Research Priorities for Percutaneous Arteriovenous Fistula Creation in Patients with End-Stage Renal Disease: Proceedings and Recommendations from a Multidisciplinary Research Consensus Panel.

Recently developed endovascular techniques to create percutaneous arteriovenous fistulas are an alternative to surgical arteriovenous fistula creation, although there is currently a lack of high-level evidence regarding their creation, maturation, utilization, and long-term function. Recognizing this, the Society of Interventional Radiology Foundation sponsored a Research Consensus Panel and Summit for the prioritization of a research agenda to identify and address the gaps in current knowledge.

Evaluation of a three-session biliary dilation protocol following transplant-related biliary stricture in pediatric patients.

To evaluate whether a serial biliary dilation protocol improves outcomes and decreases total biliary drainage time for biliary strictures following pediatric liver transplantation. From 2006 to 2016, 213 orthotopic deceased and living related liver transplants were performed in 199 patients with a median patient age of 3.1 years at a single pediatric hospital. Patients with biliary strictures were managed by IR or surgically by the transplant team. Patients managed by IR were divided into two groups. The first group was managed with a standardized three-session protocol consisting of dilation every two weeks for three dilations. The second group was managed clinically with varying number and interval of dilations as determined by a multidisciplinary team. The location of biliary stricture, duration of drainage, number of balloon dilations, balloon diameter, time interval between dilations, and success of percutaneous treatment were recorded. Thirty-four patients developed biliary strictures. Thirty-one patients were managed with percutaneous intervention. Three strictures could not be crossed and were converted to operative management. Ten patients were managed in the three-session protocol, and 18 patients were managed in the clinically treated group. There was no significant difference in clinical success rates between groups, 80% and 61%, respectively. The three-session protocol group trended toward a lower total biliary drain indwell time (median 49 days) compared with the clinically treated group (median 89 days), P = .089. Our study suggests that a three-session dilation protocol following transplant-related biliary stricture may decrease total biliary drainage time for some patients.

Single-Institution Experience with Irreversible Electroporation for T4 Pancreatic Cancer: First 50 Patients.

BACKGROUND: Irreversible electroporation (IRE) for treatment of locally advanced pancreatic tumors is garnering increasing attention. This study was conducted to determine perioperative morbidity and mortality for locally advanced pancreatic cancer. METHODS: Prospective data of 50 consecutive patients receiving IRE for T4 lesions at a single tertiary center were analyzed. The primary end point was Clavien-Dindo complications at 90 days, and the secondary outcomes were survival and recurrence. RESULTS: A total of 50 patients underwent 53 IRE procedures for primary treatment (n = 29) or margin extension (n = 24), and 47 patients had adenocarcinoma. Six patients died within 90 days after the procedure (5 in the primary control group). Mortality occurred a median of 26 days (range, 8-42 days) after the procedure. Five patients in both the margin-extension and primary control groups experienced grade 3 or 4 morbidity (p = 0.739). The incidences of grades 3 to 5 complications did not differ significantly based on the adjustable parameters of IRE, tumor size, or primary treatment versus margin extension. After a median follow-up period of 8.69 months [interquartile range (IQR), 0.26-16.26 months], the median overall survival period for the primary control group was 7.71 months [95 % confidence interval (CI), 6.03-12.0 months) and was not reached in the margin-extension group (p = 0.01, log-rank). CONCLUSIONS: At the authors' center, the mortality rate after IRE was higher than reported in other series, with the majority occurring in the primary control group. Major morbidity trended around upper gastrointestinal bleeding, visceral ulcerations/perforations, and portal vein thromboses. This favors further investigation of the safety and efficacy of IRE.

Bland embolization versus chemoembolization of hepatocellular carcinoma before transplantation.

