Transradial versus Transfemoral Access for Hepatic Chemoembolization: Intrapatient Prospective Single-Center Study.

PURPOSE: To compare transfemoral approach (TFA) and transradial approach (TRA) in patients undergoing hepatic chemoembolization in terms of safety, feasibility, and procedural variables, including fluoroscopy time, radiation dose (reference air kerma [RAK]), and patient preference. MATERIALS AND METHODS: A single-center prospective intrapatient comparative study was conducted with 42 consecutive patients with hepatic malignancies who received 2 consecutive treatment sessions of unilobar hepatic chemoembolization within a 4-week interval over a 6-month period with both TRA and TFA. All procedures were performed by 1 interventional radiologist who assessed the eligibility of patients for inclusion in the study. The primary endpoint was intraprocedural conversion rate. Secondary endpoints were access site complications, angiographic and procedural variables, and evaluation of patient discomfort and preferences. RESULTS: A 100% technical success rate and a crossover rate of 0% were recorded. There were no major vascular complications and similar rates of minor complications (4.8% for TRA, 7.1% for TFA; P = .095), which were self-limited and without any clinical sequelae. TRA treatments required a significantly longer preparation time for the procedure (P = .008) with no significant differences for other procedural variables. Greater discomfort at the access route and patient inability to perform basic activities after the procedure were recorded for TFA (P < .001). TRA was preferred by 35 patients (35/42) for potential future transarterial procedures. CONCLUSIONS: TRA is safe and feasible for transarterial hepatic chemoembolization, with high technical success, low overall complications, and improved patient comfort.

Persistent Urogenital Sinus: Diagnostic Imaging for Clinical Management. What Does the Radiologist Need to Know?

BACKGROUND: Persistent urogenital sinus (PUGS) is a congenital pathological condition characterized by an abnormal communication between the urethra and vagina. It may be a part of a complex syndrome and can be more often associated with congenital malformations affecting the genitourinary tract system (33%) such as intersex, rectovaginal communication, bladder agenesis, absence of vagina, and hydrocolpos. The correct radiological assessment of PUGS is especially useful for clinicians since the exact anatomical evaluation of this abnormality is a crucial factor for surgical planning. The imaging study modalities, which are essentially based on ultrasonography, voiding cystourethrography, and magnetic resonance imaging, could be misinterpreted if not correctly performed. AIM: The aim of this article is to highlight this rare pathological condition and to help general radiologists in achieving the correct technical approach for the diagnosis. Special attention will be paid in discussing the role of different imaging modalities and their contribution to the diagnosis and clinical management of patients.

Combination of Local Ablative Techniques with Radiotherapy for Primary and Recurrent Lung Cancer: A Systematic Review.

In patients with early-stage or recurrent NSCLC who are unable to tolerate surgery, a benefit could derive only from a systemic therapy or another few forms of local therapy. A systematic review was performed to evaluate the feasibility and the effectiveness of radiotherapy combined with local ablative therapies in the treatment of primary and recurrent lung cancer in terms of toxicity profile and local control rate. Six studies featuring a total of 115 patients who met eligibility criteria and 119 lesions were included. Three studies evaluated lung cancer patients with a medically inoperable condition treated with image-guided local ablative therapies followed by radiotherapy: their local control rate (LC) ranged from 75% to 91.7% with only 15 patients (19.4%) reporting local recurrence after combined modality treatment. The other three studies provided a salvage option for patients with locally recurrent NSCLC after RT: the median follow-up period varied from 8.3 to 69.3 months with an LC rate ranging from 50% to 100%. The most common complications were radiation pneumonitis (9.5%) and pneumothorax (29.8%). The proposed intervention appears to be promising in terms of toxicity profile and local control rate. Further prospective studies are need to better delineate combining LTA-RT treatment benefits in this setting.

MRI in uterine cancers with uncertain origin: Endometrial or cervical? Radiological point of view with review of the literature.

