Society of Interventional Radiology Multidisciplinary Position Statement on Percutaneous Ablation of Non-small Cell Lung Cancer and Metastatic Disease to the Lungs: Endorsed by the Canadian Association for Interventional Radiology, the Cardiovascular and Interventional Radiological Society of Europe, and the Society of Interventional Oncology.

PURPOSE: To state the Society of Interventional Radiology's position on the use of image-guided thermal ablation for the treatment of early stage non-small cell lung cancer, recurrent lung cancer, and metastatic disease to the lung. MATERIALS AND METHODS: A multidisciplinary writing group, with expertise in treating lung cancer, conducted a comprehensive literature search to identify studies on the topic of interest. Recommendations were drafted and graded according to the updated SIR evidence grading system. A modified Delphi technique was used to achieve consensus agreement on the recommendation statements. RESULTS: A total of 63 studies, including existing systematic reviews and meta-analysis, retrospective cohort studies, and single-arm trials were identified. The expert writing group developed and agreed on 7 recommendations on the use of image-guided thermal ablation in the lung. CONCLUSION: SIR considers image-guided thermal ablation to be an acceptable treatment option for patients with inoperable Stage I NSCLC, those with recurrent NSCLC, as well as patients with metastatic lung disease.

Society of Interventional Radiology Quality Improvement Standards on Percutaneous Ablation of Non-Small Cell Lung Cancer and Metastatic Disease to the Lungs.

PURPOSE: To provide guidance on quality improvement thresholds for outcomes and complications of image-guided thermal ablation for the treatment of early stage non-small cell lung cancer, recurrent lung cancer, and metastatic disease. MATERIALS AND METHODS: A multidisciplinary writing group conducted a comprehensive literature search to identify studies on the topic of interest. Data were extracted from relevant studies and thresholds were derived from a calculation of 2 standard deviations from the weighted mean of each outcome. A modified Delphi technique was used to achieve consensus agreement on the thresholds. RESULTS: Data from 29 studies, including systematic reviews and meta-analyses, retrospective cohort studies, and single-arm trials were extracted for calculation of the thresholds. The expert writing group agreed on thresholds for local control, overall survival and adverse events associated with image-guided thermal ablation. CONCLUSION: SIR recommends utilizing the indicator thresholds to review and assess the efficacy of ongoing quality improvement programs. When performance falls above or below specific thresholds, consideration of a review of policies and procedures to assess for potential causes, and to implement changes in practices, may be warranted.

Clinical and Imaging Follow-up Practices after Transarterial Therapy for Primary and Secondary Hepatic Malignancies: Results of an Online Survey.

RATIONALE AND OBJECTIVES: To characterize practices and quantify variation in longitudinal follow-up approaches among interventional radiologists (IRs) after liver transarterial locoregional therapy (LRT) in contemporary Interventional Oncology practice. MATERIALS AND METHODS: In November/December 2014, Society of Interventional Radiology members were invited to participate in a survey regarding clinical and imaging follow-up of liver cancer patients treated with transarterial LRT. On survey closure, responses were compiled and analyzed. RESULTS: The 30-item survey response rate was 11% (361 of 3290). Respondents were predominantly American IRs (311 of 355, 88%) who perform 1-5 LRTs monthly (196 of 354, 55%). Most (305 of 336, 91%) IRs reported longitudinal follow-up, with patient encounters within 1-month (73%, 211 of 290) postprocedure and every 3 months (68%, 196 of 287) thereafter and involvement in imaging (up to 80%, 235 of 290) ordering and evaluation. Preferred timing of first follow-up imaging (1 month vs. 3 months) and response criteria used (mRECIST favored) varied. CONCLUSIONS: Although IRs are actively involved in clinical and imaging follow-up of patients with liver malignancies treated with transarterial LRTs, there are differences in imaging frequency and response assessment. These data may serve as a starting point for standardization of LRT follow-up.

Perception of radiation exposure and risk among patients, medical students, and referring physicians at a tertiary care community hospital.

