Hepatic venous-portal gradient (HVPG) measurement: pearls and pitfalls.

Hepatic venous pressure gradient (HVPG) is the gold-standard for measurement of portal hypertension, a common cause for life-threatening conditions such as variceal bleeding and hepatic encephalopathy. HVPG also plays a crucial role in risk stratification, treatment selection and assessment of treatment response. Thus recognition of common pitfalls and unusual hepatic venous conditions is crucial.

A sonographic Doppler study of the hepatic vein, portal vein and hepatic artery in liver cirrhosis: Correlation of hepatic hemodynamics with clinical Child Pugh score in Singapore.

Objective: Liver cirrhosis has been a rising complication of chronic liver disease in Singapore. Ultrasound has been widely accepted as a non-invasive imaging modality for the evaluation of hepatic haemodynamics. This study aims to correlate the Doppler ultrasound values with the progression of liver cirrhosis to allow further understanding and possible prediction of clinical events for timely intervention.

Percutaneous Endovascular Treatment to Salvage Non-Maturing Arteriovenous Fistulas in a Multiethnic Asian Population.

Introduction: An arteriovenous fistula (AVF) is the preferred method for haemodialysis in patients with end-stage renal failure. Previous studies have shown value in attempting percutaneous transluminal angioplasty (PTA) to salvage AVFs that fail to mature, but they are relatively small in size and mainly reported in Western populations. We reviewed our data of PTA in non-maturing AVFs to establish whether this technique is translatable to our local multiethnic population.

Single administration of Selective Internal Radiation Therapy versus continuous treatment with sorafeNIB in locally advanced hepatocellular carcinoma (SIRveNIB): study protocol for a phase iii randomized controlled trial.

Background: Approximately 20 % of hepatocellular carcinoma (HCC) patients diagnosed in the early stages may benefit from potentially curative ablative therapies such as surgical resection, transplantation or radiofrequency ablation. For patients not eligible for such options, prognosis is poor. Sorafenib and Selective Internal Radiation Therapy (SIRT) are clinically proven treatment options in patients with unresectable HCC, and this study aims to assess overall survival following either SIRT or Sorafenib therapy for locally advanced HCC patients.

Differences in Patient Characteristics and Midterm Outcome Between Asian and European Patients Treated with Radiofrequency Ablation for Hepatocellular Carcinoma.

Purpose: The aim of this study was to compare patient characteristics and midterm outcomes after RFA for unresectable Hepatocellular carcinoma (HCC) in Asian and European cohorts.

Materials And Methods: The study was based on retrospective analysis of 279 patients (mean 64.8 ± 12.

National Cancer Centre Singapore Consensus Guidelines for Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is the 6th most common cancer in the world, but the second most common cause of cancer death. There is no universally accepted consensus practice guidelines for HCC owing to rapid developments in new treatment modalities, the heterogeneous epidemiology and clinical presentation of HCC worldwide. However, a number of regional and national guidelines currently exist which reflect practice relevant to the epidemiology and collective experience of the consensus group.

Quantitative Study on the Effect of Abnormalities on Respiration-Induced Kidney Movement.

Respiration-induced movement of abdominal organs hampers the targeting accuracy of non-invasive surgical techniques such as focused ultrasound surgery and radiosurgery. Unaccounted organ movement can result in either under dosage or damage to intervening healthy tissues. The respiration-induced movement is known to be significantly large in kidneys; however, the impact of abnormalities such as tumors and cysts on kidney movement is poorly understood.

Current role of selective internal radiation with yttrium-90 in liver tumors.

An expert panel met to review the evidence for selective internal radiation therapy (SIRT) using yttrium-90 microspheres in hepatocellular carcinoma and metastases from colorectal cancer and neuroendocrine tumors. There is now convincing evidence for the safety and efficacy of SIRT in these situations albeit mostly from retrospective cohort studies. There are a number of ongoing prospective randomized controlled clinical trials investigating the role of SIRT in liver tumors; however, data from these trials are still several years away (although the SIRFLOX study has been recently published).

