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For other articles and previous issues click here. May 8, 2006
Greetings From Toronto! News From the Society of Interventional
Radiology’s 31st Annual Scientific Meeting Editor’s Note: The annual meeting of the Society of Interventional Radiology (SIR) showcases research and practice news from around the world. These short articles update research on some of the key topics as selected by SIR. They include information provided by the researchers, SIR, and Radiology Today at the meeting. Embolization
and Foam Treat Varicoceles and Pelvic Pain The embolization procedure closes off the faulty veins so they can no longer enlarge with blood, alleviating symptoms in both men and women. It differs from a standard embolization technique by adding foam to close off small collateral vessels in the faulty veins that were previously unreachable with coils. The new foam agent, Sotradecol, has only recently become available in the United States. Sotradecol is the brand name for sodium tetradecyl sulfate, distributed in the United States by AngioDynamics, Inc. “This simple and elegant embolization technique allows us to treat testicular atrophy in young boys, reverse infertility in some men, and relieve the debilitating pain in women—all nonsurgically,” said Robert I. White, Jr, MD, study author. In the typical embolization procedure, a physician makes a nick in the skin to access the femoral vein, then uses fluoroscopy to guide a catheter up the femoral vein and into the faulty vein. Then, small coils are released to block the vein. The coils have Dacron filaments that allow clots to form on them and help seal the malfunctioning vein in addition to the mechanical occlusion. In this technique, the coils could only be deployed in larger areas of the faulty vein. The addition of the foam liquid allows physicians to block even the smallest collateral veins. “Varicocele embolization is a standard interventional radiology treatment that is widely available across the country,” White said. “No incision is made. No general anesthesia is used. No scars are left behind. When we are done, the patient leaves with only a Band-aid.” The embolization procedure requires an average of one to two days for complete recovery to normal physical activity. Surgery typically requires two to three weeks of recovery time, with another two to three weeks until the patient can return to full exercise. Approximately 80,000 men have surgery for varicoceles in the United States each year. White reported results from 16 patients, all of whom were successfully treated to relieve symptoms, according to his presentation at SIR. The patients had been followed for 12 months before SIR with no reported cases of recurrence in the first year after treatment.
White cautioned that treating embolizing pelvic congestion syndrome is a much newer treatment option for women and more study data needs to be gathered. In the eight patients White reported on at SIR, five of them were symptom free two years after treatments. “Most women I have treated have spent years looking for a solution to their chronic pelvic pain—suffering needlessly because they aren’t aware interventional radiologists have a treatment,” White said.
Lencioni, professor of radiology at the University of Pisa in Italy, presented research results at SIR showing that RFA has produced a three-year survival rate at least equivalent to surgical resection. “Radiofrequency ablation is increasingly accepted as the best treatment option for patients with early-stage hepatocellular carcinoma when surgical resection is precluded,” Lencioni said. “This [new] study is important because it shows that patients who receive radiofrequency ablation can have the same life expectancy as patients in similar condition who undergo surgery.” Offering the same effectiveness as surgery is important because most patients with hepatocellular carcinoma are not candidates for surgery. “Although historically surgery has offered the only chance for a cure, most patients with liver cancer cannot tolerate surgical resection because of the limited functional reserve of the liver caused by the coexisting cirrhosis,” Lencioni said. “Radiofrequency ablation offers patients a nonsurgical option that preserves healthy tissue, is well tolerated, and has a short recovery time. It can be repeated as needed to control tumor growth in case of relapse or to treat newly developed tumors.” Lencioni believes RFA should be considered earlier for many patients because it offers similar survival outcomes in a procedure that’s less invasive, has a shorter recovery period, and is available to more patients. The primary endpoint of the Pisa study was overall survival. Secondary endpoints were local tumor progression and tumor recurrence. The RFA was performed under ultrasound guidance. The energy was delivered using 150-watt generator and electrodes developed by RITA Medical Systems. The study followed 162 patients (38 surgical cases and 124 RFA cases). Cases were matched by date of diagnosis, patient age at diagnosis, tumor size, and serum alphafetoprotein level. The researchers found a higher local tumor progression rate in the RFA group, but the incidence of tumor recurrence and the patients’ overall survival were similar between the two groups. Overall survival rates were 89% at one year, 78% at two years, and 65% at three years in the resection group, compared with 97% at one year, 84% at two years, and 72% at three years in the RFA group. “It’s important for the medical community to be aware that this option should be offered as early as possible in the course of this disease,” Lencioni said.
“With this image-guided technique, we now have an accurate way to treat this disease in its earliest stage,” said Kevin M. Baskin, MD, of CHOP. “We hope to be able to alleviate pain and to prevent irreversible deformity before the bones fuse together.” Juvenile idiopathic arthritis is a new term for juvenile rheumatoid arthritis. It is an inflammatory disorder of the connective tissues characterized by joint swelling, pain, and tenderness. Types of this disease can occur in children as early as 6 weeks old, but the peak onsets are between the ages of 1 and 3 and again between the ages of 8 and 12. The cause is not clear to physicians but appears to be linked to genetic factors, abnormal immune responses, viral or bacterial infections, trauma, and emotional stress. There are several forms of the disease with both acute and chronic phases. Joint pain and inflammation associated with the disease can be treated by injecting corticosteroids into afflicted joints. “In our opinion, early treatment of this disease is essential,” Baskin said. “If you can prevent chronic pain, improve mobility, and reduce inflammation with treatment while patients are in the acute phase, you may preserve the integrity of the joint until their disease ‘burns out,’ giving them normal use of their joint throughout adulthood. By calming down smaller flare-ups, the chronic and irreversible changes appear to be less likely. It’s important for interventional radiologists and rheumatologists to pool their expertise to fight this disease together, to improve the quality of life for affected children and the long-term chances that those who outgrow this diseases may live as active, mobile, pain-free adults.” Baskin presented results from 38 children who received 55 subtalar injections. Clinical improvement was observed after 50 of 55 (91%) injections and the average duration of improvement was 1.3 years. The researchers concluded that a fluoroscopically guided ankle joint injection is an effective way to treat juvenile arthritis, and that earlier treatment after diagnosis was more likely to produce a successful outcome. “Imaging allows us to deliver the medicine more precisely into the affected, inflamed joint,” Baskin said. “The use of image guidance provides a more accurate treatment, ensuring the patient receives the maximum benefit—pain reduction and joint mobility.”
“Our research shows uterine fibroid embolization had no major complications, no infections, and no incidence of pulmonary embolisms compared to the surgical treatments for uterine fibroids, plus two fewer days in the hospital,” said Sanjoy Kundu, MD, who presented the results from a study of 377 women at SIR’s annual meeting in Toronto last month. “Nonsurgical UFE offers less risk and less recovery time than surgery and should be the first line of treatment offered to patients.” While UFE is not a candidate in all cases, it could provide a less risky alternative when appropriate. Approximately one third of the 650,000 hysterectomies performed each year in the United States and Canada are done because the women have fibroids. Kundu and researchers at Toronto’s Scarborough General Hospital reported no major complications in the 65 women who underwent UFE. This compares with 20 (6.3%) major complications—ranging from death to bowel injury to anemia—in the 313 surgical cases. There were no cases of infection or pulmonary embolism in the UFE group, while there were 27 infections (10.5%) and three pulmonary embolisms (0.01%) in the surgical group. The surgical patients’ average hospital stay
was 3.5 days, compared with 1.2 days for the UFE patients.
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