Implications of COVID-19 pandemic on lung cancer management: A multidisciplinary perspective.

Treatment of patients with lung cancer during the current COVID-19 pandemic is challenging. Lung cancer is a heterogenous disease with a wide variety of therapeutic options. Oncologists have to determine the risks and benefits of modifying the treatment plans of patients especially in situation where the disease biology and treatment are complex. Health care visits carry a risk of transmission of SARS-CoV-2 and the similarities of COVID-19 symptoms and lung cancer manifestations represent a dominant problem. Efforts to modify treatment of lung cancer during the current pandemic have been adapted by many healthcare institutes to reduce exposure of lung cancer patients to SARS-CoV-2. We summarized the implications of COVID-19 pandemic on the management of lung cancer from the perspective of different specialties of thoracic oncology multidisciplinary team.

Frequency and Characteristics of Incidental Pulmonary Embolism in Cancer Patients: A Retrospective Study at a Large Oncology Center in Saudi Arabia.

INTRODUCTION: Oncology patients are predisposed to incidental-asymptomatic Pulmonary Embolism (PE) which has a substantial morbidity and mortality in untreated patients. As the cancer patients frequently undergo contrast enhanced Computed Tomography (CT) scanning for staging their primary disease, there is a higher chance of detecting unsuspected PE. METHODOLOGY: Our sample included a retrospective review of one-thousand consecutive oncology patients who had CT scan of the chest for reasons other than PE. We excluded females on oral contraceptives, patients who had a prior history of PE or deep veins thrombosis, and history of intensive care unit admission, surgery, trauma, or lower limb fractures within 6 months prior to the CT study. A positive case of incidental PE is considered if it was confirmed by CT pulmonary angiogram study within 24 hours of the staging CT or if there is an agreement for positive PE by two experienced radiologists. The overall incidence of asymptomatic PE in cancer patients, rate of incidental PE in different types and stages of cancer, and location of the PE within the pulmonary vasculature are described. DISCUSSION: The true incidence, prevalence, and mortality rates of incidental PEs in oncology patients is underestimated due to its silent nature. Since the mortality and morbidity are exceptionally high in cancer patients with incidental pulmonary embolism, staging CT chest examinations should include a meticulous search for incidental PE. CONCLUSION: The rate of pulmonary embolism in oncology patients is higher in female and in the advanced stage of the disease. There are certain tumors associated with a higher rate of incidental PEs, which may be related to tumors characteristics or to its treatment.

Saudi lung cancer management guidelines 2017.

BACKGROUND: Lung cancer management is getting more complex due to the rapid advances in all aspects of diagnostic and therapeutic options. Developing guidelines is critical to help practitioners provide standard of care. METHODS: The Saudi Lung Cancer Guidelines Committee (SLCGC) multidisciplinary members from different specialties and from various regions and healthcare sectors of the country reviewed and updated all lung cancer guidelines with appropriate labeling of level of evidence. Supporting documents to help healthcare professionals were developed. RESULTS: Detailed lung cancer management guidelines were finalized with appropriate resources for systemic therapy and short reviews highlighting important issues. Stage based disease management recommendation were included. A summary explanation for complex topics were included in addition to tables of approved systemic therapy. CONCLUSION: A multidisciplinary lung cancer guidelines was developed and will be disseminated across the country.

Percutaneous Approach for Removal of a Migrated Cystogastric Stent from a Pancreatic Pseudocyst: A Case Report and Review of the Literature.

Stent migration into pancreatic pseudocysts during endosonographic (EUS) cystogastrostomy is a relatively rare complication. The migrated stent may induce, if it remains within the body, infection and perforation. Therefore, retrieval and/or re-stenting is necessary. Endoscopic retrieval is commonly attempted first. However, it is technically challenging and largely dependent on the skill of the endoscopists; if retrieval is unsuccessful, surgery is usually carried out. We report a case of stent migration into a pancreatic pseudocyst that was retrieved with a percutaneous approach under imaging guidance using a simple technique with available devices. A technique that enhances the role of interventional radiology in the management of this rare complication.

