Consensus Guidelines of Irreversible Electroporation for Pancreatic Tumors: Protocol Standardization Using the Modified Delphi Technique.

Since no uniform treatment protocol for pancreatic irreversible electroporation (IRE) exists, the heterogeneity throughout literature complicates the comparison of results. To reach agreement among experts, a consensus study was performed. Eleven experts, recruited according to predefined criteria regarding previous IRE publications, participated anonymously in three rounds of questionnaires according to a modified Delphi technique. Consensus was defined as having reached ≥80% agreement. Response rates were 100, 64, and 64% in rounds 1 to 3, respectively; consensus was reached in 93%. Pancreatic IRE should be considered for stage III pancreatic cancer and inoperable recurrent disease after previous local treatment. Absolute contraindications are ventricular arrhythmias, implantable stimulation devices, congestive heart failure NYHA class 4, and severe ascites. The inter-electrode distance should be 10 to 20 mm and the exposure length should be 15 mm. After 10 test pulses, 90 treatment pulses of 1,500 V/cm should be delivered continuously, with a 90-µs pulse length. The first postprocedural contrast-enhanced computed tomography should take place 1 month post-IRE, and then every 3 months. This article provides expert recommendations regarding patient selection, procedure, and follow-up for IRE treatment in pancreatic malignancies through a modified Delphi consensus study. Future studies should define the maximum tumor diameter, response evaluation criteria, and the optimal number of preoperative FOLFIRINOX cycles.

Research Priorities for Percutaneous Arteriovenous Fistula Creation in Patients with End-Stage Renal Disease: Proceedings and Recommendations from a Multidisciplinary Research Consensus Panel.

Recently developed endovascular techniques to create percutaneous arteriovenous fistulas are an alternative to surgical arteriovenous fistula creation, although there is currently a lack of high-level evidence regarding their creation, maturation, utilization, and long-term function. Recognizing this, the Society of Interventional Radiology Foundation sponsored a Research Consensus Panel and Summit for the prioritization of a research agenda to identify and address the gaps in current knowledge.

Student-Authored Autopsy Reports of Anatomical Donors: Their First Patients.

The preparation of student-authored autopsy reports of anatomical donors was added to the Gross Anatomy course to integrate the basic and clinical sciences and determine whether students considered this early clinical exposure to be a valuable experience. All donors were scanned using computerized tomography (CT) and student groups received the scan of their donor and a report written by a radiologist. As students dissected, they took photographs and biopsies of pathological findings that were processed for microscopic evaluation. Following consultation with pathologists and radiologists, each group prepared an autopsy report that proposed a cause of death supported with macroscopic, microscopic, and CT images. Cardiovascular events and cancer were the most common. Autopsy reports were evaluated by the faculty and each student group received feedback with respect to content, accuracy, and completeness and whether faculty agreed with students' proposed cause of death. A majority of students answering an anonymous survey indicated that this exercise was valuable or somewhat valuable, but did not agree that preparation of the autopsy report resulted in their being more engaged during the course. Students agreed or somewhat agreed that the exercise should be repeated next year, that they gained insight into the clinical manifestations of disease, that they were able to interpret the CT scan themselves, that meeting with a pathologist was interesting, and that the time required to prepare the report was adequate. Since autopsy reports prepared by students are feasible and students found it to be a valuable experience, we suggest that medical schools add this to Gross Anatomy courses to introduce clinical material and increase clinical relevance.

Practical Considerations Relating to Routine Clinical Biomarker Testing for Non-small Cell Lung Cancer: Focus on Testing for RET Fusions.

