The Prevalence of Financial Conflict of Interest Disclosures by Endovascular Specialists on X (Twitter).

PURPOSE: To evaluate conflicts of interest (COIs) among interventional radiologists and related specialties who mention specific devices or companies on the social media (SoMe) platform X, formerly Twitter. MATERIALS AND METHODS: In total, 13,809 posts between October 7, 2021, and December 31, 2021, on X were evaluated. Posts by U.S. interventional radiologists and related specialties who mentioned a specific device or company were identified. A positive COI was defined as receiving a payment from the device manufacturer or company within 36 months prior to posting. The Center for Medicare & Medicaid Services Open Payment database was used to identify financial payments. The prevalence and value of COIs were assessed and compared between posts mentioning a device or company and a paired control group using descriptive statistics and chi-squared tests and independent t tests. RESULTS: Eighty posts containing the mention of 100 specific devices or companies were evaluated. COIs were present in 53% (53/100). When mentioning a specific device or product, 40% interventional radiologists had a COI, compared with 62% neurosurgeons. Physicians who mentioned a specific device or company were 3.7 times more likely to have a positive COI relative to the paired control group (53/100 vs 14/100; P < .001). Of the 31 physicians with a COI, the median physician received $2,270. None of the positive COIs were disclosed. CONCLUSIONS: Physicians posting on SoMe about a specific device or company were more likely to have a financial COI than authors of posts not mentioning a specific device or company. No disclosure of any COI was present in the posts, limiting followers' ability to weigh potential bias.

Pulmonary interstitial lymphography: A prospective trial with potential impact on stereotactic ablative radiotherapy planning for early-stage lung cancer.

This prospective feasibility trial investigated pulmonary interstitial lymphography to identify thoracic primary nodal drainage (PND). A post-hoc analysis of nodal recurrences was compared with PND for patients with early-stage lung cancer; larger studies are needed to establish correlation. Exploratory PND-inclusive stereotactic ablative radiotherapy plans were assessed for dosimetric feasibility.

Single-shot quantitative x-ray imaging using a primary modulator and dual-layer detector.

BACKGROUND: Conventional x-ray imaging and fluoroscopy have limitations in quantitation due to several challenges, including scatter, beam hardening, and overlapping tissues. Dual-energy (DE) imaging, with its capability to quantify area density of specific materials, is well-suited to address such limitations, but only if the dual-energy projections are acquired with perfect spatial and temporal alignment and corrected for scatter. PURPOSE: In this work, we propose single-shot quantitative imaging (SSQI) by combining the use of a primary modulator (PM) and dual-layer (DL) detector, which enables motion-free DE imaging with scatter correction in a single exposure. METHODS: The key components of our SSQI setup include a PM and DL detector, where the former enables scatter correction for the latter while the latter enables beam hardening correction for the former. The SSQI algorithm allows simultaneous recovery of two material-specific images and two scatter images using four sub-measurements from the PM encoding. The concept was first demonstrated using simulation of chest x-ray imaging for a COVID patient. For validation, we set up SSQI geometry on our tabletop system and imaged acrylic and copper slabs with known thicknesses (acrylic: 0-22.5 cm; copper: 0-0.9 mm), estimated scatter with our SSQI algorithm, and compared the material decomposition (MD) for different combinations of the two materials with ground truth. Second, we imaged an anthropomorphic chest phantom containing contrast in the coronary arteries and compared the MD with and without SSQI. Lastly, to evaluate SSQI in dynamic applications, we constructed a flow phantom that enabled dynamic imaging of iodine contrast. RESULTS: Our simulation study demonstrated that SSQI led to accurate scatter correction and MD, particularly for smaller focal blur and finer PM pitch. In the validation study, we found that the root mean squared error (RMSE) of SSQI estimation was 0.13 cm for acrylic and 0.04 mm for copper. For the anthropomorphic phantom, direct MD resulted in incorrect interpretation of contrast and soft tissue, while SSQI successfully distinguished them quantitatively, reducing RMSE in material-specific images by 38%-92%. For the flow phantom, SSQI was able to perform accurate dynamic quantitative imaging, separating contrast from the background. CONCLUSIONS: We demonstrated the potential of SSQI for robust quantitative x-ray imaging. The integration of SSQI is straightforward with the addition of a PM and upgrade to a DL detector, which may enable its widespread adoption, including in techniques such as radiography and dynamic imaging (i.e., real-time image guidance and cone-beam CT).

