Percutaneous ablation of malignant and locally aggressive solid tumors in pediatric patients.

Image-guided percutaneous ablation is an accepted treatment modality for common adult cancers. Unfortunately, its use in patients younger than 18 years is rare. This retrospective review presents our series of pediatric patients treated with ablation at our institution. From January 2002 to December 2021, a total of 14 patients (17 lesions) younger than 18 years were treated with percutaneous image-guided ablation. Estimated overall survival at 5 years was 58%; median survival of this group was not reached. Estimated local tumor progression-free survival at 5 years was 62%. One major complication was recorded.

Abnormal photoplethysmography waveforms are associated with chemotherapy induced neuropathy.

Background: Chemotherapy-induced peripheral neuropathy (CIPN) is a dose-dependent adverse event of many chemotherapy agents that affects autonomic, motor, and sensory nerve fibers. The purpose of this study is to describe abnormal photoplethysmography waveforms (PPGs) in the setting of CIPN in cancer patients screened for peripheral arterial disease (PAD), which to our knowledge has not been previously described. Patients and methods: 147 patients who underwent vascular physiologic testing in evaluation for PAD with an ankle brachial index (ABI) or toe brachial index (TBI), segmental pressures, pulse volume recordings, and toe PPGs, in a tertiary cancer center's vascular lab between January 1, 2019 and January 31, 2021 were included in the study. Results: Odds ratio analysis demonstrates 3 times increased odds of abnormal PPGs in patients with PAD (OR 3.2256 95% CI 1.523-6.832, p=0.002), 7 times increased odds of abnormal PPGs in patients with CIPN (OR 7.802 95% CI 3.606-16.880, p<0.001), 9 times increased odds of abnormal PPGs in patients with both CIPN and PAD (9.895 95% CI 2.643-37.043, p=0.001), and 7 times increased odds of abnormal PPGs in patients with chemotherapy agent known to cause CIPN (7.821 95% CI 3.619-16.902, p<0.001). Logistic regression demonstrated that PAD (coefficient 1.171 std. error 0.383 wald 9.354 p=0.002), CIPN (coefficient 2.054 std. error 0.394 wald 27.227 p<0.001), and chemo agent known to cause CIPN (coefficient 2.057 std. error 0.393 wald 27.370 p<0.001) were all predictors of abnormal PPGs. Conclusions: CIPN had greater odds for abnormal PPGs than PAD. Additional larger studies are needed to assess if PPG analysis could be utilized to assess for early diagnosis of CIPN.

Multidisciplinary Treatment of Non-Spine Bone Metastases: Results of a Modified Delphi Consensus Process.

Purpose: Local treatment for bone metastases is becoming increasingly complex. National guidelines traditionally focus only on radiation therapy (RT), leaving a gap in clinical decision support resources available to clinicians. The objective of this study was to reach expert consensus regarding multidisciplinary management of non-spine bone metastases, which would facilitate standardizing treatment within an academic-community partnership. Methods and Materials: A multidisciplinary panel of physicians treating metastatic disease across the Memorial Sloan Kettering (MSK) Cancer Alliance, including community-based partner sites, was convened. Clinical questions rated of high importance in the management of non-spine bone metastases were identified via survey. A literature review was conducted, and panel physicians drafted initial recommendation statements. Consensus was gathered on recommendation statements through a modified Delphi process from a full panel of 17 physicians from radiation oncology, orthopaedic surgery, medical oncology, interventional radiology, and anesthesia pain. Consensus was defined a priori as 75% of respondents indicating "agree" or "strongly agree" with the consensus statement. Strength of Recommendation Taxonomy was employed to assign evidence strength for each statement. Results: Seventeen clinical questions were identified, of which 11 (65%) were selected for the consensus process. Consensus was reached for 16 of 17 answer statements (94%), of which 12 were approved after Round 1 and additional 4 approved after Round 2 of the modified Delphi voting process. Topics included indications for referral to surgery or interventional radiology, radiation fractionation and appropriate use of stereotactic approaches, and the handling of systemic therapies during radiation. Evidence strength was most commonly C (n = 7), followed by B (n = 5) and A (n = 3). Conclusions: Consensus among a multidisciplinary panel of community and academic physicians treating non-spine bone metastases was feasible. Recommendations will assist clinicians and potentially provide measures to reduce variation across diverse practice settings. Findings highlight areas for further research such as pathologic fracture risk estimation, pre-operative radiation, and percutaneous ablation.

Prevalence, Outcome, and Management of Risk Factors in Patients With Breast Cancer With Peripheral Arterial Disease: A Tertiary Cancer Center's Experience.

