Clinical indications, safety, and effectiveness of percutaneous image-guided adrenal mass biopsy: an 8-year retrospective analysis in 160 patients.

PURPOSE: To assess indications, safety, and effectiveness of percutaneous adrenal mass biopsy in contemporary practice. METHODS: This institutional review board-approved, retrospective study included all patients undergoing percutaneous image-guided adrenal mass biopsies at an academic health system from January 6, 2015, to January 6, 2023. Patient demographics, biopsy indications, mass size, laboratory data, pathology results, and complications were recorded. Final diagnoses were based on pathology or ≥ 1 year of imaging follow-up when biopsy specimens did not yield malignant tissue. Test performance calculations excluded repeat biopsies. Continuous variables were compared with Student's t test, dichotomous variables with chi-squared test. RESULTS: A total of 160 patients underwent 186 biopsies. Biopsies were indicated to diagnose metastatic disease (139/186; 74.7%), for oncologic research only (27/186; 14.5%), diagnose metastatic disease and oncologic research (15/186; 8%), and diagnose an incidental adrenal mass (5/186; 2.7%). Biopsy specimens were diagnostic in 154 patients (96.3%) and non-diagnostic in 6 (3.8%). Diagnostic biopsies yielded malignant tissue (n = 136), benign adrenal tissue (n = 12), and benign adrenal neoplasms (n = 6) with sensitivity = 98.6% (136/138), specificity = 100% (16/16), positive predictive value = 100% (136/136), and negative predictive value = 88.9% (16/18). Adverse events followed 11/186 procedures (5.9%) and most minor (7/11, 63.6%). The adverse event rate was similar whether tissue was obtained for clinical or research purposes (10/144; 6.9% vs. 1/42; 2.4%, p = 0.27), despite more specimens obtained for research (5.8 vs. 3.7, p < 0.001). CONCLUSION: Percutaneous adrenal mass biopsy is safe, accurate, and utilized almost exclusively to diagnose metastatic disease or for oncologic research. The negative predictive value is high when diagnostic tissue samples are obtained. Obtaining specimens for research does not increase adverse event risk.

Safety of image guided research biopsies in patients with thoracic malignancies.

OBJECTIVE: A common opportunity to collect research samples is during image-guided percutaneous core needle biopsies (CNBs) performed when clinically indicated or for assessing clinical trial eligibility. The relative safety of extra CNBs collected for research is undefined. MATERIALS AND METHODS: Patients who underwent CNB for research purposes only [RO], as clinically indicated [CI], or as part of a clinical trial [CT] were identified. 30-day post-procedure adverse events (AEs) among the cohorts were examined and compared to the 2020 Society of Interventional Radiology QI guidelines. RESULTS: 236 patients with thoracic cancers (90 % NSCLC, 5 % SCLC, 4 % mesothelioma, and 1 % thymic) had 292 CNBs (63 RO, 229 CI + CT). AEs occurred in 13 % of both the RO and CI + CT groups. Compared to the CI + CT group, the RO group did not have a higher pneumothorax incidence (RO: 5/29 [17 %], CI + CT: 18/114 [16 %], p = 0.79); both were below the suggested QI threshold of 45 % for pneumothorax. There was a negative association between number of cores obtained and risk of AE (AE vs no AE mean cores = 3.5 vs 4.8). After adjusting for the number of cores and smoking history, RO vs CI + CT lung biopsies had a higher risk of AEs (adjusted relative risk [aRR] = 2.44, 1.08-5.55, p = 0.03 vs non-lung aRR = 0.86, 0.10-7.09, p = 0.89). CONCLUSION: CNBs performed for research purposes do not have a significantly increased risk of AEs when compared to those performed for clinical trials and/or when clinically indicated. However, AEs were most frequent in lung biopsies. When performing research biopsies, a target other than lung may be preferred when clinically appropriate.

The Impact of COVID-19 on Clinical Trial Execution at the Dana-Farber Cancer Institute.