Therapeutic options and clinical management of cervical and endometrial cancers differs significantly. When clinical and histological analysis of a uterine mass are unable to differentiate between an endocervical or endometrial origin, magnetic resonance imaging (MRI) plays a pivotal role in discriminating the anatomical origin, supporting the clinician in the treatment planning. Cervical adenocarcinomas are more likely to be centered in the cervical region and involving both cervical canal and stromal ring, with possible parametrial invasion. Endometrial adenocarcinomas usually present an elongated morphology and are centered in the endometrial cavity predominantly involving endometrium and myometrium. On contrast-enhanced sequences, cervical cancers are more frequently hypervascular compared to endometrial cancers. In cases of uncertain findings, diffusion-weighted imaging (DWI) can provide additional helpful information with significantly higher apparent coefficient diffusion (ADC) values in cervical adenocarcinomas compared to endometrial adenocarcinomas. However, even when MRI cannot precisely reveal the origin of the tumor, it provides valuable information on several prognostic factors that can help treatment planning.

Features of cystadenofibroma on magnetic resonance imaging: an update using the O-RADS lexicon and considering diffusion-weighted and perfusion imaging.

PURPOSE: Cystadenofibroma (CAF) is a rare tumour of the ovary that can be confused with a borderline or malignant lesion due to its morphological characteristics. The study aims to analyse the MRI (magnetic resonance imaging) features of histologically proven ovarian cystadenofibromas according to lexicon-based and O-RADS (Ovarian-Adnexal Reporting and Data System) descriptors, with particular attention to time-intensity curves (TIC) and Diffusion-Weighted sequences (DWI); we also wanted to test the performance of O-RADS MRI risk stratification system in this particular subgroup of patients. METHODS: We have included all patients who performed MR between October 2019 and December 2021 after an inconclusive trans-vaginal ultrasound. All patients underwent surgery with histological results of CAF. According to the O-RADS lexicon, we reported the morphological characteristics of each lesion and their appearance in the perfusion-weighted imaging (PWI) and DWI sequences. We assessed the risk of malignancy for each lesion through O-RADS MRI score. RESULTS: Twenty-one histologically proven CAF were analysed, of which 20 benign and one borderline with degeneration into adenocarcinoma. We described the typical morphological characteristics of CAF according to lexicon-based and O-RADS descriptors. Analysis of time-intensity curves (TIC) in PWI sequences showed a slow and progressive enhancement of solid tissue (type I curve), configuring an O-RADS score of 2 or 3, except for the only malignant lesion that showed a type II curve and restriction in DWI (O-RADS 4). CONCLUSIONS: Our study is the largest comprising PWI and DWI sequences, highlighting their pivotal role. O-RADS score correctly classified the masses as benign or malignant.

Multimodal locoregional procedures for cancer pain management: a literature review.

Pain is the most common and fearsome symptom in cancer patients, particularly in the advanced stage of disease. In cancer pain management, the first option is represented by analgesic drugs, whereas surgery is rarely used. Prior to considering surgical intervention, less invasive locoregional procedures are available from the wide pain management arsenal. In this review article, comprehensive information about the most commonly used locoregional options available for treating cancer pain focusing on interventional radiology (neurolysis, augmentation techniques, and embolization) and interventional radiotherapy were provided, also highlighting the potential ways to increase the effectiveness of treatments.

Outpatient Transradial Emborrhoid Technique: A Pilot Study.

PURPOSE: To determine whether outpatient transradial emborrhoid technique can be performed safely and effectively in the treatment of symptomatic hemorrhoids. MATERIALS AND METHODS: The transradial emborrhoid technique was used to treat 12 patients with symptomatic hemorrhoids in an outpatient setting during a 4-month period. After percutaneous catheterization of the left radial artery, a 5-Fr sheath was introduced to catheterize the inferior mesenteric artery and a microcatheter was advanced into the branches of the superior rectal artery for embolization with 0.018-inch detachable coils (Interlock and IDC-interlocking detachable coils). After embolization, the sheath was withdrawn and puncture site hemostasis was achieved using a wrist band. All patients were evaluated 6 h after the procedure to determine whether they meet the discharge criteria and were discharged the following day. The results of the emborrhoid treatment were assessed at the 4-week follow-up. RESULTS: The emborrhoid technique was successful in all patients. There was no major complication associated with the procedure. All patients met the discharge criteria 6 h after the procedure. Reduction of local edema and of hemorrhoidal congestion was observed in all patients. At the follow-up visit, the mean Rorvik score (HDSS + SHS-HD) decreased from 31.50 (7.50) to 13.11 (8.33) (p < .001). CONCLUSIONS: Transradial rectal artery embolization is a safe and effective treatment option for patients with chronic symptoms of hemorrhoid disease.