There is conflicting literature regarding the superiority of transarterial chemoembolization (TACE) versus bland transarterial embolization (TAE), and this has not been well studied before transplantation. Twenty-five TAE patients were matched in a 1:2 ratio with TACE patients by the initial radiographic tumor size and number in a retrospective, case-controlled study. The patients were otherwise treated according to the same protocols. The method of embolization was chosen on the basis of interventionalist practices at 2 sites within the program. Kaplan-Meier survival analyses at 1 and 3 years were the primary endpoints. There were no significant demographic differences between the groups. The mean adjusted Model for End-Stage Liver Disease scores at transplantation and waiting times were not significantly different between the TAE and TACE patients (MELD scores: 26 ± 3 versus 24 ± 3 points, P = 0.12; waiting times: 13 ± 8 versus 11 ± 10 months, P = 0.43). TAE patients (16%) were less likely than TACE patients (40%) to require 2 procedures (P = 0.04). Explant tumors were completely necrotic for 36% of the TAE patients and for 26% of the TACE patients. The 3-year overall survival rates were 78% for the TAE patients and 74% for the TACE patients (P = 0.66), and the 3-year recurrence-free survival rates were 72% for the TAE patients and 68% for the TACE patients (P = 0.67). On an intention-to-treat basis, there was no significant risk of wait-list dropout associated with TAE or TACE (P = 0.83). In conclusion, there were no significant differences in wait-list dropout or in overall or recurrence-free survival between HCC patients undergoing TAE and HCC patients undergoing TACE before transplantation.

Historical perspective: eponyms of vascular radiology.

Eponyms are ubiquitous throughout the medical literature, especially the radiology lexicon. In particular, vascular radiology is replete with dozens of eponyms named after pathologic and anatomic features and various medical devices. Several disease processes are known exclusively by their eponyms or by both their eponyms and their descriptive names. Although some authors advocate abandoning eponyms in favor of more descriptive terms, the established history and common use of eponyms make it unlikely that they will disappear from the vocabulary. Radiologists should be familiar with both the eponymous and descriptive names of disease processes to ensure effective communication and prevent erroneous identification. Study of these eponyms provides information about these disease processes and other medical knowledge for use in daily practice. In addition, biographic information about the pertinent physicians can yield insights into the sometimes surprising origins of these eponyms. The authors provide biographic sketches of these physicians and discuss the clinical relevance of the anatomic features, malformations, and syndromes that bear their names.

Retrospective cohort study of wrong-patient imaging order errors: how many reach the patient?

Studying near-miss errors is essential to preventing errors from reaching patients. When an error is committed, it may be intercepted (near-miss) or it will reach the patient; estimates of the proportion that reach the patient vary widely. To better understand this relationship, we conducted a retrospective cohort study using two objective measures to identify wrong-patient imaging order errors involving radiation, estimating the proportion of errors that are intercepted and those that reach the patient. This study was conducted at a large integrated healthcare system using data from 1 January to 31 December 2019. The study used two outcome measures of wrong-patient orders: (1) wrong-patient orders that led to misadministration of radiation reported to the New York Patient Occurrence Reporting and Tracking System (NYPORTS) (misadministration events); and (2) wrong-patient orders identified by the Wrong-Patient Retract-and-Reorder (RAR) measure, a measure identifying orders placed for a patient, retracted and rapidly reordered by the same clinician on a different patient (near-miss events). All imaging orders that involved radiation were extracted retrospectively from the healthcare system data warehouse. Among 293 039 total eligible orders, 151 were wrong-patient orders (3 misadministration events, 148 near-miss events), for an overall rate of 51.5 per 100 000 imaging orders involving radiation placed on the wrong patient. Of all wrong-patient imaging order errors, 2% reached the patient, translating to 50 near-miss events for every 1 error that reached the patient. This proportion provides a more accurate and reliable estimate and reinforces the utility of systematic measure of near-miss errors as an outcome for preventative interventions.

Consensus Guidelines of Irreversible Electroporation for Pancreatic Tumors: Protocol Standardization Using the Modified Delphi Technique.

Since no uniform treatment protocol for pancreatic irreversible electroporation (IRE) exists, the heterogeneity throughout literature complicates the comparison of results. To reach agreement among experts, a consensus study was performed. Eleven experts, recruited according to predefined criteria regarding previous IRE publications, participated anonymously in three rounds of questionnaires according to a modified Delphi technique. Consensus was defined as having reached ≥80% agreement. Response rates were 100, 64, and 64% in rounds 1 to 3, respectively; consensus was reached in 93%. Pancreatic IRE should be considered for stage III pancreatic cancer and inoperable recurrent disease after previous local treatment. Absolute contraindications are ventricular arrhythmias, implantable stimulation devices, congestive heart failure NYHA class 4, and severe ascites. The inter-electrode distance should be 10 to 20 mm and the exposure length should be 15 mm. After 10 test pulses, 90 treatment pulses of 1,500 V/cm should be delivered continuously, with a 90-µs pulse length. The first postprocedural contrast-enhanced computed tomography should take place 1 month post-IRE, and then every 3 months. This article provides expert recommendations regarding patient selection, procedure, and follow-up for IRE treatment in pancreatic malignancies through a modified Delphi consensus study. Future studies should define the maximum tumor diameter, response evaluation criteria, and the optimal number of preoperative FOLFIRINOX cycles.

