RPS 1309 - Interventions in malignant liver disease

Author Block: J. Uhlig¹, L. Biggemann¹, J. Nadjiri², T. Kroencke³; ¹Göttingen/DE, ²Munich/DE, ³Augsburg/DE
Purpose: To assess the current utilization, technical approaches and complications of oncologic ablation in Germany.
Methods or Background: The German Society of Interventional Radiology (“DeGIR”) registry was queried for patients receiving ablation treatments between 2018-2023. Patient demographics, indications, and technical ablation parameters were descriptively assessed.
Results or Findings: N=9157 patients receiving oncologic ablation were included (34.3% female; median age 67yo). Between 2018-2023, annual ablation number remained approximately constant at 1000 cases/year.
Ablations were performed in the liver (71.4%), kidney (11.3%), musculoskeletal system (7.3%) and lung (5.4%), mainly with curative intent (64%) or for symptomatic treatment / palliation (30.6%).
N=7371 patients were imaged with CT before ablation (80.5%), 4176 with MRI (45.6%), and 173 with PET (1.9%; not mutually exclusive).
Ablation guidance was achieved using CT (89.6%), ultrasound (5.7%), MRI (2.8%), cone-beam CT or fluoroscopy (0.9%, each). Ablation procedures were mainly performed under general anesthesia (74.6%) or analgosedation (14.5%).
Microwave ablation was performed in most cases (69.4%), followed by radiofrequency (23.6%) and cryoablation (2.8%), often combined with tract ablation (51.2%). Only 48 procedures (0.5%) were preemptively terminated, mainly due to anatomical difficulties (n=16) or uncooperative patients (n=11).
During or within the first 24h after ablation, 4.8% of patients experienced any complications, the majority being low-grade. Another 45 patients (0.5%) experienced delayed complications 24h or later after ablation, mainly infections/abscesses (n=21).
Conclusion: Oncologic ablations are routinely performed in Germany with low procedural complication rates, mostly using CT-guided microwave or radiofrequency ablation for hepatic or renal tumors.
Limitations: Since participation in the DeGIR registry is not mandatory, there could be selection bias of included cases and participating sites, limiting the generalizability of results.
Funding for this study: Not applicable.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: Not applicable - retrospective anonymised registry data.

Author Block: T. Kao¹, E. Meister¹, J. Santana², J. Israel², A. Shewarega², J. Tefera², D. C. Madoff², L. J. Savic¹, J. Chapiro²; ¹Berlin/DE, ²New Haven, CT/US
Purpose: Hepatocellular carcinoma (HCC) exhibits an immunosuppressive microenvironment which can be aggravated by incomplete tumor ablation. Immune checkpoint inhibitors (ICIs) such as anti-PD-1 are guideline-approved therapies for advanced HCC. Combining ablation with ICIs could potentially strengthen anti-cancer immunity, but supporting evidence is limited. We aim to evaluate the effect of neoadjuvant systemic anti-PD-1 on the local immune response in residual tumors following partial cryoablation in a TIB-75 murine HCC model.
Methods or Background: Forty-eight male and female BALB/c mice aged 6-12 weeks underwent orthotopic inoculation of TIB-75 cells to induce a solitary HCC lesion. After 7 days, mice were randomized into 4 treatment groups: (a) control, (b) anti-PD-1, (c) partial cryoablation, and (d) anti-PD-1 followed by partial cryoablation. The percentage of positively stained T-cell subsets and tumor-associated macrophages within the tumor was assessed in paraffinized liver tissue samples using immunohistochemistry (CD3+, CD4+, CD8+, CD68+, CD206+, FOXP3+) and quantified on digitized slides. Treatment groups were compared using unpaired Mann-Whitney U and Kruskal-Wallis test with Dunn correction.
Results or Findings: Mice treated with anti-PD-1 (n=12, group b) showed greater tumoral infiltration of CD3+, CD4+ and CD8+ T-cells than control (CD3+: mean 21.4% vs. 6.7%; P=<0.0001, CD4+: mean 21.3% vs. 6.0%; P=<0.0001, CD8+: mean 7.5% vs. 3.8%; P=0.005). Partial cryoablation alone (n=12) had greater infiltration of CD206+ M2-like macrophages than control (mean 32.4% vs. 14.6%; P=0.007). Anti-PD-1 combined with partial cryoablation (n=12) showed significantly more infiltration of CD3+ T-cells (mean 13.7% vs. 6.1%; P=0.002) and fewer CD206+ M2-like macrophages (mean 26.1% vs. 32.4%; P=0.3474) than partial cryoablation alone (n=12).
Conclusion: Immune evasion following partial cryoablation can be counteracted with neoadjuvant anti-PD-1, suggesting effective combination therapy to treat both early-stage and advanced-stage HCC.
Limitations: The model was inoculated in healthy, non-cirrhotic mouse liver.
Funding for this study: NIH grant 2R01CA206180
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: All experimental procedures were approved by the Yale University Institutional Animal Care and Use Committee (IACUC protocol number: 2022-20262).