Patient Decision Aids Before Informed Consent Conversations for Image-Guided Procedures: Controlled Trials at Two Institutions.

BACKGROUND. Patient decision aids (PDAs) improve informed consent practices. Available PDAs for image-guided procedures are of limited quality. OBJECTIVE. The purpose of this article was to evaluate the impact of PDAs on understanding and satisfaction among patients undergoing informed consent conversations before outpatient image-guided procedures. METHODS. This prospective study included patients awaiting an interventional radiology clinic visit to discuss and obtain informed consent for an image-guided procedure. The study was conducted at two academic medical centers (site A, visits from August 2020 to July 2021; site B, visits from January 2021 to October 2021). Patients were assigned systematically at site A and randomly at site B to electronically receive or not receive a two-page PDA before the visit. PDAs described procedures and their benefits, risks, and alternatives at a sixth- to eighth-grade health literacy level and were vetted by diverse patient focus groups. Patients completed a postvisit survey (site A, by telephone; site B, online) assessing understanding of the procedure and satisfaction with the consent conversation using 5-point scales. Data were pooled between sites. RESULTS. The study included 105 patients (59 men, 46 women; median age, 67 years; 51 from site A, 54 from site B; 53 who received PDA, 52 who did not). Survey response rate was 100% (51/51) at site A and 67% (62/92) at site B. Patients who received, versus did not receive, a PDA reported greater understanding of benefits (4.5 vs 4.0, p < .001), risks (4.4 vs 3.6, p < .001), and alternatives (4.0 vs 3.3, p < .001), and of what procedures involved (4.4 vs 4.1, p = .02) and were more likely to feel that they were provided with enough time with the clinician (4.7 vs 4.5, p = .03), listened to carefully (4.8 vs 4.4, p < .001), free to choose any option including not to have the procedure (4.7 vs 4.3, p < .001), given enough time to make a decision (4.8 vs 4.3, p < .001), encouraged to ask questions (4.8 vs 4.5, p < .001), and had questions answered (4.8 vs 4.4, p = .001). CONCLUSION. Well-vetted plain-language PDAs provided before image-guided procedure consent conversations improve patients' self-perceived understanding of the procedure and satisfaction with the conversation. CLINICAL IMPACT. PDAs can be implemented effectively without requiring additional clinician time or effort.

Proceedings from the Society of Interventional Radiology Foundation Research Consensus Panel on Artificial Intelligence in Interventional Radiology: From Code to Bedside.

Artificial intelligence (AI)-based technologies are the most rapidly growing field of innovation in healthcare with the promise to achieve substantial improvements in delivery of patient care across all disciplines of medicine. Recent advances in imaging technology along with marked expansion of readily available advanced health information, data offer a unique opportunity for interventional radiology (IR) to reinvent itself as a data-driven specialty. Additionally, the growth of AI-based applications in diagnostic imaging is expected to have downstream effects on all image-guidance modalities. Therefore, the Society of Interventional Radiology Foundation has called upon 13 key opinion leaders in the field of IR to develop research priorities for clinical applications of AI in IR. The objectives of the assembled research consensus panel were to assess the availability and understand the applicability of AI for IR, estimate current needs and clinical use cases, and assemble a list of research priorities for the development of AI in IR. Individual panel members proposed and all participants voted upon consensus statements to rank them according to their overall impact for IR. The results identified the top priorities for the IR research community and provide organizing principles for innovative academic-industrial research collaborations that will leverage both clinical expertise and cutting-edge technology to benefit patient care in IR.