For patients with advanced non-small cell lung cancer, genomic profiling of tumors to identify potentially targetable alterations and thereby inform treatment selection is now part of standard care. While molecular analyses are primarily focused on actionable biomarkers associated with regulatory agency-approved therapies, there are a number of emerging biomarkers linked to investigational agents in advanced stages of clinical development will become approved agents. A particularly timely example is the reported data and US Food and Drug Administration approval of highly specific small molecule inhibitors of the proto-oncogene tyrosine-protein kinase receptor RET indicate that testing for tumor RET gene fusions in patients with NSCLC has become clinically important. As the number of biomarkers to be tested in NSCLC grows, it becomes increasingly important to optimize and prioritize the use of biopsy tissue, in order to both continue to allow accurate histopathological diagnosis and also to support concurrent genomic profiling to identify perhaps relatively uncommon genetic events. In order to provide practical expert consensus guidance to optimize processes facilitating genomic testing in NSCLC and to overcome barriers to access and implementation, a multidisciplinary advisory board was held in New York, on January 30, 2019. The panel comprised physicians involved in sample procurement (interventional radiologists and a thoracic surgeon), surgical pathologists specializing in the lung, molecular pathologists, and thoracic oncologists. Particular consideration was given to the key barriers faced by these experts in establishing institutional genomic screening programs for NSCLC. Potential solutions have been devised in the form of consensus opinions that might be used to help resolve such issues.

Evaluation of a three-session biliary dilation protocol following transplant-related biliary stricture in pediatric patients.

To evaluate whether a serial biliary dilation protocol improves outcomes and decreases total biliary drainage time for biliary strictures following pediatric liver transplantation. From 2006 to 2016, 213 orthotopic deceased and living related liver transplants were performed in 199 patients with a median patient age of 3.1 years at a single pediatric hospital. Patients with biliary strictures were managed by IR or surgically by the transplant team. Patients managed by IR were divided into two groups. The first group was managed with a standardized three-session protocol consisting of dilation every two weeks for three dilations. The second group was managed clinically with varying number and interval of dilations as determined by a multidisciplinary team. The location of biliary stricture, duration of drainage, number of balloon dilations, balloon diameter, time interval between dilations, and success of percutaneous treatment were recorded. Thirty-four patients developed biliary strictures. Thirty-one patients were managed with percutaneous intervention. Three strictures could not be crossed and were converted to operative management. Ten patients were managed in the three-session protocol, and 18 patients were managed in the clinically treated group. There was no significant difference in clinical success rates between groups, 80% and 61%, respectively. The three-session protocol group trended toward a lower total biliary drain indwell time (median 49 days) compared with the clinically treated group (median 89 days), P = .089. Our study suggests that a three-session dilation protocol following transplant-related biliary stricture may decrease total biliary drainage time for some patients.

Evaluating Factors and Resources Affecting Ranking of Diagnostic Radiology Residency Programs by Medical Students in 2016-2017.

RATIONALE AND OBJECTIVES: Recent changes in radiology curriculum and access to residency program information, including the introduction of various online resources and the Interventional Radiology integrated pathway, may influence the rank list order of medical student applicants. The purpose of this study is to assess factors that affect the rank lists of medical students applying to our radiology residency program in the 2016-2017 academic year. MATERIALS AND METHODS: After IRB approval, an anonymous online 19 question survey was emailed to 622 applicants to our diagnostic radiology and/or interventional radiology integrated pathway. Applicants ranked 35 unique factors that may influence their residency rank list order from 1 (not important at all) to 5 (very important), listed their top five 'very important' factors, and ranked various sources of information used to learn about residency programs. General applicant demographic questions were also included. RESULTS: Response rate was 18.8% (117/622). The 5 most important factors affecting applicant ranking of programs are perceived happiness of the residents and faculty (4.69), fellowship and job placement of recent graduates (4.34), interactions with programs' current residents (4.33), stability of the department and program (4.29), and geographic location of the program (4.27). The top 5 resources for learning about residency programs were interactions with current residents at the program (4.47), program director (3.87), and interviewing faculty (3.87). Individual program websites were ranked more highly than internet message boards and forums as an information source. CONCLUSION: Medical students consider a large number of factors and resources in determining their rank lists, with factors encountered during the interview day playing a significant role in shaping the applicants' view of a residency program.

Single-Institution Experience with Irreversible Electroporation for T4 Pancreatic Cancer: First 50 Patients.