Author Block: W. Wang, Y-C. Wang; Nanjing/CN
Purpose: Accurate risk stratification of viable hepatocellular carcinomas (HCC) following transarterial chemoembolization (TACE) is essential for the development of individualized treatment strategies and enhancing the accuracy of prognosis predictions.
Methods or Background: This multi-center, retrospective study includes HCC patients who received TACE as their initial and sole treatment from February 2015 to October 2022 as training set (203 viable tumors). Additionally, a dataset from a multicenter clinical trial (NCT03113955) was subject to secondary analysis as test set (102 viable tumors). The final pathological validation set consists of a separate center, including individuals who had liver resection post-first TACE (120 viable tumors). All participants in both the training and test cohorts underwent contrast-enhanced MRI scans at baseline, and at one and six months after TACE. In the training set, univariate and multivariate logistic regression analysis was performed to identify clinical, laboratory and imaging variables to include in the predictive model.
Results or Findings: The predictive model incorporated five key imaging features: Mild-moderate T2 hyperintensity, T2-weighted peritumoral hyperintensity, Diffusion restriction, Irregular shape, and Heterogeneity. The model achieved areas under the curve (AUCs) of 0.85 (95% confidence interval [CI] 0.79 to 0.90) for the training cohort and 0.88 (95% CI 0.81 to 0.95) for the external test cohort. The risk model effectively distinguished high-risk from low-risk groups in the test cohort, with significant differences in progression-free survival (PFS) (P = 0.004) and two-year overall survival (OS) (P = 0.028). In the pathology cohort, the model correlated with microvascular invasion (MVI) grades (P = 0.003) and liver capsule invasion (P = 0.007).
Conclusion: This risk model based on imaging features for viable HCCs post-TACE exhibits robust predictive power for tumor viability at six months and for long-term survival outcomes.
Limitations: Not applicable
Funding for this study: This study has received funding by National Natural Science Foundation of China (NSFC, No. 82271978, 92359304, 82330060) and Zhongda Hospital Affiliated to Southeast University, Jiangsu Province High-Level Hospital Pairing Assistance Construction Funds (No. zdyyxy09).
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: This multicenter, retrospective study was reviewed and approved by IEC for clinical research of the Zhongda Hospital, Southeast University, approval number [2022ZDSYLL410-P01], and conducted following the ethical principles outlined in the Helsinki Declaration of 1964 and its subsequent amendments, or other ethical standards with equivalent requirements. All patients and their families signed informed consent forms prior to surgery.