Limitations of Fluorine 18 Fluoromisonidazole in Assessing Treatment-induced Tissue Hypoxia after Transcatheter Arterial Embolization of Hepatocellular Carcinoma: A Prospective Pilot Study.

Purpose To determine the variance and correlation with tumor viability of fluorine 18 (18F) fluoromisonidazole (FMISO) uptake in hepatocellular carcinoma (HCC) prior to and after embolization treatment. Materials and Methods In this single-arm, single-center, prospective pilot study between September 2016 and March 2017, participants with at least one tumor measuring 1.5 cm or larger with imaging or histologic findings diagnostic for HCC were enrolled (five men; mean age, 68 years; age range, 61-76 years). Participants underwent 18F-FMISO PET/CT before and after bland embolization of HCC. A tumor-to-liver ratio (TLR) was calculated by using standardized uptake values of tumor and liver. The difference in mean TLR before and after treatment was compared by using a Wilcoxon rank sum test, and correlation between TLR and tumor viability was assessed by using the Spearman rank correlation coefficient. Results Four participants with five tumors were included in the final analysis. The median tumor diameter was 3.2 cm (IQR, 3.0-3.9 cm). The median TLR before treatment was 0.97 (IQR, 0.88-0.98), with a variance of 0.02, and the median TLR after treatment was 0.85 (IQR, 0.79-1), with a variance of 0.01; both findings indicate a narrow range of 18F-FMISO uptake in HCC. The Spearman rank correlation coefficient was 0.87, indicating a high correlation between change in TLR and nonviable tumor. Conclusion Although there was a correlation between change in TLR and response to treatment, the low signal-to-noise ratio of 18F-FMISO in the liver limited its use in HCC. Keywords: Molecular Imaging-Clinical Translation, Embolization, Abdomen/Gastrointestinal, Liver Clinical trial registration no. NCT02695628 © RSNA, 2022.

Tunneled Peritoneal Catheter vs Repeated Paracenteses for Recurrent Ascites: A Cost-Effectiveness Analysis.

PURPOSE: To compare the cost-effectiveness of tunneled peritoneal catheter (TPC) versus serial large-volume paracenteses (LVP) for patients with recurrent ascites. MATERIALS AND METHODS: Retrospective, single-institution analysis of 100 consecutive patients undergoing LVP and eventual TPC placement (2015-2018) was performed with extraction of procedural complications and hospital admissions. LVPs were associated with 17 adverse events (AEs) while only 9 AEs occurred after TPC placement. While undergoing routine LVP, the patients had 30 hospitalizations monthly (177 days in total) and 10 hospitalizations monthly (51 days) after TPC placement. A cost-effectiveness analysis with Markov modeling was performed comparing TPC and LVP. Costs were based on Medicare reimbursement rates. Statistical analyses include base case calculation, Monte Carlo simulations, and deterministic sensitivity analyses. RESULTS: TPC placement was the dominant strategy with a comparable health benefit of 0.08060 quality-adjusted life-years (QALY) (LVP: 0.08057 QALY) at a lower cost of $4151 (LVP: $8401). Probabilistic sensitivity analysis showed TPC was superior in 97.49% of simulations. Deterministic sensitivity analysis demonstrated the superiority of TPC compared to LVP if the TPC complication rate was < 9.47% per week and the complication rate for LVP was > 1.32% per procedure. TPC was more cost-effective when its procedural cost was < $5427 (base case: 1174.5), and remained as such when the cost of LVP was varied as much as $10,000 (base case: $316.48). CONCLUSION: In this study, TPC was more cost-effective than LVP in patients with recurrent ascites due to the reduced risk of infection, emergency department visits, and length of hospitalization stays.

Cost-effectiveness of tunneled peritoneal catheters versus repeat paracenteses for recurrent ascites in gynecologic malignancies.

