paper 20, Poster 39

Cha, In-Ho - Poster 60, Poster 61

Chang, Samuel - Paper 4

Charpentier, Kevin P - Paper 29

Cheah, Grace - Paper 5

Chen, Jeane - Paper 47

Chen, Zhengjia - Poster 10

Chiang, Jason - Paper 21

Chiarion, Vanna - Paper 33

Cho, Sung Bum - Poster 60

Cho, Sung-Ki - Poster 3

Choi, Sun Young - Poster 53

Chung, Hwan Hoon - Poster 60

Chung, Jin Wook - Poster 64

Clark, Timothy - Paper 14, Paper 48

Cohn, Alexandra - Poster 39, Poster 66

Coldwell, Douglas - Paper 37

Comelli, Simone - Poster 58

Conrad, Kirk - Paper 37

Cooke, Jeff - Poster 54

Coschiera, Paolo - Paper 30

Covey, Anne - Paper 31, Paper 35

Cressman, Erik - Poster 7

Critchfield, Jeffery - Poster 41

D

Dagli, Mandeep - Paper 43

Dalvie, Prasad - Poster 66

Dauer, Lawrence T - Paper 11

Davalos, Eric A - Paper 2

Dawson, Tanner - Poster 42

Dean, Thad - Poster 36, Poster 65

Dedes, Ioannis Nikos - Poster 14

Deitrick, Ginna - Poster 30

Demers, Virginie - Paper 23, Poster 43,

Poster 44

DePena, Charles - Paper 37

Devarajan, Karthik - Paper 34

Dharia, Tejas - Paper 38, Poster 24,

Poster 25

Dhokai, Shekhar - Poster 34

Di Lieto, Marco - Poster 11

Dikopf, Mark S - Paper 8

Dodd, Gerald D - Paper 26

Douek, Michael - Poster 49

Drevelegas, Antonios - Poster 14

Dupuy, Damian E - Paper 29

Durack, Jeremy - Paper 11, Paper 31,

Poster 17

Durham, Janette - Paper 4, Paper 7

E

El-Rayes, Bassel - Paper 3, Paper 6,

Paper 45, Poster 5, Poster 23,

Poster 56

Elbich, JEffrey D - Poster 8

Ensor, Joe - Poster 42

Erinjeri, Joseph P - Paper 11, Paper 12,

Paper 31, Paper 35, Poster 15,

Poster 17

Estfan, Bassam - Paper 5

F

Fan, Ning - Poster 15

Faramarzalian, Ali - Paper 5

Farrelly, Cormac - Paper 14

Fedi, Massimo - Poster 11

Fiorentini, Giammaria - Paper 30

Fischman, Aaron M - Paper 1, Paper 20

Flanders, Vincent - Poster 54

Fleischer, Debra - Poster 30

Folan, Thomas - Poster 51

Fotheringham, Tim - Poster 35

Fourzali, Roberto - Paper 25

Froud, Tatiana - Paper 25

Fujisawa, Sho - Poster 15

G

Gaba, Ron C - Paper 8

Gadani, Sameer - Poster 18, Poster 42

Gade, Terence P. - Paper 48

Galfione, Matthew - Paper 14

Gallo, Giacomo - Poster 58

Galt, James R. - Paper 50

Gandhi, Rozil - Paper 38, Poster 24,

Poster 25

Garcia, Alessandra R - Paper 31,

Poster 15

Garcia, Eduardo - Poster 27

García Marcos, Raul - Paper 30

Georgiou, Michael - Poster 9

Georgy, Bassem - Paper 37, Paper 39

Geschwind, Jean-Francois H - Paper 41

Getrajdman, George - Paper 31, Paper 35

Gholamrezanejhad, Ali - Paper 41

Giannessi, Sandro - Poster 11

Gill, Amanjit - Paper 5

Glueck, Deborah H - Paper 26

Goel, Mahesh - Poster 24

Gomes, Antoinette - Poster 3