Interventions designed to limit the spread of coronavirus disease 2019 (COVID-19) are having profound effects on the delivery of health care, but data showing the impact on oncology clinical trial enrollment, treatment, and monitoring are limited. We prospectively tracked relevant data from oncology clinical trials at Dana-Farber Cancer Institute from January 1, 2018, to June 30, 2020, including the number of open trials, new patient enrollments, in-person and virtual patient visits, dispensed investigational infusions, dispensed or shipped oral investigational agents, research biopsies, and blood samples. We ascertained why patients came off trials and determined on-site clinical research staffing levels. We used 2-sided Wilcoxon rank sum tests to assess the statistical significance of the reported changes. Nearly all patients on interventional treatment trials were maintained, and new enrollments continued at just under one-half the prepandemic rate. The median number of investigational prescriptions shipped to patients increased from 0 to 74 (range = 22-107) per week from March to June 2020. The median number of telemedicine appointments increased from 0 to 107 (range = 33-267) per week from March to June 2020. Research biopsies and blood collections decreased dramatically after Dana-Farber Cancer Institute implemented COVID-19-related policies in March 2020. The number of research nurses and clinical research coordinators on site also decreased after March 2020. Substantial changes were required to safely continue clinical research during the pandemic, yet we observed no increases in serious adverse events or major violations related to drug dosing. Lessons learned from adapting research practices during COVID-19 can inform industry sponsors and governmental agencies to consider altering practices to increase operational efficiency and convenience for patients.

Treatment of malignant inferior vena cava obstruction with Gianturco-Rosch-Z stents: a single center 13-year experience.

RATIONALE AND OBJECTIVES: Malignant obstruction of the IVC can cause severe morbidity and impairment of quality of life in end-stage oncology patients. However, medical literature regarding minimally-invasive palliation using large diameter percutaneous stents, particularly the Gianturco-Rosch-Z (GRZ) stent is limited. MATERIALS & METHODS: A retrospective review from January 2004 to February 2017, revealed 17 subjects with malignant obstruction of the IVC who were treated with a total of 34 GRZ stents. Pre- and post-stent pressure gradients were measured in 10. Available data regarding clinical presentation and follow-up were recorded. RESULTS: Technical success for stent deployment was 100%. A median of 2 stents (range 1 to 5) were deployed per patient, with median stent diameter 20 mm (range 15 to 30 mm). The median pre-treatment pressure gradient of 17.5 mmHg (range 9-31 mmHg) decreased to a median of 4.5 mmHg (range 0-21 mmHg, p < .0004) after stent placement. One subject developed recurrent stent occlusion due to disease progression requiring additional intervention, for a primary patency rate of 94%. Lower extremity edema improved or resolved in 58% of those for whom follow-up data was recorded. Median survival after treatment was only 28 days (range 5 to 607 days). There were no procedural complications. CONCLUSION: Endovascular treatment of malignant IVC obstruction can be safely performed with GRZ stents. Although overall survival is poor, this technique can effectively palliate lower extremity edema symptoms.

ACR Appropriateness Criteria Imaging in the Diagnosis of Thoracic Outlet Syndrome.

Thoracic outlet syndrome is a clinical entity characterized by compression of the neurovascular bundle, and may be associated with additional findings such as venous thrombosis, arterial stenosis, or neurologic symptoms. The goal of imaging is to localize the site of compression, the compressing structure, and the compressed organ or vessel, while excluding common mimics. A literature review is provided of current indications for diagnostic imaging, with discussion of potential limitations and benefits of the respective modalities. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. In this document, we provided guidelines for use of various imaging modalities for assessment of thoracic outlet syndrome.

ACR Appropriateness Criteria® nontraumatic aortic disease.

The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. In this document we provided guidelines for use of various imaging modalities for assessment of nontraumatic aortic diseases.

Thoracic duct embolization and disruption for treatment of chylous effusions: experience with 105 patients.