Interventional radiology in the multidisciplinary management of liver lesions: pre- and postoperative roles.

The management algorithm for patents with liver lesions, most often hepatocellular carcinoma (HCC) or colorectal cancer metastasis, are complex, ever-changing, and involve multiple treatment modalities including chemotherapy, external-beam radiation, surgery, and locoregional therapies (LRTs). This complexity necessitates a multidisciplinary approach including hepatologists, oncologists, hepatobiliary surgeons, radiation oncologists, and interventional radiologists to coordinate and deliver the complex care that these patients need in a timely manner. The interventional radiologist and hepatobiliary surgeon work closely together in both the pre- and postoperative setting. Preoperative roles include delivering LRTs to patients with HCC and interventions aimed at hepatic optimization prior to resection or transplantation. LRT in this setting is performed either to bridge the patient to transplant or to downstage the initially nontransplant candidate so appropriate transplant criteria are met. Postoperative roles include the management of biliary and vascular complications that may occur after resection or transplantation.

Treatment of hepatocellular carcinoma combining sorafenib and transarterial locoregional therapy: state of the science.

The potential for increased efficacy with combined transarterial chemoembolization and sorafenib is a topic of increased interest to specialists who care for patients with unresectable hepatocellular carcinoma. There is strong scientific rationale for combination therapy: transarterial chemoembolization produces ischemia and stimulates hypoxia-inducible factor-1α, resulting in a local and systemic upregulation of vascular endothelial growth factor (VEGF), which can increase tumor angiogenesis. This upregulation can theoretically be counteracted with the multikinase inhibitor sorafenib, which is thought to act directly on platelet-derived growth factor, Raf kinase, and VEGF receptors. The potential of this approach has not yet been fully realized in clinical trials, and many unanswered questions remain. This review article discusses the state of the science of arterial locoregional therapies and sorafenib.

Minimally Invasive Treatment Options for Hepatic Uveal Melanoma Metastases.

Uveal melanoma is one of the most common primary intraocular malignancies that accounts for about 85% of all ocular melanomas. The pathophysiology of uveal melanoma is distinct from cutaneous melanoma and has separate tumor profiles. The management of uveal melanoma is largely dependent on the presence of metastases, which confers a poor prognosis with a one-year survival reaching only 15%. Although a better understanding of tumor biology has led to the development of novel pharmacologic agents, there is increasing demand for minimally invasive management of hepatic uveal melanoma metastases. Multiple studies have already summarized the systemic therapeutic options available for metastatic uveal melanoma. This review covers the current research for the most prevalent locoregional treatment options for metastatic uveal melanoma including percutaneous hepatic perfusion, immunoembolization, chemoembolization, thermal ablation, and radioembolization.

Anti-PD-1 immunotherapy with androgen deprivation therapy induces robust immune infiltration in metastatic castration-sensitive prostate cancer.

When compared to other malignancies, the tumor microenvironment (TME) of primary and castration-resistant prostate cancer (CRPC) is relatively devoid of immune infiltrates. While androgen deprivation therapy (ADT) induces a complex immune infiltrate in localized prostate cancer, the composition of the TME in metastatic castration-sensitive prostate cancer (mCSPC), and the effects of ADT and other treatments in this context are poorly understood. Here, we perform a comprehensive single-cell RNA sequencing (scRNA-seq) profiling of metastatic sites from patients participating in a phase 2 clinical trial (NCT03951831) that evaluated standard-of-care chemo-hormonal therapy combined with anti-PD-1 immunotherapy. We perform a longitudinal, protein activity-based analysis of TME subpopulations, revealing immune subpopulations conserved across multiple metastatic sites. We also observe dynamic changes in these immune subpopulations in response to treatment and a correlation with clinical outcomes. Our study uncovers a therapy-resistant, transcriptionally distinct tumor subpopulation that expands in cell number in treatment-refractory patients.