INTRODUCTION: The risk factors of breast cancer overlap with those of peripheral arterial disease (PAD), with increasing prevalence. In addition, there is under-utilization of risk factor modification measures in patients with PAD. MATERIALS AND METHODS: Electronic medical records of patients with breast cancer with International Classification of Diseases 9/10 codes for PAD spanning 10 years from June 1, 2009 to June 1, 2019 were reviewed. RESULTS: A total of 248 patients, 98% women, with a median age of 75 years and with a median follow-up of 76 months, were included. PAD risk factors were identified as smoking (44%), obesity (38%), hyperlipidemia (68%), hypertension (HTN) (74%), and diabetes (42%). Overall, survival was significantly impacted by smoking (P = .0301) and HTN (P = .0052). In a Cox proportion hazard ratio regression, HTN (overall death hazard ratio [HR], 3.1784; 95% CI, 1.0291-6.7490; P = .0070; cancer-related death HR, 2.6354; 95% confidence interval [CI], 1.0291-6.7490; P = .0434) and smoking (overall death HR, 1.7452; 95% CI 1.0707-2.8444; P = .0255; cancer-related death HR, 2.7432; 95% CI, 1.4190-5.3030; P = .0027) were predictors of overall death and cancer-related death. Of all patients, 48% were on statins and 54% were on antiplatelet therapies. Of the patients, 62% of current smokers were offered a smoking cessation program, 27% of obese patients were offered a nutrition consult, 42% of patients with diabetes had blood glucose controlled, and 54% of patients with HTN had blood pressure controlled. CONCLUSION: Smoking and HTN are risk factors associated with decreased survival and predictive of overall death and cancer-related death. In this population, risk factor modification was under-utilized.

Replacing 30 Gy in 10 fractions with stereotactic body radiation therapy for bone metastases: A large multi-site single institution experience 2016-2018.

BACKGROUND: Bone metastases cause significant morbidity in patients with cancer, and radiation therapy (RT) is an effective treatment approach. Indications for more complex ablative techniques are emerging. We sought to evaluate RT trends at a large multi-site tertiary cancer center. METHODS: Patients who received RT for bone metastases at a single institution (including regional outpatient clinics) from 2016 to 2018 were identified. Patients were grouped by RT regimen: single-fraction conventional RT (8 Gy × 1), 30 Gy in 10 fractions, SBRT, and "other". Multinomial logistic regression was performed to assess trends in regimens over time. Binary logistic regression was performed to evaluate factors associated with receipt of SBRT. RESULTS: Between 2016 and 2018, 5,952 RT episodes were received by 2,969 patients with bone metastases. Overall, 76% of episodes were ≤ 5 fractions. The median number of fractions planned for SBRT and non-SBRT episodes was 3 (IQR 3-3) and 5 (IQR 5-10), respectively. Use of SBRT increased from 2016 to 2018 (39% to 53%, p < 0.01) while use of 30 Gy in 10 fractions decreased (26% to 12%, p < 0.01), and 8 Gy × 1 was stable (5.3% to 6.9%, p = 0.28). SBRT was associated with higher performance status (p < 0.01) and non-radiosensitive histology (p < 0.01). Use of SBRT increased in the regional network (19% to 48%, p < 0.01) and at the main center (52% to 59%, p = 0.02), but did not increase within 30 days of death. More patients treated with 8 Gy × 1 than SBRT died within 30 days of treatment (24% vs 3.8%, respectively, p < 0.01). CONCLUSIONS: SBRT is replacing 30 Gy in 10 fractions for bone metastases, especially among patients with high performance status and non-radiosensitive histologies. Better prognostic algorithms could further improve patient-centered treatment selection at the end of life.

Pathophysiology of right ventricular failure in acute pulmonary embolism and chronic thromboembolic pulmonary hypertension: a pictorial essay for the interventional radiologist.

Pulmonary embolus (PE) is the third most common cause of cardiovascular death with more than 600,000 cases occurring in the USA per year. About 45% of patients with acute PE will have acute right ventricular failure, and up to 3.8% of patients will develop chronic thromboembolic pulmonary hypertension (CTEPH) with progressive, severe, chronic heart failure. The right ventricle (RV) is constructed to accommodate a low-resistance afterload. Increases in afterload from acute massive and submassive PE and CTEPH may markedly compromise the RV function leading to hemodynamic collapse and death. The purpose of this educational manuscript is to instruct on the pathophysiology of RV failure in massive and submassive PE and CTEPH. It is important to understand the pathophysiology of these diseases as it provides the rationale for therapeutic intervention by the Interventional Radiologist. We review here the pathophysiology of right ventricular (RV) failure in acute massive and submassive PE and CTEPH.

Percutaneous treatment of a duodenocutaneous high-flow fistula using a new biological plug.

Enterocutaneous fistula is a challenging entity and a gold-standard treatment is not settled so far. Here, we describe the successful closure of a duodenocutaneous fistula with the use of the Biodesign enterocutaneous fistula plug (Cook Medical), which is derived from a biological plug that has been used in recent years in order to close anorectal fistula tracts.

[Difficulties in the treatment of symptomatic varicocele using percutaneous embolization: the circumaortic renal vein]. / Dificultades en el tratamiento del varicocele sintomático mediante embolización percutánea: la vena renal circumaórtica.

OBJECTIVE: The anatomic anomalies of the inferior cava and its collaterals, even though they do not normally show symptoms, can cause difficulties in different diagnostic and therapeutic procedures, such as the percutaneous treatment by gonadal embolization of the varicocele. METHODS: We analyzed the incidence of one of these anomalies, specifically the left circumaortic renal vein, in a series of 50 gonadal embolization procedures for symptomatic varicocele. RESULTS: We found two cases (4%) of left circumaortic renal vein in our series. Gonadal embolization was possible in only one of the cases since the ostium of the gonadal vein could not be localized in the other case. In the first case, the gonadal ostium was in the paraaortic confluence of the venous ring, and could be catheterized and selectively embolized. CONCLUSIONS: The presence of a circumaortic left renal vein can make it technically impossible to perform embolization of the symptomatic varicocele.