Common complications of nonvascular percutaneous thoracic interventions: diagnosis and management.

Percutaneous thoracic interventions are among the most common procedures in today's medical practice. From the simple placement of a pleural drain to the ablation of lung tumors, the advent of image guidance has revolutionized minimally invasive procedures and has allowed for the introduction of new techniques and widened the range of indications. It is therefore imperative to understand the complications associated with these interventions and their management. This article illustrates the common complications associated with these interventions and highlights the relative safety of these interventions.

Transarterial therapy: an evolving treatment modality of hepatocellular carcinoma.

Liver cancer is the fifth most common cancer in men, the seventh most common in women, and the third most common cause of death from cancer worldwide. Only 30-40% of liver cancer patients present early enough to undergo curative treatments such as surgery or liver transplantation. Local treatment with radiofrequency ablation or ethanol injection is often reserved for non-surgical candidates with early stages of disease. Transarterial embolization has become a widely accepted treatment for asymptomatic patients with unresectable lesions. This review discusses in details the three major forms of transarterial therapies: Bland embolization, chemoembolization, and radioembolization.

Diagnosis and predictive molecular analysis of non-small-cell lung cancer in the Africa-Middle East region: challenges and strategies for improvement.

The identification of tumor biomarkers provides information on the prognosis and guides the implementation of appropriate treatment in patients with many different cancer types. In non-small cell lung cancer (NSCLC), targeted treatment plans based on biomarker identification have already been used in the clinic. However, such predictive molecular testing is not currently a universally used practice. This is the case, in particular, in developing countries where lung cancer is increasingly prevalent. In September 2012 and November 2013, a committee of 16 lung cancer experts from Africa and the Middle East met to discuss key issues related to diagnosis and biomarker testing in NSCLC and the implementation of personalized medicine in the region. The committee identified current challenges for effective diagnosis and predictive analysis in Africa and the Middle East. Moreover, strategies to encourage the implementation of biomarker testing were discussed. A practical approach for the effective diagnosis and predictive molecular testing of NSCLC in these regions was derived. We present the key issues and recommendations arising from the meetings.

Guidelines for multimodality radiological staging of lung cancer.

Lung cancer is among the most common type of cancers and is a leading cause of cancer-related deaths with smoking representing the leading risk factor. It is classified into non-small cell lung cancer (NSCLC) representing 70-80% of cases and small cell lung cancer (SCLC) which has neuroendocrine properties with poor outcome. Staging of NSCLC is based on the TNM classification system while SCLC was usually classified into limited and extensive disease, though the use of TNM staging system for SCLC is recommended. Imaging studies are used to determine the pre-operative staging of lung cancer. Accurate radiological staging is essential to determine tumor resectability as well as to avoid futile surgeries and to assess patient's outcome. Moreover, radiological examinations are used for the evaluation of tumor response to treatment. This manuscript will review the utilization of imaging studies in the management of lung cancer based on the most recent guidelines by the National Comprehensive Cancer Network (NCCN).

Image-guided percutaneous transthoracic biopsy in lung cancer--emphasis on CT-guided technique.

Image-guided percutaneous transthoracic core biopsy especially with CT guidance is playing an increasing role in the diagnosis and management of lung cancer. The recent advances in the specific chemotherapy and novel targeted therapy and the increasing need for specific diagnosis of tumor histopathologic subtypes have direct impact on the radiologists performing lung biopsy and important implications for the biopsy technique. Close cooperation between radiologists and referring physicians with understanding of the technical aspects of the biopsy procedure can help clinicians make appropriate referrals for this procedure and understand the significance and limitations of the results. Additionally, the appropriate management of complications can limit morbidity related to the biopsy procedure.

Predictors of response to radio-embolization (TheraSphere®) treatment of neuroendocrine liver metastasis.

