Twelve patients who had undergone esophageal reconstruction because of cancer and in whom conventional percutaneous radiologic or endoscopic gastrostomy was considered difficult are reported. These patients underwent placement of a percutaneous gastrojejunostomy catheter through the reconstructed gastric tube using a slow-leak balloon that had been developed for percutaneous transesophageal gastrotubing. Retrospective evaluation showed successful outcomes without severe complications in all patients. Eight (66.6%) were able to resume oral intake, which allowed gastrojejunostomy catheter withdrawal in 3 (25%). This technique is feasible with acceptable clinical outcomes for patients who have undergone gastric tube reconstruction after esophagectomy.

10090 Background: Malignant gastrointestinal obstruction occurs in approximately 10-16% of end-stage cancer patients. Nasogastric tubing (NGT) is a standard palliative treatment; however, NGT causes nasopharyngeal discomfort, pain, skin ulcer, and difficulties in the appearance care such as shaving or makeup. Percutaneous transesophageal gastrotubing (PTEG) was developed as an image-guided, minimally invasive tube placement directly accessing to the cervical esophagus under local anesthesia. As the previous phase II study of PTEG (JIVROSG-0205) demonstrated high technical success (100%) and clinical efficacy (91%), we hypothesized that patients receiving PTEG would have higher quality of life (QOL) than NGT. The aim of this multicenter, open-label, randomized controlled trial (JIVROSG-0805) was to evaluate the efficacy of PTEG. Methods: Patients with symptomatic malignant gastrointestinal obstruction were randomly assigned (1:1) to receive PTEG or NGT. The primary endpoint was symptomatic scores of four elements (nasopharyngeal discomfort, satisfaction with appearance, restriction of daily life, and sleep disturbance) evaluated with area under the curve (AUC) during 2 weeks after the treatments. Secondary endpoints included change in global health-related QOL (EQ-5D, SF-8) and incidence of adverse events evaluated with CTCAE v.3.0. Results: From October 2009 to January 2015, 40 patients were enrolled (PTEG: 20; NGT: 20). Symptomatic scores were evaluable in 39 patients (PTEG: 19; NGT: 20) and the safety was evaluable in all patients. The AUC of the symptomatic scores of the PTEG group (mean: 149.6; 90% CI: 125.2, 173.9) was significantly higher than that of NGT group (mean: 44.9; 90% CI: 21.2, 68.7) (p< 0.0001). Differences in EQ-5D (mean: 3.5; 90% CI: 1.6, 5.3; p< 0.036) and SF-8 (mean: 220.7; 90% CI: 113.3, 328.1; p< 0.0020) between two groups were statistically significant. There was no procedure-related complication in both groups. Conclusions: This analysis demonstrated the statistical superiority of the PTEG compared to the NGT. PTEG was effective in reduction of the distressing symptoms caused by NGT. Clinical trial information: UMIN000003565.

Malecot catheters have been widely accepted for use during nephrostomy, abscess drainage, and with gastrostomy tubes. Malecot catheters may occasionally be resistant to extraction because of tissue entrapment. Although entrapped catheters are typically removed using traction, this method may be unsuccessful in a few cases, which therefore become difficult to manage. We present 3 cases of entrapped Malecot catheters and discuss the interventional techniques used to treat these patients.

Purpose: To evaluate the feasibility of drug-eluting bead (DEB)-transarterial chemoembolization (TACE) with 75 mg epirubicin for hepatocellular carcinoma (HCC) in Japanese patients with unresectable HCC prior to conducting a planned randomized controlled trial. Materials and Methods: This study was conducted as a prospective multi-center feasibility study. Eligible patients had unresectable Barcelona Clinic Liver Cancer stage A or B HCC that was unsuitable for curative treatments, and all patients received TACE with 75 mg epirubicin-loaded DEB. Tumor response, as the primary endpoint, was assessed after 4 weeks by computed tomography or magnetic resonance imaging, based on the modified Response Evaluation Criteria in Solid Tumors. Adverse events after treatment were evaluated as the secondary endpoint, based on the Common Terminology Criteria for Adverse Events version 4.0. Results: Between May and August 2014, 8 patients from two institutions were enrolled in this clinical study. There were no instances of complete response observed, partial response was obtained in 4 patients, and the overall response rate was 50%. No patients experienced grade 4 or higher adverse events. Grade 3 thrombocytopenia occurred in 1 patient. One patient experienced a grade 3 increase in aspartate aminotransferase, alanine aminotransferase, and bilirubin levels. All adverse events were well managed with conservative medical care. There were no procedure-related deaths. Conclusions: DEB-TACE with 75 mg epirubicin was found to be feasible in Japanese patients, and it was deemed appropriate to proceed to a randomized controlled trial comparing DEB-TACE and conventional TACE.

