Unreimbursed Costs of Multidisciplinary Conferences to a Radiology Department: A Prospective Analysis at an Academic Medical Center.

PURPOSE: Multidisciplinary conferences (MDCs) are important for clinical care but are unreimbursed and can be time-consuming for radiologists to prepare for and present. The purpose of this single-center, prospective, survey-based study is to measure the per-conference time and total time radiologists devote to MDCs at a single academic medical center. Secondary objectives are to determine the source of radiologist preparation time, and calculate the per conference and overall radiology departmental costs of MDC participation. METHODS: A prospective survey was performed to capture all radiology preparation and presentation time for MDCs in a 3-month period, which was then annualized. Total cost was calculated on the basis of Association of Administrators in Academic Radiology survey data for nonchair academic radiologist compensation plus a 30% fringe-benefit rate. RESULTS: The survey response rate was 86.9%. A total of 3,358 hours were devoted annually to MDCs, which represents time equivalent to 1.9 full-time equivalents or $1,155,152 in unreimbursed radiology departmental costs. Per-MDC total preparation and presentation time was 2.7 hours, at an annual cost of $46,440 for each weekly MDC. Radiologists used a combination of personal time (49.7%), academic time (42%), and/or clinical time (35.4%) to prepare for MDCs. Radiologists devoted a mean of 47.9 hours (1.2 weeks) of time per annum to MDCs. CONCLUSIONS: Radiologist time devoted to MDCs at the survey institution was substantial, and preparation time was drawn disproportionately from personal and academic time, which may have negative implications for burnout, recruitment and retention, and academic productivity unless it is effectively mitigated.

Report of a national conference on liver allocation in patients with hepatocellular carcinoma in the United States.

A national conference was held to better characterize the long-term outcomes of liver transplantation (LT) for patients with hepatocellular carcinoma (HCC) and to assess whether it is justified to continue the policy of assigning increased priority for candidates with early-stage HCC on the transplant waiting list in the United States. The objectives of the conference were to address specific HCC issues as they relate to liver allocation, develop a standardized pathology report form for the assessment of the explanted liver, develop more specific imaging criteria for HCC designed to qualify LT candidates for automatic Model for End-Stage Liver Disease (MELD) exception points without the need for biopsy, and develop a standardized pretransplant imaging report form for the assessment of patients with liver lesions. At the completion of the meeting, there was agreement that the allocation policy should result in similar risks of removal from the waiting list and similar transplant rates for HCC and non-HCC candidates. In addition, the allocation policy should select HCC candidates so that there are similar posttransplant outcomes for HCC and non-HCC recipients. There was a general consensus for the development of a calculated continuous HCC priority score for ranking HCC candidates on the list that would incorporate the calculated MELD score, alpha-fetoprotein, tumor size, and rate of tumor growth. Only candidates with at least stage T2 tumors would receive additional HCC priority points.

Comparison of percutaneous and laparoscopic cryoablation for the treatment of solid renal masses.

OBJECTIVE: The goal of this study was to compare the outcome, complications, and charges of percutaneous renal cryoablation and laparoscopic cryoablation of solid renal masses. MATERIALS AND METHODS: A total of 30 percutaneous renal cryoablations (mean tumor size, 2.1 cm) in 30 patients (mean age, 67.0 years) and 60 laparoscopic renal cryoablations (mean tumor size, 2.5 cm) in 46 patients (mean age, 67.4 years) were compared. The size of the tumor, procedural complications, hospital charges, length of hospital stay, and tumor follow-up parameters were recorded. Monitoring after ablation was performed every 3 months using contrast-enhanced MRI or CT. RESULTS: Both percutaneous cryoablation and laparoscopic cryoablation of solid renal masses had a high technical success rate (30/30 [100%] and 59/60 [98.3%]). There was no significant difference in the rate of residual disease (3/30 [10%] and 4/60 [6.7%], p = 0.68), and the secondary effectiveness rate is 100% for both groups to date. One renal mass treated using laparoscopic cryoablation had a local recurrence, but none of the masses treated using percutaneous cryoablation had a recurrence. The disease-specific survival is 100% in both groups with no significant difference in the mean follow-up time (14.5 vs 14.6 months, p = 1.0) or major complication rate (0/30 [0%] vs 3/60 [5.0%], p = 0.55). For the treatment of solid renal masses, percutaneous cryoablation was associated with 40% lower hospital charges (mean, $14,175 vs $23,618, p < 0.00001) and a shorter hospital stay (mean +/- SD, 1.1 +/- 0.3 vs 2.4 +/- 2.1 days; p < 0.0001) than laparoscopic cryoablation. CONCLUSION: Although certain tumors require laparoscopic intervention because of the location or size of the tumor, percutaneous renal cryoablation is safe and effective and is associated with lower charges when used for the treatment of small renal tumors.

Cryoablation of small renal masses: assessment of the outcome at one institution.