Gomez Munoz, Fernando - Paper 30

Gonen, Mithat - Paper 35

Goo, Dong Erk - Poster 50

Green, Tyler J - Paper 4, Paper 7

Gregory, Walter - Paper 16

Guan, Xiao-Pei - Poster 34

Gulia, Ashish - Paper 38

Gupta, Niraj K - Poster 54

Gupta, Sanjay - Poster 42

Gutta, Narendra - Poster 29

Gutta, Narendra Babu - Poster 66

Guzzo, Thomas - Paper 14

H

Ha, Eun Ju - Poster 52

Haas, Richard A - Paper 29

Habib, Nagy - Poster 1, Poster 2

Hammelman, Benjamin D - Poster 38

Hanif, Muzammil - Paper 9

Hanish, Steven I - Paper 3, Paper 6,

Poster 5, Poster 56

Hardy, Andrew H - Poster 6

Hegg, Ryan - Paper 17

Hieb, Robert A - Poster 8

Hinshaw, J. Louis - Paper 20

Hinshaw, Louis - Paper 24, Paper 28,

Paper 32, Poster 39

Hofmann, Lawrence V - Paper 2

Hohenwalter, Eric J - Poster 8

Hohenwalter, Mark D - Poster 8

Hong, Soon Uk - Poster 53

Hsia, Shih-Min - Poster 20

Hsu, Shih-Lan - Poster 20

Huang, Kai-Wen - Poster 21, Poster 45

Hunt, Stephen - Paper 48

Hur, Saebeom - Poster 64

Hussain, Khozema - Paper 9

Hussain, Saad M - Paper 41

Hwang, Gloria L - Paper 2

I

Iannopollo, Mauro - Poster 11

Iannuccilli, Jason - Paper 29

Ip, Ivan - Paper 35

Itkin, Max - Paper 46, Poster 38

J

Jae, Hwan Jun - Poster 64

Jaggi, Manu - Poster 34

Jain, Nitin - Poster 41

Jennings, Jack - Paper 37

Joyce, Adrian D - Paper 16

K

Kang, Byeong-cheol - Poster 53

Kang, Jian - Paper 36

Kauh, John - Paper 3, Paper 6, Poster 5,

Poster 56

Kavali, Pavan K - Poster 56

Kee, Stephen T - Poster 3

Kemeny, Nancy - Paper 31, Poster 15

Kennedy, Matthew - Poster 30

Khanna, Regina - Paper 1

Kim, Dong-Hyun - Paper 47

Kim, Edward - Paper 1

Kim, Hyo-Cheol - Poster 64

Kim, Hyun Sik - Paper 3

Kim, Hyun S - Paper 6, Paper 36,

Paper 45, Paper 50, Poster 5,

Poster 10, Poster 23, Poster 31

Kim, Hyun S - Poster 56

Kim, Pyo Nyun - Poster 48

Kim, Yong Jae - Poster 50

Kim, Yun Hwan - Poster 60

Klimstra, David - Poster 15

Knuttinen, Martha-Gracia - Paper 8

Ko, Heung Kyu - Poster 50

Kobayashi, Katsuhiro - Paper 9,

Poster 32

Koethe, Yilun - Paper 42

Kogut, Matthew J - Poster 22

Kokabi, Nima - Paper 6, Paper 45,

Paper 50, Poster 5, Poster 31

Kooby, David - Poster 23

Kothary, Nishita - Paper 2, Paper 44

Kreidler, Sarah M - Paper 26

Kuang, Ming - Poster 57

Kuker, Russ - Poster 9

Kulkarni, Suyash - Paper 38, Poster 24,

Poster 25

Kurup, Anil Nicholas - Paper 15

Kurup, Anil - Paper 17

Kwak, Byung Kook - Poster 53

Kwan, Sharon W - Poster 22

L

Lance, Craig - Paper 5

Lanctot, Anthony C - Paper 26

Larson, Andrew - Paper 47

Lee, Aram J - Poster 3

Lee, Edward - Poster 3

Author Index

759.e39

Lee, Fred - Paper 24, Poster 39, Poster 66

