Endovascular image-guided sampling of tumor-draining veins provides an enriched source of oncological biomarkers.

Introduction: Circulating tumor-derived biomarkers can potentially impact cancer management throughout the continuum of care. This small exploratory study aimed to assess the relative levels of such biomarkers in the tumor-draining vascular beds in patients with solid tumors compared to levels in their peripheral veins. Methods: Using an endovascular image-guided approach, we obtained blood samples from peripheral veins and other vascular compartments-including the most proximal venous drainage from solid tumors-from a set of nine oncology patients with various primary and metastatic malignancies. We then interrogated these samples for a panel of oncological biomarkers, including circulating tumor cells (CTCs), exosome-derived microRNAs (miRNAs), circulating tumor DNA (ctDNA) mutations, and certain cancer-related proteins/biochemical markers. Results: We found substantially higher levels of CTCs, certain miRNAs, and specific ctDNA mutations in samples from vascular beds closer to the tumor compared with those from peripheral veins and also noted that some of these signals were altered by treatment procedures. Discussion: Our results indicate that tumor-proximal venous samples are highly enriched for some oncological biomarkers and may allow for more robust molecular analysis than peripheral vein samples.

Thermal ablation for primary and metastatic lung tumors: Single-center analysis of peri-procedural and intermediate-term clinical outcomes.

PURPOSE: To evaluate the peri-procedural and intermediate-term clinical outcomes of thermal ablation of primary and metastatic lung cancer through analysis of a 5-year institutional experience. METHODS: In this retrospective, IRB-approved study, 55 consecutive lung ablation interventions (33 cryoablation and 22 microwave ablations) performed at an academic medical center from 2017 to 2022 were evaluated. Cryoablation was performed utilizing multiple 14-guage probes using a triple freeze/thaw protocol. Microwave ablation required a single 14-guage probe, set to 60-80 watts for 5-10 min. Lung disease distribution was 58.2 % bilateral with largest lesion size of 5.5 cm. Periprocedural outcomes including technical success and complications as well as long-term outcomes including radiographic response, objective response ratio (ORR), disease control rate (DCR), progression free survival (PFS), overall survival (OS), and functional status were elucidated. RESULTS: Technical success rate was 100 %. The most common complication was pneumothorax which occurred in 36 (65.5 %) patients, with 27 (49.1 %) requiring chest tube placement. At 6 months, 52 (98.2 %) of the patients demonstrated a complete response and 1 patient exhibited a partial response, yielding an ORR and a DCR of 100 %. The PFS was 26 ± 19 months, and the OS was 90.9 %, 83.6 %, and 74.5 % at 1, 3, and 5 years, respectively. Additionally, 92.7 % (51) of patients maintained or improved their functional status (ECOG) at 6 months. CONCLUSION: Percutaneous thermal ablation techniques are evolving and promising treatments for both primary and metastatic lung tumors. Our 5-year institutional experience demonstrated their safety and efficacy with preservation of functional performance.

Outcomes of bellwether cases related to inferior vena cava filters in multidistrict litigations.

OBJECTIVE: In the present study, we identified and reviewed the outcomes of bellwether cases related to inferior vena cava (IVC) filter multidistrict litigations (MDLs). METHODS: The legal research database, LexisNexis (New York, NY), was used to identify all cases related to IVC filters. Cases unrelated to the MDLs were excluded. Court documents recording the proceedings for bellwether cases sent to jury trials were retrieved from the LexisNexis subsidiary, Law360. Data on plaintiffs, filter models, reported complications, filed claims, decision-making body, verdicts, and rewards were reviewed. RESULTS: A total of 678 cases pertaining to IVC filters were found in the database, of which 12 were identified as bellwether cases for MDL. Of the 12, 2 (16.7%) were initially ruled in favor of the plaintiffs in jury trials, although the judgment for 1 of these was later vacated by a judge. The remaining 10 (83.3%) had been decided in favor of the manufacturers by judges and juries. CONCLUSIONS: Verdicts in all bench trials were in favor of manufacturers, suggesting that judges perceived the presented complications by patients to be within the normal realm of the expected risk of IVC filter use. The findings from the present study have emphasized the treating physicians' legal responsibility to adequately warn patients of all the associated risks with IVC filters. The findings have also indicated that physicians can still be found liable in product liability cases directed at manufacturers. Physicians should continue to actively monitor patients to optimize the IVC retrieval windows.

