Whole-lesion assessment of volume and signal changes after sclerotherapy of extremity venous malformations.

PURPOSE: To investigate quantitative changes in MRI signal intensity (SI) and lesion volume that indicate treatment response and correlate these changes with clinical outcomes after percutaneous sclerotherapy (PS) of extremity venous malformations (VMs). METHODS: VMs were segmented manually on pre- and post-treatment T2-weighted MRI using 3D Slicer to assess changes in lesion volume and SI. Clinical outcomes were scored on a 7-point Likert scale according to patient perception of symptom improvement; treatment response (success or failure) was determined accordingly. RESULTS: Eighty-one patients with VMs underwent 125 PS sessions. Treatment success occurred in 77 patients (95 %). Mean (±SD) changes were -7.9 ± 24 cm3 in lesion volume and -123 ± 162 in SI (both, P <.001). Mean reduction in lesion volume was greater in the success group (-9.4 ± 24 cm3) than in the failure group (21 ± 20 cm3) (P =.006). Overall, lesion volume correlated with treatment response (ρ = -0.3, P =.004). On subgroup analysis, volume change correlated with clinical outcomes in children (ρ = -0.3, P =.03), in sodium tetradecyl sulfate-treated lesions (ρ = -0.5, P =.02), and in foot lesions (ρ = -0.6, P =.04). SI change correlated with clinical outcomes in VMs treated in 1 PS session (ρ = -0.3, P =.01) and in bleomycin-treated lesions (ρ = -0.4, P =.04). CONCLUSIONS: Change in lesion volume is a reliable indicator of treatment response. Lesion volume and SI correlate with clinical outcomes in specific subgroups.

Prospective Study of Polytetrafluoroethylene-Covered Microplugs and Detachable Coils for Embolization of Pulmonary Arteriovenous Malformations: Technical Results, Procedure Times, and Costs.

PURPOSE: To determine time to occlusion and procedure costs of embolization of pulmonary arteriovenous malformations (PAVMs) using a polytetrafluoroethylene-covered microplug compared with embolization using detachable coils. MATERIALS AND METHODS: In this prospective study, 37 patients (mean age, 39.1 years [SD ± 17.6]) with 82 PAVMs underwent embolization with microplug or detachable coils between April 2019 and January 2023. Technical success, procedure time intervals, and costs were analyzed. RESULTS: In 37 patients, 82 PAVMs and 101 feeding arteries were successfully treated (microplug, 64; microplug + another device, 5; detachable coils alone, 32). Time from embolic device inserted into the catheter to device deployed and time to occlusion differed significantly between microplug and detachable coil cohorts (P < .0001 for both). Embolization with ≥1 microplug had a significantly shorter occlusion time than embolization with detachable coils (median, 10.0 minutes saved per feeding artery) (P < .0001). Compared with detachable coil embolization, microplug embolization saved a median of 9.0 minutes per feeding artery (P < .0001) and reduced room cost by a median of $429 per feeding artery (P < .0001). Device costs per feeding artery did not differ significantly between microplug ($2,790) and detachable coil embolization ($3,147) (P = .87). CONCLUSIONS: Compared with coils, microplugs had an equally high technical success rate but significant time to occlusion and room costs savings per feeding artery. Total room cost and device cost together did not differ significantly between microplugs and coils. Microplugs may be considered technically effective and at least cost-neutral for PAVM embolization where clinically appropriate.

Risk factors and clinical features associated with basal ganglia manganese deposition in patients with hereditary hemorrhagic telangiectasia.

BACKGROUND: T1-hyperintensity of the basal ganglia (BG) due to manganese deposition is a known radiologic finding in patients with hereditary hemorrhagic telangiectasia (HHT), but risk factors and associated clinical manifestations are unclear. This study conducted a quantitative analysis of the association of T1-hyperintensity in HHT patients with specific risk factors, signs, and symptoms. METHODS: Patients seen at our center between 2005 and 2020 with a definitive diagnosis of HHT who had an available non-contrast T1-weighted brain MRI were included. Hyperintensity was evaluated using oval regions of interest measurements. The BG: thalamus intensity ratio was used to quantitatively evaluate T1-hyperintensity. Patient laboratory values and clinical findings were collected from electronic medical records. Hyperintensity was analyzed for its association with laboratory values, and clinical findings. Variables were analyzed through regression analysis. RESULTS: A total of 239 patients were included in this study. On 1.5 T scanners, values that were significant on multivariable regression analysis were age (p < .001), hepatic AVMs (p < .001), iron deficiency anemia (p = .0021), and cirrhosis (p = .016). On 3 T scanners, values that were significant on multivariable analysis were hepatic AVMs (p = .0024) and cirrhosis (p = .0056). On 3 T scanners, hyperintensity was significantly associated with tremor (OR = 1.17, p = .033), restless leg syndrome (OR = 1.22, p = .0086), and memory problems (OR = 1.17, p = .046). CONCLUSIONS: BG hyperintensity due to manganese deposition is significantly associated with hepatic risk factors on 1.5 T and 3 T scanners and iron deficiency anemia on 1.5 T scanners. On 3 T scanners, T1-hyperintensity is associated with neuropsychiatric signs and symptoms, such as tremor, restless leg syndrome, and memory problems.