BACKGROUND: Irreversible electroporation (IRE) for treatment of locally advanced pancreatic tumors is garnering increasing attention. This study was conducted to determine perioperative morbidity and mortality for locally advanced pancreatic cancer. METHODS: Prospective data of 50 consecutive patients receiving IRE for T4 lesions at a single tertiary center were analyzed. The primary end point was Clavien-Dindo complications at 90 days, and the secondary outcomes were survival and recurrence. RESULTS: A total of 50 patients underwent 53 IRE procedures for primary treatment (n = 29) or margin extension (n = 24), and 47 patients had adenocarcinoma. Six patients died within 90 days after the procedure (5 in the primary control group). Mortality occurred a median of 26 days (range, 8-42 days) after the procedure. Five patients in both the margin-extension and primary control groups experienced grade 3 or 4 morbidity (p = 0.739). The incidences of grades 3 to 5 complications did not differ significantly based on the adjustable parameters of IRE, tumor size, or primary treatment versus margin extension. After a median follow-up period of 8.69 months [interquartile range (IQR), 0.26-16.26 months], the median overall survival period for the primary control group was 7.71 months [95 % confidence interval (CI), 6.03-12.0 months) and was not reached in the margin-extension group (p = 0.01, log-rank). CONCLUSIONS: At the authors' center, the mortality rate after IRE was higher than reported in other series, with the majority occurring in the primary control group. Major morbidity trended around upper gastrointestinal bleeding, visceral ulcerations/perforations, and portal vein thromboses. This favors further investigation of the safety and efficacy of IRE.

Retrieval of a Dislodged Catheter Using Combined Fluoroscopy and Intracardiac Echocardiography.

This report details a method of percutaneous, transluminal retrieval of an intracardiac foreign body using fluoroscopy in combination with intracardiac echocardiography. During retrieval, intracardiac echocardiography (ICE) provided real-time anatomic localization of a constantly moving, almost radiolucent micropuncture coaxial dilator fragment with respect to the tricuspid and pulmonary valves. This method may serve as a crucial aid in retrieval of intracardiac foreign bodies that are difficult to see with fluoroscopy and which may be adjacent to cardiac valves.

An evaluation of the sensitivity of MRI at detecting hepatocellular carcinoma in cirrhotic patients utilizing an explant reference standard.

OBJECTIVE: To evaluate the sensitivity of magnetic resonance imaging (MRI) at detecting hepatocellular carcinoma (HCC). MATERIALS AND METHODS: MRIs performed within 120 days of transplant, and pathology, were reviewed. RESULTS: Of the 87 patients included in the final analysis, 58 had HCC at explant (106 total HCCs). The per-patient and per-lesion sensitivity was 74.1% (43/58) and 81.1% (86/106), respectively. The sensitivity based on size <1cm, 1-2 cm, and >2 cm was 80.0% (28/35), 77.2% (44/57), and 100% (14/14). CONCLUSION: MRI accurately detects HCC, including HCCs <2 cm. In our study population, the imaging disease staging was concordant with pathological staging in 80% of patients.

Bland embolization versus chemoembolization of hepatocellular carcinoma before transplantation.

There is conflicting literature regarding the superiority of transarterial chemoembolization (TACE) versus bland transarterial embolization (TAE), and this has not been well studied before transplantation. Twenty-five TAE patients were matched in a 1:2 ratio with TACE patients by the initial radiographic tumor size and number in a retrospective, case-controlled study. The patients were otherwise treated according to the same protocols. The method of embolization was chosen on the basis of interventionalist practices at 2 sites within the program. Kaplan-Meier survival analyses at 1 and 3 years were the primary endpoints. There were no significant demographic differences between the groups. The mean adjusted Model for End-Stage Liver Disease scores at transplantation and waiting times were not significantly different between the TAE and TACE patients (MELD scores: 26 ± 3 versus 24 ± 3 points, P = 0.12; waiting times: 13 ± 8 versus 11 ± 10 months, P = 0.43). TAE patients (16%) were less likely than TACE patients (40%) to require 2 procedures (P = 0.04). Explant tumors were completely necrotic for 36% of the TAE patients and for 26% of the TACE patients. The 3-year overall survival rates were 78% for the TAE patients and 74% for the TACE patients (P = 0.66), and the 3-year recurrence-free survival rates were 72% for the TAE patients and 68% for the TACE patients (P = 0.67). On an intention-to-treat basis, there was no significant risk of wait-list dropout associated with TAE or TACE (P = 0.83). In conclusion, there were no significant differences in wait-list dropout or in overall or recurrence-free survival between HCC patients undergoing TAE and HCC patients undergoing TACE before transplantation.

