Predictive Dosimetry and Outcomes of Hepatocellular Carcinoma Treated by Yttrium-90 Resin Microsphere Radioembolization: A Retrospective Analysis Using Technetium-99m Macroaggregated Albumin SPECT/CT and Planning Software.

PURPOSE: To characterize estimated mean absorbed tumor dose (ADT), objective response (OR), and estimated target dose of hepatocellular carcinoma (HCC) after resin microsphere yttrium-90 (90Y) radioembolization using partition dosimetry. MATERIALS AND METHODS: In this retrospective, single-center study, multicompartment dosimetry of index tumors receiving 90Y radioembolization between October 2015 and June 2022 was performed using a commercial software package and pretreatment technetium-99m macroaggregated albumin single photon emission computed tomography (SPECT)/computed tomography (CT). In total, 101 patients with HCC underwent 102 treatments of 127 index tumors. Patients underwent imaging every 2-3 months after treatment to determine best response per modified Response Evaluation Criteria in Solid Tumors (mRECIST). Best response was defined as the greatest response category per mRECIST and categorized as OR or nonresponse (NR). A Cox proportional hazards model evaluated the probability of tumor OR and progression-free survival using ADT. RESULTS: The median follow-up period was 148 days (interquartile range [IQR], 92-273 days). The median ADT of OR was 141.9 Gy (IQR, 89.4-215.8 Gy) compared with the median ADT of NR treatments of 70.8 Gy (IQR, 42.0-135.3 Gy; P < .001). Only ADT was predictive of response (hazard ratio = 2.79 [95% confidence interval {CI}: 1.44-5.40]; P = .003). At 6 months, an ADT of 157 Gy predicted 90.0% (95% CI: 41.3%-98.3%) probability of OR. At 1 year, an ADT of 157 Gy predicted 91.6% (95% CI: 78.3%-100%) probability of progression-free survival. Partition modeling and delivered activity were predictive of progression (P = .021 and P = .003, respectively). CONCLUSIONS: For HCC treated with resin microspheres, tumors receiving higher ADT exhibited higher rates of OR. An ADT of 157 Gy predicted 90.0% OR at 6 months.

Boosted-Dose Yttrium-90 Radiation Segmentectomy or Lobectomy for Hepatocellular Carcinoma Refractory to Prior Transarterial Embolization or Chemoembolization: A Single Institution Retrospective Case Series.

PURPOSE: To assess the tumor response rates and liver toxicity of boosted-dose transarterial radioembolization (TARE) for treatment of hepatocellular carcinoma (HCC) refractory to previous transarterial embolization (TAE) and/or chemoembolization (TACE). MATERIALS AND METHODS: All patients were identified who had HCC treated between 2017 and 2020 that had been refractory to prior TAE or TACE, then treated with boosted-dose segmental or lobar TARE. Tumor response was assessed by multiphasic CT or MRI using localized mRECIST imaging criteria and serological alpha-fetoprotein levels at three and six months after TARE, if available. Liver toxicity was evaluated using serial serological liver function tests, platelet counts, and clinical Child-Pugh and MELD scores. RESULTS: Twenty-four patients met inclusion criteria. Mean age was 68.7 years (54-89); 8 were females. Three (12.5%) patients had Barcelona Clinical Liver Cancer stage A, 4 (16.7%) stage B, and 17 (70.8%) stage C disease. Three months after TARE, 52% of patients had a complete response and 33% had a partial response. Mean AFP decreased from 33.2 ng/mL at baseline to 17 ng/mL at 3 months (p = 0.782). The median MELD-Na score increased from 11 at baseline to 16 at 6 months post-TARE (p = 0.044); the mean Child-Pugh score rose from 5 at baseline to 6 at 3 months post-TARE (p < 0.01). CONCLUSION: Boosted-dose TARE resulted in statistically significant favorable tumor responses by imaging criteria in 85% of patients previously refractory to TAE or TACE. TARE resulted in transient but acceptable deterioration of liver function and clinical scores.

Percutaneous application of fibrin sealant in surgically recalcitrant urinomas following oncocytoma resection.

Surgical application of fibrin sealant is well established as a hemostatic agent. However, reports of its percutaneous application and its uses within the urinary tract are limited. Presented below are two patients with recalcitrant urinomas despite diversion therapy following partial nephrectomy for oncocytomas. Both patients were successfully treated with percutaneous application of fibrin sealant via a sheath at the time of percutaneous perinephric drain removal. Follow-up imaging demonstrated resolution of the urinomas with stabilization of creatinine. Percutaneous application of fibrin sealant may be considered as an alternative treatment for recalcitrant urinomas prior to surgical intervention, though more studies are required to confirm its effectiveness and safety.

Subcapsular hematoma resulting in hepatic ischemia as a complication of necrotizing pancreatitis.