Responsiveness of the Patient-Reported Outcome Measure for Vascular Malformation Questionnaire in Patients with Low-Flow Vascular Malformations.

PURPOSE: To assess the responsiveness, defined as the ability to detect change in a patient's health or function, of the Patient-Reported Outcome Measure for Vascular Malformation (PROVAM) questionnaire in a cohort of patients with low-flow vascular malformations (VMs). MATERIALS AND METHODS: PROVAM was previously developed to assess symptoms, functional limitations, and social/emotional effects experienced by patients with VMs. This is a prospective cohort study of 56 patients with venous and lymphatic VMs who completed at least 2 PROVAM questionnaires, of whom 43 had undergone treatment with sclerotherapy in the interim between questionnaires. External responsiveness was assessed using a receiver operating characteristic (ROC) curve to ascertain whether a change in the total PROVAM score predicts whether patients reported symptom improvement and by correlating the change in the total PROVAM score and change in symptoms reported during clinic visit. Internal responsiveness was evaluated using Wilcoxon signed rank test, Cohen d effect size (ESp), and standard response mean difference (SRM). RESULTS: The total PROVAM score demonstrated excellent discrimination for symptom improvement with an area under the ROC curve of 0.856. There was a statistically significant, moderate positive correlation between the change in the total PROVAM score and the change in patient symptoms as determined from clinical visits (Spearman correlation coefficient [rs] = 0.67, P < .001). The total PROVAM score and all subdomain scores improved significantly after treatment (all P < .05). ESp and SRM were 0.80 and 0.83, respectively. CONCLUSIONS: PROVAM is responsive to improvement after treatment and may be useful to assess health-related quality of life in patients treated for VMs.

Interval Breast Cancers Versus Screen Detected Breast Cancers: A Retrospective Cohort Study.

RATIONALE AND OBJECTIVE: Mammographic screening detects most breast cancers but there are still women diagnosed with breast cancer between annual mammograms. We aim to identify features that differentiate screen detected breast cancers from interval breast cancer. MATERIALS AND METHODS: All screening mammograms (n = 211,517) performed 7/1/2013-6/30/2020 at our institution were reviewed. Patients with breast cancer diagnosed within one year of screening were included and divided into two distinct groups: screen detected cancer group and interval cancer group. Characteristics in these groups were compared using the chi square test, fisher test, and student's T test. RESULTS: A total of 1,232 patients were included (mean age 64 +/- 11). Sensitivity of screening mammography was 92% (1,136 screen detected cancers, 96 interval cancers). Patient age, race, and personal history of breast cancer were similar between the groups (p > 0.05). Patients with interval cancers more often had dense breast tissue (75/96 = 78% versus 694/1136 = 61%, p < 0.001). Compared to screen detected cancers, interval cancers were more often primary tumor stage two or higher (41/96 = 43% versus 139/1136 = 12%, p < 0.001) and regional lymph node stage one or higher (21/96 = 22% versus 132/1136 = 12%, p = 0.003). Interval cancers were more often triple negative (16/77 = 21% versus [48/813 = 6%], p < 0.001) with high Ki67 proliferation indices (28/45 = 62% versus 188/492 = 38%, p = 0.002). CONCLUSION: Mammographic screening had high sensitivity for breast cancer detection (92%). Interval cancers were associated with dense breast tissue and had higher stage with less favorable molecular features compared to screen detected cancers.

Racial and Ethnic Disparities among Participants in Hepatocellular Carcinoma Clinical Studies Evaluating Transarterial Therapies.

