Performing thermal ablations for hepatomas - is it a worthy skill for hepatologists?

INTRODUCTION AND OBJECTIVES: The role of hepatologists in the management of hepatocellular carcinoma (HCC) is not well defined. We conducted a cross-sectional study to assess the feasibility of hepatology-directed HCC treatment. PATIENTS: We evaluated 107 patients with newly diagnosed HCC, undergoing locoregional therapy as the first therapy between January 2017 and February 2019. RESULTS: The hepatologist directly participated in most of the microwave ablations. This descriptive cross-sectional study reveals the feasibility of the hepatologist-directed thermal ablation therapy, with decent outcome including response rate. CONCLUSIONS: Hepatologists can play a key role in the management of HCC in the current era of multidisciplinary team approach. Training fellows in performing ultrasound guided thermal ablation techniques would be one step forward in this direction.

Feasibility of Hepatology-Directed Microwave Ablation in Management of Hepatocellular Carcinoma in North America: A Pilot Project.

In North America, the role of Hepatologists in treatment of hepatocellular carcinoma is limited. We conducted a pilot project wherein a Hepatologist participated directly in microwave ablation of HCC at an academic center in the United States (n = 14). The pilot project shows promising outcomes, with complete remission rate of 93%.

Splenic artery steal syndrome after liver transplantation: A case series and review of literature.

Splenic steal syndrome (SASS) represents a challenge to interventional radiologists after orthotopic liver transplantation. In this case series, we present three cases of patients who developed SASS after their liver transplants.

Sequential Active Contour Based on Morphological-Driven Thresholding for Ultrasound Image Segmentation of Ascites.

Paracentesis is a high-demanding and routine operation, which has great potentials and benefits if semi-autonomous procedures can be developed. One of the most important techniques that facilitate semi-autonomous paracentesis is to segment the ascites from ultrasound images accurately and efficiently. The ascites, however, is usually with significantly different shapes and noise among different patients, and its shape/size changes dynamically during the paracentesis. This makes most of existing image segmentation methods either time consuming or inaccurate for segmenting ascites from its background. In this article, we propose a two-stage active contour method to facilitate accurate and efficient segmentation of ascites. First, a morphological-driven thresholding method is developed to locate the initial contour of the ascites automatically. Then, the identified initial contour is fed into a novel sequential active contour algorithm to segment the ascites from background accurately. The proposed method is tested and compared with state-of-the-art active contour methods on over 100 real ultrasound images of ascites, and the results show the superiority of our method in both accuracy and time efficiency.

Vidutolimod in Combination With Atezolizumab With and Without Radiation Therapy in Patients With Programmed Cell Death Protein 1 or Programmed Death-Ligand 1 Blockade-Resistant Advanced NSCLC.

Introduction: Vidutolimod, a CpG-A TLR9 agonist, was investigated in a phase 1b study (CMP-001-003; ClinicalTrials.gov, NCT03438318) in combination with atezolizumab with and without radiation therapy (RT) in patients with advanced NSCLC. Methods: Patients with progressive disease after anti-programmed cell death protein 1 or programmed death-ligand 1 therapy received either vidutolimod and atezolizumab (part A) or vidutolimod, atezolizumab, and RT (part B). The primary objective was to evaluate the safety of vidutolimod and atezolizumab with and without RT. Key secondary end point was best objective response rate per Response Evaluation Criteria in Solid Tumors, version 1.1. Results: Between March 28, 2018, and July 25, 2019, a total of 29 patients were enrolled and received at least one dose of vidutolimod (part A, n = 13; part B, n = 16). Intratumoral injections of vidutolimod were administered successfully, including injection of visceral lesions. The most common treatment-related adverse events (≥30%) were flu-like symptoms and hypotension. No objective responses were observed; 23.1% and 50.0% of the patients in parts A and B, respectively, had stable disease as best response. In parts A and B, 15.4% and 25.0% of the patients, respectively, had tumor shrinkage (<30% decrease in tumor size, nonirradiated). Enrollment was stopped owing to lack of objective responses. In the two patients with initial tumor shrinkage in part A, a strong serum induction of C-X-C motif chemokine ligand 10 was observed. Conclusions: Vidutolimod and atezolizumab with and without RT had a manageable safety profile, with minimal clinical activity in heavily pretreated patients with programmed cell death protein 1 or programmed death-ligand 1 blockade-resistant NSCLC.

Transarterial Radioembolization Agents: a Review of the Radionuclide Agents and the Carriers.

Liver tumors, both primary and secondary to metastatic disease, remain a major challenge, with an increasing incidence. In this context, taking advantage of the dual blood supply of the liver, and the fact that liver tumors derive majority of their blood supply from the hepatic artery, intraarterial therapies are gaining popularity. Intraarterial liver-directed therapy (IALDT) is the option when the surgery is not feasible due to the number of metastases or for other reasons. Transarterial radioembolization (TARE) is a specific type of IALDT, where a carrier particle/microsphere is labeled with a radioactive substance and then is injected into hepatic artery for therapeutic purposes. As this field is rapidly evolving, with multiple agents being investigated and being introduced into clinical practice, it is hard for the practitioners and researchers to encompass all the available information concisely. This article aims to present a comprehensive review of the prominent TARE technologies.