Lee, Kyoungmouk - Poster 17

Lee, Seung Hwa - Poster 60

Lee Jr., Fred T - Paper 20, Paper 28,

Paper 32

Leli, Renzo - Poster 58

Lertdilok, Patrick - Poster 42

Levitin, Abraham - Paper 5

Lewandowski, Robert - Paper 10,

Paper 47

Li, Ju - Poster 47

Li, Su-Yu - Paper 34

Liapi, Eleni - Paper 41

Lindsay, Richard - Paper 23, Poster 43,

Poster 44

Liu, Dong - Paper 27

Lo, Richard H - Poster 16

Loh, Christopher - Poster 3

Lookstein, Robert - Paper 1

Louie, John D - Paper 2

Lu, David - Poster 46, Poster 49

Lu, Mingde - Poster 57

Lu, Yang - Paper 8

Lubner, Meghan G - Paper 20

Lubner, Meghan - Paper 24, Paper 28,

Paper 32, Poster 39

Lupi, Martina - Poster 11

M

Machan, Jason T - Paper 29

Magee, Derek M - Paper 18

Magistris, Fabio - Paper 19

Maglione, Katharine - Paper 1

Mahvash, Armeen - Poster 18

Malkowicz, Bruce - Paper 14

Manenti, Guglielmo - Paper 22

Manova-Todorova, Katia - Poster 15

Mantoan, Alessandra - Paper 33

Martin, Jason - Paper 19

Martinez, Brandon Keith - Poster 54

Martinez, Felix - Poster 28

Master, Viraj - Poster 10, Poster 31

Matejowsky, Rebecca - Paper 9

Mathur, Archna - Poster 34

Maybody, Majid - Paper 11, Paper 31,

Paper 35

McLennan, Gordon - Paper 5

McWilliams, Justin - Poster 46, Poster 49

Meier, Mark - Poster 12

Menezes, Marcos - Poster 27

Menon, Hari - Paper 38

Menon, Narayanan - Paper 5

Mete, Mihriye - Paper 13

Metrakos, Peter - Poster 43

Meyer, Joshua - Paper 34

Minocha, Jeet - Paper 8

Mirpour, Sahar - Paper 41

Mishra, Bhanvi - Poster 34

Mizandari, Malkhaz - Poster 1, Poster 2

Mondschein, Jeffrey - Paper 43

Monette, Sebastian - Poster 15, Poster 29

Monroe, Eric James - Poster 22

Monsky, Wayne Laurence - Poster 6,

Poster 22

Monson, David - Poster 36, Poster 40,

Poster 65

Morales, Adam Fernando - Paper 36,

Poster 10, Poster 23

Moreland, Anna J - Paper 20

Moura, Mauricio - Poster 27

Mulazzani, Luca - Paper 30

Murthy, Ravi - Poster 18

N

Narayanan, Govindajaran - Paper 25,

Poster 9

Natarajan, Kannan - Poster 54

Nie, Chun-Hui - Poster 47

Nieh, Peter - Poster 10, Poster 31

Nocera, Vincenzo - Poster 62, Poster 63

Nowakowski, Francis S - Paper 1

O

Obuchowski, Nancy - Paper 5

Odisio, Bruno - Poster 18

Oh, John - Paper 48

Ohri, Rachit - Poster 34

Omary, Reed - Paper 47

ONeill, Michael Lancaster - Poster 9

Ozkan, Orhan S - Poster 66

P

Pacini, Patrizio - Poster 11

Padia, Siddharth A - Poster 6, Poster 22

Padua, Horacio - Paper 40

Pagliari, Andrea - Poster 11

Pandit-Taskar, Neeta - Paper 31

Park, Harold Han Sung - Paper 36

Park, Harold - Poster 10, Poster 23,

Poster 40

Park, Jonathan - Poster 3, Poster 46