Survival and pattern of tumor progression with yttrium-90 microsphere radioembolization in predominantly hepatitis B Asian patients with hepatocellular carcinoma.

Purpose: Intra-arterial yttrium-90 ((90)Y) microsphere radioembolization (RE) is an emerging treatment option with good outcomes reported predominantly in hepatitis C Western populations with hepatocellular carcinoma (HCC). We report outcomes in predominantly hepatitis B Asian patients treated with (90)Y-RE focusing on overall survival (OS), time to progression (TTP), tumor response, pattern of tumor recurrence and adverse events. Prognostic factors for survival were also identified.

Underlying liver disease influences volumetric changes in the spared hemiliver after selective internal radiation therapy with 90Y in patients with hepatocellular carcinoma.

Objective: Hypertrophy of the contralateral liver lobe after treatment with yttrium-90 ((90)Y) microspheres has recently been reported. This study aimed to quantify left hepatic lobe hypertrophy after right-sided radioembolization for hepatocellular carcinoma (HCC) and to identify pretreatment predictive factors of hypertrophy in an Asian population.

Methods: A retrospective review of patients with inoperable HCC undergoing selective internal radiation treatment (SIRT) with (90)Y microspheres at a single institution from January 2008 to January 2012 was performed.

Single centre experience of transjugular liver biopsy in 152 patients.

Introduction: Liver biopsy is considered the definitive investigation in the diagnosis and management of liver disease. This study describes the experience of performing transjugular liver biopsy (TJLB) over the last 9 years in a local single centre.

Materials And Methods: A retrospective review of consecutive TJLB procedures performed at our institution was conducted.

Portobiliary fistula: successful transcatheter treatment with embolisation coils.

Although portobiliary fistula is a recognised complication of percutaneous transhepatic biliary drainage, it is extremely uncommon and can result in haemobilia. Herein, we present a case of complicated transhepatic biliary drainage catheter insertion in a patient with underlying hepatitis B liver cirrhosis, which resulted in a portobiliary fistula. The patient had a preoperative transhepatic biliary drainage procedure done prior to a Whipple's operation for a large, obstructive, gastrointestinal stromal tumour of the duodenum.

Multicenter phase II study of sequential radioembolization-sorafenib therapy for inoperable hepatocellular carcinoma.

Background: The safety and tolerability of sequential radioembolization-sorafenib therapy is unknown. An open-label, single arm, investigator-initiated Phase II study (NCT0071279) was conducted at four Asia-Pacific centers to evaluate the safety and efficacy of sequential radioembolization-sorafenib in patients with hepatocellular carcinoma (HCC) not amenable to curative therapies.

Methods: Sorafenib (400 mg twice-daily) was initiated 14 days post-radioembolization with yttrium-90 (90Y) resin microspheres given as a single procedure.

Non-Target Activity Detection by Post-Radioembolization Yttrium-90 PET/CT: Image Assessment Technique and Case Examples.

High resolution yttrium-90 ((90)Y) imaging of post-radioembolization microsphere biodistribution may be achieved by conventional positron emission tomography with integrated computed tomography (PET/CT) scanners that have time-of-flight capability. However, reconstructed (90)Y PET/CT images have high background noise, making non-target activity detection technically challenging. This educational article describes our image assessment technique for non-target activity detection by (90)Y PET/CT, which qualitatively overcomes the problem of background noise.

Post-radioembolization yttrium-90 PET/CT - part 2: dose-response and tumor predictive dosimetry for resin microspheres.

Background: Coincidence imaging of low-abundance yttrium-90 (90Y) internal pair production by positron emission tomography with integrated computed tomography (PET/CT) achieves high-resolution imaging of post-radioembolization microsphere biodistribution. Part 2 analyzes tumor and non-target tissue dose-response by 90Y PET quantification and evaluates the accuracy of tumor 99mTc macroaggregated albumin (MAA) single-photon emission computed tomography with integrated CT (SPECT/CT) predictive dosimetry.

