Locoregional Therapies for Hepatobiliary Tumors: Contemporary Strategies and Novel Applications.

A large majority of primary hepatobiliary tumors are hepatocellular carcinomas (HCC), with the remainer being cholangiocarcinoma. While surgical resection remains the gold standard treatment for hepatobiliary tumors, relatively few patients are operative candidates, and systemic treatments have limited effectiveness. Locoregional therapies offer significant promise in the management of HCC. Ablation and radioembolization may offer similar outcomes to surgery for early-stage hepatocellular carcinoma while radioembolization and chemoembolization are valuable in the management of advanced disease. There is significantly less evidence for the role of locoregional therapy in the treatment of cholangiocarcinoma, although it appears to be well tolerated.

Liver-Directed Locoregional Therapies for Neuroendocrine Liver Metastases: Recent Advances and Management.

Neuroendocrine tumors (NETs) are a heterogeneous class of cancers, predominately occurring in the gastroenteropancreatic system, which pose a growing health concern with a significant rise in incidence over the past four decades. Emerging from neuroendocrine cells, these tumors often elicit paraneoplastic syndromes such as carcinoid syndrome, which can manifest as a constellation of symptoms significantly impacting patients' quality of life. The prognosis of NETs is influenced by their tendency for metastasis, especially in cases involving the liver, where the estimated 5-year survival is between 20 and 40%. Although surgical resection remains the preferred curative option, challenges emerge in cases of neuroendocrine tumors with liver metastasis (NELM) with multifocal lobar involvement, and many patients may not meet the criteria for surgery. Thus, minimally invasive and non-surgical treatments, such as locoregional therapies, have surfaced. Overall, these approaches aim to prioritize symptom relief and aid in overall tumor control. This review examines locoregional therapies, encompassing catheter-driven procedures, ablative techniques, and radioembolization therapies. These interventions play a pivotal role in enhancing progression-free survival and managing hormonal symptoms, contributing to the dynamic landscape of evolving NELM treatment. This review meticulously explores each modality, presenting the current state of the literature on their utilization and efficacy in addressing NELM.

Understanding ChatGPT for evidence-based utilization in interventional radiology.

Advancement in artificial intelligence (AI) has the potential to improve the efficiency and accuracy of medical care. New techniques used in machine learning have enhanced the functionality of software to perform advanced tasks with human-like capabilities. ChatGPT is the most utilized large language model and provides a diverse range of communication tasks. Interventional Radiology (IR) may benefit from the implementation of ChatGPT for specific tasks. This review summarizes the design principles of ChatGPT relevant to healthcare and highlights activities with the greatest potential for ChatGPT utilization in the practice of IR. These tasks involve patient-directed and physician-directed communications to convey medical information efficiently and act as a medical decision support tool. ChatGPT exemplifies the evolving landscape of new AI tools for advancing patient care and how physicians and patients may benefit with strategic execution.

Utility and Clinical Outcomes of Perioperative Inferior Vena Cava Filter Prophylaxis in Spine Surgery Patients.

STUDY DESIGN: Single-center retrospective chart review study. OBJECTIVE: This study aimed to assess the clinical outcomes of prophylactic inferior vena cava (IVC) filter use for pulmonary embolism (PE) prevention in spine surgery patients. SUMMARY OF BACKGROUND DATA: IVC filters can serve an important prophylactic role in preventing PE, though research involving spine surgery patients is sparse. MATERIALS AND METHODS: This Institutional Review Board-approved single-center retrospective study assessed the characteristics and outcomes of patients who underwent spine surgery and received perioperative IVC filters for PE prophylaxis from January 2007 until December 2021. Clinical outcomes centered primarily on the occurrence of venous thromboembolism (VTE) as well as complications related to filter placement and retrieval. Thrombi that may have been entrapped by the filters were recorded incidentally on computed tomography or during the filter retrieval procedure. RESULTS: This cohort included 380 spine surgery patients (female 51%/male 49%; median age, 61) who had received perioperative prophylactic IVC filters. The mean dwell time was 6.7 months (1-39 mo), with an overall 62% retrieval rate. Retrievals were further categorized by retrieval complexity, with 92% classified as routine and 8% as involving advanced removal techniques, while complications involved 1% (four retrievals) and were all minor. Regarding VTE event occurrence, deep vein thrombi (DVT) were experienced by 11% of patients in the postplacement period, with 1% (n=4) experiencing a PE. There were 11 incidences of thrombi that were found within or near the filters (2.9%). A multivariate analysis further assessed patient characteristics that correlated with the occurrence of PE, DVT, entrapped filter thrombi, advanced technique filter removal, and removal complications. CONCLUSIONS: IVC filters in this high-risk spine surgery cohort achieved a relatively low rate of DVT and PE as well as a low complication rate, whereas several patient characteristics were identified that correlated with VTE events and filter retrieval outcomes.