Patel, Indravadan - Poster 13

Patel, Niraj R - Poster 32

Patel, Parag J - Poster 8

Patel, Rahul - Paper 1

Patel, Rosan - Poster 41

Patil, Sushil - Poster 24, Poster 25

Patil, Sushilkumar Shantaram - Paper 38

Pattaras, John - Poster 10, Poster 31

Pelley, Robert - Paper 5

Pendse, Himanshu Ajay - Paper 38,

Poster 24, Poster 25

Perez-Rojas, Evelyn - Paper 25

Peterson, Matthew Craig - Poster 7

Petre, Elena N - Paper 12, Paper 31,

Paper 35

Petrovic, Lydia - Poster 15

Philbeck, Thomas - Poster 28

Pocha, Christine - Poster 7

Polnaya, Ashwin - Paper 38, Poster 24,

Poster 25

Popat, Rita - Paper 44

Prajapati, Hasmukh J - Paper 3

Prajapati, Hasmukh Jagdishbhai -

Paper 45

Prajapati, Hasmukh J - Poster 56

Prater, Scott - Paper 36

Prevoo, Warner - Poster 12

Price, Melissa - Poster 46

Prologo, John D - Poster 13

Puri, Ajay - Paper 38

R

Raman, Steven - Poster 46, Poster 49

Ramondo, Gaetano - Paper 33

Ray, Charles E - Paper 4, Paper 7

Reeves, Patrick - Paper 13

Reidy-Lagunes, Diane - Paper 35

Rezai, Pedram - Poster 51

Rezvani, Arzu - Poster 35

Ricasoli, Miriam - Poster 11

Riccadonna, Sara - Poster 11

Richard, Shimko - Poster 38

Ridge, Carole A - Paper 12

Rilling, William - Poster 8

Ripa, Carmine - Poster 62, Poster 63

Rivas, Maria - Paper 36, Poster 10

Rochon, Paul J - Paper 4, Paper 7

Romin, Yevgeniy - Poster 15

Rutledge, Neal - Paper 37

S

Sahani, Vivek G - Poster 32

Salem, Riad - Paper 10, Paper 47

Salsamendi, Jason - Poster 9

Sam, Kenny - Poster 32

Sampson, Lisa - Paper 24, Paper 28,

Paper 32

Sands, Mark - Paper 5

Sard, Howard - Poster 34

Savio, Daniele - Poster 58

Schmit, Grant - Paper 15, Paper 17

Schnall, Mitchell - Paper 48

Schuster, David M. - Paper 50

Selby, Peter J - Paper 16, Paper 18

Sengar, Manju - Paper 38

Seo, Tae-Seok - Poster 60, Poster 61

Shady, Waleed - Paper 31

Shahkarami, Ashkan - Paper 34, Paper 43

Shaikh, Raja - Paper 40

Shamis, Michael - Paper 11

Shea, Lonnie - Paper 47

Shetty, Nitin - Paper 38, Poster 24,

Poster 25

Shim, Hyung Jin - Poster 53

Shin, Ji Eun - Poster 52

Shin, Yong Moon - Poster 48

Shrikhande, Shailash - Poster 24

Shulman, Benjamin C - Paper 4

Sidhar, Vishal - Paper 44

Siegelbaum, Robert - Paper 31

Silk, Mikhail - Paper 12

Silk, Mikhail Thomas - Poster 17

Simon, Celeste - Paper 48

Singh, Anu - Poster 34

Siripongsakun, Surachate - Poster 46,

Poster 49

Smith, Darryl - Poster 32

Smith, Jonathan T - Paper 16

Sofocleous, Constantinos T - Paper 12,

Paper 31, Paper 35, Poster 15,

Poster 17, Poster 29

Solomon, Stephen - Paper 11, Paper 31,

Paper 35

Solomon, Stephen B - Poster 17

Solomon, Stephen - Poster 29

Song, Myung Gyu - Poster 60, Poster 61

