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Functional Popliteal Entrapment Syndrome (FPES) is caused by compression of neurovascular structures in the popliteal fossa by hypertrophic muscles, provoking severe leg pain with exercise. Treatment is limited to myotomy of hypertrophic musculature. 8 FPES patients underwent imaging and exercise studies, before receiving botulinum toxin A injections (BTX-A) into the gastrocnemius and plantaris muscles. 81.3 % of patients reported clinical improvement on follow-up, and pathological ankle–brachial indices were normalized. BTX-A injection may present a new, safe, effective and non-invasive approach to FPES.

PAVMs are usually congenital in origin, but may be acquired in various conditions, such as cirrhosis, trauma, mitral stenosis, and schistosomiasis.1 Although uncommon in the general population, they occur in 15-30% of individuals with hereditary haemorrhagic telangiectasia.1 Careful physical examination and family history taking is vital in patients diagnosed with incidental PAVMs. Progressive PAVM enlargement, paradoxical embolisation, and symptomatic hypoxaemia, especially in PAVMs with feeding arteries of 3 mm or greater require intervention (surgery for large or multiple PAVMs; embolisation for smaller solitary PAVM).4 Coil embolisation was preferred over surgical resection in our patient because it was less invasive and done because of the technical feasibility of selective catheterisation of the solitary feeding artery.

Introduction We report the largest series to date on the safety and efficacy of yttrium-90 (90Y) radioembolization for the treatment of unresectable, chemorefractory colorectal cancer liver metastases (CRCLM). Methods A total of 302 patients underwent resin-based 90Y radioembolization for unresectable, chemorefractory CRCLM between 2006 and 2013 in Sydney, Australia. All patients were followed up with imaging studies at regular intervals until death. Radiologic response was evaluated with the response criteria in solid tumors criteria. Clinical toxicities were prospectively recorded. Survival was calculated by the Kaplan–Meier method, and potential prognostic variables were identified on univariate and multivariate analysis. Results Median follow-up in the complete cohort was 7.2 months (range 0.2–72.8), and the median survival after 90Y radioembolization was 10.5 months with a 24-month survival of 21 %. On imaging follow-up of 293 patients who were followed up beyond 2 months, complete response to treatment was observed in 2 patients (1 %), partial response in 111 (38 %), stable disease in 96 (33 %), and progressive disease in 84 (29 %). Four factors were independently associated with a poorer prognosis: extensive tumor volume, number of previous lines of chemotherapy, poor radiological response to treatment, and low preoperative hemoglobin. One hundred fifteen (38 %) developed clinical toxicity after treatment; most complications were minor (grade I/II) and resolved without active intervention. Conclusions 90Y radioembolization is a safe and effective treatment for unresectable, chemorefractory CRCLM.

Introduction There are a paucity of data on the treatment of unresectable, chemoresistant breast cancer liver metastases (BRCLM) with yttrium-90 (Y90) radioembolization. Methods Forty patients underwent resin-based Y90 radioembolization for unresectable, chemoresistant BRCLM between 2006 and 2012 in a single institution. All patients were followed up with imaging studies at regular intervals as clinically indicated until death. Radiologic response was evaluated with the Response Criteria in Solid Tumors criteria. Clinical toxicities were prospectively recorded as per the National Cancer Institute Common Toxicity Criteria. Survival was calculated by the Kaplan–Meier method and potential prognostic variables were identified on univariate and multivariate analysis. Results Follow-up was complete in all patients. The median follow-up was 11.2 (range 0.6–30.5) months and the median survival after Y90 radioembolization was 13.6 months, with a 24-month survival of 39 %. On imaging follow-up of 38 patients who survived beyond 1 month of treatment, a complete response (CR) to treatment was observed in two patients (5 %), partial response (PR) in 10 patients (26 %), stable disease (SD) in 15 patients (39 %), and progressive disease (PD) in 11 patients (29 %). Two factors were associated with an improved survival on multivariate analysis: CR/PR to treatment (vs. SD vs. PD; p  < 0.001) and chemotherapy after radioembolization (vs. no chemotherapy; p  = 0.004). Sixteen patients (40 %) developed clinical toxicity after treatment; all complications were minor grade I/II and resolved without active intervention. Conclusion This study provides supportive evidence of the safety and efficacy on Y90 radioembolization for the treatment of unresectable, chemoresistant BRCLM. Further prospective investigation is required to assess the suitability of this treatment in this population.