Medical Malpractice and Diagnostic Radiology: Challenges and Opportunities.

Medicolegal challenges in radiology are broad and impact both radiologists and patients. Radiologists may be affected directly by malpractice litigation or indirectly due to defensive imaging ordering practices. Patients also could be harmed physically, emotionally, or financially by unnecessary tests or procedures. As technology advances, the incorporation of artificial intelligence into medicine will bring with it new medicolegal challenges and opportunities. This article reviews the current and emerging direct and indirect effects of medical malpractice on radiologists and summarizes evidence-based solutions.

Moral Injury Among Interventional Radiologists.

RATIONALE AND OBJECTIVES: To evaluate moral injury (MI) among interventional radiologists using validated assessment tools. MATERIALS AND METHODS: An anonymous 29-question online survey was distributed to interventional radiologists using the Society of Interventional Radiology Connect Open Forum website, Twitter, Facebook, LinkedIn, and electronic mail. The survey consisted of demographic and practice environment questions, a global quality of life (QoL) scale (scored 1-100), the MI Symptom Scale­Healthcare Professional (MISS-HP) (scored 1-100), and two open-ended questions. A MISS-HP score ≥ 36 was indicative of experiencing MI. P < .05 was considered statistically significant for all two-sided tests. RESULTS: Beginning on March 30, 2023, 365 surveys were completed over 5 days. Of the respondents, 299 (81.9%) were male, 65 (17.8%) were female, and one preferred not to disclose gender. The respondents included practicing interventional radiologists (299; 81.9%) and interventional radiologists-in-training (66; 18.1%). Practice settings included academic (146; 40.0%), community (121; 33.2%), hybrid (84; 23.0%), or other (14; 3.8%) centers. Mean QoL was 71.1 ± 17.0 (range: 0-100) suggestive of "good" QoL. Mean QoL in the MI subgroup was significantly different from that for the rest of the group (67.6 ± 17.0 vs. 76.6 ± 16.0; P < 0.05). 223 (61.1%) respondents scored ≥ 36 on the MISS-HP, and thus were categorized as having profession-related MI. Mean MISS-HP was 39.9 ± 12.6 (range: 10-83). Mean MISS-HP in the MI subgroup was significantly different from that for the rest of the group (47.4 ± 9.6 vs. 28.0 ± 5.7; P < 0.05). There was a negative correlation between MI and QoL (r = -0.4; P < 0.001). Most common themes for greatest contribution to MI were ineffective leadership, barriers to patient care, corporatization of medicine, non-physician administration, performing futile procedures, turf battles, and reduced resources. Most common themes for ways to reduce MI were more autonomy, less bureaucracy, more administrative support, physician-directed leadership, adequate staffing, changes to the medical system, physician unionization, transparency with insurance companies, more time off, and leaving medicine/retirement. CONCLUSION: MI is prevalent among interventional radiologists, and it negatively correlates with QoL. Future work should investigate causative factors and mitigating solutions.

Wellness Among Interventional Radiologists: Results From a Multidimensional Survey.