Sonntag, Paul - Poster 66

Soulen, Michael - Paper 14, Paper 43,

Paper 48, Paper 49

Spain, James - Paper 5

Spivey, James R - Paper 3, Paper 6,

Poster 5, Poster 56

Srimathveeravalli, Govindarajan -

Poster 29

Stavropoulos, S. William - Paper 14

Stephen, Solomon B - Paper 12,

Poster 15

Sullivan, Patrick - Paper 44

Sultenfuss, Mark A - Paper 9, Poster 32

Sun, Jun-Hui - Poster 47

Suthar, Rekhaben - Paper 25

Symington, Kenneth - Poster 28

Sze, Daniel Y - Paper 2

T

Tacher, Vania - Paper 41

Tam, Alda - Poster 42

Tan, Bien Soo - Poster 16

Tarantino, Luciano - Poster 59, Poster 62,

Poster 63

Thakur, Meenakshi - Paper 38, Poster 24

Thornton, Raymond H - Paper 11,

Paper 12, Paper 31, Paper 35

Tilli, Massimo - Paper 30

Too, Chow Wei - Poster 16

Tran, Nam - Paper 37

Tucker, Liz - Paper 48

Tun, Jimmy K - Poster 35

Turkekul, Mesruh - Poster 15

Tutton, Sean M - Poster 8

U

Underhill, Marc P - Poster 54

V

Valenti, David - Paper 23, Poster 43,

Poster 44

Valentin, Roberto C - Paper 11

Valpione, Sara - Paper 33

van Erkel, Arian R - Poster 16

VanHouten, Diana - Poster 30

Vannucchi, Letizia - Poster 11

Vaudano, Giacomo Paolo - Poster 58

Velusamy, Gnanasekar - Paper 42

Venkatesan, Aradhana M - Paper 42

Verma, Ritu - Poster 34

Veronese, Marta - Paper 33

Viana, Publio - Poster 27

Violari, Elena - Paper 31

Viora, Tiziana - Poster 58

Vouche, Michael - Paper 10

Vrionis, Frank - Paper 37

W

Wah, Tze Min - Paper 16, Paper 18

Wallace, Michael - Poster 42

Wang, David S - Paper 2, Paper 44

Wang, Wei-Lin - Poster 47

Wang, Xiaojing - Paper 6, Poster 10

Watts, Micah - Poster 38

Weil, Elizabeth M - Poster 8

Wein, Alan - Paper 14

Weisbrod, Adam J - Paper 15

Weisman, Nicholas Joseph - Paper 46

Weisse, Chick - Paper 49

Wells, Shane - Poster 39

White, Sarah Beth - Poster 8

Willey, Bridgett - Paper 21

Williams, Roger S - Poster 36

Williams, Roger - Poster 40

Williams, Roger S - Poster 65

Williams, Susan - Poster 9

Wimmer, Thomas - Poster 17, Poster 29

Winston, Helena - Paper 4, Paper 7

Wolf, Farrah J - Paper 29

Won, Hyung Jin - Poster 48

Wood, Bradford J - Paper 42

Wu, Chi-Hao - Poster 20

X

Xie, Xiaoyan - Poster 55, Poster 57

Xing, Minzhi - Paper 6, Poster 5

Xu, Sheng - Paper 42

Author Index

759.e40

Y

Yim, Douglas - Poster 36, Poster 40,

Poster 65

Yrizarry, Jose - Paper 25

Yung-Hung Chang, Jerry - Paper 37

Z

Zablow, Bruce - Paper 37

Zamora, Nelson - Paper 25

Zhang, Yue-Lin - Poster 47

Zheng, Shu-Sen - Poster 47

Ziemlewicz, Timothy J - Paper 20

Ziemlewicz, Timothy - Paper 24,

Paper 28, Paper 32, Poster 39,

Poster 66

Zivin, Sean - Paper 8

Author Index