Electromagnetic navigation with multimodality image fusion for image-guided percutaneous interventions.

Percutaneous image-guided interventions are performed for a variety of clinical indications: to obtain tissue biopsies, to alleviate pain, and to treat diseases including a variety of malignancies. The efficacy of all of the above is directly related to accurate positioning of the procedural device using imaging guidance. The ability to achieve accurate positioning can be limited by a variety of technical factors including small lesion size, a lesion that is best seen on an imaging modality that is impractical for guiding intervention, and a lesion that is difficult to access or in a tenuous location. Electromagnetic navigation with image fusion has the ability to improve the speed and accuracy of percutaneous image-guided interventions by providing real-time feedback and allowing image overlay of diagnostic-imaging modalities with the guiding modality. The article discusses the technical aspects of electromagnetic navigation including potential clinical applications, procedures that may be facilitated by navigation, and inherent limitations of the technology.

Interventional radiology in the multidisciplinary management of liver lesions: pre- and postoperative roles.

The management algorithm for patents with liver lesions, most often hepatocellular carcinoma (HCC) or colorectal cancer metastasis, are complex, ever-changing, and involve multiple treatment modalities including chemotherapy, external-beam radiation, surgery, and locoregional therapies (LRTs). This complexity necessitates a multidisciplinary approach including hepatologists, oncologists, hepatobiliary surgeons, radiation oncologists, and interventional radiologists to coordinate and deliver the complex care that these patients need in a timely manner. The interventional radiologist and hepatobiliary surgeon work closely together in both the pre- and postoperative setting. Preoperative roles include delivering LRTs to patients with HCC and interventions aimed at hepatic optimization prior to resection or transplantation. LRT in this setting is performed either to bridge the patient to transplant or to downstage the initially nontransplant candidate so appropriate transplant criteria are met. Postoperative roles include the management of biliary and vascular complications that may occur after resection or transplantation.

Treatment of hepatocellular carcinoma combining sorafenib and transarterial locoregional therapy: state of the science.

The potential for increased efficacy with combined transarterial chemoembolization and sorafenib is a topic of increased interest to specialists who care for patients with unresectable hepatocellular carcinoma. There is strong scientific rationale for combination therapy: transarterial chemoembolization produces ischemia and stimulates hypoxia-inducible factor-1α, resulting in a local and systemic upregulation of vascular endothelial growth factor (VEGF), which can increase tumor angiogenesis. This upregulation can theoretically be counteracted with the multikinase inhibitor sorafenib, which is thought to act directly on platelet-derived growth factor, Raf kinase, and VEGF receptors. The potential of this approach has not yet been fully realized in clinical trials, and many unanswered questions remain. This review article discusses the state of the science of arterial locoregional therapies and sorafenib.

Single-center experience with elective transcatheter coil embolization of splenic artery aneurysms: technique and midterm follow-up.