The present study describes the technical feasibility of a combined-modality angiography/computed tomography (angio-CT)-assisted balloon dissection technique for bowel protection during renal cryoablation in six procedures in five patients. A retrospective review was performed to evaluate balloon dissection using the angio-CT system. Mean bowel-to-tumor distances before and after balloon dissection were 0.9 mm (range, 0-3 mm) and 13.0 mm (range, 11-17 mm), respectively. No bowel injury was observed during the mean follow-up period of 19 months (range, 7-44 mo). Our preliminary experience suggests that balloon dissection using the angio-CT system for bowel protection during renal cryoablation may be feasible and effective.

We retrospectively evaluated the safety and efficacy of artificial pneumothorax induction to perform computed tomography (CT)-guided radiofrequency ablation (RFA) for sub-diaphragm hepatocellular carcinomas (HCCs). From June 2008 to October 2010 at our institution, 19 HCCs (16 patients) were treated using CT-guided RFA after artificial pneumothorax induction. A 23-G needle was inserted into the liver surface at a site of 2 connected pleurae without lung tissue. After a small amount of air was injected, the pleural space widened, creating a small pneumothorax. Additional air was insufflated via a newly inserted 18-G cannula to raise the lung away from the planned puncture line for RFA. The electrode was then advanced transthoracically. Ablation was performed using a cool-tip electrode with manual impedance control mode. The injected air was then aspirated as much as possible. Artificial pneumothorax was successfully induced in all cases. The average total volume of injected air in each case was 238ml. No artificial pneumothorax-related complication occurred; lung injury occurred in one case during RF electrode insertion. No local progression occurred during follow-up. Recurring HCCs were observed in eight patients. Artificial pneumothorax induction is safe and effective for CT-guided RFA of sub-diaphragm HCCs, which are difficult to locate on US.

Purpose: To retrospectively evaluate radiofrequency (RF) ablation of lung tumors performed via the transosseous approach.Materials and Methods: Twelve lung tumors (mean diameter, 1.0 cm; range, 0.4-1.6 cm) in 12 patients were treated by RF ablation via a transscapular and/or transrib route with the use of a bone biopsy needle under computed tomographic fluoroscopy guidance. Therapeutic outcomes evaluated included feasibility, safety, and local efficacy. Complications were assessed based on the National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0.Results: The transosseous route was successfully employed in all patients, and the electrode was successfully advanced into all tumors with this approach. The mean distance of penetrated bone was 0.57 cm (range, 0.19-1.16 cm). Complications occurred in eight RF ablation sessions, including six grade 1 events (two cases of pneumothorax and one case each of asymptomatic rib fracture 6 mo after treatment, neuralgia, pulmonary hemorrhage, and hemothorax), two grade 2 events (pneumonia and high fever), and one grade 3 event (pneumothorax requiring pleurodesis). No adverse events of-grade >= 4 occurred. The mean and median tumor follow-up periods were 19.5 and 15.2 mo (range, 3.0-41.5 mo). Local progression occurred in two cases at 3 and 12 mo after treatment and Was successfully treated with a: second RF ablation procedure. The technique efficacy rates were 91.7% at 6 mo, 81.5% at 1 y, and 81.5% at 2 y.Conclusions: The transosseous approach was feasible in computed tomographic fluoroscopy guided RF ablation of select lung tumors when no other option was available.

Hepatic arterial infusion chemotherapy (HAIC) has been performed for patients with life-threatening liver tumors resistant to standard therapies for more than 30 years. Placement of the port and catheter system for HAIC is performed by surgeons or interventional radiologists. Surgical placement requires laparotomy, whereas the interventional radiologic approach places a port and a catheter percutaneously. The interventional radiologic technique of implanting a port and catheter was originally developed in Japan in the 1980s. The procedure consists of arterial redistribution, catheter and port placement, and evaluation and management of the drug distribution. For the catheter and port placement, the subclavian artery, femoral artery, or inferior epigastric artery is used as an access route. We have used a subclavian artery for HAIC to have the stability of the system at the anterior chest wall and the ease to advance a catheter into hepatic arteries at the time of the placement; however, there are some risks, such as cerebral infarction, and the specific skills of a cutdown procedure are required to access the subclavian artery. No procedure can be perfectly appropriate for all patients, and we should consider what we choose on a case-by-case basis. With this video (available online at www.jvir.org), we hope many interventional radiologists will be aware that this could be within their scope of practice with training.