Introduction The management of unresectable, chemorefractory colorectal cancer liver metastases (CRCLM) is a clinical dilemma. Yttrium-90 (Y90) radioembolization is a potentially safe and effective treatment for patients with CRCLM who have failed conventional chemotherapy regimens. Methods A systematic review of clinical studies before November 2012 was performed to examine the radiological response, overall survival and progression-free survival of patients who underwent Y90 radioembolization of unresectable CRCLM refractory to systemic therapy. The secondary objectives were to evaluate the safety profile of this treatment and identify prognostic factors for overall survival. Results Twenty studies comprising 979 patients were examined. Patients had failed a median of 3 lines of chemotherapy (range 2–5). After treatment, the average reported value of patients with complete radiological response, partial response and stable disease was 0 % (range 0–6 %), 31 % (range 0–73 %) and 40.5 % (range 17–76 %), respectively. The median time to intra-hepatic progression was 9 months (range 6–16). The median overall survival was 12 months (range 8.3–36). The overall acute toxicity rate ranged from 11 to 100 % (median 40.5 %). Most cases of acute toxicity were mild (Grade I or II) (median 39 %; range 7–100 %) which resolved without intervention. The number of previous lines of chemotherapy (≥3), poor radiological response to treatment, extra-hepatic disease and extensive liver disease (≥25 %) were the factors most commonly associated with poorer overall survival. Conclusion Y90 radioembolization is a safe and effective treatment of CRCLM in the salvage setting and should be more widely utilized.

Background There are no treatment options for unresectable intrahepatic cholangiocarcinoma (ICC) with proven efficacy. The objective of this study was to present data on the safety and efficacy of a novel treatment option, yttrium-90 ( 90 Y) radioembolization for unresectable ICC. Methods Twenty-five patients underwent resin-based 90 Y radioembolization for unresectable ICC between January 2004 and May 2009. Patients were assessed at 1 month and then at 3-month intervals after treatment. Radiologic response was evaluated with the Response Criteria in Solid Tumors (RECIST) criteria. Clinical and biochemical toxicities were prospectively recorded. Survival was calculated by the Kaplan-Meier method and potential prognostic variables were identified. Results No patient was lost to follow-up. The median follow-up was 8.1 (range, 0.4–56) months and the median survival after 90 Y radioembolization was 9.3 months. Two patients died within 1 month of treatment; the median follow-up for the remaining 23 was 8.9 (range, 1.5–56) months. Two factors were associated with an improved survival: peripheral tumor type (vs. infiltrative, P  = .004) and Eastern Cooperative Oncology Group performance status of 0 (vs. 1 and 2, P  < .001). On imaging follow-up of 23 patients, a partial response to treatment was observed in 6 patients (24%), stable disease in 11 patients (48%), and progressive disease in 5 patients (20%). The most common clinical toxicities were fatigue (64%) and self-limiting abdominal pain (40%). Two patients (8%) each developed grade III bilirubin and albumin toxicity. One patient (4%) developed grade III alkaline phosphatase toxicity. Conclusions 90 Y radioembolization may be a relatively safe and efficacious treatment for unresectable ICC. In the absence of other effective therapeutic options, this treatment warrants further investigation.

