Ultrasound-guided catheterization of the infraclavicular axillary vein is a useful alternative technique for central venous cannulation with few complications.

PurposeTo evaluate and compare outcome of stereotactic body radiation therapy (SBRT), yttrium-90 radioembolization, radiofrequency ablation (RFA), or transarterial chemoembolization (TACE) as bridge to liver transplant (LT) in patients with hepatocellular carcinoma.Methods and materialsWe retrospectively reviewed patients treated at our institution with SBRT, TACE, RFA, or yttrium-90 as bridge to LT between 2006 and 2013. We analyzed radiologic and pathologic response and rate of failure after bridge therapy. Toxicities were reported using Common Terminology Criteria for Adverse Events, 4.0. Kaplan-Meier method was used to calculate disease-free survival (DFS) and overall survival after LT.ResultsSixty patients with a median age 57.5 years (range, 44-70) met inclusion criteria. Thirty-one patients (50.7%) had hepatitis C cirrhosis, 14 (23%) alcoholic cirrhosis, and 8 (13%) nonalcoholic steatohepatitis cirrhosis. Patients received a total of 79 bridge therapies: SBRT (n = 24), TACE (n = 37), RFA (n = 9), and Y90 (n = 9). Complete response (CR) was 25% for TACE, 8.6% for SBRT, 22% for RFA, and 33% for Y90. Grade 3 or 4 acute toxicity occurred following TACE (n = 4) and RFA (n = 2). Transplant occurred at a median of 7.4 months after bridge therapy. Pathological response among 57 patients was 100% necrosis (n = 23, 40%), >50% necrosis (n = 20, 35%), <50% necrosis (n = 9, 16%), and no necrosis (n = 5, 9%). Pathologic complete response was as follows: SBRT (28.5%), TACE (41%), RFA (60%), Y90 (75%), and multiple modalities (33%). At a median follow-up of 35 months, 7 patients had recurrence after LT. DFS was 85.8% and overall survival was 79% at 5 years.ConclusionAll bridge therapies demonstrated good pathological response and DFS after LT. SBRT and Y90 demonstrated significantly less grade ≥3 acute toxicity. Choice of optimal modality depends on tumor size, pretreatment bilirubin level, Child-Pugh status, and patient preference. Such a decision is best made at a multidisciplinary tumor board as is done at our institution.

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Purpose: Deep tissue abscesses remain a serious cause of morbidity, mortality, and hospital stay despite development of percutaneous drainage and increasing use of perioperative antibiotics. The goal of this study was to examine the feasibility of methylene blue (MB) mediated photodynamic therapy (PDT) for treatment of infected abscesses with intracavity MB delivery, using computed tomography (CT) imaging data from a representative abscess patient population and Monte Carlo simulation of light delivery. Methods: This retrospective study included all adult subjects that received percutaneous abscess drainage between 1 January 2014 and 31 December 2014 at our institution whose abscess was confirmed by abdominal CT imaging less than 1 week preprocedure (n = 358). Of these, 40 subjects were further analyzed with Monte Carlo simulation. Abscess volumes were segmented from CT images, and imported into the Monte Carlo simulation space. Monte Carlo simulations were performed with a single fiber placement for each abscess, with the optical power at which a fluence rate of either 4 or 20 mW/cm 2 was achieved for 95% of the abscess wall recorded. Subjects for which a fluence rate of 4 mW/cm 2 was attainable in 95% of the abscess wall with a maximum input optical power of 2000 mW were considered eligible for MB-PDT. Results: 42.5% of subjects would have been eligible for MB-PDT, with 17.5% attaining the higher threshold of 20 mW/cm 2 in 95% of the abscess wall, given a 1% Intralipid concentration within the abscess cavity and the assumed abscess wall optical properties. The mean optical power necessary was 680 AE 580 mW for the 4 mW/cm 2 threshold, and 1100 AE 600 mW for the 20 mW/cm 2 threshold. Abscess surface area and threshold optical power were correlated (Spearman q = 0.73, P = 0.001), with larger abscesses requiring higher optical power. Of the subjects who were not eligible for MB-PDT, abscess volumes (150 AE 120 vs 62 AE 41 cm 3 , P = 0.0049) and surface areas (320 AE 200 vs 140 AE 70 cm 2 , P = 0.0015) tended to be larger than for those who were eligible. There were no significant differences in eligibility, optical power required, or abscess volume or surface area based on abscess location. For all eligible subjects, at the optical power necessary to achieve 4 mW/cm 2 in 95% of the abscess wall, 2.5 AE 3.7% (0%-13.2%) of the wall experienced a fluence rate greater than or equal to 400 mW/cm 2 . At the 20 mW/cm 2 threshold, 8.8 AE 11.4% (0%-31.1%) of the wall surpassed this 400 mW/cm 2 level. If subjects with greater than 5% of the wall exceeding 400 mW/cm 2 are treated as ineligible, overall eligibility becomes 32.5% for the 4 mW/cm 2 threshold and 10.0% for the 20 mW/cm 2 threshold. Conclusions: Assuming that the subjects analyzed were representative of the overall patient population, over 150 patients that received percutaneous abscess drainage during the study period would have been eligible for MB-PDT at the time of drainage, with smaller abscesses being more amenable for treatment. This technique could potent...