The mainstay of treatment for iliofemoral deep vein thrombosis (DVT) in pregnant patients has traditionally been anticoagulation with unfractionated or low-molecular-weight heparin. In nonpregnant patients, there has been a trend toward more aggressive endovascular treatment of acute iliofemoral DVT to mitigate the risks of postthrombotic syndrome. This strategy is uncommonly performed in pregnant women because of the procedural and radiation risks of catheter-directed thrombolysis (CDT) to the mother or fetus (1).

Although radiofrequency ablation for lung cancer is generally safe (with a mortality rate <1%), it may cause various complications. Common complications include pneumothorax, pleural effusion, and parenchymal hemorrhage. Although most complications can be treated conservatively or with minimal therapy, physicians should be aware of rare but serious complications. Potentially fatal complications include massive hemorrhage, intractable pneumothorax due to bronchopleural fistula, pulmonary artery pseudoaneurysm, systemic air embolism, and pneumonitis. Other serious complications include injury to the nearby tissues (e.g., brachial nerve plexus, phrenic nerve, diaphragm, and chest wall), needle tract seeding, lung abscess, empyema, and skin burn. Although cavitation of the ablation zone is usually insignificant clinically, such a cavity occasionally ruptures, leading to pneumothorax and bleeding. Cavities may also serve as a scaffold for fungal colonization. Precautions to minimize risk should be taken whenever possible. Nevertheless, serious complications may occur, and thus physicians should be aware of the appropriate treatments for these complications. This article reviews complications associated with lung cancer ablation.

Purpose To determine risk factors for systemic air embolism by percutaneous computed tomography (CT)-guided lung biopsy. Methods This case-control study used data from 2216 percutaneous lung biopsy procedures performed over 11 years at 12 institutions in Japan. Systemic air embolism was identified by retrospective review of CT images obtained during and immediately after the procedures. To fulfill our objective, multiple variables were compared between cases and controls with univariate analyses by using Student’s t test and Fisher’s exact test for numerical and categorical values, respectively. Multivariate logistic regression analysis was then performed using selected variables. Results Ten cases of systemic air embolism and 2,206 controls were identified. Univariate analyses showed that the lesions in the lower lobe ( P = 0.025) and occurrence of parenchymal hemorrhage ( P = 0.019) were significant risk factors. Multivariate analysis showed that the use of a larger biopsy needle was a significant risk factor ( P = 0.014). Conclusion Parenchymal hemorrhage during the procedure, lesions in the lower lobe, and the use of larger biopsy needles may be risk factors for systemic air embolism by percutaneous CT-guided lung biopsy. Our findings may provide clues toward minimizing the risk of this complication.

We retrospectively evaluated the accumulation of fluorodeoxy glucose (FDG) in pulmonary malignancies without local recurrence during 2-year follow-up on positron emission tomography (PET)/computed tomography (CT) after radiofrequency ablation (RFA). Thirty tumors in 25 patients were studied (10 non-small cell lung cancers;20 pulmonary metastatic tumors). PET/CT was performed before RFA, 3 months after RFA, and 6 months after RFA. We assessed the FDG accumulation with the maximum standardized uptake value (SUVmax) compared with the diameters of the lesions. The SUVmax had a decreasing tendency in the first 6 months and, at 6 months post-ablation, FDG accumulation was less affected by inflammatory changes than at 3 months post-RFA. The diameter of the ablated lesion exceeded that of the initial tumor at 3 months post-RFA and shrank to pre-ablation dimensions by 6 months post-RFA. SUVmax was more reliable than the size measurements by CT in the first 6 months after RFA, and PET/CT at 6 months post-RFA may be more appropriate for the assessment of FDG accumulation than that at 3 months post-RFA.

A relatively large number of women in their 40s with high-density breasts, in which it can be difficult to detect lesions, are encountered in mammography cancer screenings in Japan. Here, we retrospectively investigated factors related to breast density. Two hundred women (40-49 years old) were examined at the screening center in our hospital. Multivariate analysis showed that factors such as small abdominal circumference, high HDL cholesterol, and no history of childbirth were related to high breast density in women in their 40s undergoing mammography. Other non-mammographic screening methods should be considered in women with abdominal circumferences < 76cm, HDL-C ≥ 53mg/dl, and no history of childbirth, as there is a strong possibility of these women having high-density breasts that can make lesion detection difficult.