BACKGROUND: It is important for physicians to be aware of the radiation doses as well as the risks associated with diagnostic imaging procedures that they are ordering. METHODS: A survey was administered to patients, medical students, and referring physicians from a number of specialties to determine background knowledge regarding radiation exposure and risk associated with commonly ordered medical imaging tests. RESULTS: A total of 127 patients, 32 referring physicians, and 30 medical students completed the survey. The majority of patients (92%) were not informed of the radiation risks associated with tests that they were scheduled to receive and had false perceptions about the use of radiation and its associated risks. Physicians and medical students had misconceptions about the use of ionizing radiation in a number of radiologic examinations; for example, 25% and 43% of physicians and medical students, respectively, were unaware that interventional procedures used ionizing radiation, and 28% of physicians were unaware that mammography used ionizing radiation. Computed tomographies and barium studies were thought to be associated with the least ionizing radiation among physicians. CONCLUSION: There is a need for educating the public, medical students, and referring physicians about radiation exposure and associated risk so that (1) patients receiving multiple medical imaging tests are aware of the radiation that they are receiving and (2) physicians and future physicians will make informed decisions when ordering such tests to limit the amount of radiation that patients receive and to promote informed consent among patients.

What do family physicians know about interventional radiology? A survey of family physicians at a Large Canadian Annual Scientific Assembly.

PURPOSE: To quantify the level of background knowledge among family physicians with regard to interventional radiology (IR) procedures, duties, and clinical responsibilities and to develop recommendations on how to further educate family physicians in IR. MATERIALS AND METHODS: Paper surveys were administered to family physicians who attended the Ontario College of Family Physicians' Annual Scientific Assembly. Each survey consisted of 14 questions pertaining to IR procedures, clinical duties, collaboration, and education. RESULTS: A total of 213 of 229 (93%) attempted paper surveys were completed. Family physicians rated their knowledge of IR as poor (31%), adequate (53%), good (14%), or excellent (2%). A total of 98%, 71%, 47%, and 38% correctly identified that interventional radiologists performed image-guided biopsies, uterine artery embolization, radiofrequency ablation of tumors, and vascular angioplasties, respectively. Only 7% correctly identified that interventional radiologists are currently not recognized as distinct subspecialists by the Royal College of Physicians and Surgeons of Canada. Approximately 71% would refer patients directly to an interventional radiologist. A total of 96% believed that future education about IR would be "very" or "somewhat" helpful. Approximately 43% selected presentations given by interventional radiologists at family medicine conferences as their preferred method of future education. CONCLUSIONS: The data quantify and demonstrate the knowledge gap that exists among family physicians in Canada regarding IR procedures, duties, and responsibilities. Family physicians strongly support future education and collaboration with interventional radiologists. Eight results-based recommendations are made to further educate family physicians about IR and promote increased collaboration.

Ablative technologies in the management of patients with primary and secondary liver cancer: an overview.

Interventional ablative technologies have played an increasingly important role in the management of patients with primary or secondary liver malignancies. Ethanol and acetic acid ablation were the primary modalities available 2 decades ago. Today, several new technologies are available, including radiofrequency ablation, cryoablation, and microwave ablation. Radiofrequency ablation is the most widely practiced, however, cryoablation and microwave ablation are reasonable choices in certain situations. Irreversible electroporation is a newer technique, which has yet to enter clinical practice, but shows promising preliminary results. Herein, we provide a brief overview of the above-mentioned technologies with a focus on principles of ablation and technique. We also describe the use of these techniques in the context of cytoreduction, a noncurative approach aimed at reducing the overall tumour burden and providing concomitant survival benefit.

Traumatic Cervical Vertebral Artery Transection Associated with a Dural Tear Leading to Subarachnoid Extravasation.

Vertebral artery injuries can be seen following trauma. Most traumatic vertebral artery injuries are limited to an intimal dissection. Rarely, transection of the vertebral artery can be seen with extravasation of hemorrhage into the surrounding soft tissues of the neck. Dural tears are rare in the setting of trauma. They are usually the result of penetrating trauma or severe blunt trauma. We present a case with both a vertebral artery transection and a dural tear. The combination of these lethal injuries resulted in extravasation of hemorrhage into the soft tissues of the neck, through the dural tear, and into the subarachnoid space of the cervical spine. The subarachnoid hemorrhage extended superiorly into the brain. The diagnosis was made by computed tomography (CT) and computed tomography angiography (CTA). The treatment of traumatic vertebral artery transections and dural tears are discussed.

Performance of carotid stenting, vertebroplasty, and EVAR: how many are we doing and why are we not doing more? A survey by the Canadian Interventional Radiology Association.