Metastatic disease to the liver: Locoregional therapy strategies and outcomes.

Secondary cancers of the liver are more than twenty times more common than primary tumors and are incurable in most cases. While surgical resection and systemic chemotherapy are often the first-line therapy for metastatic liver disease, a majority of patients present with bilobar disease not amenable to curative local resection. Furthermore, by the time metastasis to the liver has developed, many tumors demonstrate a degree of resistance to systemic chemotherapy. Fortunately, catheter-directed and percutaneous locoregional approaches have evolved as major treatment modalities for unresectable metastatic disease. These novel techniques can be used for diverse applications ranging from curative intent for small localized tumors, downstaging of large tumors for resection, or locoregional control and palliation of advanced disease. Their use has been associated with increased tumor response, increased disease-free and overall survival, and decreased morbidity and mortality in a broad range of metastatic disease. This review explores recent advances in liver-directed therapies for metastatic liver disease from primary colorectal, neuroendocrine, breast, and lung cancer, as well as uveal melanoma, cholangiocarcinoma, and sarcoma. Therapies discussed include bland transarterial embolization, chemoembolization, radioembolization, and ablative therapies, with a focus on current treatment approaches, outcomes of locoregional therapy, and future directions in each type of metastatic disease.

Temporal and geospatial variations among the interventional radiology physician workforce in the United States.

OBJECTIVE: To analyze the temporal trends and state-wide geospatial variations in Vascular and Interventional Radiology (VIR) workforce in the United States. METHODS: The State Physician Workforce Data from the AAMC website was accessed for years 2015, 2017, and 2019. The variables collected for each state included total number of active physicians, total number of physicians per specialty and total number of female physicians in VIR. Comparative data was obtained for vascular surgery (VS), diagnostic radiology (DR), and radiation oncology (RO). The annual growth rate for total physicians and sub-analysis of female physicians in each state was computed for each specialty. RESULTS: From 2015 to 2019, the total number of active physicians in the United States grew by 1.8% per year. Growth of active physicians in VIR grew by 8.3%, DR 0.06%, VS 4.4%, and RO 1.9% per year. Colorado and Minnesota had the highest growth rate for VIR physicians (15%). VIR physicians per 100,000 people increased from 0.84 (2015) to 1.10 (2019) in the US. In comparison, VS physicians increased from 0.99 (2015) to 1.14 (2019), DR physicians decreased from 8.61 (2015) to 8.43 (2019), and RO physicians grew from 1.48 (2015) to 1.56 (2019). Women represented 6.8% of the VIR workforce in the US in 2019 and increased by a rate of 16% annually in the US from 2015 to 2019. In comparison, the number of women in VS has grown by 21%, DR by 2%, and RO by 2.4% during the same period. The state of Maryland has the highest proportion of women in VIR at 18%. CONCLUSION: The number of VIR physicians is increasing at a higher rate than the national overall physician growth, and while female VIR physicians makeup a small fraction of the VIR workforce, their numbers have increased at a faster rate than overall VIR physicians.

Retrieval of Bard Simon Nitinol inferior vena cava filters: Approaches, technical successes, complications, and clinical outcomes.