OBJECTIVE: To report our 5-year experience with laparoscopic and percutaneous cryoablation (LCA and PCA) for managing small renal masses. PATIENTS AND METHODS: We retrospectively analysed patients undergoing LCA and PCA between October 2000 and March 2006 at our institution. After approval from the Institutional Review Board, charts were reviewed retrospectively for variables during and after CA, and for clinical outcomes, the latter including the efficacy of the procedure in achieving overall, cancer-specific and recurrence-free survival. RESULTS: In all, 78 patients had CA of 88 small renal masses, by LCA in 58 and PCA in 20. The median American Society of Anesthesiology score was 3 and the mean body mass index was 30 kg/m(2). All procedures were done under general anaesthesia, with a mean anaesthesia time of 220 min. The mean tumour size was 2.6 cm and the mean hospital stay was 2.1 days. At a mean follow-up of 19 months, the overall, cancer-specific and recurrence-free survival rates were 88.5%, 100% and 98.7%, respectively. Four patients required a repeat treatment due to persistent disease and one had progression to locally advanced disease. Five patients had complications during CA and seven had complications afterward. CONCLUSION: This study suggests that CA is a safe, minimally invasive treatment option for patients with small renal masses, at the intermediate-term follow-up.

Phase I trial of a monoclonal antibody specific for alphavbeta3 integrin (MEDI-522) in patients with advanced malignancies, including an assessment of effect on tumor perfusion.

At present, a variety of agents targeting tumor angiogenesis are under clinical investigation as new therapies for patients with cancer. Overexpression of the alpha(v)beta(3) integrin on tumor vasculature has been associated with an aggressive phenotype of several solid tumor types. Murine models have shown that antibodies targeting the alpha(v)beta(3) integrin can affect tumor vasculature and block tumor formation and metastasis. These findings suggest that antibodies directed at alpha(v)beta(3) could be investigated in the treatment of human malignancies. The current phase I dose escalation study evaluated the safety of MEDI-522, a monoclonal antibody specific for the alpha(v)beta(3) integrin, in patients with advanced malignancies. Twenty-five patients with a variety of metastatic solid tumors were treated with MEDI-522 on a weekly basis with doses ranging from 2 to 10 mg/kg/wk. Adverse events were assessed weekly; pharmacokinetic studies were done; and radiographic staging was done every 8 weeks. In addition, dynamic computed tomography imaging was done at baseline and at 8 weeks in patients with suitable target lesions amenable to analysis, to potentially identify the effect of MEDI-522 on tumor perfusion. Treatment was well tolerated, and a maximum tolerated dose was not identified by traditional dose-limiting toxicities. The major adverse events observed were grade 1 and 2 infusion-related reactions (fever, rigors, flushing, injection site reactions, and tachycardia), low-grade constitutional and gastrointestinal symptoms (fatigue, myalgias, and nausea), and asymptomatic hypophosphatemia. Dynamic computed tomography imaging suggested a possible effect on tumor perfusion with an increase in contrast mean transit time from baseline to the 8-week evaluation with increasing doses of MEDI-522. No complete or partial responses were observed. Three patients with metastatic renal cell cancer experienced prolonged stable disease (34 weeks, >1 and >2 years) on treatment. With this weekly schedule of administration, and in the doses studied, MEDI-522 seems to be without significant toxicity, may have effects on tumor perfusion, and may have clinical activity in renal cell cancer. These findings suggest the MEDI-522 could be further investigated as an antiangiogenic agent for the treatment of cancer.

Using a saline chaser to decrease contrast media in abdominal CT.

OBJECTIVE: The purpose of this study was to compare hepatic tumor conspicuity on CT after injection of either 150 mL of contrast material or 100 mL of contrast material plus a 50-mL saline chaser. SUBJECTS AND METHODS: We evaluated 86 hypoattenuating liver metastases in 26 patients. Patients underwent CT in two sessions separated by a mean of 85 days: one time with 150 mL of contrast material and the other time with 100 mL of contrast material followed by a 50-mL saline chaser. The order of the sessions was randomized. Contrast material was administered via power injector and matched for injection rate and delay time. Attenuation values were obtained from normal liver tissue and metastases and from the spleen, kidney, aorta, and inferior vena cava. RESULTS: The 150 mL dose of contrast material caused slightly greater liver and tumor attenuation than 100 mL of contrast material with a chaser (mean hepatic attenuation, 95.6 vs 89.8 H, respectively; p < 0.03, paired t test; mean tumor attenuation, 53.2 vs 49.1 H, respectively; r = 0.71, p = 0.09). The difference in conspicuity of liver lesions was slightly greater with 150 mL than with 100 mL with a chaser (46.8 H vs 44.2 H; r = 0.46, p = 0.08, paired t test), but was of doubtful clinical significance (2.6 H). Kidney, spleen, and vascular structures enhanced more with 150 mL than with 100 mL and a chaser. CONCLUSION: Using 100 mL of contrast material and a saline chaser did not result in a meaningful difference in liver parenchyma attenuation or lesion conspicuity compared with using 150 mL of contrast medium alone. Routine use of a chaser for abdominal CT may yield cost savings and a decreased risk of contrast nephropathy.