Background Reports show that selective internal radiation therapy (SIRT) may downsize inoperable liver tumors to resection or transplantation, or enable a bridge-to-transplant. A small-cohort study found that long-term survival in patients undergoing resection following SIRT appears possible but no robust studies on postsurgical safety outcomes exist. The Post-SIR-Spheres Surgery Study was an international, multicenter, retrospective study to assess safety outcomes of liver resection or transplantation following SIRT with yttrium-90 (Y-90) resin microspheres (SIR-Spheres ® ; Sirtex). Methods Data were captured retrospectively at participating SIRT centers, with Y-90 resin microspheres, surgery (resection or transplantation), and follow-up for all eligible patients. Primary endpoints were perioperative and 90-day postoperative morbidity and mortality. Standard statistical methods were used. Results The study included 100 patients [hepatocellular carcinoma: 49; metastatic colorectal cancer (mCRC): 30; cholangiocarcinoma, metastatic neuroendocrine tumor, other: 7 each]; 36% of patients had one or more lines of chemotherapy pre-SIRT. Sixty-three percent of patients had comorbidities, including hypertension (44%), diabetes (26%), and cardiopathy (16%). Post-SIRT, 71 patients were resected and 29 received a liver transplant. Grade 3+ peri/postoperative complications and any grade of liver failure were experienced by 24 and 7% of patients, respectively. Four patients died <90 days postsurgery; all were trisectionectomies (mCRC: 3; cholangiocarcinoma: 1) and typically had one or more previous chemotherapy lines and presurgical comorbidities. Conclusions In 100 patients undergoing liver surgery after receiving SIRT, mortality and complication rates appeared acceptable given the risk profile of the recruited patients.

Purpose To evaluate the role of radioembolization and systemic chemotherapy as a combined modality therapy for unresectable colorectal liver metastases. Patients and methods Prospective database of a major yttrium-90 microsphere radioembolization treatment center in Sydney, Australia, that included 140 patients with unresectable colorectal liver metastases was analyzed. Tumor response, overall survival, treatment-related complications and an evaluation of its role as a combined modality therapy with systemic chemotherapy were performed. Results One hundred and thirty-three patients (95%) had a single treatment, and seven patients (5%) had repeated treatments. Response following treatment was complete in two patients (1%), partial in 43 patients (31%), stable in 44 patients (31%), and 51 patients (37%) developed progressive disease. Combining chemotherapy with radioembolization was associated with a favorable treatment response ( P  = 0.007). The median overall survival was 9 (95% CI 6.4–11.3) months with a 1-, 2-, and 3-year survival rate of 42, 22, and 20%, respectively. Primary tumor site ( P  = 0.019), presence of extrahepatic disease ( P  = 0.033), and a favorable treatment response ( P  < 0.001) were identified as independent predictors for survival. Conclusion Combined modality therapy appears to improve tumor response rates. Survival is influenced by tumor site, presence of extrahepatic disease, and response to therapy. Yttrium-90 microsphere radioembolization is safe and may best be combined with systemic chemotherapy for patients with unresectable colorectal liver metastases.

The anatomy of the mesenteric system and the hepatic arterial bed has been demonstrated to have a high degree of variation. This is important when considering pre-surgical planning, catheterization, and trans-arterial hepatic therapies. Although anatomical variants have been well described, the characterization and understanding of regional hepatic perfusion in the context of radioembolization have not been studied with great depth. The purpose of this review is to provide a thorough discussion and detailed presentation of the angiographic and technical aspects of radioembolization. Normal vascular anatomy, commonly encountered variants, and factors involved in changes to regional perfusion in the presence of liver tumors are discussed. Furthermore, the principles described here apply to all liver-directed transarterial therapies.

The anatomy of the mesenteric system and the hepatic arterial bed has been demonstrated to have a high degree of variation. This is important when considering pre-surgical planning, catheterization, and trans-arterial hepatic therapies. Although anatomical variants have been well described, the characterization and understanding of regional hepatic perfusion in the context of radioembolization have not been studied with great depth. The purpose of this review is to provide a thorough discussion and detailed presentation of the angiographic and technical aspects of radioembolization. Normal vascular anatomy, commonly encountered variants, and factors involved in changes to regional perfusion in the presence of liver tumors are discussed. Furthermore, the principles described here apply to all liver-directed transarterial therapies.