OBJECTIVE: To compare the cost-effectiveness of tunneled peritoneal catheter (TPC) versus repeated large-volume paracentesis (LVP) for patients with recurrent ascites secondary to gynecological malignancy. METHODS: A retrospective cohort study was performed at a single institution from 2016 through 2019 of patients with recurrent ascites from gynecologic malignancies that underwent either TPC or LVP. Data on procedural complications and hospital admissions were extracted. A cost-effectiveness analysis with Markov modeling was performed comparing TPC and LVP. Statistical analyses include base case calculation, Monte Carlo simulations and deterministic sensitivity analyses. RESULTS: There were no significant differences between the cohorts in the average number of hospital days (p = 0.21) or emergency department visits (p = 0.69) related to ascites. Palliative care was more often involved in the care of patients who had a TPC. The base case calculation showed TPC to be the more cost-effective strategy with a slightly lower health benefit (0.22980 versus 0.22982 QALY) and lower cost ($3043 versus $3868) relative to LVP (ICER of LVP compared to TPC: $44,863,103/QALY). Probabilistic sensitivity analysis showed TPC was the more cost-effective strategy in 8028/10,000 simulations. Deterministic sensitivity analysis showed TPC to be more cost-effective if its complication risk was >0.81% per 22 days or its procedural cost of TPC insertion was >$1997. When varying the cost of complications, TPC was more cost-effective if the cost of its complication was less than $49,202. CONCLUSIONS: TPC is the more cost-effective strategy when compared to LVP in patients with recurrent ascites from gynecological malignancy.

Perceptions of Ethics in Interventional Radiology.

PURPOSE: To characterize perceptions of ethics among interventional radiologists to guide the development of an applied, specialty-specific approach to ethics. MATERIALS AND METHODS: A 17-question survey on perceptions of ethics and use of ethics resources was developed and vetted via cognitive interviewing of 15 diverse, representative members of the target population. The survey was distributed via the Society of Interventional Radiology, receiving 685 responses (48% participation and 90% completion rates). Responses were compared between different demographics, and common themes from free text responses were identified via content analysis. RESULTS: Most respondents indicated ethics is important for IR (93%) and more focus on practical approaches to ethical issues is needed (73%). Various ethical issues were perceived to be important for IR, but differentiating palliative from futile care was ranked as the top ethical issue. Trainees had more ethics training (P=0.05) but less confidence in navigating ethical issues (P<0.01). Regardless of career stage, those with ethics training (44%) were more confident in navigating ethical issues (P<0.01). Use of resources such as information sheets for patients and resources for coping with complications were variable and limited by lack of availability or knowledge of such resources in IR. CONCLUSIONS: Interventional radiologists believe ethics is important and face diverse ethical issues, but they are challenged by variable experiences and access to practical tools to navigate these challenges.

The Need to Mitigate Unconscious Bias to Improve Sponsorship Opportunities for Underrepresented Faculty in Academic Radiology.

Women physicians and those from racial and ethnic groups underrepresented in medicine face unique barriers to career advancement in academic medicine, especially in specialties that lack diversity such as radiology. One such barrier is the effect of unconscious bias on the ability of faculty from these groups to find effective sponsors. Given the central role of sponsorship in career advancement, departments are called on to implement formal sponsorship programs to address inequities stemming from bias.

Reimagining the IR Workflow for a Better Work-Life Balance.

Several workflow changes were implemented in a large academic interventional radiology practice, including separation of inpatient and outpatient services, early start times, and using an adaptive learning system to predict case length tailored to individual physicians. Metrics including procedural volume, on-time start, accuracy at predicting case length, and room shutdown time were assessed before and after the intervention. Considerable improvements were seen in accuracy of first case start times, predicting block times, and last case encounter ending times. It is proposed that with improved role clarity, interventional radiologists can regain control over their schedules, utilize work hours more efficiently, and improve work-life balance.

Efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain after surgery or trauma: systematic review.