Single-center experience with elective transcatheter coil embolization of splenic artery aneurysms: technique and midterm follow-up.

PURPOSE: To review a single-center experience with elective coil embolization of splenic artery aneurysm (SAA) and analyze efficacy of the technique at midterm follow-up. MATERIALS AND METHODS: From 2002 through 2011, 50 patients (28 women, 22 men; age range, 24-89 y; mean age, 53.5 y ± 13.6) underwent transcatheter coil embolization for treatment of SAAs. Pseudoaneurysms and ruptured aneurysms were excluded. A total of 63 SAAs were treated (size, 13-97 mm; mean, 29 mm). Ninety-eight percent of aneurysms were treated with coils alone. Regular follow-up consisted of an office visit and imaging. Patient medical records were reviewed for aneurysm location, procedural approach, and technical and clinical outcomes. RESULTS: Ninety-eight percent of procedures were technically successful at thrombosing the aneurysm at the time of procedure. Repeat intervention was performed in four of 47 patients (9%) because of continued aneurysm perfusion at follow-up. Mean time to repeat intervention was 125 days (range, 42-245 d). All repeat interventions were technically successful. Neither aneurysm growth nor aneurysm rupture was observed in any patient during the follow-up period (mean, 78 weeks; range, 9 d to 7.1 y). There were no major adverse events. Major splenic infarction occurred in three of 33 patients (9%) with no underlying liver disease and normal splenic volume and in seven of 14 patients (50%) with portal hypertension. CONCLUSIONS: Percutaneous transcatheter coil embolization is a safe, effective, and minimally invasive treatment for SAAs as evidenced by high rates of technical success and freedom from aneurysm rupture.

The clinical impact of preoperative percutaneous drainage of abdominopelvic abscesses in patients with Crohn's disease.

PURPOSE: Although image-guided percutaneous drainage is increasingly being used to treat Crohn's disease-related abdominopelvic abscesses, surgery is seldom avoided. The aim of this study was to compare outcomes following the treatment of intra-abdominal Crohn's abscesses with percutaneous drainage followed by surgery to those after surgery alone. METHODS: We retrospectively reviewed the charts of patients treated for Crohn's-related abdominopelvic abscesses at Mount Sinai Medical Center between April 2001 and June 2010. Patients who underwent drainage followed by surgery were compared to those who underwent surgery alone. Differences in operative and postoperative outcomes were compared. RESULTS: Seventy patients with Crohn's disease-related abdominopelvic abscesses were identified, 38 (54%) of whom underwent drainage before surgery. Percutaneous drainage was technically successful in 92% of patients and clinically successful in 74% of patients. No differences in rate of septic complications (p = 0.14) or need for stoma creation (p = 0.78) were found. Patients who underwent percutaneous drainage had greater overall hospital lengths of stay (mean 15.8 versus 12.2 days, p = 0.007); 8.6% of patients had long-term postponement of surgery after percutaneous drainage. CONCLUSIONS: In our series, the treatment of Crohn's abscesses with percutaneous drainage prior to surgery did not decrease the rate of postoperative septic complications.

Recurrent intrahepatic pigmented stones after liver transplantation in a patient with hemoglobin SC disease: case report and review of the literature.

Patients with hemoglobinopathies may have hepatic involvement, which if severe, can lead to chronic liver disease and a need for liver transplant. Here, we present a case of a 16-yr-old female adolescent who presented to our center with hemoglobin SC disease, obstructive jaundice because of pigmented intrahepatic biliary stones, and progressive liver disease. She underwent a successful liver transplant but a few years later, she developed recurrent cholangitis and graft dysfunction because of recurrent intrahepatic biliary stones. Recurrent formation of intrahepatic stones after liver transplant is a rare and severe complication in patients with hemoglobinopathies. We recommend hypertransfusion therapy and surveillance imaging studies after liver transplant for early detection and prevention of this complication.

Gastroduodenal ulceration associated with radioembolization for the treatment of hepatic tumors: an institutional experience and review of the literature.

