Scientific Session 27Embolization

source 1998 1999 2000 2001GynecologislS(% IOIll!) 20(83%) 20(57%) 13(52%) 14(9%)PrimaryMD 0 2 6 4Media 2 10 22 110Family/Friends 2 3 4 32Toel! 24 35 52 160

The Role and Effect of Gynecologists in ReferringPatients for Uterine Artery Embolization.N.M. Lvoff, Northwestern Memorial Hospital, Chicago, fL,USA· R.A. Omary· R.K. Ryu· H.B. Chrisman· S.A.Resnick· RL Vogelzang, et al.

PURPOSE: Uterine artery embolization (UAE) has become amajor treatment option for fibroids and gynecologists are nowfaced with the option of referring their patients tointerventionalists. The aims of this study were to quantify

The Impact of Direct Consumer Marketing on a UterineFibroid Embolization (UFE) Program.H.B. Chrisman, Northwestern University, Chicago, fL, USA• R.A. Omary· S. Resnick· M.B. Saker· R. Vogelzang·A.A. NemcekJr., et al.

PURPOSE: lnterventional radiology relies on other physicians,many ofwhom are now direct competitors, for patient referrals.The specialty is faced with the issue of how to best competein this increasingly hostile envirorunent. Therefore, we aimedto test the hypothesis that a strategy of direct consumermarketing ofUFE to women minimizes the need for referralsfrom gynecologists.

MATERIALS AND METHODS: In 1998 we beganprospectively acquiring a database ofpotential candidates forUFE. This information included demographics, history, andsource ofreferrals. From 1998 - 2000, we employed marketingStrategy A: educating referring gynecologists, with the aim ofmainly relying on their referrals. In January 200 I, we adoptedmarketing Strategy B: direct marketing to consumers via amedia (television, print, and internet) campaign. We comparedthe two strategies by computing the absolute numbers andrelative proportions of procedures due to each strategy. Weassessed statistical differences between the two strategiesusing the chi-squared test, with alpha set at 0.05. We thencalculated the estimated net professional revenues gained as aresult ofthe advertising campaign.

RESULTS: The Table demonstrates UFE procedural volume,with 1998 and 200 I data annualized. UFE procedures increasedfrom 24 patients in 1998 to 160 patients in 200 I.Gynecologists referred 20/24 patients (83%) in 1998, butonly 14/160 patients (9%) in 2001 (p < 0.001). In the sametime period, UFE patients who were referred from media orfamily increased from 4/24 (17%) to 142/160 (89%) (p <0.001). A gain in physician revenues of $225,000 wasattributable to the direct marketin..z stratc:;gy.

CONCLUSION: Direct consumer marketing is a successfulalternative strategy to ex.pand UFE procedural volume. UFEprograms should strongly consider consumer marketing ratherthan gynecological referrals to increase UFE procedures.

Abstract No. 2113:37 PM

Influence of the Embolization Microspheres Size on thePenetration in the Tissues (Analysis of 92 Specimens).A. Laurent, Hopital Lariboisiere, Paris, France· M. Wassel• R. Chapot • E. Houdart • J.p. Saint Maurice· J.J. Merland

PURPOSE: We developed, since 1987, hydrophilic acrylicmicrospheres (MS) for embolization which allowedtheoretically to master the size of the occluded vessels QV

selecting an appropriate MS size since these MS are calibratedin various size ranges. To verify if this hypothesis was valid,we reviewed histological specimens from patients who havebeen embolized with these MS before surgery.

MATERiALS AND METHODS: Ninety two specimens wereobtained from 78 patients (23 AVM, 55 tumors) who hadbeen embolized, prior to surgery, between 1987 and 2000,with MS of various sizes (100, 200, 400, 600,800 and 1000!lm, Embosphere®, Biosphere Medical, Louvres) Thesespecimens were analyzed under microscope with amicrometric ocular (x 10, HES staining). We verified if MSwere present or absent. On the specimens containing MS, weexamined 1909 vessels and noted for each one: its diameter,the number and the diameter of the MS it contained, itslocalization intra- or extra-lesional (this for tumors only, sincefor AVMs, it was impossible to differentiate the pathologicalvessels from the "normal" vessels).

