Bronchial artery embolization using small particles is safe and effective: a single center 12-year experience.

BACKGROUND: Bronchial artery embolization (BAE) using particles is an established treatment for hemoptysis. The use of polyvinyl alcohol (PVA) with a particle size of 300 µm or larger is thought to reduce the risk of non-target embolization but may result in more proximal vessel occlusion than is ideal, resulting in a high rate of early recurrent hemorrhage. OBJECTIVE: This study evaluates the safety and efficacy of BAE using PVA particles with a size of less than 300 µm. METHODS: All patients who underwent BAE between 2010 and 2022 at a tertiary center were included. Demographic data, etiology and volume of hemoptysis, technical and clinical success, procedure-related complications, and follow-up information were collected from patients' electronic records. 150-250 µm PVA particles were used to commence embolization in all patients with the subsequent use of larger-sized particles in some individuals. The Kaplan-Meier method was used to estimate recurrence and survival rates. RESULTS: One hundred forty-four patients underwent 189 embolization procedures between 2010 and 2022 and were followed up for a median of 35 months [IQR 19-89]. 150 µm to 250 µm PVA particles were used as the sole embolic agent in 137 cases. Hemoptysis recurred within 30 days in 7%. The median time to repeat intervention was 144 days [IQR 42-441]. Seventeen out of 144 patients had a pulmonary artery branch pseudoaneurysm. The rate of major complications was 1% with no instances of stroke or spinal artery ischemia. Thirty-day mortality was 2% (4/189). CONCLUSION: BAE using 150-250 µm PVA particles is safe and effective with few complications and low rates of early hemoptysis recurrence. CLINICAL RELEVANCE STATEMENT: BAE using small particles is likely to improve outcomes, particularly the rate of early recurrence, in patients with hemoptysis, without an increase in procedural complications. KEY POINTS: BAE is a safe and effective treatment for patients with hemoptysis. Using small PVA particles in BAE has few complications and low rates of early recurrence. Pulmonary artery pseudoaneurysms should be actively sought in those with hemoptysis undergoing BAE.

Pulmonary arteriovenous malformations may be the only clinical criterion present in genetically confirmed hereditary haemorrhagic telangiectasia.

Pulmonary arteriovenous malformations (PAVMs) result in preventable complications demanding specialty care. Underlying hereditary haemorrhagic telangiectasia (HHT) can be identified by genetic testing, if the diagnosis is considered. Retrospectively reviewing 152 unrelated adults with genetically confirmed HHT due to ACVRL1, ENG or SMAD4, we found that only 104/152 (68%) met a clinical diagnosis of HHT with three Curaçao criteria. The genetic diagnostic rate was similar for patients with three (104/137, 76%) or one to two (48/71, 68%; p=0.25) criteria. Of 83 unrelated probands with PAVM(s) and genetically-confirmed HHT, 20/83 (24%) had few, if any, features of HHT. Enhanced clinical suspicion, as well as HHT genetic testing, is recommended if one or more PAVMs are present.

Contemporary Multimodality Imaging of Primary Hyperparathyroidism.

Primary hyperparathyroidism (PHPT) is a disorder characterized by hypercalcemia and an elevated or inappropriately normal parathyroid hormone level. Classic features include bone pain, fractures, renal impairment, nephrolithiasis, and mental disturbance. However, most cases of PHPT are now asymptomatic at diagnosis or associated with nonspecific neurocognitive changes. The most frequent cause of PHPT is a solitary adenoma that secretes parathyroid hormone without the normal suppressive effect of serum calcium. A smaller number of cases can be attributed to multigland disease. Parathyroidectomy is curative and is considered for nearly all affected patients. Although PHPT is primarily a clinical and biochemical diagnosis, imaging is key to the localization of adenomas, which can lie in conventional locations adjacent to the thyroid gland or less commonly at ectopic sites in the neck and mediastinum. In addition, accurate localization facilitates the use of a minimally invasive or targeted surgical approach. Frequently used localization techniques include US, parathyroid scintigraphy, and four-dimensional CT. Second- and third-line modalities such as MRI, PET/CT, and selective venous sampling with or without parathyroid arteriography can increase confidence before surgery. These localization techniques, along with the associated technical aspects, relative advantages, and drawbacks, are described. Local expertise, patient factors, and surgeon preference are important considerations when determining the type and sequence of investigation. A multimodality approach is ultimately desirable, particularly in challenging scenarios such as multigland disease, localization of ectopic adenomas, and persistent or recurrent PHPT. Online supplemental material is available for this article. ©RSNA, 2022.