BACKGROUND: There is a critical need for non-narcotic analgesic adjuncts in the treatment of thoracic pain. We evaluated the efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain, specifically addressing the applicability of intercostal cryoneurolysis for pain control after chest wall trauma. METHODS: A systematic review was performed through searches of PubMed, EMBASE, and the Cochrane Library. We included studies involving patients of all ages that evaluated the efficacy of intercostal cryoneurolysis as a pain adjunct for chest wall pathology. Quantitative and qualitative synthesis was performed. RESULTS: Twenty-three studies including 570 patients undergoing cryoneurolysis met eligibility criteria for quantitative analysis. Five subgroups of patients treated with intercostal cryoneurolysis were identified: pectus excavatum (nine studies); thoracotomy (eight studies); post-thoracotomy pain syndrome (three studies); malignant chest wall pain (two studies); and traumatic rib fractures (one study). There is overall low-quality evidence supporting intercostal cryoneurolysis as an analgesic adjunct for chest wall pain. A majority of studies demonstrated decreased inpatient narcotic use with intercostal cryoneurolysis compared with conventional pain modalities. Intercostal cryoneurolysis may also lead to decreased hospital length of stay. The procedure did not definitively increase operative time, and risk of complications was low. CONCLUSIONS: Given the favorable risk-to-benefit profile, both percutaneous and thoracoscopic intercostal cryoneurolysis may serve as a worthwhile analgesic adjunct in trauma patients with rib fractures who have failed conventional medical management. However, further prospective studies are needed to improve quality of evidence. LEVEL OF EVIDENCE: Level IV systematic reviews and meta-analyses.

The Role of Physician-Driven Device Preference in the Cost Variation of Common Interventional Radiology Procedures.

PURPOSE: To analyze the impact of physician-specific equipment preference on cost variation for procedures typically performed by interventional radiologists at a tertiary care academic hospital. MATERIALS AND METHODS: From October 2017 to October 2019, data on all expendable items used by 9 interventional radiologists for 11 common interventional radiology procedure categories were compiled from the hospital analytics system. This search yielded a final dataset of 44,654 items used in 2,121 procedures of 11 different categories. The mean cost per case for each physician as well as the mean, standard deviation, and coefficient of variation (CV) of the mean cost per case across physicians were calculated. The proportion of spending by item type was compared across physicians for 2 high-variation, high-volume procedures. The relationship between the mean cost per case and case volume was examined using linear regression. RESULTS: There was a high variability within each procedure, with the highest and the lowest CV for radioembolization administration (56.6%) and transjugular liver biopsy (4.9%), respectively. Variation in transarterial chemoembolization cost was mainly driven by microcatheters/microwires, while for nephrostomy, the main drivers were catheters/wires and access sets. Mean spending by physician was not significantly correlated with case volume (P =.584). CONCLUSIONS: Physicians vary in their item selection even for standard procedures. While the financial impact of these differences vary across procedures, these findings suggest that standardization may offer an opportunity for cost savings.

The Economic Footprint of Interventional Radiology in the United States: Implications for Systems Development.

PURPOSE: Despite the growing presence of interventional radiology (IR) in inpatient care, its global impact on the health care system remains uncharacterized. The aim of this study was to quantitate the use of IR services rendered to hospitalized patients in the United States and the impact on cost. METHODS: The National Inpatient Sample 2016 was queried. Using the International Classification of Diseases, 10th revision, Clinical Modification/Procedure Classification System, adult inpatients who underwent routine IR procedures were identified. Unadjusted and adjusted analyses were performed. Weighted patient data are presented to provide national estimates. RESULTS: Of the 29.7 million inpatient admissions in 2016, 2.3 million (7.8%) had at least one IR procedure. Patients who needed IR were older (62.8 versus 57.1 years, P < .001), were sicker on the basis of the All Patient Refined Diagnosis Related Groups (27% major or extreme versus 14% for non-IR, P < .001), and had higher inpatient mortality (8.2% versus 1.7%, P < .001). While representing 7.8% of all admissions, this cohort accounted for 18.4% ($68.4 billion) of adult inpatient health care costs and about 3 times higher mean hospitalization cost compared with other inpatients ($29,402 versus $11,062, P < .001), which remained significant even after controlling for age and All Patient Refined Diagnosis Related Group. CONCLUSIONS: Approximately 1 in 10 US inpatients are treated by IR during their hospitalizations. These patients are sicker, with about 4 times higher mortality and 2.5 times greater length of stay, accounting for almost one-fifth of all health care costs. These findings suggest that IR should have a voice in discussions of means to save costs and improve patient outcomes in the United States.