Prognostic Factors for Surgical Failure in Malignant Bowel Obstruction and Peritoneal Carcinomatosis.

Introduction: Patients with peritoneal metastasis frequently develop malignant bowel obstruction (MBO). Medical palliative management is preferred but often fails. Conversely, the role of palliative surgery remains unclear and debated. This study aims to identify patients who could benefit from invasive surgical interventions and factors associated with successful surgical palliation. Materials and Methods: In this retrospective study, 98 consecutive patients who underwent palliative surgery for MBO over 5 years were reviewed. We evaluate as the primary outcome surgical failure to select patients who could benefit from palliative surgery, avoiding unnecessary surgery. A prognostic score was developed based on a logistic regression model to identify patients at risk of surgical failure. The score was evaluated for overall accuracy by receiver operating characteristic curve analysis. Results: Palliative surgery was achieved in 76 (77.5%) patients. The variables that were found to be significant factors for surgical failure are recurrent disease (P = 0.015), absence of bowel obstruction (P < 0.001), absence of bowel distension (P < 0.001), and mesenteric involvement (P = 0.001) and retraction (P < 0.001). The absence of bowel distension (P = 0.046) and bowel obstruction (P = 0.012) emerged as independent predictors of surgical failure. Carcinomatosis level assessment for peritoneum score, based on these factors, was built to evaluate the risk of surgical failure. Conclusion: Our proposed scoring system might help select patients most likely to benefit from palliative surgery.

MRI Staging in Locally Advanced Vulvar Cancer: From Anatomy to Clinico-Radiological Findings. A Multidisciplinary VulCan Team Point of View.

MR imaging provides excellent spatial and contrast resolution to stage locally advanced vulvar cancer (LAVC) for tumor and nodal evaluation in order to facilitate the planning of treatment. Although there are no standard indications for how to estimate the clinical stage of International Federation of Gynecology and Obstetrics at diagnosis, MR imaging can depict the tumor and its extension to the vulvar region and adjacent organs, such as the vagina, urethra, and anus. Optimizing the MR imaging protocol and technique is fundamental for correct staging. The aim of this overview was to focus on the role of MR imaging in LAVC staging. We define vulvar anatomy and corresponding MR imaging findings, MR imaging protocol, and technique. Moreover, we describe the MR imaging findings of LAVC with example cases stage by stage. Key imaging findings based on signal intensity, diffusion restriction, and enhancement are portrayed to correctly identify and stage vulvar cancer. A structured report for LAVC staging is reported in order to give all necessary information to the clinicians and to facilitate MR imaging comprehension.

Radiologist Checklist for Selecting Patients to Undergo PIPAC (Pressurized IntraPeritoneal Aerosol Chemotherapy).

Peritoneal carcinomatosis frequently occurs in advanced gastrointestinal and gynecological cancers. As factors such as poor drug uptake and distribution cause chemotherapy to be less effective, alternative therapies have been explored. Introduced in 2013, PIPAC (pressurized intraperitoneal aerosol chemotherapy) uses aerosolized chemotherapeutics sprayed into the patient's peritoneal cavity using a laparoscopic approach. Despite the literature showing encouraging data regarding the tolerability and efficacy of PIPAC, there is a lack of articles on the role that imaging plays in selecting patients suitable for PIPAC. The aim of this study is to combine literature-based evidence and clinical experience to provide information able to support training radiologists, as well as experienced radiologists interested in innovative therapies.

Immunotherapy-Related Imaging Findings in Patients with Gynecological Malignancies: What Radiologists Need to Know.