Author Block: M. Taninokuchi Tomassoni¹, M. Renzulli¹, S. Zanella¹, A. Doriguzzi Breatta², P. Marra³, F. De Cobelli⁴, C. Mosconi¹; ¹Bologna/IT, ²Turin/IT, ³Bergamo/IT, ⁴Milan/IT
Purpose: This randomized clinical trial aims to compare transarterial embolization (TAE)and drug-eluted beads transarterial chemoembolization (DEB-TACE) in the treatment of hepatocellular carcinoma (HCC).
Methods or Background: Patients diagnosed with unresectable HCC were randomly assigned to either theTAE or DEB-TACE group. The primary endpoint was time to progression (TTP), and secondary endpoints included overall survival, cost-effectiveness, tumor response rates, and
adverse events.
Results or Findings: A total of 111 patients were enrolled, with 56 in the TAE group and55 in the DEB-TACE group. Baseline characteristics were balanced between the two groups. The primary endpoint analysis showed that TAE was not different from DEB-TACE in termsof TTP (average of 12.13 and 10.87 months respectively, p=0.432). Overall survival, tumorresponse rates, and adverse events were also similar between the two groups. The cost-effectiveness ratio of DEB-TACE vs. TAE was evaluated considering that, with equaleffectiveness of the two treatments highlighted by the previous points, there being nostatistically significant difference in terms of days of hospitalization between DEB-TACEand TAE (average of 4.62 days and 5.20 days respectively, p=0.638).
Conclusion: In this randomized clinical trial, TAE showed comparable outcomes to DEB-TACE in the treatment of unresectable hepatocellular carcinoma. These findings suggest that TAE could be considered as an alternative for treating HCC with no differences in
terms of safety and efficacy.
Limitations: The relatively small sample size and short-term follow-up period may limit the
generalizability of the findings and the ability to detect subtle differences in outcomes
between TAE and DEB-TACE.
Funding for this study: This study was funded by the Italian Ministry of Health.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The trial was conducted in accordance with ethical standards and received approval from the institutional review boards. The study was registered at www.clinicaltrials.gov
(NCT04803019).

Author Block: M. P. Fabritius, A. Haghpanah, O. Dietrich, D. Puhr-Westerheide, V. F. Schmidt, S. Corradini, J. Ricke, O. Öcal, M. Seidensticker; Munich/DE
Purpose: To show feasibility and safety of MR guided catheter-based radiotherapy/brachytherapy of primary or secondary liver tumours
Methods or Background: Between June 2023 and April 2024, 27 patients with 54 liver lesions were treated within a prospecitve single-center trial on MR-guided catheter-based radiotherapy (MR BRIGHT trial). Treatments were performed under conscious sedation and local anesthesia using a 1.5T MRI system (Magnetom Solafit, Siemens) with a 15 cm loop coil. Gadoxetic acid (0.1 mmol/kg) was administered for contrast enhancement, followed by insertion of an 18G coaxial needle and navigation to the lesion via real-time gradient-echo fluoroscopy sequences (iMRI UI Extension, Research Software Package). The needle was exchanged for a 6F hydrophilic angiography sheath with a brachytherapy catheter. 3D T1-weighted sequences were sent to the radiation department for brachytherapy with an IR192 high-dose-rate (HDR) afterloading unit. Target doses ranged from 15 to 25 Gy, depending on tumor type (HCC, CRC, GIST, NET, and other metastases). Catheters were removed after BT, and the radiation tract sealed with gelatin sponge.
Results or Findings: The average lesion diameter was 13 ± 6 mm, whereas the average clinical target volume (CTV) was 3.0 ± 2.9 cm3. The average room time was 74 ± 35 minutes, the average time for catheter placement was 19 ± 11 minutes. The mean dose administered per lesion (D100) was 18.9 ± 3.6 Gy. Complications during and after BT were generally rare with only 2 patients (7.4 %.) having a minor bleeding without need for blood transfusion or intervention.
Conclusion: Overall, MR-guided catheter-based radiotherapy for liver tumours is feasible and safe, particularly for small lesions. With low complication rates and precise dosimetry achieved through advanced imaging, this approach holds promise for effective tumour management.
Limitations: n/a
Funding for this study: None
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: LMU Munich

