The patients with unresectable perihilar cholangiocarcinoma require biliary drainage to relieve symptoms and allow for palliative systemic chemotherapy. The aim of this study was to establish the success, complication, and mortality rates of the initial biliary drainage in patients with unresectable perihilar cholangiocarcinoma at presentation. In this retrospective multicenter study, patients with unresectable perihilar cholangiocarcinoma who underwent initial endoscopic or percutaneous transhepatic biliary drainage between 2002 and 2014 were included. The success of drainage was defined as a successful biliary stent or drain placement, no unscheduled reintervention within 14 days, and serum bilirubin levels 50% decrease in serum bilirubin after 14 days. Severe complications, and 90-day mortality were recorded. Included were 186 patients: 161 (87%) underwent initial endoscopic biliary drainage and 25 (13%) underwent initial percutaneous transhepatic biliary drainage. The success of initial drainage was observed in 73 patients (45%) after endoscopic biliary drainage and 6 (24%) after percutaneous transhepatic biliary drainage. The reasons for an unsuccessful initial drainage were: the failure to place a drain or stent in 39 patients (21%), an unplanned reintervention within 14 days in 52 patients (28%), and the bilirubin level >50 μmol/L (or not halved) after 14 days of initial drainage in 16 patients (9%). Severe drainage-related complications occurred in 19 patients (12%) after endoscopic biliary drainage and in 3 (12%) after percutaneous transhepatic biliary drainage. Overall, 66 patients (36%) died within 90 days after initial biliary drainage. Initial biliary drainage in patients with unresectable perihilar cholangiocarcinoma had a success rate of 45% and a 90-day mortality rate of 36%. Future studies for patients with perihilar cholangiocarcinoma should focus on improving biliary drainage.

Background: In unresectable pCCA, the standard of care is palliative chemotherapy. We investigated the feasibility and safety of adding stereotactic body radiation therapy (SBRT) after chemotherapy. Methods: Patients with unresectable pCCA, stage T1-T4N0-N1M0, ECOG 0-1, having finished 6–8 cycles of cisplatin and gemcitabine without disease progression were eligible. SBRT was planned in 15 fractions of 3.0–4.5 Gy. The primary endpoints were feasibility (defined as completing SBRT as planned) and toxicity, evaluated within 3 months after SBRT (CTCAE v4.03). A conventional “3 + 3” design was used, corresponding to a sample size of 6 patients. Dose-limiting toxicity (DLT) was defined as grade ≥ 4 hepatobiliary or grade ≥ 3 gastrointestinal toxicity. The secondary endpoints, measured from the start of radiotherapy, were local control, progression-free survival, overall survival, and quality of life (QoL). ClinicalTrials.gov identifier: NCT03307538. Results: Six patients were enrolled between November 2017 and March 2020. SBRT was delivered as planned. All patients were treated with 60Gy (15 × 4.0Gy). No SBRT-related DLT was observed. The most common grade ≥ 3 toxicity was cholangitis (n = 5). The median follow-up was 14 months. The 12-month local control rate was 80%. We observed no substantial changes in QoL. Conclusion: In patients with unresectable pCCA with stable disease after palliative chemotherapy, adding SBRT is feasible and safe. The observed local control merits an additional evaluation of effectiveness.

Purpose: To evaluate NC-AMRI for the detection of HCC in high-risk patients. Methods: Patients who underwent yearly contrast-enhanced MRI (i.e., full MRI protocol) of the liver were included retrospectively. For all patients, the sequences that constitute the NC-AMRI protocol, namely diffusion-weighted imaging (DWI), T2-weighted (T2W) imaging with fat saturation, and T1-weighted (T1W) in-phase and opposed-phase imaging, were extracted, anonymized, and uploaded to a separate research server and reviewed independently by three radiologists with different levels of experience. Reader I and III held a mutual training session. Levels of suspicion of HCC per patient were compared and the sensitivity, specificity, and area under the curve (AUC) using the Mann–Whitney U test were calculated. The reference standard was a final diagnosis based on full liver MRI and clinical follow-up information. Results: Two-hundred-and-fifteen patients were included, 36 (16.7%) had HCC and 179 (83.3%) did not. The level of agreement between readers was reasonable to good and concordant with the level of expertise and participation in a mutual training session. Receiver operating characteristics (ROC) analysis showed relatively high AUC values (range 0.89–0.94). Double reading showed increased sensitivity of 97.2% and specificity of 87.2% compared with individual results (sensitivity 80.1%–91.7%–97.2%; specificity 91.1%–72.1%–82.1%). Only one HCC (2.8%) was missed by all readers. Conclusion: NC-AMRI presents a good potential surveillance imaging tool for the detection of HCC in high-risk patients. The best results are achieved with two observers after a mutual training session.