A combination of surgery, theranostics, and liquid biopsy - a personalised oncologic approach to treatment of patients with advanced metastatic neuroendocrine neoplasms.

Rationale: Neuroendocrine neoplasia (NEN) of small bowel (SBNEN) frequently present with metastatic disease. Theranostics (molecular imaging followed by targeting therapy) allow for personalised medicine. Liquid biopsies enable precise identification of residual disease and real-time monitoring of therapeutic response. Our aim was to determine the clinical utility of a combination of surgery, theranostics, and a multigene blood measurement in metastasised SBNEN. Methods: Inclusion criteria were SBNEN, G1/G2 NEN, initial tumour diagnosis, stage IV NEN, positivity on 68Ga somatostatin analogue PET/CT, eligible for surgery, and 177Lu peptide receptor radionuclide therapy (PRRT). Blood samples for NETest were collected longitudinally. Progression-free survival (PFS) and overall survival (OS) were calculated. NETest results were assessed prior to surgery and during clinical follow-up. Results: A surgical cohort of 39 SBNEN patients met eligibility criteria. Thirty-two patients underwent ileal resection and 7 right hemicolectomy. The mean number of 177Lu PRRT cycles was 4. Mortality was nil. Surgical morbidity was 10.3%. Transient grade 1/2 toxicity occurred in 41% (PRRT). NETest scores (n=9 patients) decreased in 100% following treatment and correlated with diminished tumour volume and disease stabilization following surgery and PRRT. Median follow-up: 78 months. Median PFS and OS: 42.7 and 110 months, respectively. Progression-free survival at 1-, 3-, and 5-years was 79.4%, 57.1% and 40.5%, respectively. Overall survival at 1-, 3-, and 5-years was 97.4%, 97.4%, and 94.1%, respectively. Conclusions: Surgery combined with 177Lu PRRT is safe and provides favourable PFS and OS in selected patients with advanced SBNEN. Liquid biopsy (NETest) has the potential to accurately delineate disease status.

Radioembolisation with 90Y microspheres for neuroendocrine liver metastases: an institutional case series, systematic review and meta-analysis.

BACKGROUND: Neuroendocrine liver metastases are clinically challenging due to their frequent disseminated distribution. This study aims to present a British experience with an emerging modality, radioembolisation with yttrium-90 labelled microspheres, and embed this within a meta-analysis of response and survival outcomes. METHODS: A retrospective case series of patients treated with SIR-Spheres (radiolabelled resin microspheres) was performed. Results were included in a systematic review and meta-analysis of published results with glass or resin microspheres. Objective response rate (ORR) was defined as complete or partial response. Disease control rate (DCR) was defined as complete/partial response or stable disease. RESULTS: Twenty-four patients were identified. ORR and DCR in the institutional series was 14/24 and 21/24 at 3 months. Overall survival and progression-free survival at 3-years was 77.6% and 50.4%, respectively. There were no grade 3/4 toxicities post-procedure. A fixed-effects pooled estimate of ORR of 51% (95% CI: 47%-54%) was identified from meta-analysis of 27 studies. The fixed-effects weighted average DCR was 88% (95% CI: 85%-90%, 27 studies). CONCLUSION: Current data demonstrate evidence of the clinical effectiveness and safety of radioembolisation for neuroendocrine liver metastases. Prospective randomised studies to compare radioembolisation with other liver directed treatment modalities are needed.

Role of US Contrast Agents in the Assessment of Indeterminate Solid and Cystic Lesions in Native and Transplant Kidneys.