Immunotherapy is an effective treatment option for gynecological malignancies. Radiologists dealing with gynecological patients undergoing treatment with immune checkpoint inhibitors should be aware of unconventional immune-related imaging features for the evaluation of tumor response and immune-related adverse events. In this paper, immune checkpoint inhibitors used for gynecological malignancies and their mechanisms of action are briefly presented. In the second part, patterns of pseudoprogression are illustrated, and different forms of immune-related adverse events are discussed.

Depiction of periprostatic nerve fibers by means of 1.5 T diffusion tensor imaging.

PURPOSE: The knowledge of periprostatic nerve fiber (pNF) is still incomplete by means of conventional MRI. The purpose of our study was to demonstrate if DTI imaging is able to depict anatomical features of pNF. METHODS: For this retrospective study, fifty-six patients (mean age 63.5 years), who underwent 1.5-T prostate MRI, including 32 directions DTI, were enrolled between October 2014 and December 2018. ANOVA test and Student's t-test were performed between the mean values of the number, FA values, and fiber length of pNF between base and mid-gland, mid-gland and apex, base and apex, right and left side, and anterior and posterior face of the prostate. A qualitative analysis was performed to detect the main orientation of pNF through a colorimetric 3D tractographic reconstruction. RESULTS: The number of pNF showed a decrease from the base (322) to mid-gland (248) and apex (75) (p < 0.05). The FA values were higher at base and mid-gland (0.435 and 0.456) compared to the apex (0.313) (p < 0.05). The length of pNF was higher at apex (13.4 mm) compared to base (11.5 mm) and mid-gland (11.7 mm) (p < 0.05). The number of pNF was higher on the posterior face compared to the anterior face at base (186 vs 137), (p < 0.001). The FA values were higher on the posterior face compared to the anterior face at base (0.452 vs 0.417), mid-gland (0.483 vs 0.429), and apex (0.42 vs 0.382), (p < 0.05). The length of the pNF was higher in the posterior (14.7 mm) than in the anterior face (12 mm) at apex (p < 0.001). The main orientation of pNF was longitudinal in all patients (56/56, 100%). CONCLUSIONS: DTI imaging has been demonstrated able to depict anatomical features of pNF.

Prognostic CT findings of malignant bowel obstruction in patients with advanced ovarian cancer.

OBJECTIVE: To evaluate computed tomography (CT) findings able to predict outcome in patients with ovarian cancer (OC) and concomitant bowel occlusion. METHODS: This institutional review board-approved retrospective study included 31 patients with OC and clinical evidence of bowel occlusion who underwent CT at presentation between February 2013 and June 2015. Two radiologists recorded various qualitative CT features. Correlations between CT and survival data were made with Mann-Whitney test, Wilcoxon test, and χ2 test, as appropriate. Receiver operating characteristic curves were generated for statistically significant CT findings using logistic regression model. RESULTS: Two of 31 patients (6.5%) were alive at the end of this study; 29 patients (93.5%) died of disease. Median overall survival was 90 days. CT features associated with short life expectancy were bowel mural thinning (p=0.03), mesenteric tumor deposits (p=0.009), mesenteric infiltration (p=0.02), and ascites (p=0.04). Area under the curve was 0.728 (p=0.03) for mesenteric tumor deposits in predicting malignant bowel obstruction. CONCLUSIONS: Accurate interpretation of CT features may guide decisions in care of women with OC and bowel obstruction.

Systemic chemotherapy and pressurized intraperitoneal aerosol chemotherapy (PIPAC): A bidirectional approach for gastric cancer peritoneal metastasis.