Gender Differences in Patient Perceptions of Physicians' Communal Traits and the Impact on Physician Evaluations.

Background: Communal traits, such as empathy, warmth, and consensus-building, are not highly valued in the medical hierarchy. Devaluing communal traits is potentially harmful for two reasons. First, data suggest that patients may prefer when physicians show communal traits. Second, if female physicians are more likely to be perceived as communal, devaluing communal traits may increase the gender inequity already prevalent in medicine. We test for both these effects. Materials and Methods: This study analyzed 22,431 Press Ganey outpatient surveys assessing 480 physicians collected from 2016 to 2017 at a large tertiary hospital. The surveys asked patients to provide qualitative comments and quantitative Likert-scale ratings assessing physician effectiveness. We coded whether patients described physicians with "communal" language using a validated word scale derived from previous work. We used multivariate logistic regressions to assess whether (1) patients were more likely to describe female physicians using communal language and (2) patients gave higher quantitative ratings to physicians they described with communal language, when controlling for physician, patient, and comment characteristics. Results: Female physicians had higher odds of being described with communal language than male physicians (odds ratio 1.29, 95% confidence interval 1.18-1.40, p < 0.001). In addition, patients gave higher quantitative ratings to physicians they described with communal language. These results were robust to inclusion of controls. Conclusions: Female physicians are more likely to be perceived as communal. Being perceived as communal is associated with higher quantitative ratings, including likelihood to recommend. Our study indicates a need to reevaluate what types of behaviors academic hospitals reward in their physicians.

Comparison of Drug-Eluting Embolics versus Conventional Transarterial Chemoembolization for the Treatment of Patients with Unresectable Hepatocellular Carcinoma: A Cost-Effectiveness Analysis.

PURPOSE: To compare the cost-effectiveness of using doxorubicin-loaded drug-eluting embolic (DEE) transarterial chemoembolization versus that of using conventional transarterial chemoembolization for patients with unresectable hepatocellular carcinoma (HCC). MATERIALS AND METHODS: A decision-analysis model was constructed over the lifespan of a payer's perspective. The model simulated the clinical course, including periprocedural complications, additional transarterial chemoembolization or other treatments (ablation, radioembolization, or systemic treatment), palliative care, and death, of patients with unresectable HCC. All clinical parameters were derived from the literature. Base case calculations, probabilistic sensitivity analyses, and multiple two-way sensitivity analyses were performed. RESULTS: In the base case calculations for patients with a median age of 67 years (range for conventional transarterial chemoembolization: 28-88 years, range for DEE-transarterial chemoembolization: 16-93 years), conventional transarterial chemoembolization yielded a health benefit of 2.11 quality-adjusted life years (QALY) at a cost of $125,324, whereas DEE-transarterial chemoembolization yielded 1.71 QALY for $144,816. In 10,000 Monte Carlo simulations, conventional transarterial chemoembolization continued to be a more cost-effective strategy. conventional transarterial chemoembolization was cost-effective when the complication risks for both the procedures were simultaneously varied from 0% to 30%. DEE-transarterial chemoembolization became cost-effective if the conventional transarterial chemoembolization mortality exceeded that of DEE-transarterial chemoembolization by 17% in absolute values. The two-way sensitivity analyses demonstrated that conventional transarterial chemoembolization was cost-effective until the risk of disease progression was >0.4% of that for DEE-transarterial chemoembolization in absolute values. Our analysis showed that DEE-transarterial chemoembolization would be more cost-effective if it offered >2.5% higher overall survival benefit than conventional transarterial chemoembolization in absolute values. CONCLUSIONS: Compared with DEE-transarterial chemoembolization, conventional transarterial chemoembolization yielded a higher number of QALY at a lower cost, making it the more cost-effective of the 2 modalities.