BACKGROUND: Microsphere radioembolization is a method of delivering radiation therapy directly to tumors, thereby minimizing toxicity to adjacent structures. Despite the relatively high precision of this modality, numerous adverse effects have been recognized. One particularly untoward complication is the development of severe gastroduodenal ulceration. METHODS: In order to further characterize gastroduodenal ulceration associated with radioembolization, our institutional experience as well as the reported literature were reviewed. RESULTS: The current evidence suggests that radioembolization-associated gastroduodenal ulceration results from inadvertent delivery of microspheres to the microvasculature of the gastrointestinal tract, leading to direct radiation toxicity. The reported incidence of this entity ranges between 2.9% and 4.8%. Most patients with this complication present with abdominal pain, often associated with nausea, vomiting, and anorexia. Symptoms can arise from hours to months after radioembolization treatment; diagnosis is made by endoscopic biopsy and histopathologic evaluation of the ulcer specimen. Radiation-induced ulcers have proven to be extremely difficult to treat. Current therapy based on acid suppression has had limited success, and the evidence for the addition of antioxidants and anti-inflammatory agents is still sparse. CONCLUSIONS: The increasing utilization of radioembolization will lead to adverse events including gastroduodenal ulceration. This entity must be considered in any patient treated with radioactive microspheres presenting with symptoms of dyspepsia. Accurate diagnosis and aggressive treatment are necessary to improve patient outcomes.

Student-Authored Autopsy Reports of Anatomical Donors: Their First Patients.

The preparation of student-authored autopsy reports of anatomical donors was added to the Gross Anatomy course to integrate the basic and clinical sciences and determine whether students considered this early clinical exposure to be a valuable experience. All donors were scanned using computerized tomography (CT) and student groups received the scan of their donor and a report written by a radiologist. As students dissected, they took photographs and biopsies of pathological findings that were processed for microscopic evaluation. Following consultation with pathologists and radiologists, each group prepared an autopsy report that proposed a cause of death supported with macroscopic, microscopic, and CT images. Cardiovascular events and cancer were the most common. Autopsy reports were evaluated by the faculty and each student group received feedback with respect to content, accuracy, and completeness and whether faculty agreed with students' proposed cause of death. A majority of students answering an anonymous survey indicated that this exercise was valuable or somewhat valuable, but did not agree that preparation of the autopsy report resulted in their being more engaged during the course. Students agreed or somewhat agreed that the exercise should be repeated next year, that they gained insight into the clinical manifestations of disease, that they were able to interpret the CT scan themselves, that meeting with a pathologist was interesting, and that the time required to prepare the report was adequate. Since autopsy reports prepared by students are feasible and students found it to be a valuable experience, we suggest that medical schools add this to Gross Anatomy courses to introduce clinical material and increase clinical relevance.

Practical Considerations Relating to Routine Clinical Biomarker Testing for Non-small Cell Lung Cancer: Focus on Testing for RET Fusions.

For patients with advanced non-small cell lung cancer, genomic profiling of tumors to identify potentially targetable alterations and thereby inform treatment selection is now part of standard care. While molecular analyses are primarily focused on actionable biomarkers associated with regulatory agency-approved therapies, there are a number of emerging biomarkers linked to investigational agents in advanced stages of clinical development will become approved agents. A particularly timely example is the reported data and US Food and Drug Administration approval of highly specific small molecule inhibitors of the proto-oncogene tyrosine-protein kinase receptor RET indicate that testing for tumor RET gene fusions in patients with NSCLC has become clinically important. As the number of biomarkers to be tested in NSCLC grows, it becomes increasingly important to optimize and prioritize the use of biopsy tissue, in order to both continue to allow accurate histopathological diagnosis and also to support concurrent genomic profiling to identify perhaps relatively uncommon genetic events. In order to provide practical expert consensus guidance to optimize processes facilitating genomic testing in NSCLC and to overcome barriers to access and implementation, a multidisciplinary advisory board was held in New York, on January 30, 2019. The panel comprised physicians involved in sample procurement (interventional radiologists and a thoracic surgeon), surgical pathologists specializing in the lung, molecular pathologists, and thoracic oncologists. Particular consideration was given to the key barriers faced by these experts in establishing institutional genomic screening programs for NSCLC. Potential solutions have been devised in the form of consensus opinions that might be used to help resolve such issues.