Venous thromboembolism in the setting of IVC calcification managed with pharmacomechanical thrombectomy and anticoagulation: A case report.

In this paper, we describe a case of an otherwise healthy 51 year old Caucasian male who presented with extensive venous thrombosis and a large retroperitoneal hepatoma without active bleeding. On imaging he was found to have focal calciifcation in the juxtarenal IVC and extensive thrombosis of the iliofemoral and femoropoliteal veins as well as the infrarenal IVC. Despite treating the patient with pharmacomechanical thrombectomy and anticoaguation, he passed away likely due to a new pulmonary embolism. According to the literature available to us, IVC calcification is a rare finding in adults and has been associated with an increased incidence of recurrent deep vein thrombosis and pulmonary embolism. While long term anticoagulation has been recommended for patients with recurrent venous thromboembolism (VTE), there is no expert consensus or societal guidelines for the treatment VTE in the setting of IVC calcification, specifically, regarding pharmacomechanical Vs. surgical thrombectomy [1]. Furthermore, no recommendations currently exist regarding whether expectant management Vs. prophylactic anticoagulation is appropriate. In conclusion, disease specific management guidelines by professional medical societies may be needed regarding the utility and appropriateness of pharmacomechanical thrombectomy Vs. surgical thrombectomy for symptomatic cases as well as expectant management Vs. prophylactic anticoagulation for asymptomatic cases in the setting of IVC calcification.

Outcomes of Microwave Ablation for Small Renal Masses: A Single Center Experience.

Purpose: To investigate the safety of microwave ablation (MWA) as an emerging technology for treating small renal masses. Materials and Methods: Patients with renal masses treated at a high-volume center with MWA between March 2015 and June 2019 were retrospectively identified. Safety, changes in renal function, primary treatment efficacy, and the natural history of imaging characteristics of masses postablation were examined. Results: Forty-five patients underwent MWA during the study period. Median age was 71 years (range 31-87). Median RENAL nephrometry score was 6 (range 4-9) with mean tumor size 2.6 ± 0.7 cm. Thirty-three percent of tumors were within 4 mm of the collecting system. Median total microwave energy applied was 400 W (range 105-2600 W). There was no significant change in creatinine (p = 0.21) or glomerular filtration rate (GFR) (p = 0.09) from preoperative to postoperative day 1 (POD#1) levels. There was a statistically but not clinically significant decrease in hemoglobin from preoperative to POD#1 levels (estimated -0.06 from 7 days before procedure to POD#1, p = 0.02). There was no durable change in creatinine (p = 0.16) or GFR (p = 0.72) at median follow-up of 7.5 months. There were 4 (9%) complications: three Clavien grade 1 and one Clavien grade 3 that led to loss of the kidney. Tumor size decreased postoperatively by an estimated -0.03 cm/month (range 0-1.9 cm, p < 0.01). Initial technical success was 100%. Primary treatment efficacy was 94%. Conclusion: MWA shows promise as an alternative thermal ablative technique with excellent short-term outcomes.

Thrombolytic Use in Management of Frostbite Injuries: Eight Year Retrospective Review at a Single Institution.

Frostbite injuries are uncommon, understudied, and lack standardized treatment protocols. Although thrombolytics are commonly used, their efficacy remains controversial. Herein, we report the results of a retrospective review of frostbite treatment practices at a single institution. The impact of thrombolytics on outcomes was evaluated. Medical records of frostbite patients admitted between January 2010 and April 2018 were reviewed. Demographics, injury details, treatment, and outcomes were collected. Descriptive statistics were obtained. A case-control analysis comparing patients who received tissue plasminogen activator (tPA) with those who did not was performed. A total of 102 patients were included. The mean age was 43 ± 17.7; 82.4% were male. About 13% of patients were presented with first-degree, 54% with second-degree, 29% with third-degree, and 5% with fourth-degree frostbite. Toes (69%), fingers (53%), and feet (43%) were most commonly affected. Thirteen patients had angiograms. Twelve patients received tPA: three systemic tPA and nine catheter-directed tPA. Overall, 32 patients (31%) required surgery and 27 (26.5%) patients required amputation with an average of 6.5 digits amputated. Digit salvage rate based on angiography was 84.7%. Length of stay (P = .046), number of operations (P = .037), and need for surgery (P = .030) were significantly lower for patients who received thrombolytics. Two patients had bleeding complications but did not require intervention or interruption of therapy. Despite its small sample size, our study suggests benefits from thrombolytic therapy. Prospective, well designed, and multi-institutional studies are warranted to establish evidence-based treatment guidelines for the management of frostbite injuries.