PURPOSE: To review the indications, technical approach, and clinical outcomes of thoracic duct embolization (TDE) and thoracic duct disruption (TDD) in patients with symptomatic chylous effusions. MATERIALS AND METHODS: A total of 105 patients who underwent 120 consecutive TDE/TDD procedures were retrospectively reviewed. Data including cause of effusion, procedural technique, and pre- and postprocedural effusion volume were analyzed. Technical and clinical success were evaluated for each procedure, with technical success defined as successful interruption of the thoracic duct by embolization or needle disruption and clinical success defined as resolution of effusion without surgical intervention. RESULTS: The technical success rate was 79% (95 of 120); 53 TDEs were performed, resulting in a 72% clinical success rate (n = 38), whereas 42 TDDs showed a 55% clinical success rate (n = 23; P = .13). Procedures to treat postpneumonectomy chylous effusions had a success rate of 82% (14 of 17), compared with 47% (nine of 19) in postpleurectomy subjects (P < .05). Clinically successful cases had lower 24-, 48-, and 72-hour postprocedural effusion volumes versus clinically unsuccessful cases (P < .05), as well as greater rates of reduction in effusion volume at these time points (P < .05). Clinical success rate in subjects with traumatic effusions was higher than in subjects with nontraumatic effusions (62% [60 of 97] vs 13% [one of eight]; P < .05), and 6.7% of subjects (n = 7) experienced minor complications. CONCLUSIONS: TDE and TDD are safe and effective minimally invasive treatments for traumatic thoracic duct injuries. In the present series, factors affecting procedural success included etiology of effusion, postprocedural effusion volume, and rate of postprocedural effusion volume reduction.

ACR appropriateness criteria imaging for transcatheter aortic valve replacement.

Although aortic valve replacement is the definitive therapy for severe aortic stenosis, almost half of patients with severe aortic stenosis are unable to undergo conventional aortic valve replacement because of advanced age, comorbidities, or prohibitive surgical risk. Treatment options have been recently expanded with the introduction of catheter-based implantation of a bioprosthetic aortic valve, referred to as transcatheter aortic valve replacement. Because this procedure is characterized by lack of exposure of the operative field, image guidance plays a critical role in preprocedural planning. This guideline document evaluates several preintervention imaging examinations that focus on both imaging at the aortic valve plane and planning in the supravalvular aorta and iliofemoral system. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR Appropriateness Criteria ® imaging of mesenteric ischemia.

Mesenteric ischemia is a rare disease associated with high morbidity and mortality. Acute mesenteric ischemia is most commonly secondary to embolism followed by arterial thrombosis, nonocclusive ischemia, and less commonly venous thrombosis. Chronic mesenteric ischemia is almost always caused by atherosclerotic disease, with rare causes including fibromuscular dysplasia and vasculitis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Patients with mesenteric ischemia usually present with nonspecific abdominal symptoms and laboratory findings. This document evaluates and rates the appropriateness of imaging to evaluate patients with clinically suspected mesenteric ischemia. While catheter-based angiography has been considered the reference standard and enables diagnosis and treatment, advances in computed tomography have made it a first-line test in many patients because it is a fast, widely available, and noninvasive study. Abdominal radiographs and ultrasound have a limited role in diagnosing mesenteric ischemia but are commonly the first ordered tests in patients with abdominal pain and may diagnose more common pathologies.

ACR Appropriateness Criteria® pulsatile abdominal mass, suspected abdominal aortic aneurysm.

Clinical palpation of a pulsating abdominal mass alerts the clinician to the presence of a possible abdominal aortic aneurysm (AAA). Generally an arterial aneurysm is defined as a localized arterial dilatation ≥50% greater than the normal diameter. Imaging studies are important in diagnosing the cause of a pulsatile abdominal mass and, if an AAA is found, in determining its size and involvement of abdominal branches. Ultrasound (US) is the initial imaging modality of choice when a pulsatile abdominal mass is present. Noncontrast computed tomography (CT) may be substituted in patients for whom US is not suitable. When aneurysms have reached the size threshold for intervention or are clinically symptomatic, contrast-enhanced multidetector CT angiography (CTA) is the best diagnostic and preintervention planning study, accurately delineating the location, size, and extent of aneurysm and the involvement of branch vessels. Magnetic resonance angiography (MRA) may be substituted if CT cannot be performed. Catheter arteriography has some utility in patients with significant contraindications to both CTA and MRA. The American College of Radiology Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR Appropriateness Criteria® Suspected upper extremity deep vein thrombosis.