Radiologic monitoring of hepatocellular carcinoma tumor viability after transhepatic arterial chemoembolization: estimating the accuracy of contrast-enhanced cross-sectional imaging with histopathologic correlation.

PURPOSE: Cross-sectional diagnostic imaging studies such as contrast-enhanced quadruple-phase helical computed tomography (CT) and contrast-enhanced magnetic resonance (MR) imaging are routinely performed to evaluate tumor response to transhepatic arterial chemoembolization. However, the true correlation between imaging characteristics and histopathologic tumor viability is not known. The aim of the present retrospective study was to determine the sensitivity and specificity of contrast-enhanced CT and contrast-enhanced MR imaging with use of histopathologic analysis. MATERIALS AND METHODS: Between February 2002 and October 2005, a total of 31 patients (age, 51-74 years; mean, 60 y) who had undergone chemoembolization underwent follow-up diagnostic cross-sectional imaging before transplantation. The mean time interval between the imaging study and transplantation was 32 days (range, 1-117 d). Imaging studies were assessed for residual or recurrent tumor and were then correlated to the findings of histopathologic analysis performed on the surgical specimens at the time of transplantation. RESULTS: The overall sensitivity and specificity rates of cross-sectional imaging studies were 35% and 64%, respectively. The overall accuracy rate of CT was 43%, with 36% sensitivity and 57% specificity. The overall accuracy rate of MR imaging was 55%, with 43% sensitivity and 75% specificity. Gross macroscopic disease was missed in one patient (9%) who underwent MR imaging and four patients (19%) who underwent CT. CONCLUSIONS: Contrast-enhanced CT and MR imaging after chemoembolization are associated with high error rates. Between the two modalities, MR has higher sensitivity and specificity and may be a preferable imaging tool for patients who have undergone chemoembolization.

Efficacy and safety of partial splenic embolization for hypersplenism in pre- and post-liver transplant patients: A 16-year comparative analysis.

PURPOSE: To report the effect of partial splenic embolization (PSE) on hematological indices and the procedure's safety in pre- and post-liver transplant (LT) patients. MATERIALS AND METHODS: A single-center retrospective study evaluating all patients who underwent PSE over a 16-year period was performed. Inclusion criteria were splenomegaly confirmed by imaging and at least one of the following cytopenias: hemoglobin ≤10 g/dL, WBC count ≤1500 µL-1, or platelet count ≤100,000 µL-1. 38 of 102 patients (37%) met criteria (24 pre- and 14 post-LT) for a total of 40 PSEs. RESULTS: No effect was seen on median hemoglobin beyond 2 weeks post-PSE. There was a significant and sustained increase in median WBC counts (from 3400 µL-1 to 5400 µL-1 at 2 years) and platelet count (from 65,000 µL-1 to 117,000 µL-1 at 3.5 years). In 6 out of 40 PSEs (15%) a major complication occurred which included pleural effusion, ascites, spontaneous bacterial peritonitis, pneumonia, and inferior vena cava thrombus. Similar efficacy was observed in pre- and post-LT cohorts, with a trend toward higher complication rate in pre-LT patients. CONCLUSIONS: PSE is efficacious in increasing WBC count out to 2 years and platelet count out to 3.5 years in patients with hypersplenism. Efficacy and safety appeared independent of pre- or post-LT status. The intervention is associated with major complications and special care should be taken when selecting patients for PSE.

Combined transarterial chemoembolization and radiofrequency ablation for hepatocellular carcinoma.

Transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) are both efficacious in treating well-selected patients who have hepatocellular carcinoma (HCC). The sequential combination of these two modalities has a sound theoretical basis and raises the probability of complete local response in tumors that are beyond the size at which the likelihood of failure with RFA alone begins to rise. Cheng et al. have found that when limited to patients with well-compensated liver disease, combined TACE and RFA does not seem to dramatically increase the risk of complications beyond the risk levels associated with the individual procedures. The survival benefit demonstrated in this recent article is, however, an artifact of a rigid study design that did not allow rational selection of treatment on the basis of individual patient and tumor characteristics. This study bolsters the evidence that the combination of TACE with RFA enhances local response, strengthening the status of nonsurgical treatment compared with resection for the treatment of early HCC.