BACKGROUND: Few patients affected by gastric cancer peritoneal metastasis (GCPM) are offered locoregional treatment, despite several proof-of-efficacy trials. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) has emerged in recent years as a promising tool to control peritoneal carcinomatosis. The combination of PIPAC with systemic chemotherapy may offer a greater clinical benefit than standard treatment alone. METHODS: A single-center cohort of 28 consecutive patients affected by GCPM was scheduled for bidirectional treatment, comprising PIPAC and systemic chemotherapy, from September 2017 to September 2019. Data recorded included safety, efficacy and survival outcomes. Ascite volumes, the Peritoneal Cancer Index (PCI) and pathological response through the Peritoneal Regression Grading Score (PRGS) were compared in those patients who underwent more than one PIPAC procedure. RESULTS: Forty-six PIPAC procedures were administered, with a mean of 1.7 PIPAC procedures per patient. The median time to resume systemic chemotherapy after PIPAC was 6 days (range 4-7). Concerning safety, two grade 3-4 CTCAE (Common Terminology Criteria for Adverse Events v4.0) toxicity events and one intraoperative complication were recorded. Thirteen patients repeated PIPAC. A pathological response was recorded in 61.5% of patients (one with complete and seven with partial regression). The median overall survival was 12.3 months in the overall population and 15.0 months in patients undergoing more than one PIPAC procedure. CONCLUSIONS: A bidirectional approach for GCPM was feasible and safe, as the PIPAC procedure integrates well with several systemic chemotherapy regimens. The pathological response demonstrated the antitumoral efficacy of PIPAC. The proposed bidirectional approach may be further investigated in the first-line treatment of metastatic gastric cancer.

Operator learning curve for transradial liver cancer embolization: implications for the initiation of a transradial access program.

PURPOSE: We aimed to analyze transradial access (TRA) learning curve on patients undergoing hepatic chemoembolization, investigating the relationship between procedural volumes and various benchmarks of procedural success. METHODS: We enrolled 60 consecutive patients who received two unilobar hepatic chemoembolizations within a 4-week interval performed by a single interventional radiologist, highly-trained in conventional transfemoral access (TFA) procedures, but without any previous practical experience in TRA procedures and with a preliminary 2-day theoretical training only. Consecutive patients were prospectively enrolled and analyzed in 3 groups: A (cases 1 to 20), B (cases 21 to 40), and C (cases 41 to 60). All patients underwent one hepatic chemoembolization using TRA and the other one using TFA in random order. All TFA procedures performed by the same operator in the same series of patients were considered as the control group. Primary endpoint was to analyze the relationship between TRA procedure operator experience and benchmarks of procedural success, to define the optimal procedural learning curve. RESULTS: Technical success was obtained in all patients, with a crossover rate (radial to femoral access) of 0%. An association between incremental TRA operator experience (in terms of performed procedures) and decrease of preparation, puncture, fluoroscopy, and total examination times was observed. Similarly, inverse associations between incremental TRA operator experience and contrast medium (CM) volumes (P < 0.001) and radiation dose (RD) values (in terms of RAK - Reference Air Kerma) (P < 0.001) were also observed. Compared with TFA, CM volumes and RD values were significantly higher only in group A (cases 1-20). Procedure success remained high in all TRA groups and no significant association between TRA incremental experience and postprocedural outcomes was found. Higher postprocedural complaints at the access route and more limitations in performing basic activities were recorded after TFA vs. TRA (P < 0.001). CONCLUSION: TRA catheterizations can be safely performed in patients treated for liver cancer embolization after a relatively short training in controlled conditions and with a better performance in comparison with TFA. Operator proficiency improves with greater TRA experience, with a threshold needed to overcome the learning curve represented by about 20 procedures.

Early detection of recurrence or progression disease in patients with ovarian cancer after primary debulking surgery. Correlation between CT findings and CA 125 levels.

BACKGROUND: There are no standard approaches for follow up in advanced ovarian cancer (AOC) patients; the aim of this study is to evaluate correlation between computed tomography (CT) and CA 125 levels to assess early detection of recurrence or progression disease (PD). METHODS: We included 76 patients with AOC, who had prior debulking surgery, starting first or second line of chemotherapy and underwent follow-up CT examinations. Evaluation of tumor response to treatment by imaging was assessed using RECIST 1.1. Site of relapse was classified as: abdomen, chest and neck (observed in the upper chest scans). RESULTS: Change in CA 125 levels was calculated in respect previous evaluation at the end of treatment for each patient. The most suitable cut-offs could be identified in an increase in CA 125 levels >10.5% (sensitivity: 67.9%; specificity: 83.6%; LR+: 4.1; LR-: 0.4) in order to predict PD and in a change of -0.5% in order to exclude PD (sensitivity 83.0%; specificity: 69.6%; LR+: 2.7; LR-: 0.2). Site of relapse was abdomen (58.5%), abdomen and chest (33.9%), chest (3.8%), chest and neck (1.9%), and abdomen, chest and neck (1.9%). CONCLUSIONS: Increase in CA 125 levels >10.5% could be sufficiently predictive of PD requiring CT examination. Change of -0.5% is sufficiently predictive of absence of PD. Increase <10.5% and >0.5% needs clinical correlation to establish correct timing and extension of CT examination. Attention must be played in reducing number and extent of CT examinations to reduce exposure dose.