Upper-extremity venous thrombosis often presents as unilateral arm swelling. The differential diagnosis includes lesions compressing the veins and causing a functional venous obstruction, venous stenosis, an infection causing edema, obstruction of previously functioning lymphatics, or the absence of sufficient lymphatic channels to ensure effective drainage. The following recommendations are made with the understanding that venous disease, specifically venous thrombosis, is the primary diagnosis to be excluded or confirmed in a patient presenting with unilateral upper-extremity swelling. Contrast venography remains the best reference-standard diagnostic test for suspected upper-extremity acute venous thrombosis and may be needed whenever other noninvasive strategies fail to adequately image the upper-extremity veins. Duplex, color flow, and compression ultrasound have also established a clear role in evaluation of the more peripheral veins that are accessible to sonography. Gadolinium contrast-enhanced MRI is routinely used to evaluate the status of the central veins. Delayed CT venography can often be used to confirm or exclude more central vein venous thrombi, although substantial contrast loads are required. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR Appropriateness Criteria(®) blunt chest trauma--suspected aortic injury.

The purpose of these guidelines is to recommend appropriate imaging for patients with blunt chest trauma. These patients are most often imaged in the emergency room, and thus emergency radiologists play a substantial role in prompt, accurate diagnoses that, in turn, can lead to life-saving interventions. The ACR Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Imaging largely focuses on the detection and exclusion of traumatic aortic injury; a large proportion of patients are victims of motor vehicle accidents. For those patients who survive the injury and come to emergency radiology, rapid, appropriate assessment of patients who require surgery is paramount.

ACR Appropriateness Criteria(®) on suspected lower extremity deep vein thrombosis.

Lower extremity deep vein thrombosis (DVT) is a common clinical concern, with an incidence that increases with advanced age. DVT typically begins below the knee but may extend proximally and result in pulmonary embolism. Pulmonary embolism can occur in 50% to 60% of patients with untreated DVT and can be fatal. Although clinical examination and plasma d-dimer blood evaluation can often predict the presence of DVT, imaging remains critical for the diagnostic confirmation and treatment planning of DVT. Patients with above-the-knee or proximal DVT have a high risk for pulmonary embolism and are recommended to receive anticoagulation therapy. On the other hand, patients with below-the-knee or distal DVT rarely experience pulmonary embolism, and anticoagulation therapy in these patients remains controversial. However, one sixth of patients with distal DVT may experience extension of their thrombus above the knee and therefore are recommended to undergo serial imaging assessment at 1 week to exclude proximal DVT extension if anticoagulation therapy is not initiated. Ultrasound is the preferred imaging method for evaluation of patients with newly suspected lower extremity DVT. Magnetic resonance and CT venography can be especially helpful for the evaluation of suspected DVT in the pelvis and thigh. Contrast x-ray venography, the historic gold standard for DVT assessment, is now less commonly performed and primarily reserved for patients with more complex presentations such as those with suspected recurrent acute DVT.

Hepatic arterial chemoembolization using drug-eluting beads in gastrointestinal neuroendocrine tumor metastatic to the liver.