Genomic Analysis of Vascular Invasion in HCC Reveals Molecular Drivers and Predictive Biomarkers.

BACKGROUND AND AIMS: Vascular invasion (VI) is a critical risk factor for HCC recurrence and poor survival. The molecular drivers of vascular invasion in HCC are open for investigation. Deciphering the molecular landscape of invasive HCC will help identify therapeutic targets and noninvasive biomarkers. APPROACH AND RESULTS: To this end, we undertook this study to evaluate the genomic, transcriptomic, and proteomic profile of tumors with VI using the multiplatform cancer genome atlas (The Cancer Genome Atlas; TCGA) data (n = 373). In the TCGA Liver Hepatocellular Carcinoma cohort, macrovascular invasion was present in 5% (n = 17) of tumors and microvascular invasion in 25% (n = 94) of tumors. Functional pathway analysis revealed that the MYC oncogene was a common upstream regulator of the mRNA, miRNA, and proteomic changes in VI. We performed comparative proteomic analyses of invasive human HCC and MYC-driven murine HCC and identified fibronectin to be a proteomic biomarker of invasive HCC (mouse fibronectin 1 [Fn1], P = 1.7 × 10-11 ; human FN1, P = 1.5 × 10-4 ) conserved across the two species. Mechanistically, we show that FN1 promotes the migratory and invasive phenotype of HCC cancer cells. We demonstrate tissue overexpression of fibronectin in human HCC using a large independent cohort of human HCC tissue microarray (n = 153; P < 0.001). Lastly, we showed that plasma fibronectin levels were significantly elevated in patients with HCC (n = 35; mean = 307.7 µg/mL; SEM = 35.9) when compared to cirrhosis (n = 10; mean = 41.8 µg/mL; SEM = 13.3; P < 0.0001). CONCLUSIONS: Our study evaluates the molecular landscape of tumors with VI, identifying distinct transcriptional, epigenetic, and proteomic changes driven by the MYC oncogene. We show that MYC up-regulates fibronectin expression, which promotes HCC invasiveness. In addition, we identify fibronectin to be a promising noninvasive proteomic biomarker of VI in HCC.

Perceptions of Futility in Interventional Radiology: A Multipractice Systematic Qualitative Analysis.

PURPOSE: To characterize perceptions of palliative versus futile care in interventional radiology (IR) as a roadmap for quality improvement. METHODS: Interventional radiologists (IRs) and referring physicians were recruited for anonymous interviews and/or focus groups to discuss their perceptions and experiences related to palliative verse futile care in IR. Sessions were recorded, transcribed, and systematically analyzed using dedicated software, content analysis, and grounded theory. Data collection and analysis continued simultaneously until additional interviews stopped revealing new themes: 24 IRs (21 males, 3 females, 1-39 years of experience) and 7 referring physicians (3 males, 4 females, 6-14 years of experience) were analyzed. RESULTS: Many IRs (75%) perceived futility as an important issue. Years of experience (r = 0.60, p = 0.03) and being in academics (r = 0.62, p = 0.04) correlated with greater perceived importance. Perceptions of futility and whether a potentially inappropriate procedure was performed involved a balance between four sets of factors (patient, clinician, procedural, and cultural). These assessments tended to be qualitative in nature and are challenged by a lack of data, education, and consistent workflows. Referring clinicians were unaware of this issue and assumed IR had guidelines for differentiating between palliation and futility. CONCLUSION: This study characterized the complexity and qualitative nature of assessments of palliative verses futile care in IR while highlighting potential means of improving current practices. This is important given the number of critically ill patients referred to IR and costs of potentially inappropriate interventions.