RESULTS: MS were present in 86% (74/86) of specimens(49/59 tumors and 25/27 AVMs). When MS were present intumors, the size ofMS llsed for embolization was significantlysmaller than when MS were absent (p=.0019). For AVMspecimens there was no difference. No MS aggregate was

the rate at which gynecologists discuss UAE and refer patientsfor therapy, and to determine the impact of this on patients'satisfaction with their gynecologic care.

MATERiALS AND METHODS: 100 consecutive patients whohad undergone UAE for the treatment of leiomyomata at asingle institution were interviewed by telephone at least 3months following the procedure. We assessed initial knowledgeof UAE, options presented and recommended by thegynecologist, and patients' satisfaction with their gynecologiccare. Chi square tests were used to compare groups ofpatientswhose gynecologists did and did not discuss UAE, with thenull hypothesis rejected at the p<0.05 level.

RESULTS: 100 women (age range, 3 I-59) completed the phoneinterview. 100% of patients had discussed treatment optionsfor fibroids with their gynecologist. 15% of patients learnedabout UAB from their gynecologists, and 85% from othersources, including the news (34%), Internet (29%), and familyor friends (14%). 79% of patients said that their gynecologistdid not present UAE as a treatment option. Discussion ofUAE as a treatment option was not related to presentingsymptoms (p< 1.0). 13% of patients said that theirgynecologist recommended UAE, 64% recommendedhysterectomy, with the remainder recommendingmyomectomy, hormone treatment, or watchful waiting. Womenwho were presented with the option ofUAE were significantlymore satisfied with their gynecologist's care (p<0.0 I). Therewas no relationship between satisfaction with gynecologiccare and continued visits to the same gynecologist (p>0.5).

CONCLUSION: Virtually all women discuss fibroid treatmentoptions with their gynecologist; however, women were morethan [Ive times as likely to get UAE information fromtelevision, newspapers, or the Internet, than from theirgynecologist. Future studies will address factors that limitUAE referrals from gynecologists.

Abstract No. 209

Abstract No. 210

3:15 PM

Thursday, April 11 ,20021:00 PM - 2:30 PMModerator(s): Karen T. Brown, MD

3:26PM

572

Pathologic Sequence of Embolization Effect on RabbitKidney Using Chitosan Microspheres as a New EmbolicMaterial.B.K. Kwak, Department ofRadiology. Chung-AngUniversity, Seoul, Korea' HJ. Shim' SM. Han' rc Lee'YB. Kim' S Tokura, et al.

PURPOSE: To evaluate the pathologic sequence ofembolization effect on rabbit kidney using chitosanmicrospheres as a new embolic material.

found in the occluded vessels. The median number ofMS pervessel was one. The diameter of the MS containing vesselswas correlated - to the MS size in histology (Rho = 0.914,p<O.OOO I) - and to the diameter of the MS used forembolization (Rho = 0.687, p<O.OOO I). The MS used fortumor embolization were smaller than for AVM (p = .0003).This size difference between the two pathologies was alsoobserved in histology (295 /lm ± 241 vs 357 /lm ± 236, p <.000 I). In tumors specimens, 91 % of MS were located thetumor vessels, 9% in peritumoral vessels. Moreover the sizeofthe embolized intratumoral vessels was significantly smallerthan the size of the embolized vessels located around thetumor (p < .0001).

CONCLUSION: The size of vessels occluded by MS andtheir intra- or extra-Iesionallocation depend directly on thesize of the MS injected.

(TACE) affects the total volwne ofchemoembolization materialadministered into the tumor and subsequent arterial patency.