Beyond warfarin: The advent of new oral anticoagulants.

New oral anticoagulants (NOAC) are the latest addition to anticoagulant armamentarium. Unlike traditional anti-coagulants like warfarin, lab monitoring and management of bleeding complications secondary to these agents is different. As more and more patients are being switched to these drugs, interventional radiologists in particular will benefit from a clinical review of NOAC.

Catheter-based transarterial therapies for hepatocellular cancer.

As the prevalence of liver cancer increases, so does the demand for nonsurgical, minimally invasive alternatives to surgery, since many patients have tumors that cannot be surgically resected. Catheter-based hepatic arterial procedures may be an option in patients with primary and metastatic liver cancer. The authors describe four catheter-based hepatic arterial procedures and outline the management of potential complications during the immediate postprocedural period.

Endothelium and the lipid metabolism: the current understanding.

The endothelium is a dynamic organ and responds to various physical and humoral conditions. The endothelium secretes several biologically active substances, both vasoconstrictors and vasodilators, which control these processes. Endothelial function is most commonly assessed as the vasodilatory response to stimuli. Several endothelium-dependent agonists have been identified, each of which acts through a membrane receptor. Nitric oxide which is continuously synthesized by the endothelium has a wide range of biological properties that maintain vascular homeostasis. It is a potent vasodilator and inhibitor of platelet aggregation and thus has an important protective role. Endothelial dysfunction in hypercholesterolemic patients is in large part due to a reduced bioavailability of NO. Traditional coronary risk factors, especially hypercholesterolemia, produce endothelial dysfunction even in patients with normal blood vessels. The underlying mechanisms involve a local inflammatory response, release of cytokines and growth factors, activation of oxidation-sensitive mechanisms in the arterial wall, modulation of intracellular signaling pathways, increased oxidation of low-density lipoprotein cholesterol, and quenching of nitric oxide. Clinical studies have shown a significant improvement in endothelial dysfunction following lowering of serum cholesterol levels, infusion of nitric oxide donors like L-arginine and exercise training. Clinical trials are underway examining the role of endothelin-1 receptor antagonists like bosentan in the prevention of graft atherosclerosis.

Drug-eluting stents. A review of the current literature.

Coronary interventions have revolutionized the treatment of coronary artery disease (CAD). Stents, which were used initially for the complications arising from coronary angiography gradually, came to occupy a more prominent role in coronary interventions. However, restenosis remained a limiting factor from a therapeutic point of view. Recent development of drug-eluting stents is a step toward overcoming this problem. This development has elicited a great interest in both physician as well as patient communities. We have reviewed the available medical evidence regarding drug-eluting stents.

Predictive value of absent bone marrow iron stores in the clinical diagnosis of iron deficiency anemia.

The examination of Prussian-blue-stained bone marrow aspirates for the presence or absence of histiocytic iron granules has been considered the gold standard in evaluating iron-depeleted states. We performed this study to evaluate the predictive accuracy of absent stainable bone marrow iron for iron deficiency anemia (IDA). A retrospective study was performed on an unselected series of 53 consecutive bone marrow biopsy specimens. Only those patients who had totally depleted iron stores and who had iron studies done within 6 months of bone marrow biopsy were included in the study. Based on these criteria, 12 patients were found eligible. After complete evaluation to determine the cause of the patient's illness, the final diagnosis was IDA in only 6 patients (50%). There was no significant difference between the two groups as regards hemoglobin level, reticulocyte count, serum iron levels, total iron binding capacity, red blood cell mean corpuscular volume, ferritin and the transferrin saturation levels. The finding of absent bone marrow iron stores is not necessarily predictive of iron deficiency anemia. The finding of absent stores of iron in the bone marrow needs to be taken in conjunction with other laboratory findings and the clinical scenario while making a diagnosis of IDA, since certain other hematological diseases may co-exist.

A diagnostic dilemma of atypical gallbladder appearance on Tc-99m HIDA cholescintigraphy resolved with SPECT/CT.

Tc-99m HIDA cholescintigraphy is the diagnostic procedure of choice for acute cholecystitis. Acute cholecystitis is associated in vast majority of the cases with cystic duct obstruction. The demonstration of presence (cystic duct patency) or absence (cystic duct obstruction) of visualization of the gallbladder on cholescintigraphy is critical to the diagnosis of acute cholecystitis. The visualization of the gallbladder rules out acute cholecystitis in most of the cases. Although, in most cases, determination of visualization or nonvisualization of gallbladder is straight forward, occasionally it can be challenging. We describe a patient with suspected acute cholecystitis, in whom an unusual appearance of the gallbladder on hepatobiliary scintigraphy was clarified with SPECT/CT, an approach that is rarely used in Tc-99m HIDA cholescintigraphy.