Author Block: M. Z. Erforth, L. K. Segger, U. Fehrenbach, F. Collettini, B. Gebauer, T. A. Auer; Berlin/DE
Purpose: To evaluate feasibility for CT guided high dose rate (HDR) brachytherapy under analgosedation performed by interventional radiologists in patients with liver tumors.
Methods or Background: In this prospective single-center study (EA/122/23), 97 patients who received CT-guided HDR brachytherapy along with analgosedation using fentanyl and midazolam were enrolled and 77 were included in the final analysis. At the outset, a personality profile (from the EORTC catalog) related to their pain experience was also recorded for each patient. Structured questionnaires were employed to assess the patients' pain levels and satisfaction both at and after the intervention. Three months later, the patients were recontacted, and a follow-up survey was conducted. The results were recorded by means of a numeric analog scale and presented as categorical variables.
Results or Findings: First, pain was measured (0: no pain; to 10: maximum pain) 1. at catheter placement; 2. at the radiation; 3. after the radiation (catheter removal). At catheter placement, 75.5% (58/77) rated the pain as low (0-2), 18.0% (14/77) as moderate (3-6), and 6.5% (5/77) as severe (7-10). At the radiation and afterwards pain levels were rated as low in 83.0% (64/77) and 79.0% (61/77), as moderate in 11.5% (9/77) and 17.0% (13/77) and as severe in 5.5% (4/77) and 4.0% (3/77), respectively. Second, patient satisfaction was measured (1: completely dissatisfied; to 10: completely satisfied). In 1.3% (1/77) the lowest score was recorded while in 98.7% (76/77) a score ≥7 was recorded.
Conclusion: CT guided HDR brachytherapy under analgosedation is feasible and can be performed by interventional radiologists themselves without general anesthesia.
Limitations: Limitations include the short observation period and the small cohort of patients with a heterogeneous clinical history, neoplasm histology, and location, as well as inhomogeneity regarding previous treatments.
Funding for this study: None
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Institutional Review Board approved prospective study (EA1/122/23).

Author Block: N. Rossini¹, C. Floridi¹, M. Macchini¹, L. M. Cacioppa¹, A. Felicioli¹, C. Mincarelli², R. Candelari¹, A. Giovagnoni¹; ¹Ancona/IT, ²Macerata/IT
Purpose: To evaluate how intra-procedural DP-CBCT navigation guidance influences TACE success rate in terms of residual disease in follow-up imaging.
Methods or Background: This retrospective analysis includes all patients with HCC treated with TACE (cTACE or DEB-TACE) in our centre between January 2017 and January 2024 with at least 1 month of imaging (CT or MRI) follow-up available. All patients had a recent baseline CT or MRI before TACE. Patients were divided in two groups, the first one included patients with DP-CBCT performed intra-procedurally during TACE (DP-CBCT group), the second included patients with no CBCT performed during treatment (no-DP-CBCT group). The two groups were similar in vascular anatomy, lesions number, morphology and localization. Response to treatment was evaluated in imaging follow-up with mRECIST criteria. The two groups were compared for treatment response after TACE in terms of residual disease in follow-up imaging.
Results or Findings: 152 patients were included in the study (M:F 112:40). 82 patients were included in the DP-CBCT group whereas 70 in the no-DP-CBCT group. Residual disease was of 26.9% in DP-CBCT group and of 63.0% in no-DP-CBCT group. A significant difference in terms of residual disease was observed between the two groups (p<0.05). Significant lower cases of residual disease were present in DP-CBCT group.
Conclusion: DP-CBCT imaging navigation guidance improves significantly success rate in TACE, ensuring a better visualization of HCC lesions feeding vessels and a consequent higher possibility of complete treatment of the nodules without residual disease.
Limitations: The main limitation of this study is the brief follow up imaging that should be extended in future studies.
Funding for this study: This research received no external funding.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: All the procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. This study obtained the approval of the Internal Review Board (IRB) of University Politecnica Delle Marche.