BACKGROUND: Neuroendocrine tumours (NET) frequently metastasize to the liver. NET liver metastasis has been shown to respond to Yttrium-90 microspheres therapy. The aims of the present study were to define factors that predict the response to radio-embolization in patients with NET liver metastases. METHODS: From January 2006 until March 2009, all patients with NET liver metastasis that received radio-embolization using TheraSphere® (glass microspheres) were reviewed. The response was determined by a change in the percentage of necrosis (ΔN%) after the first radio-embolization based on the modified RECIST criteria (mRECIST) criteria. The following confounding variables were measured: age, gender, size of the lesions, liver involvement, World Health Organization (WHO) classification, the presence of extra-hepatic metastasis, octereotide treatment and previous operative [surgery and (RFA)] and non-operative treatments (chemo-embolization and bland-embolization). RESULTS: In all, 25 patients were identified, with a median follow-up of 21.7 months. The median age was 64.6 years, 28% had extra-hepatic metastasis and 56% were WHO stage 2. Post-treatment, the mean ΔN% was 48.4%. Previous surgical therapy was a significant predictor of the response with a response rate of 66.7 ΔN% vs. 31.5 ΔN% (P= 0.02). Bilateral liver disease, a high percentage of liver involvement and large metastatic lesions were inversely related to the degree of tumour response although did not reach statistical significance. CONCLUSION: Radio-embolization increased the necrosis of NET liver metastasis mainly in patients with less bulky disease. This may imply that surgical therapy before radio-embolization would increase the response rates.

Hepatocellular carcinoma treated with radio frequency ablation: an early evaluation with magnetic resonance imaging.

PURPOSE: To determine the usefulness of nonenhanced T1-weighted spoiled gradient-recalled acquisition in the steady-state (SPGR) MRI in the early assessment of the efficacy of radio frequency (RF) therapy for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: A total of 23 patients with 28 HCC nodules treated with percutaneous RF ablation underwent nonenhanced MRI within two days after the RF procedure and contrast-enhanced computed tomography (CT) one week after. MR assessment of ablation efficacy according to the concentric zonal pattern on T1-weighted SPGR imaging was compared with the one-week CT and presence of local recurrence by means of follow-up study for 12 months or more. RESULTS: In 18 of 28 ablated nodules, SPGR images revealed a central hyperintense zone covering the entire tumor, CT showed a nonenhanced area covering the entire tumor, and no local recurrence was demonstrated in the follow-up studies. In nine of 28 nodules, the central hyperintense zone did not cover the entire tumor; and local recurrence was demonstrated in three nodules. In the remaining one nodule, no signal change was seen in the treated area on SPGR images and CT showed the presence of residual viable tumor. CONCLUSION: Nonenhanced T1-weighted MRI was considered useful for early assessment of the efficacy of RF therapy for HCC.

Near-real-time feedback control system for liver thermal ablations based on self-referenced temperature imaging.

Our challenge was to design and implement a dedicated temperature imaging feedback control system to guide and assist in a thermal liver ablation procedure in a double-donut 0.5T open MR scanner. This system has near-real-time feedback capability based on a newly developed "self-referenced" temperature imaging method using "moving-slab" and complex-field-fitting techniques. Two phantom validation studies and one ex vivo experiment were performed to compare the newly developed self-referenced method with the conventional subtraction method and evaluate the ability of the feedback control system in the same MR scanner. The near-real-time feedback system was achieved by integrating the following primary functions: (1) imaging of the moving organ temperature; (2) on-line needle tip tracking; (3) automatic turn-on/off the heating devices; (4) a Windows operating system-based novel user-interfaces. In the first part of the validation studies, microwave heating was applied in an agar phantom using a fast spoiled gradient recalled echo in a steady state sequence. In the second part of the validation and ex vivo study, target visualization, treatment planning and monitoring, and temperature and thermal dose visualization with the graphical user interface of the thermal ablation software were demonstrated. Furthermore, MR imaging with the "self-referenced" temperature imaging method has the ability to localize the hot spot in the heated region and measure temperature elevation during the experiment. In conclusion, we have demonstrated an interactively controllable feedback control system that offers a new method for the guidance of liver thermal ablation procedures, as well as improving the ability to assist ablation procedures in an open MR scanner.