This report presents a case of necrotizing pancreatitis resulting in a large hepatic subcapsular hematoma that led to development of hepatic ischemia and early stages of liver failure. Following surgical decompression, liver function dramatically improved, but large areas of peripheral hepatic infarction had developed. This case demonstrates the risks of a rapidly expanding hepatic subcapsular hematoma, emphasizes the importance of recognizing and aggressively treating active bleeding, and cautions against administering anticoagulation and tissue-plasminogen activator in this clinical scenario.

Survey of Intern Year Experiences for Those Going into Interventional Radiology: Comparing Surgery, Medicine and Transitional Year Internships.

SURGERY, INTERNAL MEDICINE, OR TRANSITION YEAR FOR INTERNS GOING INTO INTERVENTIONAL RADIOLOGY: Comparison of intern year specialty in regards to preparation for interventional radiology (IR) with results and analysis of the resident, fellow, and student (RFS) survey of trainees. PURPOSE: Evaluate trainee experiences regarding internship variables with respect to IR preparedness. MATERIALS: A questionnaire created by members of the Society of Interventional Radiology (SIR) RFS IR Residency Training Committee was distributed to RFS members at SIR 2017 conference and via an online survey. The anonymous survey consisted of Likert scale, dichotomous questions, and free response questions. Results were analyzed utilizing a one-way analysis of variance (ANOVA), calculation of mean, standard deviation (SD) and 95% confidence interval (CI). RESULTS: A total of 112 residents completed the survey (47 Surgery, 33 Medicine, 29 Transitional Year [TY]), and 3 nontraditional internships categorized as other (2 Pediatric, and 1 Neurosurgery). The average procedures performed as intern were; Surgery: 51-75, Medicine: 0-25, TY: 25-50, Other: 25-50. Trainees who completed a surgical internship reported an overall higher comfort level with procedures (Mean: 4.23, SD: 0.81, CI: 0.21, p < 0.00001) compared to medicine interns (2.84, SD: 1.42, CI: 0.48), and TY interns (3.03, SD: 1.48, CI: 0.55). There was no statistical difference between subgroups when comparing; months of night float, maximum consecutive hours worked, ancillary work, etc. Preliminary surgery residents reported a higher quality preparation for IR in their programs (4.3, SD: 0.93, CI: 0.27, p < 0.01) in comparison to Medicine (3.4, SD: 1.1, CI: 0.4), and TY residents (3.6, SD: 1.2, CI: 0.46). Ninety-four percent of surgery residents would choose to repeat a surgery internship. TY residents were next likely to choose the same type of internship at 83%, while the remaining 17% would choose to do surgery year. Medicine residents were least likely to choose medicine again, 23/33 (70%). Surgery, TY, and then medicine residents would choose the same program again (83%, 79%, 75%, respectively). CONCLUSION: In alignment with SIR recommendations, the general consensus of trainees surveyed support that a preliminary surgery internship provides the greatest preparation for IR training. Surgical internships provided the greatest opportunity to perform procedures, corresponding with greater comfort levels, and self-reported better preparedness for future training in IR.

Characterization of intramuscular calf vein thrombosis on routine knee MRI.

OBJECTIVE: Literature regarding intramuscular calf vein thrombosis (IMCVT) or infrapopliteal deep vein thrombosis (DVT) evaluation by magnetic resonance imaging (MRI) is limited, particularly with regard to routine unenhanced knee examinations. We attempt to correlate routine unenhanced MRI findings with ultrasound evaluations of the lower extremity deep venous system. MATERIALS AND METHODS: The radiology information system was searched, yielding a total of 67 patients who had undergone both routine knee MRI and duplex ultrasound examinations within 14 days. The MRI examination findings recorded were the presence and pattern of edema, segmental vein dilation, intraluminal signal on fluid-sensitive sequences, and abnormal hyperintense signal on axial T1-weighted sequences. The presence and extent of thrombus more centrally (i.e., intramuscular calf vein thrombosis with or without extension into the popliteal vein) was reassessed on ultrasound. RESULTS: When comparing patients with positive (n = 13) and negative (n = 54) ultrasound, there were significant differences in each of these parameters: perivascular edema, intramuscular edema, focal vein dilation, and abnormal fluid-sensitive signal. In the subset of patients with popliteal extension of the intramuscular calf vein thrombosis compared with those without any deep vein thrombosis, there was a statistically significant increase in peripopliteal edema, abnormal fluid-sensitive signal, and abnormal hyperintense T1 signal. CONCLUSION: Imaging findings on routine unenhanced MRI have a high rate of concordance with duplex ultrasound performed through the calf in the detection of intramuscular calf vein thrombosis.

Ultrasound-guided percutaneous periarterial thrombin injection for paracentesis-related hemoperitoneum.