RATIONALE AND OBJECTIVES: To evaluate wellness among interventional radiologists using a multidimensional survey. MATERIALS AND METHODS: An anonymous 53-item survey, including 36 Perceived Wellness Survey (PWS) prompts, was created in Qualtrics (an online survey tool) to assess wellness among interventional radiology attendings and residents. The survey was open from June to September, 2022, 2 years into the COVID-19 Pandemic. The survey was distributed via Society of Interventional Radiology Forums, social media (Twitter, LinkedIn, and Facebook), and personal correspondence. PWS scores were categorized into Wellness Composite and subscores (physical, emotional, intellectual, psychological, social, and spiritual). RESULTS: 367 surveys were completed. 300 (81.7%) respondents were male and 67 (18.3%) were female. Respondents included attending physicians (297; 81.0%) and residents (70; 19.0%). Practice settings included academic (174; 47.4%), private (114; 31.0%), private-academic hybrid (62; 16.9%), and others (17; 4.7%). Mean Wellness Composite at academic centers (14.74 ± 3.16; range: 5.42-23.50) was significantly lower than at private (15.22 ± 3.37; range: 6.13-23.51) and hybrid (16.14 ± 2.47; range: 10.20-23.50) practices (p = 0.01). Respondents < 40 years old had significantly lower emotional wellness subscores compared to those ≥ 40 years old (4.34 ± 0.86 vs. 4.60 ± 0.87; p = 0.006). There were no significant differences between geographic regions in the United States, however, International respondents had significantly lower social and intellectual wellness (INT) subscores. Physical wellness subscore (4.00 ± 0.9) was significantly lower than the other subscores (4.59 ± 0.81) (p < .001). Overall mean Wellness Composite was 15.11 ± 3.13 (range: 5.42-23.51). CONCLUSION: Overall self-reported wellness was lower among interventional radiologists practicing at academic centers. Interventional Radiologists < 40 years old and residents had lower emotional wellness, while international respondents had lower social and INT. Overall wellness scores were lower than prior PWS studies.

Interventional radiology education: Patient experience with an educational website.

RATIONALE AND OBJECTIVES: The aim of this study was to examine the impact of an educational website on patient understanding of Interventional Radiology (IR). MATERIAL AND METHODS: An informational website with descriptions and images of 12 common IR procedures was developed with the aim of educating patients. One hundred patients referred to a large, academic institution were randomly selected to participate. Anonymous 11-question, 5-point Likert-scale assessments were administered before and after engaging with the educational website. The survey evaluated patients' understanding of IR procedures and satisfaction with the website as an educational tool. RESULTS: One hundred patients completed the pre-/post-implementation evaluations. Among matched questions, there was an increase in patient understanding of IR with mean score improvement from 2.10 to 4.57 (p < 0.001), their knowledge of common procedures from 1.74 to 4.66 (p < 0.001), and their consideration for their next procedure to be with IR from 2.24 to 4.62 (p < 0.001). Additionally, patients had an overall positive impression of the website (mean 4.80). Over 75% of patients found the descriptions and images "very helpful". CONCLUSION: This study demonstrated that website use for patient education has the potential to be effective in increasing overall patient understanding of IR and familiarity with common interventional procedures.

Detecting and Characterizing Inferior Vena Cava Filters on Abdominal Computed Tomography with Data-Driven Computational Frameworks.

Two data-driven algorithms were developed for detecting and characterizing Inferior Vena Cava (IVC) filters on abdominal computed tomography to assist healthcare providers with the appropriate management of these devices to decrease complications: one based on 2-dimensional data and transfer learning (2D + TL) and an augmented version of the same algorithm which accounts for the 3-dimensional information leveraging recurrent convolutional neural networks (3D + RCNN). The study contains 2048 abdominal computed tomography studies obtained from 439 patients who underwent IVC filter placement during the 10-year period from January 1st, 2009, to January 1st, 2019. Among these, 399 patients had retrievable filters, and 40 had non-retrievable filter types. The reference annotations for the filter location were obtained through a custom-developed interface. The ground truth annotations for the filter types were determined based on the electronic medical record and physician review of imaging. The initial stage of the framework returns a list of locations containing metallic objects based on the density of the structure. The second stage processes the candidate locations and determines which one contains an IVC filter. The final stage of the pipeline classifies the filter types as retrievable vs. non-retrievable. The computational models are trained using Tensorflow Keras API on an Nvidia Quadro GV100 system. We utilized a fine-tuning supervised training strategy to conduct our experiments. We find that the system achieves high sensitivity on detecting the filter locations with a high confidence value. The 2D + TL model achieved a sensitivity of 0.911 and a precision of 0.804, and the 3D + RCNN model achieved a sensitivity of 0.923 and a precision of 0.853 for filter detection. The system confidence for the IVC location predictions is high: 0.993 for 2D + TL and 0.996 for 3D + RCNN. The filter type prediction component of the system achieved 0.945 sensitivity, 0.882 specificity, and 0.97 AUC score with 2D + TL and 0. 940 sensitivity, 0.927 specificity, and 0.975 AUC score with 3D + RCNN. With the intent to create tools to improve patient outcomes, this study describes the initial phase of a computational framework to support healthcare providers in detecting patients with retained IVC filters, so an individualized decision can be made to remove these devices when appropriate, to decrease complications. To our knowledge, this is the first study that curates abdominal computed tomography (CT) scans and presents an algorithm for automated detection and characterization of IVC filters.