Comparison of Opioid Medication Use after Conventional Chemoembolization versus Drug-Eluting Embolic Chemoembolization.

PURPOSE: To assess the use of opioid analgesics and/or antiemetic drugs for pain and nausea following selective chemoembolization with doxorubicin-based conventional (c)-transarterial chemoembolization versus drug-eluting embolic (DEE)-transarterial chemoembolization for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: From October 2014 to 2016, 283 patients underwent 393 selective chemoembolization procedures including 188 patients (48%) who underwent c-transarterial chemoembolization and 205 (52%) who underwent DEE-transarterial chemoembolization. Medical records for all patients were retrospectively reviewed. Administration of postprocedural opioid and/or antiemetic agents were collated. Time of administration was stratified as phase 1 recovery (0-6 hours) and observation (6-24 hours). Logistic regression model was used to investigate the relationship of transarterial chemoembolization type and use of intravenous and/or oral analgesic and antiemetic medications while controlling for other clinical variables. RESULTS: More patients treated with DEE-transarterial chemoembolization required intravenous analgesia in the observation (6-24 hours) phase (18.5%) than those treated with c-transarterial chemoembolization (10.6%; P = .033). Similar results were noted for oral analgesic agents (50.2% vs. 31.4%, respectively; P < .001) and antiemetics (17.1% vs. 7.5%, respectively; P = .006) during the observation period. Multivariate regression models identified DEE-transarterial chemoembolization as an independent predictor for oral analgesia (odds ratio [OR], 1.84; P = .011), for intravenous and oral analgesia in opioid-naïve patients (OR, 2.46; P = .029) and for antiemetics (OR, 2.56; P = .011). CONCLUSIONS: Compared to c-transarterial chemoembolization, DEE-transarterial chemoembolization required greater amounts of opioid analgesic and antiemetic agents 6-24 hours after the procedure. Surgical data indicate that a persistent opioid habit can develop even after minor surgeries, therefore, caution should be exercised, and a regimen of nonopiate pain medications should be considered to reduce postprocedural pain after transarterial chemoembolization.

Interreader Variability in Semantic Annotation of Microvascular Invasion in Hepatocellular Carcinoma on Contrast-enhanced Triphasic CT Images.

Purpose: To evaluate interreader agreement in annotating semantic features on preoperative CT images to predict microvascular invasion (MVI) in patients with hepatocellular carcinoma (HCC). Materials and Methods: Preoperative, contrast material-enhanced triphasic CT studies from 89 patients (median age, 64 years; age range, 36-85 years; 70 men) who underwent hepatic resection between 2008 and 2017 for a solitary HCC were reviewed. Three radiologists annotated CT images obtained during the arterial and portal venous phases, independently and in consensus, with features associated with MVI reported by other investigators. The assessed factors were the presence or absence of discrete internal arteries, hypoattenuating halo, tumor-liver difference, peritumoral enhancement, and tumor margin. Testing also included previously proposed MVI signatures: radiogenomic venous invasion (RVI) and two-trait predictor of venous invasion (TTPVI), using single-reader and consensus annotations. Cohen (two-reader) and Fleiss (three-reader) κ and the bootstrap method were used to analyze interreader agreement and differences in model performance, respectively. Results: Of HCCs assessed, 32.6% (29 of 89) had MVI at histopathologic findings. Two-reader agreement, as assessed by pairwise Cohen κ statistics, varied as a function of feature and imaging phase, ranging from 0.02 to 0.6; three-reader Fleiss κ varied from -0.17 to 0.56. For RVI and TTPVI, the best single-reader performance had sensitivity and specificity of 52% and 77% and 67% and 74%, respectively. In consensus, the sensitivity and specificity for the RVI and TTPVI signatures were 59% and 67% and 70% and 62%, respectively. Conclusion: Interreader variability in semantic feature annotation remains a challenge and affects the reproducibility of predictive models for preoperative detection of MVI in HCC.Supplemental material is available for this article.© RSNA, 2020.