Ultrasonography (US) is often the initial imaging modality employed in the evaluation of renal diseases. Despite improvements in B-mode and Doppler imaging, US still faces limitations in the assessment of focal renal masses and complex cysts as well as the microcirculation. The applications of contrast-enhanced US (CEUS) in the kidneys have dramatically increased to overcome these shortcomings with guidelines underlining their importance. This article describes microbubble contrast agents and their role in renal imaging. Microbubble contrast agents consist of a low solubility complex gas surrounded by a phospholipid shell. Microbubbles are extremely safe and well-tolerated pure intravascular agents that can be used in renal failure and obstruction, where computed tomographic (CT) and magnetic resonance (MR) imaging contrast agents may have deleterious effects. Their intravascular distribution allows for quantitative perfusion analysis of the microcirculation, diagnosis of vascular problems, and qualitative assessment of tumor vascularity and enhancement patterns. Low acoustic power real-time prolonged imaging can be performed without exposure to ionizing radiation and at lower cost than CT or MR imaging. CEUS can accurately distinguish pseudotumors from true tumors. CEUS has been shown to be more accurate than unenhanced US and rivals contrast material-enhanced CT in the diagnosis of malignancy in complex cystic renal lesions and can upstage the Bosniak category. CEUS can demonstrate specific enhancement patterns allowing the differentiation of benign and malignant solid tumors as well as focal inflammatory lesions. In conclusion, CEUS is useful in the characterization of indeterminate renal masses and cysts.

Endovascular treatment of thoracic aortic aneurysms with a short proximal landing zone using scalloped endografts.

BACKGROUND: The suitability of the proximal landing zone remains one of the main limitations to thoracic endovascular aortic repair (TEVAR). The advent of custom-made scalloped stent grafts widens the endovascular options for patients with challenging anatomy. The objective of this study was to present our early and midterm results of custom-made scalloped thoracic stent grafts. METHODS: Prospectively acquired data relating to patient demographics, procedure details, clinical outcome, and complications were analyzed. In addition, we analyzed preoperative and postoperative computed tomography scans to evaluate aneurysm morphology, graft placement, side-vessel patency, and endoleaks. RESULTS: Twenty-one patients with a median age of 71 years (range, 35-81 years) underwent custom-made scalloped TEVAR, eight of whom had a concomitant hybrid repair. Procedural success was achieved in all cases. Proximal seal was achieved in all cases, with no type I endoleaks. There were no cases of retrograde dissection and no conversions to open repair. The median follow-up period was 36 weeks (range, 3-183 weeks). Two patients died in the hospital. Three patients suffered a stroke. Three patients had a type II endoleak, one of whom had significant sac enlargement requiring reintervention. One patient had a type III endoleak requiring reintervention. There were no cases of graft migration. CONCLUSIONS: Our midterm results show that custom-made scalloped TEVAR is an acceptable treatment of thoracic aortic aneurysms with a short proximal landing zone. Longer term outcome data are required to establish wider use of scalloped thoracic endografts.

Adrenal Vein Sampling: Does the Location of the Non-adrenal Venous Sample Matter?

PURPOSE: Adrenal vein sampling (AVS) is used to lateralise and differentiate unilateral from bilateral aldosterone production in primary aldosteronism. The adrenal venous samples are standardised to a peripheral or low inferior vena cava (IVC) sample and compared. It is unknown whether the location of the non-adrenal sample affects the results. This study compares AVS results standardised to the low IVC and right external iliac vein (REIV). METHODS: Patients who underwent AVS between March 2021 and May 2023 were included. All procedures were undertaken by a single operator (AA). Demographic data and AVS results were collected from patients' electronic records. Catheterisation success and lateralisation were assessed using both low IVC and REIV samples. Equivalence test was used to compare the cortisol and aldosterone levels. RESULTS: Eighty-one patients, (M: F = 38:43), aged between 29 and 74 were included. Bilateral successful adrenal vein cannulation was achieved in 79/81 (97.5%) cases. The mean cortisol levels from the REIV were statistically equivalent although there was a small and not biologically significant difference from the low IVC (respective geometric means 183 nmol/l vs. 185 nmol/l, p = 0.015). This small difference in cortisol may be due to accessory adrenal venous drainage into the IVC. The aldosterone and aldosterone/cortisol ratios were statistically equivalent. There was no discordance in selectivity or lateralisation when the IVC or REIV measurements were used. CONCLUSION: The IVC and REIV samples may be used interchangeably during AVS.