Long-term Clinical Outcomes of Yttrium-90 Transarterial Radioembolization for Hepatocellular Carcinoma: A 5-Year Institutional Experience.

RATIONALE AND OBJECTIVES: To examine the clinical outcomes of yttrium-90 (Y90) transarterial radioembolization (TARE) for primary hepatocellular carcinoma (HCC) through the evaluation of a 5-year institutional experience. MATERIALS AND METHODS: This retrospective study evaluated 88 consecutive patients with primary HCC receiving Y90 TARE treatment at an academic medical center from 2017 to 2021. Disease distribution was bilobar in 60.2% of patients with an average lesion diameter of 5.0 ± 3.4 cm and Barcelona Clinic Liver Cancer stage B or C in 77% of the participants. Clinical outcomes were elucidated by examination of complications, liver function tests, biochemical response, and radiographic response. Objective response ratio (ORR) and progression-free survival (PFS) were also calculated. RESULTS: The mean administered Y90 radiation dose was 127.8 ± 20.2 Gy. No significant complications or LFT elevations occurred post-therapy. Of the 73.9% of patients with α-fetoprotein-producing tumors, 67.8% experienced a complete or partial biochemical response 1 month post-treatment. The ORR was 83.3% on 6-month imaging and PFS was 9.6 ± 8.5 months. Functional outcomes (Eastern Cooperative Oncology Group) were maintained or improved in 79.6% and 76.1% of patients by 6 months and 1 year post-treatment, respectively. The mean survival was 14.7 ± 12.1 months. At 6 months post-treatment, 77.3% of patients were downstaged to or maintained Milan criteria, which was sustained for 74.4% and 70.0% of patients 1 year and 2 years after treatment, respectively. CONCLUSION: Y90-TARE is a safe and effective therapy for primary HCC. Enduring outcomes further act as a realistic bridge to liver transplantation, with a majority of patients maintaining Milan criteria and preserving their functional status long term.

Recent Advances in Image-Guided Locoregional Therapies for Primary Liver Tumors.

Primary liver cancer is the leading cause of cancer-related deaths worldwide. with incidences predicted to rise over the next several decades. Locoregional therapies, such as radiofrequency or microwave ablation, are described as image-guided percutaneous procedures, which offer either a curative intent for early-stage hepatocellular carcinoma or bridging/downstaging for surgical resection or transplantation. Catheter-driven locoregional therapies, such as transarterial chemoembolization and radioembolization, induce tumor hypoxia, can be palliative, and improve survival for early-to-intermediate hepatocellular carcinoma and unresectable intrahepatic cholangiocarcinoma. Herein, we provide a comprehensive overview of the antineoplastic mechanisms underpinning locoregional therapies, different treatment approaches, and the current state of the literature for the efficacy of locoregional therapies for primary liver cancer. We also discuss emerging advancements, such as the adjuvant use of immunotherapies and molecular targeting agents with locoregional therapy, for the treatment of primary liver cancer.

A History and Modern Framework for Quality Improvement in Interventional Radiology.