Paracentesis is a common procedure used in the diagnostic evaluation of peritoneal fluid as well as the therapeutic removal of high-volume ascites. Although generally regarded as a safe procedure, complications may arise from arterial injury, including hematomas and pseudoaneurysms. Transcatheter embolization and surgery are first-line interventions for injuries refractory to conservative management. We present a case where a patient failed conventional therapies for hemoperitoneum following a paracentesis which resolved after thrombin injection into the subcutaneous tissues, a novel use for thrombin. Using a linear 12-3 MHz transducer, approximately 3000-3500 U of thrombin was injected through connecting tubing and a 25-gauge needle by the interventional radiologist into the subcutaneous tissues around the origin of the arterial hemorrhage. The bleeding ceased and the patient's hemoglobin and hemodynamics stabilized.

Liver-directed therapy for hepatocellular carcinoma.

Liver-directed therapy is a critical component of treatment strategies for hepatocellular carcinoma. These therapies included percutaneous image-guided ablation, transarterial chemoembolization, and transarterial radioembolization, and are administered by interventional radiologists. Depending on the stage of disease, a particular treatment modality, or a combination thereof, is expected to be most efficacious in achieving the goals of treatment for a particular patient. This article seeks to review the various liver-directed treatment modalities for treatment of hepatocellular carcinoma, with attention to their efficacy and patient selection criteria.

Fast-Track Registration: A Way to Increase Efficiency in the IR Division.

PURPOSE: To evaluate changes in patient registration process at an academic 2-suite IR Division to determine if moving registration from the waiting room to the vascular holding area decreased amount of time patients spent in the Radiology Department and improved start times. MATERIALS AND METHODS: A data collection sheet was created by evaluating patient-related processes; event timestamps were recorded on the sheet. The control group consisted of 33 patients who registered using the traditional process. The fast-track group consisted of 29 patients who bypassed the traditional registration procedure and were registered by nurses in the vascular holding area. RESULTS: Total time between control and fast-track groups significantly decreased from an average time of 215 minutes to 178 minutes (P = .020). The average start time improved significantly from an average of 63 minutes after scheduled procedure start time for the control group to 33 minutes after the scheduled procedure start time for the fast-track group (P = .009). Start time (P = .022), time spent in recovery area (P = .006), and total time, after correcting for differences in laboratory test turnaround time, (P = .010) decreased in variability after implementation of fast-track registration. CONCLUSIONS: Implementing fast-track registration for outpatient subcutaneous port placement in the IR Division improved start times and decreased total time patients spent in the hospital, while also reducing variability in the process.

Continuous Postoperative Antibiotic Irrigation via Catheter System Following Immediate Breast Reconstruction.

Breast reconstruction with implantable devices is now the most common type of technique utilized following mastectomy. Because infections are one of the most common complications for the procedure and currently no one method has been proven to stand above the rest, we designed and implemented a novel technique that employed 24 hours continuous triple-antibiotic irrigation via a catheter-based system. From August 2009 to March 2012, 79 patients underwent tissue expander-based reconstruction from a single plastic surgeon. Forty-five consecutive patients underwent breast reconstructive surgery with implant-based reconstruction alone; the remaining 34 patients underwent breast reconstructive surgery with tissue expansion and closed continuous postoperative antibiotic irrigation. Incidences of infection, seroma, hematoma, and premature explantation were recorded. Both the rate of premature explant (20% vs 2.9%; P = 0.037) and surgical site infections (22.2% vs 5.8%, P = 0.060) decreased. Twenty-four hour continuous antibiotic irrigation is a useful adjunct to tissue expander breast reconstruction.

Scattering calculation and image reconstruction using elevation-focused beams.

Pressure scattered by cylindrical and spherical objects with elevation-focused illumination and reception has been analytically calculated, and corresponding cross sections have been reconstructed with a two-dimensional algorithm. Elevation focusing was used to elucidate constraints on quantitative imaging of three-dimensional objects with two-dimensional algorithms. Focused illumination and reception are represented by angular spectra of plane waves that were efficiently computed using a Fourier interpolation method to maintain the same angles for all temporal frequencies. Reconstructions were formed using an eigenfunction method with multiple frequencies, phase compensation, and iteration. The results show that the scattered pressure reduces to a two-dimensional expression, and two-dimensional algorithms are applicable when the region of a three-dimensional object within an elevation-focused beam is approximately constant in elevation. The results also show that energy scattered out of the reception aperture by objects contained within the focused beam can result in the reconstructed values of attenuation slope being greater than true values at the boundary of the object. Reconstructed sound speed images, however, appear to be relatively unaffected by the loss in scattered energy. The broad conclusion that can be drawn from these results is that two-dimensional reconstructions require compensation to account for uncaptured three-dimensional scattering.