OBJECTIVE: The Simon Nitinol filter is a bi-level filtration device designed for permanent implantation that is no longer commercially available, but may result in similar complications to current commercially available long term indwelling temporary or permanent filters. Complications related to indwelling inferior vena cava filters include inferior vena cava thrombosis, inferior vena cava penetration, filter migration, and filter fracture. There is a paucity of reports describing the technical aspects related to retrieval of Simon Nitinol filters. MATERIALS AND METHODS: This study consisted of five patients with Simon Nitinol filters and describes the indication for retrieval, the retrieval techniques used to remove the filters, technical success, complications, and clinical course. RESULTS: The indications for retrieval included: abdominal pain (n = 2; 40%), iliocaval thrombosis (n = 1; 20%), identification of an intracardiac filter fragment (n = 1; 20%), and recurrent venous thromboembolic events (n = 1; 20%). Retrieval techniques included: biopsy forceps (n = 3; 60%), excimer laser extraction sheaths (n = 3; 60%), hangman modified loop snares (n = 3; 60%), rigid endobronchial forceps (n = 2; 40%), and balloon deflection (n = 2; 40%). All filters were successfully retrieved. One patient developed a post-procedural intramuscular hematoma near the site of right internal jugular sheath placement. CONCLUSIONS: Simon Nitinol filters may be retrieved safely and effectively using advanced inferior vena cava filter retrieval techniques.

Analysis of Demographic and Educational Backgrounds of Interventional Neuroradiology Fellowship Program Director Workforce in North America.

PURPOSE: To analyse the demographics, academic background, and scholarly activity of Interventional Neuroradiology (INR)/Endovascular Surgical Neuroradiology (ESN) program directors (PDs) in the United States (US) and Canada. METHODS: A list of all INR/ESN fellowships was obtained from the Accreditation Council for Graduate Medical Education, the Committee on Advanced Subspecialty Training, maintained by Society of Neurological Surgeons, the NeuroInterventional Training list website maintained by the Society of NeuroInterventional Surgery, and the Neurosurgical Fellowship Training Program Directory website maintained by the American Association of Neurological Surgeons. Online search was performed to identify PDs for these programs. Publicly available sources used to gather information about each PD included the program websites, the HealthGrades and Doximity websites, and Elsevier's Scopus database. Demographic and educational data including age, gender, educational background, subspecialty, appointment age, interval between residency completion and appointment as PD, additional degrees, academic rank, prior leadership positions, and metrics of scholarly activity were recorded. One-way analysis of variance was used to determine differences between the means of different groups. RESULTS: A total of 78 PDs from 72 programs were included, of which 72 (92.3%) were male with the mean age of 49.59 years (SD 7.25). Specialty division of PDs was neurosurgery (40, 51.3%), radiology (26, 33.3%), and neurology (10, 12.8%), whereas 2 PDs were dual board-certified in neurology and radiology. Twenty-five (32.1%) PDs attended an international medical school. All PDs received an MD degree or foreign equivalent, with no PD holding a DO degree. Eleven PDs received a PhD degree and 16 PDs received fellowship from a professional medical society. The mean ± SD publications, citations, and h-indexes of PDs were 111.32 ± 121.18, 2985.0 ± 1459.0 and 22.27 ± 15.45, respectively. There was no statistical difference in scholarly activity among PDs when stratified on the basis of specialty, gender, and US region. CONCLUSION: INR/ESN PDs are predominantly male, with a majority from neurosurgery background, and thirty percent having graduated from international medical schools.

Critical Evaluation of Interventional Neuroradiology Fellowship Program Websites in North America.