Quality improvement (QI) initiatives have benefited patients as well as the broader practice of medicine. Large-scale QI has been facilitated by multi-institutional data registries, many of which were formed out of national or international medical society initiatives. With broad participation, QI registries have provided benefits that include but are not limited to establishing treatment guidelines, facilitating research related to uncommon procedures and conditions, and demonstrating the fiscal and clinical value of procedures for both medical providers and health systems. Because of the benefits offered by these databases, Society of Interventional Radiology (SIR) and SIR Foundation have committed to the development of an interventional radiology (IR) clinical data registry known as VIRTEX. A large IR database with participation from a multitude of practice environments has the potential to have a significant positive impact on the specialty through data-driven advances in patient safety and outcomes, clinical research, and reimbursement. This article reviews the current landscape of societal QI programs, presents a vision for a large-scale IR clinical data registry supported by SIR, and discusses the anticipated results that such a framework can produce.

Locoregional Therapy for Intrahepatic Cholangiocarcinoma.

Intrahepatic cholangiocarcinoma (ICC) has a poor prognosis, and surgical resection (SR) offers the only potential for cure. Unfortunately, only a small proportion of patients are eligible for resection due to locally advanced or metastatic disease. Locoregional therapies (LRT) are often used in unresectable liver-only or liver-dominant ICC. This review explores the role of these therapies in the treatment of ICC, including radiofrequency ablation (RFA), microwave ablation (MWA), transarterial chemoembolization (TACE), transarterial radioembolization (TARE), external beam radiotherapy (EBRT), stereotactic body radiotherapy (SBRT), hepatic arterial infusion (HAI) of chemotherapy, irreversible electroporation (IE), and brachytherapy. A search of the current literature was performed to examine types of LRT currently used in the treatment of ICC. We examined patient selection, technique, and outcomes of each type. Overall, LRTs are well-tolerated in the treatment of ICC and are effective in improving overall survival (OS) in this patient population. Further studies are needed to reduce bias from heterogenous patient populations and small sample sizes, as well as to determine whether certain LRTs are superior to others and to examine optimal treatment selection.

Hepatocellular carcinoma: State of the art diagnostic imaging.

Primary liver cancer is the fourth most common malignancy worldwide, with hepatocellular carcinoma (HCC) comprising up to 90% of cases. Imaging is a staple for surveillance and diagnostic criteria for HCC in current guidelines. Because early diagnosis can impact treatment approaches, utilizing new imaging methods and protocols to aid in differentiation and tumor grading provides a unique opportunity to drastically impact patient prognosis. Within this review manuscript, we provide an overview of imaging modalities used to screen and evaluate HCC. We also briefly discuss emerging uses of new imaging techniques that offer the potential for improving current paradigms for HCC characterization, management, and treatment monitoring.

Clinical Outcomes of DEB-TACE in Hepatic Metastatic Neuroendocrine Tumors: A 5-Year Single-Institutional Experience.

RATIONALE AND OBJECTIVES: To evaluate single-institution outcomes of drug-eluting bead transarterial chemoembolization (DEB-TACE) in the treatment of locally advanced neuroendocrine tumor (NET) hepatic metastases with a focus on safety and efficacy of treatment. MATERIALS AND METHODS: A single-center retrospective cohort study of the outcomes of consecutive patients with NELM who underwent DEB-TACE between 2014 and 2019 was performed. Clinicopathologic characteristics, radiologic response (modified Response Evaluation Criteria in Solid Tumors) at 1-month follow-up, adverse events, progression-free survival (PFS), and overall survival were calculated. RESULTS: Among 287 patients (mean age of 62 years; 39% male: 61% female), disease burden was bilobar (90.2%) with mean largest tumor diameter measuring 4.9 ± 2.8 cm. Of these patients, 14.6% had no evidence of tumor in other organs or lymph nodes. Complete response occurred in 60 (20.9%) patients while 133 (46.3%) had partial responses. Major complication occurred in 2.4%. Liver function tests including total bilirubin and AST were overall stable at the 1-month follow-up, with only a small increase in the ALT at +8.9% (p < 0.01). Overall survival was 80.1% at 1 year, 49.1% at 3 years, and 12.3% at 5 years with a mean PFS of 14.4 ± 12.5 months. CONCLUSION: Based on this institutional experience, DEB-TACE is an acceptable locoregional therapy choice for hepatic metastases of NET due to its tolerable safety profile and relative efficacy.

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.