Evaluation of coronary artery bypass grafts using multidetector-row CT with Japanese patients.

PURPOSE: To evaluate the patency of coronary artery bypass grafting (CABG) with multidetector-row computed tomography (MDCT) in Japanese patients, who have narrower coronary arteries than Caucasians. MATERIALS AND METHODS: Nineteen patients (12 men and 7 women, mean age: 63 +/- 12 years) with 33 coronary bypass grafts were examined with three-dimensional volume rendering (3D-VR) and curved multiplanar reconstruction (MPR) of MDCT. All grafts were compared with those obtained with selective graft angiography. RESULTS: For the 19 patients with 33 grafts, the overall sensitivity and specificity, compared with those for selective bypass angiography, were 96.7% and 100%, respectively. CONCLUSION: The patency of CABG in Japanese patients can be effectively evaluated with 3D-VR and curved MPR of MDCT.

Aortic compliance in patients with aortic regurgitation: evaluation with magnetic resonance imaging.

PURPOSE: To assess by means of cine magnetic resonance imaging (MRI) aortic compliance before and after aortic valve replacement (AVR with SJM valve) in patients with aortic regurgitation (AR). MATERIALS AND METHODS: Two groups (healthy controls and patients with severe isolated AR) of 10 subjects each were included in this study. Cine MRI was performed at three locations of the aorta, and aortic compliance was calculated by dividing the maximum change in the aortic area by pulse pressure. RESULTS: Cine MRI is useful to assess abnormalities of aortic compliance in patients with AR. Compared with the control group, aortic compliance in the AR group was significantly less in the ascending aorta (p<0.05), decreasing in order of aortic location. After AVR, aortic compliance improved for all locations. CONCLUSION: Cine MRI enables assessment of aortic biophysical properties such as a compliance for evaluating the progression of AR and the efficacy of treatment.

Evaluation of major aortopulmonary collateral arteries (MAPCAs) using three-dimensional CT angiography: two case reports.

Pulmonary atresia (PA) and ventricular septal defect (VSD) are usually associated with major aortopulmonary collateral arteries (MAPCAs). Preoperative evaluation of MAPCAs is essential for effective planning of unifocalization. Multidetector-row computed tomography (MDCT) with three-dimensional volume rendering (3D-VR) demonstrates MAPCAs as well as conventional angiography. We report two cases of PA and VSD associated with MAPCAs examined pre- and postoperatively by means of angiography and MDCT with the 3D-VR technique. MDCT with the 3D-VR technique had the potential to elucidate all MAPCAs demonstrated by invasive angiography. This technique is useful with preoperative conventional angiography as a standard examination for the planning of staged surgery.

Detection of hypervascular hepatocellular carcinoma with dynamic magnetic resonance imaging with simultaneously obtained in-phase and opposed-phase echo images.

PURPOSE: The technique of double-phase echo chemical shift gradient-echo magnetic resonance (MR) imaging with the fast low-angle shot sequence (double-echo FLASH) provides in-phase and opposed-phase (double-phase) images simultaneously. The purpose of this study was to assess whether the dynamic study with a combination of in-phase and opposed-phase (double-phase) echo images improves the detectability of hypervascular hepatocellular carcinoma (HCC) compared with that with either in-phase or opposed-phase images alone. METHOD: Thirty-seven patients with 107 hypervascular HCCs who underwent the whole-liver double-phase echo dynamic MR imaging were enrolled in the study. Three radiologists blindly read in-phase images alone, opposed-phase images alone, and then double-phase images together. Sensitivity and positive predictive values as well as the areas below the alternative-free response receiver operating characteristic curve (Az values) for each imaging technique were calculated and compared statistically. RESULTS: The mean sensitivity, positive predictive values, and Az values for hypervascular HCCs were 51%, 77%, and 0.52 for in-phase imaging; 55%, 86%, and 0.58 for opposed-phase imaging; and 57%, 84%, and 0.63 for double-phase imaging, respectively. The mean sensitivity for opposed-phase imaging was significantly higher than that for in-phase imaging (P < 0.05), and the mean sensitivity for double-phase imaging was higher than that for in-phase imaging (P < 0.01). The mean Az value for the double-phase imaging was significantly higher than that for in-phase imaging (P < 0.01). CONCLUSION: Dynamic MR imaging with double-phase images was recommended for the detection of hypervascular HCC.