Spinal extradural solitary fibrous tumor with retiform and papillary features.

We report a 66-year-old man with a spinal, extradural solitary fibrous tumor showing unique retiform and papillary architecture. The patient presented in May 2008 with worsening right-sided lower back pain and urinary frequency. Magnetic resonance imaging of the spine documented a heterogeneously enhancing dumbbell-shaped extradural lesion causing cord compression at T11/12 level. The tumor extended to the paravertebral soft tissue and invaded the right adjacent vertebral pedicles and laminae. An angiogram showed prominent vascular supply mainly from the right T11 radicular artery. The patient underwent surgery to relieve cord compression in May 2008 and a second operation following embolization with coils in October 2009. No recurrence was observed at the last neuroimaging follow-up in June 2012. The tumor was composed of vimentin, CD34, Bcl-2, and CD99-positive rounded or slightly elongated cells with scant cytoplasm and oval to spindle nuclei. Several pseudovascular spaces reminiscent of the rete testis were present, and several of them contained papillary projections. Cytologic atypia was minimal, and mitotic activity was low. Focal infiltration of the paraspinal adipose tissue was seen at microscopic level. To our knowledge, retiform and papillary features have never been reported in a solitary fibrous tumor.

Instagram: A platform for ultrasound education?

INTRODUCTION: Social media has become an integral part of our daily life with 38 million users in the UK alone and the average user being logged-in for 135 minutes daily. Social media is increasingly used to disseminate learning in a variety of fields including medicine. OBJECTIVES: The aim of this study was to assess the proportion of Instagram posts using #ultrasound for educational content and compare this with #radiology. We also aimed to assess the changes in the use of the newly introduced #UltrasoundEd for ultrasound education since its introduction in November 2018. METHODS: Instagram searches were conducted using the hashtags: #ultrasound and #radiology, and the content of the first 100 posts from each search was analysed and classified into being either social or educational. A second search using #UltrasoundEd was conducted at baseline, 3 months and 12 months. Fisher's exact test was used to compare categorical data. RESULTS: The searches retrieved 461,884 #ultrasound and 243,011 #radiology posts. From the first 100 #ultrasound posts, 11 were educational and 89 were social. The social posts predominantly related to announcements of pregnancy. Of the 100 #radiology posts, 49 were educational, while 51 were classified as social. The number of posts with the hashtag #UltrasoundEd increased over the study period from 15 to 232, with the majority of posts being educational. CONCLUSIONS: Educational ultrasound content is difficult to separate from social posts on Instagram. The use of the hashtag #UltrasoundEd makes educational ultrasound content more readily identifiable.

The Vanishing Adrenal Glands: A Transient Regression of Adrenal Lymphoma After a Single Dose of 1 mg Dexamethasone.

OBJECTIVE: Dexamethasone is a known treatment for lymphoma, but the potency and rapidity of its effect have not been recognized. We present a case of bilateral adrenal lymphoma that significantly reduced in size after a single dose of dexamethasone. METHODS: We present the clinical course and investigations, including adrenocorticotropic hormone, cortisol, short synacthen test, computed tomography (CT), and adrenal biopsy results. RESULTS: A 52-year-old man had a fall and was incidentally found to have bilateral adrenal masses (left, 6 cm; right, 5 cm) on CT. His adrenal function tests included plasma metanephrines (normetanephrine, 830 pmol/L [normal, <1180]; metanephrine, <100 pmol/L [<510]; 3-methoxytyramine, <100 pmol/L [<180]); aldosterone, 270 pmol/L( 90-700); and random cortisol, 230 nmol/L (160-550). An overnight dexamethasone suppression test with 1 mg of dexamethasone showed cortisol of <28 nmol/L (0-50). A repeat CT scan 8 days thereafter showed adrenal masses of 4.5 and 3.5 cm on the left and right, respectively. He had a follow-up CT scan 3 months later that showed adrenal lesions measuring 8 cm (left) and 9 cm (right). He subsequently presented with fatigue and dizziness. Morning cortisol of 201 nmol/L (160-550) with adrenocorticotropic hormone of 216 ng/L (10-30) indicated primary adrenal insufficiency. Mineralocorticoid and glucocorticoid replacement therapy commenced. An adrenal biopsy showed abnormal enlarged B cells, consistent with a diagnosis of diffuse large B-cell lymphoma. CONCLUSION: A diagnosis of lymphoma should be considered when adrenal lesions shrink following even a single low dose of dexamethasone administered as a part of a diagnostic test.