OBJECTIVE: To investigate the accessibility and content of interventional neuroradiology (INR) fellowship program websites in North America. METHODS: We obtained a list of INR/endovascular surgical neuroradiology (ESN) fellowship programs from the Accreditation Council for Graduate Medical Education, the Committee on Advanced Subspecialty Training, the Society of NeuroInterventional Surgery, and the Neurosurgical Fellowship Training Program Directory websites. Individual program websites were evaluated for 27 different fellow recruitment and education criteria. U.S. programs were grouped based on census region and national ranking, and differences between these groups with regard to fellow recruitment and education characteristics were analyzed using nonparametric statistics. RESULTS: A total of 79 INR/ESN fellowship websites were evaluated for presence of fellow recruitment and education features. Approximately one third of all features pertinent to recruitment (32.11%) and approximately 1 in 5 features regarding education (19.11%) were described in these websites. Program description (69.6%), program coordinator/administrator contact e-mail (59.5%), program director's name (59.5%), program eligibility requirements (51.9%), research opportunities (40.5%), and faculty listing (39.2%) were among the most frequently described features, whereas details about parking (1.3%), interview day itinerary (1.3%), meal allowance (2.5%), retirement and benefits (3.8%), and call schedule (5.1%) were the least frequently described features. There was no significant difference between surveyed features and programs when stratified by U.S. census region, neurosurgery/neurology hospital rankings, or accreditation status. CONCLUSIONS: INR/ESN fellowship website content is variable across North America and there is room for improvement to develop and enhance comprehensiveness of program website content.

Increasing Volume of Bone Marrow Biopsies by Radiology Providers: Evaluation of Trends by Physician Specialty and Practice Setting.

PURPOSE: The aim of this study was to evaluate trends in bone marrow biopsies performed in the United States by physician specialty and practice setting. METHODS: The CMS Medicare Physician Supplier Procedure Summary database was queried from 2005 to 2016 for bone marrow biopsies and aspirations (BMBs). Data were categorized according to the largest subspecialty groups (medicine, surgery, radiology, pathology, and other) and encounter setting (office, inpatient hospital, and outpatient hospital). Trends in procedure volume by specialty and practice setting were evaluated. RESULTS: Between 2005 and 2016, an annual average of 11,417 BMBs were performed (range, 10,380-14,204), with no significant year-over-year change in volume. Medicine was the largest provider of BMBs by specialty, although their market share over this time period declined from 60.2% to 36.6%. Radiology saw the greatest growth in BMB market share from 4.1% to 16.2%. The compound annual growth rate (CAGR) of BMBs performed by medicine subspecialists demonstrated a decrease in year-over-year procedural volume at -5.16% (P < .001). Both surgery and radiology demonstrated positive trends in the number of BMBs performed, with CAGRs of 6.20% (P < .001) and 12.43% (P < .001), respectively. Independent of physician specialty, there was a decrease in the number of biopsies performed in the office setting, decreasing by a CAGR of -5.59% (P < .001). CONCLUSIONS: From 2005 to 2016, medicine has remained the primary provider of BMBs, although their market share has declined. Radiology has experienced the greatest rate of growth in this time period and now represents the third largest individual specialty providing this service.

Medial meniscal extrusion: Detection, evaluation and clinical implications.

The menisci play an important role in knee kinematics. Their unique anatomy allows them to channel forces generated during knee movements through the larger tibio-femoral condylar surfaces while simultaneously resisting deleterious hoop stresses. Although physiologic meniscal extrusion occurs with every knee joint movement, pathologic meniscal extrusion subjects the knee to persistent and excessive load transmission. This renders the knee structures susceptible to injury or exacerbates worsening of existing knee joint internal derangement. Detection and quantification of meniscus extrusion is important given its association with underlying pathological processes and internal derangements such as cartilage loss, osteoarthritis and meniscal tears. The medial and lateral menisci vary in size, attachments and load transmission, and the medial meniscus is more susceptible to injury. In this article, the authors illustrate the role of meniscus kinematics, and the identification and quantification of medial meniscal extrusion. Multimodality imaging appearances and implications of presence of medial meniscal extrusion in different knee joint pathologies are discussed with review of the relevant literature.

Series of rare lung diseases mimicking imaging patterns of common diffuse parenchymal lung diseases.

Diffuse parenchymal lung diseases (DPLDs) encompass a variety of restrictive and obstructive lung pathologies. In this article, the authors discuss a series of rare pulmonary entities and their high-resolution computed tomography imaging appearances, which can mimic more commonly encountered patterns of DPLDs. These cases highlight the importance of surgical lung biopsies in patients with imaging findings that do not show typical imaging features of usual interstitial pneumonia.

