Radioembolization of HCC and secondary hepatic tumors: a comprehensive review.

Transarterial radioembolization (TARE), also called Selective Internal Radiation Therapy (SIRT), has emerged as an effective locoregional therapy for primary and secondary hepatic tumors, utilizing yttrium-90 (Y90) microspheres and other agents such as holmium-166 and rhenium-188. TARE has various applications in the management of HCC across different BCLC stages. Radiation segmentectomy, which involves administering high doses of Y90 (>190 Gy), can be both curative and ablative, achieving complete necrosis of the tumor. In contrast, radiation lobectomy involves administering a lower dose of Y90 (80-120 Gy) as a neoadjuvant treatment modality to improve local control and induce future liver remnant (FLR) hypertrophy in patients who are planned to undergo surgery but have insufficient FLR. Modified radiation lobectomy combines both techniques and offers several advantages over portal vein embolization (PVE). Y90 is also used in downstaging HCC patients outside liver transplantation criteria, as well as bridging those awaiting liver transplantation (LT). Multiple studies and combined analyses were described to highlight the outcomes of TARE and compare it with other treatment modalities, including TACE and sorafenib. Additionally, the review delves into the efficacy and safety of radioembolization in managing metastatic colorectal cancer and other metastatic tumors to the liver. Recent studies have emphasized the role of personalized dosimetry for improved outcomes, and thus we described the different methods used for this purpose. Pretherapy imaging, estimating lung shunt, selection of therapeutic radionuclides, adverse effects, and cost-effectiveness were all discussed as well.

Percutaneous Fluoroscopic-Guided Creation of Neoanastomosis for the Treatment of Biliary Occlusions.

PURPOSE: Complete biliary occlusions at different anatomic locations that are not amenable to surgical, endoscopic, or routine percutaneous methods pose a challenge to physicians. Biliary ductal neoanastomosis technique can play a very important role in solving such clinical problems. MATERIALS: Between October 2004 and January 2018, six patients were treated in our institution for biliary drainage using biliary ductal neoanastomosis technique via sharp recanalization and a staged approach to achieve internal/external biliary drainage. All procedures were performed in an angiography suite by an interventional radiologist after multidisciplinary discussion. RESULTS: The mean patient age of the cohort was 54 years and 50% of the patients were female (three/six patients). The cause of obstruction was complications or disease progression after  Whipple procedure in four patients, partial hepatectomy in one patient and benign biliary stricture after radioembolization in one patient. All patients were treated with percutaneous biliary neoanastomosis. All procedures were successfully performed in all six patients (100% technical success) without any major complications. All patients were successfully managed by capped drainage catheters for the duration of the follow up (one patient was transitioned to endoscopically inserted biliary stent, and in one patient the tube was eventually removed after establishment of patent neoanastomosis). CONCLUSIONS: Biliary ductal neoanastomosis is an effective treatment option when the anatomy has been significantly altered in the post-surgical setting and wire cannot be safely passed into target draining organ or the remainder of biliary system. When performed by an experienced operator, this technique is safe and effective with a high technical success rate.

Improved Diagnostic Sensitivity of Bowel Disease of Prematurity on Contrast-Enhanced Ultrasound.

Bowel diseases of prematurity, including necrotizing enterocolitis, are dreaded ailments of neonates. Early diagnosis is difficult, with clinical and radiographic findings often inconclusive. We present a novel use of contrast-enhanced ultrasound in detection of pediatric bowel disease. Early identification of compromised blood flow or an at-risk bowel can be quantitatively detected and monitored. This ability has implications for guidance of emerging therapies, allowing targeting of inflammation. These findings represent an advancement in detection of bowel disease in neonates.

Cost-Effectiveness of Percutaneous Lymphatic Embolization for Management of Plastic Bronchitis.