To Tweet or Not to Tweet? A Look at Radiology Societies' Use of Twitter.

INTRODUCTION: Twitter is the most used social media platform by medical professionals and has become an effective way to disseminate ideas and information. AIM: To evaluate Twitter usage by some of the larger diagnostic radiology (DR) and interventional radiology (IR) societies. MATERIALS AND METHODS: Data were collected from the publicly available Twitter analytics platform, Twitonomy™. Data collected included the number of followers, Twitter output, user engagement and changes of these parameters between January 2017 and January 2019. RESULTS: DR societies have the largest number of followers. The IR group increased its number of followers by 5139 (55%) compared with 10013 (18%) by the DR group during the period studied. In both years, the IR group posted more tweets/day compared with the DR group (6.6 vs. 4.7). Although user engagement increased for both IR and DR societies, the IR subgroup had a highly engaged user audience with a similar number of 'likes' to the DR group despite their larger Twitter following (DR 65500 vs. IR 14411 in 2019). CONCLUSIONS: The IR societies studied experienced comparable Twitter engagement to the larger DR societies. The societies with the smallest number of followers (BSIR and CIRSE) enjoyed the largest relative increase in followers over the study period. IR societies should be encouraged by these results to continue to publicize their work on social media and increase awareness of the specialty.

A rare cause of severe Cushing's syndrome.

SUMMARY: Ectopic adrenocorticotropic hormone (ACTH) production is an uncommon cause of Cushing's syndrome and, rarely, the source can be a phaeochromocytoma. A 55-year-old man presented following an episode of presumed gastroenteritis with vomiting and general malaise. Further episodes of diarrhoea, joint pains and palpitations followed. On examination, he was hypertensive with no clinical features to suggest hypercortisolaemia. He was subsequently found to have raised plasma normetanephrines of 3.98 nmol/L (NR <0.71) and metanephrines of 0.69 nmol/L (NR <0.36). An adrenal CT showed a 3.8 cm right adrenal nodule, which was not MIBG-avid but was clinically and biochemically consistent with a phaeochromocytoma. He was started on alpha blockade and referred for right adrenalectomy. Four weeks later, on the day of admission for adrenalectomy, profound hypokalaemia was noted (serum potassium 2.0 mmol/L) with non-specific ST-segment ECG changes. He was also diagnosed with new-onset diabetes mellitus (capillary blood glucose of 28 mmol/L). He reported to have gained weight and his skin had become darker over the course of the last 4 weeks. Given these findings, he underwent overnight dexamethasone suppression testing, which showed a non-suppressed serum cortisol of 1099 nmol/L. Baseline serum ACTH was 273 ng/L. A preliminary diagnosis of ectopic ACTH secretion from the known right-sided phaeochromocytoma was made and he was started on metyrapone and insulin. Surgery was postponed for 4 weeks. Following uncomplicated laparoscopic adrenalectomy, the patient recovered with full resolution of symptoms. LEARNING POINTS: Phaeochromocytomas are a rare source of ectopic ACTH secretion. A high clinical index of suspicion is therefore required to make the diagnosis. Ectopic ACTH secretion from a phaeochromocytoma can rapidly progress to severe Cushing's syndrome, thus complicating tumour removal. Removal of the primary tumour often leads to full recovery. The limited literature suggests that the presence of ectopic Cushing's syndrome does not appear to have any long-term prognostic implications.