Not All Orbitopathy Is Graves': Discussion of Cases and Review of Literature.

INTRODUCTION: Graves' orbitopathy is the extra thyroidal manifestation of Graves' disease and the most common cause of exophthalmos. It is also known as thyroid-associated orbitopathy (TAO) as it occasionally occurs in euthyroid or hypothyroid patients with chronic thyroiditis. 5% of patients with Graves' orbitopathy can be euthyroid or hypothyroid as they have low titers of anti-thyrotropin-receptor antibodies, which are difficult to detect in some assays. Orbitopathy has also been seen in a small percentage of patients with Hashimotos thyroiditis. The eye involvement in Graves' is frequently bilateral and symmetric. These patients pose few diagnostic difficulties when the ocular findings occur concomitantly with the thyroid disease. However, when unilateral and asymmetric ocular findings occur with normal or mildly abnormal thyroid function tests, alternate etiologies should also be pursued. We aim to discuss some conditions like sarcoidosis, lymphoma, orbital pseudotumor, and orbital malignancy that mimic TAO. CASES: Three patients were referred to us with concern for Graves' orbitopathy. After further work-up, we diagnosed the first patient with specific orbital myositis from sarcoidosis. Our second patient had CD10-positive B-cell lymphoma. Our third patient had orbitopathy likely secondary to Hashimotos or orbital pseudotumor. CONCLUSION: Our cases and discussion describe some other conditions that clinically mimic TAO and the importance of pursuing further work-up for accurate diagnosis when presentation of orbitopathy is atypical.

Kinematic Magnetic Resonance Imaging of Peroneal Tendon Subluxation with Intraoperative Correlation.

Magnetic resonance imaging (MRI) is a noninvasive modality of choice for the detection of static peroneal tendon pathologic features. The depiction of peroneal tendon subluxation using real-time kinematic MRI has not been previously reported. We describe the MRI and intraoperative correlation of peroneal tendon and retinacular pathologic findings, and the novel use of kinematic MRI in the illustration of peroneal tendon subluxation.

Evaluation of Myocardial Strain in Patients With Amyloidosis Using Cardiac Magnetic Resonance Feature Tracking.

PURPOSE: To study the use of cardiac magnetic resonance (CMR) feature tracking technique in evaluation of myocardial amyloidosis. MATERIALS AND METHODS: CMR scans of 28 patients with biopsy proven myocardial amyloidosis and 35 controls were reviewed. Conventional short axis, vertical long axis, and 4-chamber cine steady-state free precession images from CMR scans were used to generate radial, circumferential, and longitudinal myocardial strain maps using feature tracking software. Global and regional peak radial, circumferential, and longitudinal strain values were computed. RESULTS: There were significant decreases in radial, circumferential, and longitudinal strains in patients with myocardial amyloidosis globally and across layers (all P < 0.001). Strain was relatively preserved for the apex and most affected for the basal level. The area under the receiver operating characteristic curve for base peak radial, circumferential, and longitudinal strain 0.899, 0.884, and 0.866 and cut offs of 22.9, -13.3, and -10.9, respectively, were determined by receiver operating characteristic analysis. CMR feature tracking strain analysis of base-level strain parameters was able to differentiate patients with myocardial amyloidosis from those without myocardial amyloid with high sensitivity (82.5%) and specificity (82.9%) particularly for radial strain. The maximum sensitivity (89.3%) was achieved if any of the 3 parameters were abnormal, and the maximum specificity (88.6%) when all 3 parameters were abnormal. CONCLUSION: Myocardial amyloidosis produces significant changes in regional and global strain parameters, and the peak radial and circumferential strain are the most affected at the basal layer.

Ipilimumab Induced Hypophysitis: MRI Findings in a Series of 3 Cases.

ypophysitis is a reported compli- cation of ipilimumab, a monoclo- nal antibody which augments T- cell response against tumors. The imaging changes in the pituitary may precede or coincide with the hypopituitarism, but are frequently over- looked due to the subtle alteration in size and en- hancement characteristics. We present a series of 3 patients who developed hypophysitis and pituitary dysfunction subsequent to ipilimumab therapy and describe the MR imaging features and make follow up recommendations.