Methods: Retrospective dose quantification of 90Y resin microspheres was performed on the same 23-patient data set in part 1.

Post-radioembolization yttrium-90 PET/CT - part 1: diagnostic reporting.

Background: Yttrium-90 (90Y) positron emission tomography with integrated computed tomography (PET/CT) represents a technological leap from 90Y bremsstrahlung single-photon emission computed tomography with integrated computed tomography (SPECT/CT) by coincidence imaging of low abundance internal pair production. Encouraged by favorable early experiences, we implemented post-radioembolization 90Y PET/CT as an adjunct to 90Y bremsstrahlung SPECT/CT in diagnostic reporting.

Methods: This is a retrospective review of all paired 90Y PET/CT and 90Y bremsstrahlung SPECT/CT scans over a 1-year period.

Primary hepatic artery embolization in pediatric blunt hepatic trauma.

Non-operative management of isolated blunt hepatic trauma is recommended except when hemodynamic instability requires immediate laparotomy. Hepatic artery angioembolization is increasingly used for hepatic injuries with ongoing bleeding as demonstrated by contrast extravasation on the CT scan. It is used primarily or after laparotomy to control ongoing hemorrhage.

A method in the madness in ultrasound evaluation of thyroid nodules.

Around 50% of the population harbour thyroid nodules on ultrasonography, up to 7% of which may be malignant irrespective of size. While fine-needle aspiration biopsy is reliable, subjecting every thyroid nodule to this procedure is not cost-effective. Hence, ultrasonography is used primarily to characterise thyroid nodules, whereas nodules that have suspicious features are subject to a fine-needle aspiration biopsy.

Radioembolization with infusion of yttrium-90 microspheres into a right inferior phrenic artery with hepatic tumor supply is feasible and safe.

Purpose: To evaluate the feasibility and safety of yttrium-90 ((90)Y) radioembolization through the inferior phrenic arteries (IPAs).

Materials And Methods: Retrospective analysis of 108 patients referred for radioembolization to treat primary (n = 103) or secondary (n = 5) liver malignancy was performed. Five patients had malignant hepatic tumors supplied by the IPA and met criteria for infusion of (90)Y spheres into the IPA.

Radioembolization after portal vein embolization in a patient with multifocal hepatocellular carcinoma.

Radioembolization is an effective locoregional therapy for patients with intermediate or advanced stage hepatocellular carcinoma (HCC). It has been shown that radioembolization is safe in patients with portal vein thrombosis. This case report describes safe radioembolization after portal vein embolization in a patient with multifocal HCC.

Cone beam computed tomography for vascular interventional radiology procedures: early experience.

Introduction: Cone beam computed tomography (CBCT) is a relatively new technological innovation that utilises fl at-panel detector technology to obtain CT-like images. The key strength of a CBCT system is that cross-sectional imaging can be obtained using the angiographic fl at panel unit without having to move the patient, allowing the radiologist to obtain soft tissue imaging during the procedure. This allows treatment planning, guidance, and assessment of outcome to be performed in one interventional suite.

Hepatic falciform ligament Tc-99m-macroaggregated albumin activity on SPECT/CT prior to Yttrium-90 microsphere radioembolization: prophylactic measures to prevent non-target microsphere localization via patent hepatic falciform arteries.

Yttrium-90 (Y-90) selective internal radiation therapy (SIRT) is increasingly used to treat inoperable hepatocellular carcinoma. We describe two patients where hepatic falciform ligament Technetium-99m-macroaggregated albumin (Tc-99m-MAA) activity was identified on single photon emission computed tomography with integrated low-dose CT (SPECT/CT) scan during pre-therapy planning, and the steps taken to prevent radiation dermatitis. The first patient underwent prophylactic coil embolization of the patent hepatic falciform artery; the second patient underwent super-selective infusion of Y-90 resin microspheres to avoid the patent hepatic falciform artery.