MATERIALS AND METHODS: From August 1995 toDecember 2000, 160 patients with hepatocellular carcinomaor metastatic liver cancer were treated with TACE at a singleinstitution. Three chemoembolization protocols were used.Group I (n=36) were treated with a slurry of chemotherapy,oil and polyvinyl alcohol particles (PYA), group 2 (n=91)received chemotherapy and oil followed by PYA, and group 3(n=33) received chemotherapy and oil followed by Gelfoampledgets. The amount of chemotherapeutic agents and thetotal volume ofchemoembolization material injected into theliver were recorded for each procedure. Arterial patency wasdetermined during subsequent chemoembolizations.

RESULTS: The mean percentage of intendedchemoembolization material administered was 54.6% for group1,75.3% for group 2, and 80.6% for group 3. Arterial patencyat follow-up angiography was 56% for group I, 74% forgroup 2, and 81 % for group 3.

CONCLUSION: When embolic material was injected as partof a slurry, both the amount of chemoembolization mixtureadministered and subsequent arterial patency weresignificantly reduced. However, the type ofembolic materialhad no impact on arterial patency after TACE and did notpreclude subsequent TACE.

3:48PM Abstract No. 212

4:10PM Abstract No. 214

Transcatheter Arterial Chemoembolization of LiverThmors: Effects of Embolization Material on SubsequentArterial Patency.J,F. Geschwind, Johns Hopkins University School ofMedicine, Baltimore, MD, USA' D.E. Ramsey· B. C vander Wale H Kobeiter' HS Kim' G.G. Hartnell

PURPOSE: To determine if the choice of embolic materialused during hepatic transcatheter arterial chemoembolization

MATERIALS AND METHODS: Forty eight New Zealandwhite rabbits were classified into four groups. PYA particles(150-250 /lm) were used in group I (control group), Chitinparticles (150-250 /lm) in group 2, Chitosan particles(150-250 /lm) in group 3, Chitosan microspheres were usedin group 4 (150-250 /lm), group 5 (250-355 /lm) and group 6(355-500 /lm), respectively. Rabbit right renal arteriographywas performed using 4 F Cobra catheter. Embolization wasContinued until complete occlusion ofthe artery was achieved.Successful embolizations were achieved in all forty eightrabbits. One animal was sacrificed in each group on the 1stand 3rd day, 1st, 2nd, 4th, 8th, 24th and 32nd week. Basichematologic and blood chemisty were analyzed and gross andmicroscopic pathologic fmdings were observed.

RESULTS: On gross pathologic examination, renal contractionand discoloration were similar between chitinous materialsand PYA. Histologically chitosan microspheres groups had ahigher incidence of vasculitis, but a lower incidence ofrecanalization and subintimal proliferation in comparison withPYA. Resorption was seen in chitosan microspheres slowlyafter 8 weeks, and in PYA with a similar process in renal hilararteries. Hematologic and blood chemisty showed nosignificant abnormal change in both groups.

CONCLUSION: Chitosan microspheres were slowlyabsorbed after 8 weeks, and PYA showed similar process inrenal hi lar arteries.

3:59PM Ab tract 0.213

Combined ChemoemboJization and RadiofrequencyAblation for Mid-Size Hepatic Malignancies.D. Fang, University ofPennsylvania, Philadelphia, PA, USA• M.C Soulen • HL. Nisenbaum • r W Clark' R.A. Baum •S W. Stavropoulos, et al.

PURPOSE: RadiofTequency ablation (RFA) provides excellentlocal control for liver tumors up to 3 cm. Local failure ratesincrease for larger tumors. We evaluated the combination ofchemoembolization and RFA to control liver tumors up to 6cm in diameter.