Author Block: M. Arabi, H. Alghamdi, A. A. F. Almesned, O. Alanazi, M. Alghamdi, M. Bukhaytan, M. Alkhalaf, M. Almaimoni, N. Alagrafy; Riyadh/SA
Purpose: This study aimed to identify the predictors of mortality and liver decompensation in patients with HCC treated with Y-90 radioembolization.
Methods or Background: A retrospective analysis of 140 patients with HCC who underwent Y-90 radioembolization was conducted. Kaplan‒Meier and multivariate Cox regression analyses were performed to identify the significant predictors of mortality.
Results or Findings: The cohort comprised 69.3% males with a mean age of 71.3 ±11.9 years. Most patients (73.6%) had Child-Pugh class A cirrhosis and 34.3% had BCLC stage B disease. Among the 140 patients, 57.1% died after treatment and liver decompensation was recorded in 39.2%. The median survival was significantly longer in those without liver decompensation (3.2 vs 0.7 years, p<0.001). Multivariate analysis revealed that male sex (adjusted odds ratio [aOR] 5.889, p=0.009), cirrhosis (aOR 6.82, p=0.047), and international normalized ratio (INR) (aOR 316.664, p=0.013) were independent predictors of liver decompensation. Cox regression analysis revealed several significant predictors of mortality. Ascites (HR 2.012, 95% CI, 1.122–3.61; p=0.019), portal vein invasion (HR 1.695, 95% CI, 1.057–2.718; p=0.029), and diabetes mellitus (HR 1.823, 95% CI, 1.017–3.265; p=0.044) were associated with increased mortality risk. Conversely, non-multifocal HCC (HR 0.593, 95% CI, 0.369–0.955; p=0.031), treatment of the liver lobe other than the right lobe (HR, 0.482; 95% CI 0.236–0.986, p=0.046), and age ≥60 years (HR 0.288, 95% CI, 0.139–0.597; p=0.001) were associated with a reduced risk of mortality.
Conclusion: This study identified the key predictors of mortality in patients with HCC undergoing Y-90 radioembolization, potentially improving patient selection and management strategies.
Limitations: While this study provides valuable insights, several limitations should be acknowledged. The retrospective nature of the study introduces potential biases in patient selection and data collection. The lack of post-infusion dosimetry limits the precision of dose-response analyses.
Funding for this study: The study was not supported by funding.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The study was approved by the institutional review board, and the need for informed consent was waived. This study was conducted in accordance with the 2010 guidelines of the Declaration of Helsinki.

Author Block: X. Wu; Hangzhou/CN
Purpose: Localisation of target tumours under CT guidance can be challenging due to insufficient soft tissue resolution and metal artifacts. This study aims to validate the accuracy of the automatic image registration system (AIRS) in localising target lesions throughout the CT-guided CRLM ablation procedure, thereby exploring a novel guidance method for interventional procedures.
Methods or Background: This retrospective, single-center study included patients with CRLM who underwent CT-guided liver ablation between January 2021 and August 2023. Three experienced physicians collectively annotated the visibility and lesion centre positions of CRLMs on both the preprocedural contrast-enhanced MRI and intraoperative CT image series, which served as the ground truth. The AIRS and two junior physicians delineated the lesion centre positions in the same CT sequences. The localisation errors of the AIRS and junior physicians were analysed using the non-parametric Kruskal–Wallis test for one-way analysis.
Results or Findings: One hundred and twenty consecutive patients with 224 CRLMs treated across 128 sessions were enrolled. There were 128 pairs of MR-pCT (pre-procedural CT) multi-modal registrations and 1,008 pairs of pCT-iCT (intra-procedural) mono-modal registrations. AIRS demonstrated superior localisation error than the physician group in localising lesions suboptimal visible on pCT (5.94±2.61 mm vs 8.04±5.32 mm, p=0.006), lesions excellently visible on iCT (5.14±2.65 mm vs 6.15±3.84 mm, p=0.01) and lesions suboptimal visible on iCT (6.13±2.80 mm vs 8.94±4.60 mm, p＜0.001).
Conclusion: Compared with less experienced physicians, an AIRS can quickly and accurately locate target lesions in CT-guided colorectal cancer liver metastasis ablation procedures, especially for lesions with poor visibility, thus paving the way for a new navigation method in colorectal cancer liver metastasis ablations.
Limitations: This was a retrospective investigation with a relatively small sample size, which may have restricted the generalisability of our findings.
Funding for this study: None
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This single-centre retrospective study was approved by the local ethics committee and was exempted from informed consent.