PURPOSE: To review a single-center experience with elective coil embolization of splenic artery aneurysm (SAA) and analyze efficacy of the technique at midterm follow-up. MATERIALS AND METHODS: From 2002 through 2011, 50 patients (28 women, 22 men; age range, 24-89 y; mean age, 53.5 y ± 13.6) underwent transcatheter coil embolization for treatment of SAAs. Pseudoaneurysms and ruptured aneurysms were excluded. A total of 63 SAAs were treated (size, 13-97 mm; mean, 29 mm). Ninety-eight percent of aneurysms were treated with coils alone. Regular follow-up consisted of an office visit and imaging. Patient medical records were reviewed for aneurysm location, procedural approach, and technical and clinical outcomes. RESULTS: Ninety-eight percent of procedures were technically successful at thrombosing the aneurysm at the time of procedure. Repeat intervention was performed in four of 47 patients (9%) because of continued aneurysm perfusion at follow-up. Mean time to repeat intervention was 125 days (range, 42-245 d). All repeat interventions were technically successful. Neither aneurysm growth nor aneurysm rupture was observed in any patient during the follow-up period (mean, 78 weeks; range, 9 d to 7.1 y). There were no major adverse events. Major splenic infarction occurred in three of 33 patients (9%) with no underlying liver disease and normal splenic volume and in seven of 14 patients (50%) with portal hypertension. CONCLUSIONS: Percutaneous transcatheter coil embolization is a safe, effective, and minimally invasive treatment for SAAs as evidenced by high rates of technical success and freedom from aneurysm rupture.

Emergent embolization of arterial bleeding after vacuum-assisted breast biopsy.

Vacuum-assisted core breast biopsy has become important in evaluating patients with suspicious breast lesions. It has proven to be a relatively safe procedure that in rare cases can result in vascular complications. These are the first reported cases of transcatheter embolization of uncontrolled breast hemorrhage after vacuum-assisted breast biopsy. With increased use of biopsy and larger-gauge devices, breast imaging groups may consider embolotherapy as a safe alternative for treatment of hemorrhage in a select group of patients.

Gastroduodenal ulceration associated with radioembolization for the treatment of hepatic tumors: an institutional experience and review of the literature.

BACKGROUND: Microsphere radioembolization is a method of delivering radiation therapy directly to tumors, thereby minimizing toxicity to adjacent structures. Despite the relatively high precision of this modality, numerous adverse effects have been recognized. One particularly untoward complication is the development of severe gastroduodenal ulceration. METHODS: In order to further characterize gastroduodenal ulceration associated with radioembolization, our institutional experience as well as the reported literature were reviewed. RESULTS: The current evidence suggests that radioembolization-associated gastroduodenal ulceration results from inadvertent delivery of microspheres to the microvasculature of the gastrointestinal tract, leading to direct radiation toxicity. The reported incidence of this entity ranges between 2.9% and 4.8%. Most patients with this complication present with abdominal pain, often associated with nausea, vomiting, and anorexia. Symptoms can arise from hours to months after radioembolization treatment; diagnosis is made by endoscopic biopsy and histopathologic evaluation of the ulcer specimen. Radiation-induced ulcers have proven to be extremely difficult to treat. Current therapy based on acid suppression has had limited success, and the evidence for the addition of antioxidants and anti-inflammatory agents is still sparse. CONCLUSIONS: The increasing utilization of radioembolization will lead to adverse events including gastroduodenal ulceration. This entity must be considered in any patient treated with radioactive microspheres presenting with symptoms of dyspepsia. Accurate diagnosis and aggressive treatment are necessary to improve patient outcomes.

Intra-arterial methylprednisolone infusion in treatment-resistant graft-versus-host disease.

Acute graft-versus-host disease (GVHD) is a potentially fatal complication following allogeneic hematopoietic stem cell transplant. Standard primary therapy for acute GVHD includes systemic steroids, often in combination with other agents. Unfortunately, primary treatment failure is common and carries a high mortality. There is no generally accepted secondary therapy for acute GVHD. Although few data on localized therapy for GVHD have been published, intra-arterial injection of high-dose corticosteroids may be a viable option. We treated 11 patients with steroid-resistant GVHD using a single administration of intra-arterial high-dose methylprednisolone. Three patients (27%) died periprocedurally. Four patients (36%) had a partial response to intra-arterial treatment and were discharged on total parenteral nutrition and oral medication. Four patients (36%) had a complete response and were discharged on oral diet and oral medication. No immediate treatment or procedure-related complications were noted. Twenty-seven percent of patients survived long-term. Our preliminary results suggest that regional intra-arterial treatment of steroid-resistant GVHD is a safe and potentially viable secondary therapy in primary treatment-resistant GVHD.