BACKGROUND: Plastic bronchitis is a dreaded complication of single ventricle physiology occurring following palliation via Fontan procedure. Medical management of plastic bronchitis often fails, requiring heart transplantation. Percutaneous lymphatic embolization is an emerging treatment for plastic bronchitis. METHODS: To determine the cost-effectiveness of competing management strategies, a modified Markov model was constructed with patients transiting through treatments-medical management, lymphatic embolization, or heart transplantation from a hospital system perspective. Health state transitions were modeled using an institutional review board-approved retrospective review of the Children's Hospital of Pennsylvania's plastic bronchitis cohort. Medication pricing data were obtained from the National Inpatient Sample. Differences in costs and quality-adjusted life years (QALYs) over a five-year horizon for each group were determined. The incremental cost-effectiveness ratio was then calculated. RESULTS: The mean cost of lymphatic embolization from procedure performance was US$340,941, US$385,841 for heart transplantation, and US$594,520 for medical management. The mean quality-adjusted survival of lymphatic embolization yielded an additional 0.66 QALYs (P < .03) relative to heart transplantation and 1.3 (P < .0001) relative to medical management. Orthotopic heart transplantation yielded an additional 0.66 QALYs (P = .06) when comparing heart transplantation to medical management. Compared to medical management, lymphatic embolization generated an incremental cost-effectiveness ratio of US$192,105. Similarly, compared to heart transplantation, lymphatic embolization yielded an incremental cost-effectiveness ratio of US$68,030. CONCLUSIONS: Of the available plastic bronchitis treatments, with a willingness to pay of US$150,000, lymphatic embolization produces an incremental cost-effectiveness ratio within the bounds considered to be cost-effective, potentially causing financial benefits to the health system.

Ergonomics in the Development and Prevention of Musculoskeletal Injury in Interventional Radiologists.

Interventional radiology is a constantly evolving specialty overlapping with multiple other specialties, including cardiology, vascular surgery, orthopedic surgery, urology, and minimally invasive surgery. Unique ergonomic considerations for interventional radiology include utilization of intraoperative viewing monitors and personal radiation protection equipment. Work-related injuries are common in interventional radiologists,1 often leading to pain while performing procedures or during time away from work. This review article aims to identify the ergonomic challenges related to interventional radiology and provide background, guidelines, and specific recommendations for prevention of musculoskeletal injury.

Intestinal epithelial autophagy is essential for host defense against invasive bacteria.

The mammalian intestine is colonized with a diverse community of bacteria that perform many beneficial functions but can threaten host health upon tissue invasion. Epithelial cell-intrinsic innate immune responses are essential to limit the invasion of both commensal and pathogenic bacteria and maintain beneficial host-bacterial relationships; however, little is known about the role of various cellular processes, notably autophagy, in controlling bacterial interactions with the intestinal epithelium in vivo. We demonstrate that intestinal epithelial cell autophagy protects against tissue invasion by both opportunistically invasive commensals and the invasive intestinal pathogen Salmonella Typhimurium. Autophagy is activated following bacterial invasion of epithelial cells through a process requiring epithelial cell-intrinsic signaling via the innate immune adaptor protein MyD88. Additionally, mice deficient in intestinal epithelial cell autophagy exhibit increased dissemination of invasive bacteria to extraintestinal sites. Thus, autophagy is an important epithelial cell-autonomous mechanism of antibacterial defense that protects against dissemination of intestinal bacteria.

Gammadelta intraepithelial lymphocytes are essential mediators of host-microbial homeostasis at the intestinal mucosal surface.

The mammalian gastrointestinal tract harbors thousands of bacterial species that include symbionts as well as potential pathogens. The immune responses that limit access of these bacteria to underlying tissue remain poorly defined. Here we show that γδ intraepithelial lymphocytes (γδ IEL) of the small intestine produce innate antimicrobial factors in response to resident bacterial "pathobionts" that penetrate the intestinal epithelium. γδ IEL activation was dependent on epithelial cell-intrinsic MyD88, suggesting that epithelial cells supply microbe-dependent cues to γδ IEL. Finally, γδ T cells protect against invasion of intestinal tissues by resident bacteria specifically during the first few hours after bacterial encounter, indicating that γδ IEL occupy a unique temporal niche among intestinal immune defenses. Thus, γδ IEL detect the presence of invading bacteria through cross-talk with neighboring epithelial cells and are an essential component of the hierarchy of immune defenses that maintain homeostasis with the intestinal microbiota.