MATERiALS AND METHODS: Nineteen tumors (II HCC,4colon mets, 4 sarcoma mets) in 14 patients (9 HCC, 3 colon,2 sarcoma) up to 6 cm in maximal diameter werechemoembolized with lobar CAMlEthiodolJPYA, followedby US-guided RFA the next day. Patients with bilobar diseasehad the other lobe treated one month later. Ten patients hadone tumor, 3 had two, and one had 3 tumors ablated. The first13/19 tumors were treated using a 3.5 cm radial array aDd a90W generator (Radiotherapeutics), the later 6/19 with asecond-generation 4 cm array and a 200W generator. Fourtumors were treated with one burn, 12 with two overlappingbums, one with 3, and one with 4 burns. Follow-up laboratorystudies including tumor markers, clinical assessment, and liverimaging were performed at one month, then evelY 3 months.

RESULTS: All procedures were technically successful, withrolloffachieved in all cases. Two patients with a prior Whippledeveloped bacteremia requiring rehospitalization, one ofwhomdeveloped a bilocutaneous fistula through the RF probe tract.One patient developed a large groin hematoma which did notrequire intervention. Tumor markers were elevated in 7patients; there were 4 partial responses, one minor response,and 2 remained stable. Lesion size was 4.4 ± 1.3 cm initially,5.3 ± 1.5 cm one month after RFA (p=0.05), and 4.7 ± 1.2 cm4 months after RFA. There were no local recurrences. Threepatients were transplanted within 6 months with no recurrence.Of the remaining II patients, seven developed intrahepaticprogression at new sites and 3 others developed extrahepaticdisease within 6 months. One non-transplanted patient remains

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disease free at 30 months. With a mean follow-up of8 months,overall and disease-free survival at one year are 72% and 29%,respectively.

CONCLUSION: The combination ofchemoembolization andRF ablation provides durable local control of liver tumors upto 6 em. In the absence of a transplant, progression at othersites remains a therapeutic challenge

Quality of Life Assessment in Patients UndergoingChemoembolization: A Longitudinal Follow-Up Study.P. Drescher, Medical College ofWisconsin, Milwaukee, WI,USA· ME Robertson· Ws. Rilling· MR. Crain· KSaeian • J Franco

PURPOSE: To assess the overall health status in patientsundergoing hepatic chemoembolization (HCE) utilizing a multi­scale health questionnaire (SF-36), and to provide longitudinalfollow-up over multiple HCE sessions.

MATERIALS AND METHODS: Prospectively, 25 patientswith hepatic dominant malignancy undergomg HCE completedthe SF-36 questionnaire. All patients had at least 2 HCE, 15

Chemoembolization of Metastatic Colorectal Carcinomaafter Hepatic Arterial Infusion Pump Chemotherapy.A. Kwak, University ofPennsylvania Medical Center,Philadelphia, PA, USA· CM Tuite· MC Soulen

PURPOSE: To evaluate response and survival after CAM!EthiodoVPVA chemoembolization in patients with metastaticadenocarcinoma ofthe colon and prior hepatic arterial infusionpump chemotherapy.

MATERIALS AND METHODS: Patients eligible for treatmenthad a pathologic diagnosis of colorectal cancer,bidimensionably measurable liver metastases, as well asadequate renal, cardiac and hepatic function. All patients hadfailed prior hepatic arterial infusion therapy (HAlT).Chemoembolization with cisplatinum, doxorubicin,mitomycin-C, iodized oil and polyvinyl alcohol particles wasperforriled at monthly intervals for 1-3 sessions. Morphologicand biologic response were assessed by comparing the pre­and 30 day post-treatment cross- sectional imaging and CEAlevels using the WHO criteria.

RESULTS: Eleven patients were treated with a total of 22chemoembolization sessions. No patients were untreatablebecause of infusion pump-related hepatic arterial occlusion.The cumulative survival from the time ofdiagnosis with livermetastases was 90% at one year, 70% at two years and j 7%at three years. Morphologic response could be evaluated in 8patients. Three patients had stable disease, while 5 patientsdemonstrated morphologic progression. Biologic response wasevaluated in 5 patients. Three patients had a partial response,and one patient each had a minor response or progression.Typical symptoms of postembolization syndrome occurredin all patients. Two patients developed grade 4 biliary toxicity.One patient developed grade 3 hematologic toxicity. Therewere no major complications after any of the procedures.