Time-resolved MR angiography for the classification of endoleaks after endovascular aneurysm repair.

PURPOSE: To evaluate the utility of time-resolved MR angiography (TR-MRA), compared with digital subtraction angiography (DSA), in the classification of endoleaks in patients who have undergone endovascular aneurysm repair (EVAR). MATERIALS AND METHODS: Thirty-one patients who had undergone EVAR to repair an abdominal aortic aneurysm were evaluated with both TR-MRA and DSA to determine endoleak etiology. The patient population consisted of 26 men and 5 women with a mean age of 78.5 years (range, 55-93 years). The mean time interval between TR-MRA and DSA was 1.5 weeks (range, 1-8 weeks). Endoleaks were classified as type II when enhancement of the external iliac vessels was observed before the appearance of the endoleak; otherwise the endoleak was classified as type I or III. The results of TR-MRA classification were compared with the reference gold standard, DSA. RESULTS: Agreement between TR-MRA and DSA regarding endoleak classification occurred in 30 of 31 cases (97%). Discordant classification occurred in a case in which a Type II endoleak was misclassified as a Type III due to failure to visualize a lumbar vessel. CONCLUSION: TR-MRA is highly effective in classifying endoleaks following EVAR when compared with DSA.

Transarterial chemoembolization for primary hepatocellular carcinoma in patients at high risk.

PURPOSE: Transarterial chemoembolization (TACE) has become a standard treatment option for patients with unresectable hepatocellular carcinoma (HCC). This retrospective study evaluated the safety and efficacy of TACE in patients at high risk with increased serum bilirubin level, low serum albumin level, poor hepatic reserve, or compromised hepatopetal flow in the portal vein (PV). MATERIALS AND METHODS: A total of 52 patients underwent 65 high-risk procedures. Thirty patients treated with 38 procedures (57.7% of patients and 58.5% of procedures) had serum bilirubin levels of 2-3 mg/dL (ie, moderate elevation) and 22 patients treated with 27 procedures (42.3% and 41.5%) had a serum bilirubin level of at least 3 mg/dL (ie, considerable elevation). Forty patients (76.9%) had serum albumin levels less than 3.5 mg/dL. Thirteen recipients of 15 procedures (25% and 20%) had portal diversion or obstruction. Twenty-four patients (46.2%) had a Child-Pugh (CP) score of 8 or less and 28 patients (53.8%) had a CP score of at least 9 at the time of TACE. Thirty patients (57.7%) had focal tumors and 22 patients (42.3%) had multifocal or infiltrative disease. Superselective chemoembolization could be performed in 37 procedures (56.9%); lobar chemoembolization was performed in the remaining 28 (43.1%). RESULTS: The 30-day mortality rate was 7.7% and the procedure-related morbidity rate was 10.8%. Patients with multifocal disease and lobar embolization had significantly higher mortality rates (P=.03). Individual factors such as serum bilirubin, serum albumin, and PV flow did not affect outcomes significantly. The 1- and 2-year survival rates in patients with focal disease were 67.9% and 37.7%, respectively, compared with 19.6% and 0% in patients with multifocal disease (P<.0001). CONCLUSIONS: TACE in patients considered at high risk does not necessarily incur a higher incidence of morbidity or mortality. Patient selection should be based on extent of disease, and these tumors should be treated selectively at a segmental level if possible.

A novel endovascular adjustable polytetrafluoroethylene-covered stent for the management of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt.

Transjugular intrahepatic portosystemic shunt (TIPS) is frequently complicated by hepatic encephalopathy. When medical therapy fails, TIPS narrowing and resultant increase in the portosystemic pressure gradient and blood flow to the liver is performed in order to reverse the encephalopathy. We present a method for reducing the TIPS using a polytetrafluoroethylene-covered balloon expandable stent placed over a self-expanding stent. This results in a narrowed TIPS that not only rapidly increases the portosystemic gradient but also can be adjusted by dilating the balloon expandable stent. This method was successful in narrowing the patient's TIPS, acutely increasing the portosystemic gradient and reversing the hepatic encephalopathy.