PURPOSE: To evaluate the racial and ethnic representation of transarterial therapy for hepatocellular carcinoma (HCC) clinical trials in the United States. MATERIALS AND METHODS: The ClinicalTrials.gov database was examined to identify all completed studies with transarterial therapies for the management of HCC in the United States and extract information about the observed number of participants for each racial and ethnic group (based on the Office of Management and Budget definitions). The expected number of participants was calculated by multiplying the total number of participants in a trial with the U.S.-population HCC-based proportion for each group. The effects of the study phase, funding source, number of centers involved in the study, and the location of the participating center on racial and ethnic distribution were explored. RESULTS: Seventy-nine relevant studies were identified, of which 27 (34.2%) and 18 (22.8%) reported ethnic and race characteristics, respectively. Most study participants were White (81%, 1,591/1,964) by ethnicity and not Hispanic or Latino (93%, 937/1,008) by race. In terms of the observed-to-expected ratios by race and ethnicity in all trials, White and not Hispanic or Latino participants were overrepresented with a ratio of 1.22 (1.10-1.37) and 1.33 (1.26-1.41), respectively, and all other racial and ethnic groups were underrepresented. The enrollment of African Americans and Asian Americans varied by the study phase, and a higher enrollment of African Americans was noted in the National Institutes of Health-funded and multicenter studies (P < .05). CONCLUSIONS: This cross-sectional study demonstrates that in HCC transarterial therapy clinical trials, racial and ethnic minorities were underrepresented and the majority of the studies identified failed to report this demographic information.

Impact of Patient Navigation on Reducing Breast Imaging Disparities and Applications in the COVID-19 Era.

The coronavirus (COVID-19) pandemic has impacted breast cancer screening with concerns that this may lead to increased overall breast cancer mortality and worsened racial and ethnic disparities in breast cancer survival. As pandemic recovery efforts are underway, we must be prepared to address barriers to timely access of breast imaging services, including those that existed prior to the pandemic, as well as any new barriers that may arise as a result of the pandemic. Patient navigation is an important tool that has been shown to address barriers to timely breast imaging access and help reduce disparities. Patient navigation programs can serve as a key part of the strategy to mitigate the impact of the COVID-19 pandemic on timely breast cancer diagnosis. These programs have been shown to be successful in promoting adherence to breast cancer screening guidelines as well as encouraging timely diagnostic follow-up, particularly in underserved communities. Further research is needed to explore the role of using a telehealth platform for patient navigation and evaluate the cost-effectiveness of patient navigator programs as well as more randomized controlled trials to further explore the impact of patient navigation programs.

A lack of race and ethnicity data in the treatment of hereditary hemorrhagic telangiectasia: a systematic review of intravenous bevacizumab efficacy.

BACKGROUND: For extreme hereditary hemorrhagic telangiectasia (HHT) disease, treatments such as intravenous bevacizumab are often utilized. However, whether its efficacy is similar across diverse races and ethnicities is unclear. METHODS: In this systematic review, we performed a search for English-language articles identified through PubMed, Embase, and Scopus databases whose research occurred in the United States (US). Search terms related to HHT, epistaxis, and intravenous bevacizumab. We searched specifically for the intervention of intravenous bevacizumab because the term serves as a suitable surrogate to convey a patient who has both a diagnosis of HHT and established care. We focused on number of patients recruited in intravenous bevacizumab trials who were identified by race or ethnicity. RESULTS: Our search identified 79 studies, of which four were conducted in the US. These four were selected for our systematic review. In these studies, 58 total patients were evaluated (ranging from 5 to 34 participants), whereby, information on age and gender were included. However, none of the US-based studies shared race or ethnicity data. CONCLUSION: Inability to find studies regarding intravenous bevacizumab use in patients with HHT in which race and ethnicity are reported limits our ability to understand the therapy's efficacy in specific populations. Without emphasis on race and ethnicity in such trials, showing the potential of HHT-related diversity in individuals with this disease may reaffirm implicit bias around HHT diagnosis and treatment. Future work on HHT should emphasize sociodemographic data collection and reporting in an effort to understand this disease in diverse populations.

Comparison of Outcomes for One-View Asymmetries Recalled From Digital Breast Tomosynthesis Versus Full-Field Digital Mammography Screening Examinations.