Multidetector CT appearance of the pelvis after cesarean delivery: normal and abnormal acute findings.

Cesarean section (CS) may have several acute complications that can occur in the early postoperative period. The most common acute complications are hematomas and hemorrhage, infection, ovarian vein thrombosis, uterine dehiscence and rupture. Pelvic hematomas usually occur at specific sites and include bladder flap hematoma (between the lower uterine segment and the bladder) and subfascial or rectus sheath hematoma (rectus sheath or prevescical space). Puerperal hemorrhage can be associated with uterine dehiscence or rupture. Pelvic infections include endometritis, abscess, wound infection, and retained product of conception. Radiologists play an important role in the diagnosis and management of postoperative complications as a result of increasing use of multidetector CT in emergency room. The knowledge of normal and abnormal postsurgical anatomy and findings should facilitate the correct diagnosis so that the best management can be chosen for the patient, avoiding unnecessary surgical interventions and additional treatments. In this article we review the surgical cesarean technique and imaging CT technique followed by description of normal and abnormal post-CS CT findings.

MRI anatomy of parametrial extension to better identify local pathways of disease spread in cervical cancer.

This paper highlights an updated anatomy of parametrial extension with emphasis on magnetic resonance imaging (MRI) assessment of disease spread in the parametrium in patients with locally advanced cervical cancer. Pelvic landmarks were identified to assess the anterior and posterior extensions of the parametria, besides the lateral extension, as defined in a previous anatomical study. A series of schematic drawings and MRI images are shown to document the anatomical delineation of disease on MRI, which is crucial not only for correct image-based three-dimensional radiotherapy but also for the surgical oncologist, since neoadjuvant chemoradiotherapy followed by radical surgery is emerging in Europe as a valid alternative to standard chemoradiation.

Trans-Arterial Chemoembolization with Irinotecan-Loaded Drug-Eluting Beads (DEBIRI) and Capecitabine in Refractory Liver Prevalent Colorectal Metastases: A Phase II Single-Center Study.

PURPOSE: The purpose of this study was to evaluate feasibility, safety, tolerance, and efficacy of drug-eluting beads loaded with irinotecan (DEBIRI) in combination with capecitabine in the treatment of mCRC refractory to chemotherapy in patients affected by liver predominant metastatic disease. MATERIALS AND METHODS: Twenty patients affected by CRC hepatic metastasis with liver-dominant disease, who had progression after two or more lines of chemotherapy, were enrolled. TACE with 100 mg of Irinotecan loaded into 2-ml of 70-150 µm drug-eluting beads was administrated every 4 weeks in patients with unilobar disease (2 treatments) and every 2 weeks in patients with bilobar disease (4 treatments). All patients assumed capecitabine 1000 mg/m(2) twice daily on days 1-14 every 3 weeks, until disease progression. Primary endpoints were safety, tolerance and overall disease control (ODC); secondary endpoints were progression free survival (PFS) and overall survival (OS). RESULTS: A total of 54 treatments were performed (54/66, 82%). No intra/peri-procedural death occurred. During the mean follow-up of 11 months, two partial responses (PR) were reported with ODC of 60% (2 PR + 10 stable disease). PFS and OS were 4 and 7.3 months, respectively. Univariate analysis showed that patients presenting with KRAS wild-type, good ECOG performance status and unilobar disease had a better prognosis. Only performance status (ECOG) correlated with OS in multivariate analysis (p = 0.03). CONCLUSION: DEBIRI with capecitabine seem to be a safe, technically feasible and well-tolerated treatment in chemotherapy refractory liver prevalent colorectal metastases.