PURPOSE: This study was designed to evaluate short (<3 months) and intermediate-term (>3 months) follow-up in patients with metastatic neuroendocrine tumor to the liver who underwent hepatic arterial chemoembolization with drug-eluting beads at a single institution. METHODS: Institutional review board approval was obtained for this retrospective review. All patients who were treated with 100-300 or 300-500 µm drug-eluting LC Beads (Biocompatibles, UK) preloaded with doxorubicin (range, 50-100 mg) for GI neuroendocrine tumor metastatic to the liver from June 2004 to June 2009 were included. CT and MRI were evaluated for progression using Response Evaluation Criteria In Solid Tumors (RECIST) or European Association for the Study of the Liver (EASL) criteria. Short-term (<3 months) and intermediate-term (>3 months) imaging response was determined and Kaplan-Meier survival curves were plotted. RESULTS: Thirty-eight drug-eluting bead chemoembolization procedures were performed on 32 hepatic lobes, comprising 21 treatment cycles in 18 patients. All procedures were technically successful with two major complications (biliary injuries). At short-term follow-up (<3 months), 22 of 38 (58%) procedures and 10 of 21 (48%) treatment cycles produced an objective response (OR) with the remainder having stable disease (SD). At intermediate-term follow-up (mean, 445 days; range, 163-1247), 17 of 26 (65%) procedures and 8 of 14 (57%) treatment cycles produced an OR. Probability of progressing was approximately 52% at 1 year with a median time to progression of 419 days. CONCLUSIONS: Drug-eluting bead chemoembolization is a reasonable alternative to hepatic arterial embolization and chemoembolization for the treatment of metastatic neuroendocrine tumor to the liver.

ACR Appropriateness Criteria® on upper gastrointestinal bleeding.

Upper gastrointestinal bleeding is a significant cause of morbidity and mortality, affecting 36 to 48 per 100,000 persons annually. Aggressive resuscitation and upper endoscopy remain the cornerstones of therapy; however, in cases refractory to endoscopic diagnosis and management, radiology plays an increasingly vital and often lifesaving role, thanks to improvements in both imaging and interventional techniques. The various etiologies of upper gastrointestinal bleeding are discussed along with specific management recommendations based on an extensive literature review of current radiographic methods.

Interventional radiology and anesthesia.

Interventional radiology (IR) encompasses a broad and expanding array of image-guided, minimally invasive therapies that are essential to the practice of modern medicine. The growth and diversity of these non-OR procedures presents unique challenges and opportunities to anesthesiologists and interventional radiologists alike. Collaborative action has led to better patient care and quality management. This discussion considers some angiographic and cross-sectional IR procedures in more detail and comments on some of the anesthesia choices and considerations. In addition, specific concerns regarding anesthesia in the area of IR are reviewed.

Interrelation of coronary calcification, myocardial ischemia, and outcomes in patients with intermediate likelihood of coronary artery disease: a combined positron emission tomography/computed tomography study.

BACKGROUND: Although the value of coronary artery calcium (CAC) for atherosclerosis screening is gaining acceptance, its efficacy in predicting flow-limiting coronary artery disease remains controversial, and its incremental prognostic value over myocardial perfusion is not well established. METHODS AND RESULTS: We evaluated 695 consecutive intermediate-risk patients undergoing combined rest-stress rubidium 82 positron emission tomography (PET) perfusion imaging and CAC scoring on a hybrid PET-computed tomography (CT) scanner. The frequency of abnormal scans among patients with a CAC score > or = 400 was higher than that in patients with a CAC score of 1 to 399 (48.5% versus 21.7%, P<0.001). Multivariate logistic regression supported the concept of a threshold CAC score > or = 400 governing this relationship (odds ratio 2.91, P<0.001); however, the frequency of ischemia among patients with no CAC was 16.0%, and its absence only afforded a negative predictive value of 84.0%. Risk-adjusted survival analysis demonstrated a stepwise increase in event rates (death and myocardial infarction) with increasing CAC scores in patients with and without ischemia on PET myocardial perfusion imaging. Among patients with normal PET myocardial perfusion imaging, the annualized event rate in patients with no CAC was lower than in those with a CAC score > or = 1000 (2.6% versus 12.3%, respectively). Likewise, in patients with ischemia on PET myocardial perfusion imaging, the annualized event rate in those with no CAC was lower than among patients with a CAC score > or = 1000 (8.2% versus 22.1%). CONCLUSIONS: Although increasing CAC content is generally predictive of a higher likelihood of ischemia, its absence does not completely eliminate the possibility of flow-limiting coronary artery disease. Importantly, a stepwise increase occurs in the risk of adverse events with increasing CAC scores in patients with and without ischemia on PET myocardial perfusion imaging.