OBJECTIVE: To determine the percentage of interventional radiologists who currently perform 3 interventional procedures: carotid stenting, vertebroplasty, and endovascular aneurysm repair (EVAR) in Canada, and impediments to their future performance by other interventional radiologists. METHODS: An anonymous online survey was emailed to all members of the Canadian Interventional Radiology Association (CIRA). The survey was open for a period of 2 months. RESULTS: A total of 75 survey responses were received (of an estimated 247). Carotid stenting, vertebroplasty, and EVAR were performed at 40%, 59%, and 46% of respondents' centres respectively. Wait times, from referral to consultation, and from consultation to procedure, were both typically between 2 to 4 weeks, longer for EVAR. Of respondents currently not performing these procedures, 26%, 28%, and 16% anticipated beginning to perform carotid stenting, vertebroplasty, and EVAR, respectively, in the proceeding year from time of survey. Of respondents who wished to perform the procedure, the greatest impediments were a lack of training, lack of a referral base, and lack of support from their radiology department and (or) colleagues. CONCLUSIONS: Although carotid stenting, vertebroplasty, and EVAR were being performed at about one-half of respondent's centres, and there will likely be greater adoption of the procedures in the near future, there remain substantial impediments. The greatest impediments to additional radiologists performing these procedures were a lack of training, lack of referral base, and lack of support from their radiology department and (or) colleagues. The former impediment suggested an unmet need for additional training courses.

Motivations and future trends: a survey of Canadian ophthalmology residents.

BACKGROUND: There has been little investigation into the attitudes and aspirations of current ophthalmology residents. The object of this study was to investigate the factors influencing career choice and to identify the future plans of Canadian ophthalmology residents. METHODS: All ophthalmology residents in English Canadian ophthalmology residency training programs were invited to complete an anonymous survey in June 2006. Data were categorized by demographic variables and basic statistics; chi2 comparative analyses were performed. RESULTS: Of 128 residents surveyed, 49 (38%) responded to the survey. Having the ability to combine medicine and surgery was the most common factor influencing the decision to pursue ophthalmology (98% of respondents), with intellectual stimulation (76%) and mentorship (50%) also emerging as important factors. The majority of residents (62%) plan on pursuing fellowship training, with medical retina, anterior segment/cataract, and cornea being the most popular choices (36%, 34%, and 32%, respectively). Most residents expressed plans of pursuing fellowships abroad, and only 22% planned on training within Canada. Fourteen percent indicated an interest in performing laser refractive surgery, female residents being significantly less likely than males to express such an interest (0% vs. 21%; p < 0.02). Most residents (71%) expressed the wish to practice in an urban or suburban setting, with only 6% intending to work in a rural community. INTERPRETATION: The appeal of the dual medical and surgical nature of ophthalmology is the most common motivating factor for pursuing an ophthalmology residency. The trends identified, including the high level of interest in subspecialty training and the desire to work in an urban setting, have important implications for the future of ophthalmology in Canada.

Awareness of interventional radiology among patients referred to the interventional radiology department: a survey of patients in a large Canadian community hospital.

PURPOSE: To quantify the level of knowledge about interventional radiology (IR) among patients referred for an IR procedure and to develop recommendations on how to increase public awareness of IR. MATERIALS AND METHODS: Paper surveys were prospectively administered to consecutive patients scheduled to undergo an IR procedure at a community hospital. The study was terminated at the accrual of 100 completed surveys. RESULTS: Totals of 28% and 6% knew generally the job of a diagnostic radiologist and interventional radiologist, respectively, and 6% had heard of the field of IR before their referral (despite 21% having undergone a procedure previously). Before their arrival in the IR department, 87% had not received any information about IR. Three percent, 0%, 4%, 82%, and 82% had heard about uterine artery embolization, radiofrequency ablation, vertebroplasty, biopsy (any type), and angioplasty, respectively. After the procedures, 84% had a clearer view of what interventional radiologists do, but 98% believed that most others did not know what IR was. When asked how best to educate the public about IR, the responses were: unsure (39%), other (19%), pamphlets (12%), information from physicians (9%), television (8%), and Internet (7%). Overall, the mean satisfaction rate was 8.8 (with 0 representing the minimum and 10 representing the maximum), and 97% would choose IR over surgery for future treatments. CONCLUSIONS: These data quantify and strongly support the views that (1) even among patients specifically referred to IR for a procedure, the majority of people are unaware of what the field is or may offer; and (2) most patients were satisfied with their IR experience. Six results-based recommendations are made to increase public awareness about IR.