MRI in flexor tendon rupture after collagenase injection.

Flexor tendon rupture is an unusual complication following collagenase injection to relieve contractures. These patients require a close follow-up and in the event of tendon rupture, a decision has to be made whether to repair the tendon or manage the complication conservatively. The authors report the utility of MRI in the prognostication and management of a patient with Dupuytren's contracture, who underwent collagenase injection and subsequently developed flexor digitorum profundus tendon rupture.

CT-guided Perineural Injections for Chronic Pelvic Pain.

Chronic pelvic pain is a disabling condition that affects a large number of men and women. It may occur after a known inciting event, or it could be idiopathic. A common cause of pelvic pain syndrome is neuropathy of the pelvic nerves, including the femoral and genitofemoral nerves, ilioinguinal and iliohypogastric nerves, pudendal nerve, obturator nerve, lateral and posterior femoral cutaneous nerves, inferior cluneal nerves, inferior rectal nerve, sciatic nerve, superior gluteal nerve, and the spinal nerve roots. Pelvic neuropathy may result from entrapment, trauma, inflammation, or compression or may be iatrogenic, secondary to surgical procedures. Imaging-guided nerve blocks can be used for diagnostic and therapeutic management of pelvic neuropathies. Ultrasonography (US)-guided injections are useful for superficial locations; however, there can be limitations with US, such as its operator dependence, the required skill, and the difficulty in depicting various superficial and deep pelvic nerves. Magnetic resonance (MR) imaging-guided injections are radiation free and lead to easy depiction of the nerve because of the superior soft-tissue contrast; although the expense, the required skill, and the limited availability of MR imaging are major hindrances to its widespread use for this purpose. Computed tomography (CT)-guided injections are becoming popular because of the wide availability of CT scanners, the lower cost, and the shorter amount of time required to perform these injections. This article outlines the technique of perineural injection of major pelvic nerves, illustrates the different target sites with representative case examples, and discusses the pitfalls. (©)RSNA, 2016.

Clinical impact of magnetic resonance neurography in patients with brachial plexus neuropathies.

OBJECTIVE: To study the impact of brachial plexus MR neurography (MRN) in the diagnostic thinking and therapeutic management of patients with suspected plexopathy. METHODS: MRN examinations of adult brachial plexuses over a period of 18 months were reviewed. Relevant data collection included-patient demographics, clinical history, pre-imaging diagnostic impression, pre-imaging treatment plan, post-imaging diagnosis, post-imaging treatment plan, surgical notes and electrodiagnostic (ED) results. Impact of imaging on the pre-imaging clinical diagnosis and therapeutic management were classified as no change, mild change or substantial change. RESULTS: Final sample included 121 studies. The common aetiologies included inflammatory in 31 (25.6%) of 121 patients, trauma in 29 (23.9%) of 121 patients and neoplastic in 26 (21.5%) of 121 patients. ED tests were performed in 47 (38.8%) of 121 patients and these showed concordance with MRN findings in 31 (66.0%) of 47 patients. Following MRN, there was change in the pre-imaging clinical impression for 91 (75.2%) of 121 subjects, with a mild change in diagnosis in 57 (47.1%) of 121 patients and a substantial change in 34 (28.0%) of 121 patients. 19 (15.7%) of 121 patients proceeded to therapies that would not have been performed in the same manner without the information obtained from MRN. CONCLUSION: MRN of the brachial plexus significantly impacts clinical decision-making and should be routinely performed in suspected brachial plexopathy. Advances in knowledge: MRN significantly impacts the diagnostic thinking and therapeutic management of patients with suspected brachial plexopathy. MRN not only provides concordant information to ED tests in majority of cases, but also supplements with additional diagnostic data in patients who are ED negative.