Post-kidney transplantation iliac artery stenosis due to iatrogenic injury: case report.

We report a case of left external iliac artery lesions as a complication of post-kidney transplantation due to vascular clamp application injury. The lesions were proximal stenosis and distal occlusion just near the graft anastomosis site and they were diagnosed incidentally during the embolization for arteriovenous fistula. Angiography confirmed the diagnosis and it was managed successfully by percutaneous interventional techniques.

Embolization of high flow arteriovenous malformations: experience with use of superabsorbent polymer microspheres.

PURPOSE: To determine efficacy, safety, and requirements for adjunctive embolization or surgery in the treatment of symptomatic arteriovenous malformations (AVMs) with superabsorbent polymer microsphere (SAP-MS) particles. MATERIALS AND METHODS: SAP-MS particles (sodium acrylate and vinyl alcohol copolymer) are nonbiodegradable spheres with a precisely calibrated diameter. SAP-MS particles swell by absorbing fluids and become soft and deformable. Twenty-five patients (16 men, nine women; mean age, 32 y; range 12-66 y) with symptomatic facial (n = 5), upper- (n = 8) and lower- (n = 12) extremity AVMs were treated primarily (n = 23) or preoperatively (n = 2) by transarterial embolization (TAE) treatment with use of SAP-MS particles. Direct puncture embolization (DPE; n = 4) and/or surgical intervention (n = 5; ie, skin graft, resection, or amputation) were required. Surgical specimens from the resected (n = 2) and the amputated (n = 2) patients were evaluated histologically. Follow-up study, including clinical findings and imaging studies, was performed at intervals ranging from 3 months to 1 year. Clinical outcome was evaluated retrospectively, depending on the subjective improvement of symptoms and signs, according to the medical records. RESULTS: Seventy-two TAEs (range, 1-11; mean, 2.8) and 12 DPEs (range, 1-3; mean, 2.4) were performed during the mean follow-up period of 38 months (range, 7-110 mo). Twenty patients (80%) experienced symptom improvement by embolotherapy alone (n = 17) or in combination with surgery (n = 3). One lip and two finger AVMs were totally removed by surgical excision or amputation after TAE treatment. In diffuse upper- (n = 1) and lower- (n = 1) extremity AVMs, the symptoms were uncontrolled. No nerve injury or skin necrosis was observed after TAE treatment with SAP-MS particles. Mucosal necrosis was induced by DPE with ethanol in one patient. Histologically, SAP-MS particles penetrated intralesional vessels and conformed to the vessel lumen, resulting in tight vessel occlusion. Minimal perivascular reaction was observed. CONCLUSION: SAP-MS particles were used safely in TAE treatment of AVM. TAE treatment with use of SAP-MS particles was suitable for certain symptomatic AVMs, but diffuse AVMs remain a challenge and a combination of alternative methods will be necessary for further strategy.

Transarterial embolization for large hepatocellular carcinoma with use of superabsorbent polymer microspheres: initial experience.

The authors report the initial experience with transarterial embolization of large hepatocellular carcinoma (HCC) with use of superabsorbent polymer microsphere (SAP-MS) particles. Six patients with nine HCCs (mean diameter, 8.2 cm) underwent 10 embolization procedures. Two patients underwent surgery later. In follow-up, tumor necrosis, postembolization syndrome, and laboratory data were assessed. Complete necrosis in three nodules, nearly complete necrosis in three nodules, and partial necrosis in three nodules were observed. Histologically, SAP-MS occluded intratumoral vessels tightly without ischemic damage of normal hepatic tissue. Postprocedural pain was minimal. No deterioration of liver function occurred. Our initial experience suggests that embolization with use of SAP-MS leads to extensive tumor necrosis of large nodular HCC, sparing use of chemotherapeutic agents.