CONCLUSION: [n this single institution experience,chemoembolization of metastatic colorectal carcinoma afterfailed hepatic arterial infusion pump chemotherapy providessurvival rates double those reported for current systemicchemotherapy regimens and comparable to those reported forHAlT. The incidence of significant toxicity is not increasedover that reported for HAlT alone.

Scientific Session 28Thrombectomy/Thrombolysis

Abstract No. 217

Comparison of Alteplase, Reteplase, and Tenecteplaseand Effects on Hemostatic Parameters in a Rabbit Model.c.p Semba, BioTherapeutic Unit, Genentech, Inc., SanFrancisco, CA, USA· A.S. Cheng· KP. McKeever· KRefino • D. Combs· CA. ONeill, et al.

PURPOSE: The unavailability ofurokinase in the US has ledclinicians to explore alternative thrombolytic agents forcatheter-directed thrombolysis in treating acute limb ischemiaand deep vein thrombosis. Despite widespread use ofthrombolytics,.there exists no pre-clinical comparative safetydata evaluating the effects of these agents on changes incoagulation parameters when administered using catheter­directed techniques and empiric dosing schedules. The purposeof this study was to evaluate the effect of alteplase (tPA),reteplase (rPA) and tenecteplase (TNK) on hemostaticparameters using doses and techniques similar to clinicalpractice in a rabbit model.

MATERIALS AND METHODS: The primary endpoints werechanges in coagulation parameters at varying drug dosesincluding PT, aPTr, fibrinogen, plasminogen, a-2~antiplasmin,and plasma drug concentrations. Dosing was based upon a70-kg human and compared to saline controls. Followinginduction and intubation, femoral cutdowns were performedin male NZW rabbits (2-3 kg). Intravascular catheters wereplaced in the femoral artery and vein. Subjects did not receiveheparin. TPA, rPA, and TNK were infused intravenouslyinto the femoral vein at doses corresponding to 0, 0.5, I, 2,and 10 (mg/h, tPA, TNK; UIb, rPA) for 4 hIs. Artelial bloodsamples were collected at T = 0, 0.5, 1,2, 3, 4 hrs.

patients (60%) 3 HCE, 6 patients (24%) 4 HCE,and 3 patients(12%) 5 HCE. The average time interval between HCEs was71 days (range 46 -121 days). The health scales were calculatedand averaged for each treatment using the SF-36 standardquestionnaire. Comparison was made to an age-matchedhealthy control and over the course of repeated HCE session.

RESULTS: The compliance to complete the SF-36 was 100%.Compared to an age matched healthy control, the HCE patientsscored lower in physical functioning (PF), social functioning(SF), mental health (MH), and signiflcant lower (>50%) inrole physical (RP) and role emotional (RE). At the time of thesecond HCE, patients scored lower in all health scales exceptfor MH compared to the first HCE. Significantly lower scoreswere found in bodily pain (BP). Over the course ofsubsequentHCE, the scores increased «50%) for vitality and MH andsignificantly (>50%) increased for RP, RE. Only the score forBP steadily declined over the course of treatment. Over theduration of the study the mortality rate from the underlyingdisease was 32%.

Thursday, April 11, 20023:00 PM - 4:30 PMModerator(s): Scott Savader, MD

CONCLUSION: Compared to healthy controls, patientsundergoing chemoembolization scored lower in 5 out of 8health scales. HCE appears to be a well-tolerated preservingor even improving many health scales after an initial decline.The increase in scores of physical, emotional and mentalcomponents might represent a selection bias for patients withan overaJl prolonged survival.

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Abstract No. 216

Abstract No. 215

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