To evaluate if stereotactic body radiotherapy (SBRT) for hepatocellular carcinoma (HCC) has a durable effect on tumor control and can be delivered safely. Patients included in this retrospective study have been treated at our institution from January 2008 to December 2022. Eligibility criteria were diagnosis of HCC, BCLC stage 0-A-B, non-cirrhotic liver or liver with cirrhosis Child-Pugh class A, and a maximum of three lesions with a cumulative diameter of ≤ 6 cm. Patients with relapses after surgery, thermal ablation or TACE or patients awaiting transplant were also candidates for SBRT. SBRT was delivered in 6 fractions of 8 or 9 Gy. The primary endpoint was local (target) control (LC). Secondary endpoints were time to progression (TTP), overall survival (OS), response rate (RR) and toxicity. A total of 52 patients received SBRT at our institution and 51 were included in this study. One patient objected and was excluded. Median follow-up was 2.1 years for LC and 2.3 years for OS. Median tumor size was 26 mm. LC rates at 1, 2, and 5 years were 100 %, 95 % and 95 % respectively. Median TTP was 45.6 months. Median OS was 7.1 years. RR was 96 %. No patients in this study have experienced SBRT related CTC AE grade ≥ 3 toxicity. SBRT resulted in excellent long-term local control rates and absence of severe toxicity in a group of HCC patients. The reported outcomes compare favorably with other local therapies. SBRT should be considered as one of the available local treatment options for HCC.

Purpose: Accurate interpretation of CT scans after pancreatic resection is crucial for detecting abnormalities, including postoperative complications and cancer recurrence. This study investigates the feasibility and clinical utility of a novel MKNet-family deep learning architecture for auto-segmentation of the residual pancreas on postoperative CT imaging, in comparison to previous approaches. Method: Novel MKNet, MSKNet and MAKNet architectures were developed. Two datasets were used: the National Institutes of Health (NIH) dataset, comprising 82 annotated normal preoperative CT scans, and the IMPACT Consortium dataset (NCT06055010; https://github.com/IMPACTconsortium/IMPACT ), comprising 81 annotated postoperative CT scans obtained < 4 weeks after pancreatectomy. Performance was assessed by Hausdorff Distance (HD), 95th-percentile-HD (HD95) and Normalized Surface Distance (NSD), and secondarily by Dice Similarity Coefficient (DSC), and compared with self-implemented existing models for preoperative pancreas auto-segmentation. Qualitative evaluation was conducted by ten abdominal radiologists. Results: In the postoperative setting, the MAKNet architecture showed the best performance, with an HD and HD95 of 17.3 ± 11.2 mm and 11.5 ± 10.2 mm, respectively. DSC (64.9 ± 14.8%) and NSD (27.2 ± 8.2%) were comparable to the Attention-U-Net (DSC 66.0 ± 13.8%; NSD 27.8 ± 8.4%). Clinical evaluation indicated that the MKNet-family accurately defined the postoperative pancreas (i.e., requiring minimal or no modifications) in 64 of 81 segmentations (79%). Conclusion: This study demonstrates the effectiveness of novel MKNet-family architectures to accurately segment the residual pancreas on postoperative CT imaging over previous approaches. This advances the state-of-the-art in pancreas auto-segmentation and may be beneficial for medical application and education, acceleration of data annotation, and future research.

Photon-counting CT (PCCT) has several potential benefits that can considerably improve the radiotherapy workflow, like availability of intrinsic spectral data and high resolution imaging. It is unknown which treatment sites in radiotherapy will benefit the most from PCCT. This study aimed to identify clinical applications and treatment sites where PCCT may have the most clinical value. Semi-structured interviews with expert teams were conducted about eight treatment sites. Each expert team consisted of 2 radiation oncologists and 1 radiologist with expertise in specific treatment site. During each session, PCCT images were shown to demonstrate specific PCCT features: instantly changing the energy from 40 to 190 keV with a slider, iodine maps, contrast-agent removal and high-resolution images. Next, the experts scored ten statements about clinical applications for added clinical value on a 5-point Likert scale, from 0=No added clinical value to 4 = Indispensable for the clinic. A total of 80 scores were collected about ten statements and eight treatment sites. The statements about the use of spectral data scored highest for added clinical value, while reducing imaging dose scored lowest. The radiotherapy treatment sites with the highest scores were bone, head and neck and lung tumors, while lowest was prostate where no added value was found. Semi-structured interviews identified advantages of PCCT that may have the most added clinical value for radiotherapy: the use of spectral data and increased resolution. Head and neck, bone and lung tumors are the clinical applications which were scored highest in terms of added clinical value and these could therefore be the first areas for clinical implementation.