Author Block: M. T. Winkelmann¹, J. Kuebler¹, S. Gassenmaier¹, D. Nickel², K. Nikolaou¹, S. Afat¹, R. Hoffmann¹; ¹Tuebingen/DE, ²Erlangen/DE
Purpose: This study explores the impact of deep learning-enhanced image generation for T1-weighted volume-interpolated breath-hold examinations (DL-VIBE) on image quality and procedural parameters during MR-guided thermoablation of liver malignancies, compared to standard VIBE images (SD-VIBE).
Methods or Background: 34 consecutive patients (mean age: 65.4 ± 11.5 years, women: n=13) with liver malignancies underwent MR-guided microwave ablation using a 1.5 T MR scanner. Intraprocedural VIBE sequences (SD-VIBE) were used to monitor needle position and assess the ablation zone. The raw T1-weighted VIBE data were retrospectively processed with a deep learning algorithm (DL-VIBE) to reduce noise and improve sharpness. Two interventional radiologists independently evaluated the image sets in a blinded manner, comparing DL-VIBE with unprocessed SD-VIBE images. Criteria assessed included diagnostic confidence, image quality, noise, artifacts, and sharpness. Interrater agreement was analyzed, and noise maps were created to evaluate signal-to-noise ratio improvements.
Results or Findings: DL-VIBE significantly improved overall image quality, reduced noise and artifacts, and enhanced the sharpness of liver contours and portal vein branches compared to SD-VIBE (P<0.001). Additionally, DL-VIBE improved imaging of the interventional path, needle tip detectability, and diagnostic confidence in needle positioning and the ablation zone (P<0.001), with high interrater agreement (κ = 0.86). Quantitative noise maps demonstrated a higher signal-to-noise ratio, and the reconstruction process took approximately 4 seconds, reducing breath-hold time by 2 seconds.
Conclusion: DL-VIBE significantly enhances image quality and diagnostic confidence during MR-guided thermal ablation procedures, offering time savings and potential improvements in patient outcomes.
Limitations: - Small number of patients.
- Sequences were retrospectively processed, not used during actual interventions.
- Image quality assessments were retrospective and may differ from real-time evaluations.
- Time savings are theoretical due to the retrospective study design, with uncertainty about feasibility during actual interventions.
Funding for this study: No funding was received for this study
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This retrospective study was approved by the institutional review board (Eberhard Karls University of Tübingen, project number: 055/2017BO2)

Author Block: O. Sarioğlu, A. Canturk, R. C. Yarol, H. Gulmez, E. Derebek, A. Gülcü; Izmir/TR
Purpose: To evaluate the potential of machine learning-based models for predicting the response of large hepatocellular carcinoma to transarterial radioembolization
Methods or Background: A total of 49 patients (38 responder and 11 non-responder) were included in the study. Laboratory results and clinical conditions were collected. Treatment response was assessed according to mRECIST criteria from the 3-month follow-up MR examinations. Complete or partial response was categorized as the responder group, while stable or progressive disease was classified as the non-responder group.

Radiomics features were extracted from contrast-enhanced T1-weighted images (CE-T1) and T2-weighted images (T2WI). 141 radiomics features were obtained from each lesion.
Classification learning models were used to create prediction models for TARE response. 5-fold cross-validation technique was utilized to identify the prediction rates of treatment response.
Results or Findings: Number of radiomics features demonstrated statistically significant differences between the groups are 9 and 12 on T2W and CE-T1 images, respectively.
The model based on radiomics features obtained from CE-T1 images demonstrated an accuracy rate of %79.6 to predict response with an AUC of 0.92. The sensitivity and specificity rates were %79 and %100, respectively. The accuracy and AUC rates of the model using radiomics features extracted from T2W images were %79.6 and 0.77, respectively. Sensitivity and specificity rates of the model were %80 and %67, respectively. When only clinical and laboratory parameters were used, the model showed an accuracy rate of %77.6 and an AUC of 0.65. The sensitivity and specificity values of the clinical and laboratory model were %79 and %50, respectively. Another model using both clinical and CE-T1 radiomics features showed an accuracy rate of %73.5
Conclusion: Machine learning-based radiomics models based on MRI can predict the response of large hepatocellular carcinoma to transarterial radioembolization
Limitations: None
Funding for this study: None
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Ethics committee approval obtained