BACKGROUND. Recall rates are lower for digital breast tomosynthesis (DBT) than for full-field digital mammography (FFDM). This difference could have important implications with respect to one-view asymmetries given that missed cancers are often visible on one view. OBJECTIVE. The purpose of this study is to compare the outcomes of one-view asymmetries recalled from DBT versus FFDM screening examinations and to determine predictors of malignancy among recalled asymmetries. METHODS. This retrospective study first determined recall rates associated with one-view asymmetries for screening mammography performed using DBT and FFDM from July 14, 2016, through July 14, 2020. Further analyses included patients recalled for a one-view asymmetry who completed subsequent diagnostic workup and all recommended follow-up. Patient and cancer characteristics were extracted from the electronic health record. RESULTS. The recall rate associated with asymmetries was lower for DBT screening (2.5% [3169/128,755]) than for FFDM screening (3.4% [815/23,898]) (p < .001). Further analyses of patients who completed diagnostic workup and subsequent follow-up included 3119 patients (mean age, 57 years) for DBT screening and 811 patients (mean age, 56 years) for FFDM screening. Distribution of final BI-RADS categories from subsequent diagnostic workup was not different between the two modalities (p > .99). The frequency of malignancy was not different between asymmetries recalled from DBT (1.7% [54/3119]) and FFDM (1.7% [14/811]) (p > .99). Malignant asymmetries identified on FFDM versus DBT were more frequently associated with architectural distortion on diagnostic workup (35.7% [5/14] vs 9.3% [5/54]) (p < .001) and were more commonly invasive ductal carcinoma (92.9% vs 57.4%) and less commonly invasive lobular carcinoma (0.0% vs 24.1%) (p = .05). In multivariable analysis, independent predictors of malignancy among recalled asymmetries from DBT were age (for 55-69 years, odds ratio [OR] = 2.40 [p = .04]; for ≥ 70 years, OR = 7.93 [p < .001]; reference, < 55 years) and breast density (not dense, OR = 2.47 [p = .001]; reference, dense breasts). CONCLUSION. Recalled asymmetries were less frequent for DBT than for FFDM. The malignancy rate was low for both modalities (1.7%). Age 55 years old and older and lower breast density predicted malignancy for DBT-recalled asymmetries. CLINICAL IMPACT. Our results support the use of DBT to reduce unnecessary recalls without altering PPV for asymmetry-associated malignancies. Patient factors should be considered when assessing whether a potential asymmetry on DBT screening represents overlapping fibroglandular tissue or a suspicious finding that requires diagnostic workup.

Vascular findings in CTA body and extremity of critically ill COVID-19 patients: commonly encountered vascular complications with review of literature.

The purpose of our review is to discuss the role of CT angiography (CTA) in evaluating a variety of vascular complications in critically ill COVID-19 patients. The COVID-19 pandemic continues to be a worldwide health threat. While COVID-19 pneumonia is the most common and well-recognized presentation of COVID-19, severely ill hospitalized patients often present with extrapulmonary systemic findings. Vascular complications occur not only due to known viral-induced vasculopathy, coagulopathy, and related "cytokine storm," but also due to anticoagulation medication used during hospitalization. There is a paucity of articles describing extrapulmonary vascular findings, especially in critically ill COVID-19 patients. In our article, we discuss commonly encountered vascular imaging findings in the body (chest, abdomen, and pelvis) and extremities, the importance of early radiological detection, and the role of CTA in the management of critically ill COVID-19 patients.

Diversity and Inclusion in Breast Imaging and Radiology at Large: What Can We Do to Improve?

PURPOSE OF REVIEW: A racially and ethnically diverse healthcare workforce leads to increased access to care and better health outcomes. Radiology and specifically the patient-centered subspecialty of breast imaging have a growing mismatch between the demographics of the physician workforce and the patient population served. Identifying and addressing the barriers for diversity is imperative in order to decrease disparities in breast cancer morbidity and mortality and achieve excellence in patient care. RECENT FINDINGS: Three major barriers to promoting diversity and inclusion in the field of breast imaging and in the specialty of radiology more generally are unconscious bias, lack of mentorship for underrepresented minority (URM) students, and career development challenges facing women in radiology. We focus on these three issues and provide suggestions for addressing each of them. SUMMARY: Tackling unconscious bias through encouraging individual accountability and establishing implicit bias programs at the institutional level, supporting both formal and informal mentorship opportunities for URMs, and creating an environment to support women in leadership will bring us one step closer to fostering a diverse and inclusive breast imaging workforce and meeting the healthcare needs of the diverse US population.

Clinical and molecular characterization of patients with hereditary hemorrhagic telangiectasia: Experience from an HHT Center of Excellence.

In this retrospective single-center study, we evaluated whether/how pathogenic/likely pathogenic variants of three hereditary hemorrhagic telangiectasia (HHT)-associated genes (ENG, ACVRL1, and SMAD4) are associated with specific clinical presentations of HHT. We also characterized the morphological features of pulmonary arteriovenous malformations (AVMs) in patients with these variants. Pathogenic or likely pathogenic variants were detected in 64 patients. Using nonparametric statistical tests, we compared the type and prevalence of specific HHT diagnostic features associated with these three variants. Pathogenic variants in these genes resulted in gene-specific HHT clinical presentations. Epistaxis was present in 93%, 94%, and 100% of patients with ENG, ACVRL1, and SMAD4 variants, respectively (p = 0.79). Pulmonary AVMs were more common in patients with the ENG variant (p = 0.034) compared with other subgroups. ACVRL1 variant was associated with the lowest frequency of pulmonary AVMs (p = 0.034) but the highest frequency of hepatic AVMs (p = 0.015). Patients with the ACVRL1 variant did not have significantly more pancreatic AVMs compared with the other groups (p = 0.72). ENG, ACVRL1, and SMAD4 pathogenic or likely pathogenic variants are associated with gene-specific HHT presentations, which is consistent with results from other HHT centers.