Hepatocellular Carcinoma: Advances in Systemic Therapy.

Hepatocellular carcinoma (HCC) is a prevalent primary liver cancer, representing over 90% of cases globally and ranking as the third leading cause of cancer-related death. This article reviews the evolving landscape of systemic therapies for advanced HCC, emphasizing recent advancements and their impact on patient outcomes. The advent of molecular targeted therapies has transformed HCC management, with sorafenib being the first FDA-approved molecular targeted therapy, setting a standard for a decade. However, recent breakthroughs involve the combination of atezolizumab and bevacizumab, demonstrating superior outcomes over sorafenib, leading to FDA approval in 2020. Another notable combination is tremelimumab and durvalumab, showing efficacy in a multinational phase III trial. Beyond these combinations, this article explores the role of other first-line treatments and subsequent therapies after progression. The evolving landscape of systemic therapies for HCC reflects a paradigm shift, with immunotherapy combinations emerging as key players alongside targeted therapies. This article highlights the complexity of treatment decisions, considering individual patient characteristics and disease etiology, and underscores the ongoing quest to optimize both systemic and local-regional therapies for improved long-term outcomes in HCC patients.

Imaging review of the atypical spinal epidural space pathologies.

Pathologies affecting the spinal epidural space (SES) comprise various abnormalities. However, they all have the potential to cause thecal sac narrowing or spinal cord compression. In this review, we group these pathologies into degenerative, infective, neoplastic, vascular, traumatic, and others, focusing on their imaging features. Degenerative pathologies of the SES range from disc to facet disease, with a particular emphasis on the less common degenerative pathologies in this review. Infective pathologies affecting the epidural space include spondylodiscitis and associated epidural phlegmon and abscess. Neoplasms arising from typical SES components include neurofibroma, hemangioma, and liposarcoma. MRI is the best modality to assess the anatomy and abnormalities of the epidural space. MRI, combined with computed tomography, or a radiograph, is useful for the evaluation of bones or radiopaque foreign bodies.

Update on Endovascular Therapy for Fibroids and Adenomyosis.

Uterine fibroids and adenomyosis are prevalent benign neoplasms that can lead to serious deleterious health effects including life-threatening anemia, prolonged menses, and pelvic pain; however, up to 40% of women remain undiagnosed. Traditional treatment options such as myomectomy or hysterectomy can effectively manage symptoms but may entail longer hospital stays and hinder future fertility. Endovascular treatment, such as uterine artery embolization (UAE), is a minimally invasive procedure that has emerged as a well-validated alternative to surgical options while preserving the uterus and offering shorter hospital stays. Careful patient selection and appropriate techniques are crucial to achieving optimal outcomes. There have been advancements in recent times that encompass pre- and postprocedural care aimed at enhancing results and alleviating discomfort prior to, during, and after UAE. Furthermore, success and reintervention rates may also depend on the size and location of the fibroids. This article reviews the current state of endovascular treatments of uterine fibroids and adenomyosis.

Technical outcomes of below-the-elbow revascularization for upper extremity critical limb ischemia.

OBJECTIVES: This study aims to report the technical results of below-the-elbow arterial revascularization in patients with critical hand ischemia. METHODS: We retrospectively identified upper extremity critical limb ischemia patients treated with below-the-elbow arterial intervention between 2013 and 2017. Patient demographics, comorbidities, and procedural data were reviewed and technical success was evaluated. RESULTS: Seven patients with 12 arteries that were affected by critical hand ischemia were treated. All patients had a history of end-stage renal disease. The technical success rate was 83.3%. There were no major or minor complications. The average follow-up duration was 9 months (2-26 months). One patient underwent a digital amputation at 8 months. CONCLUSION: Arterial revascularization of the below-the-elbow arteries for critical hand ischemia is safe and technically feasible.

Ablation versus Radiation Segmentectomy for Small Liver Tumors.

Hepatocellular carcinoma (HCC) is a liver malignancy that affects more than a million people worldwide with a complex multifactorial etiology. After the diagnosis of HCC is made, physicians establish management using the Barcelona Clinic Liver Cancer (BCLC) guidelines revolving around tumor stage, liver function, performance status, and patient preferences. According to recent updates to these guidelines, thermal ablation is the second-best curative option apart from surgical resection for small HCC (< 2 cm). While thermal ablation is standard of care, recent studies have suggested that radiation segmentectomy (RS) has similar outcomes, limited hepatotoxicity, and ultimately a cost-efficient approach. Although there is limited literature on RS, this article compares ablation techniques against radiation segmentectomy for small HCC tumors.

Non-surgical management of abdominal ectopic pregnancy with uterine artery embolization.

Abdominal pregnancy is a rare but life-threatening variation of ectopic pregnancy that is often treated with laparoscopic management; however, we present a case successfully treated using only minimally invasive techniques. A 36-year-old female G1P0 with a history of infertility is diagnosed with 11-weeks abdominal pregnancy by transvaginal ultrasound. She presented with vaginal bleeding and abdominal pain, and her beta-human chorionic gonadotropin was 53,680 mIU/mL. The location of the fetal sac was not amenable to surgery or percutaneous injection. We performed bilateral uterine artery embolization and subsequent intramuscular methotrexate injection. The procedure was successful with no complications. The patient was followed at postoperative week 11, and beta-human chorionic gonadotropin was 2 mIU/mL, and at 3 months, a transvaginal ultrasound revealed resolution of the abdominal pregnancy.

Hemodialysis Catheters: Update on Types, Outcomes, Designs and Complications.

Hemodialysis catheters (HDCs) are an essential part of kidney replacement therapy. While these catheters are considered only the bridge to long-term vascular access such as arteriovenous fistulas and grafts, they are associated with significant morbidity and mortality and subsequent increased health care expenditures. However, despite these risks, a large proportion of end stage kidney disease population initiates dialysis using these catheters. The pathogenicity of HDCs stems from its invasive nature to the venous vasculature tree resulting in both mechanical and infectious complications. Therefore, the wide use these catheters in dialysis population and the associated complications necessitated continuous innovations in the catheter material, design, and placement techniques. This review provides an update on the catheter types, catheter tip designs, and the new technologies and innovations aimed to improve the catheter functionality and mitigate its related complications.

Current perspectives on microwave ablation of liver lesions in difficult locations.

Microwave ablation (MWA) is becoming the standard of care in treating liver lesions smaller than 3 cm benefiting from a plethora of radiofrequency ablation (RFA) data in the literature. Some of the advantages of MWA compared to RFA are as follows: Faster ablations, more reproducible and predictable heating, better thermal conductivity in different liver tissue environments, and less susceptibility to heat-sink effect. Despite its many advantages, there are still concerns regarding MWA use in high-risk locations such as near portal veins, near the bile ducts, and near the heart. Some centers have historically considered these tumor locations as a contraindication to percutaneous thermal ablation. In this review, we summarize the current data on the safety of MWA of liver tumors in challenging locations. We also discuss several technical tips with examples provided.

Primary bilateral ovarian artery embolization for uterine leiomyomatosis in the setting of a rare anatomic variant - hypoplastic uterine arteries.

We present the case of a 50-year-old female who underwent bilateral ovarian artery embolization for uterine fibroids in the setting of hypoplastic uterine arteries. Ovarian artery embolization is usually conducted during uterine artery embolization for fibroids to increase the procedure success when ovarian feeders are seen. The bilateral ovarian artery embolization is rarely performed due to fears of amenorrhea and early menopause from decreased blood supply to both ovaries. According to our knowledge, this the first case report describing primary bilateral ovarian artery embolization in the setting of a rare anatomic variant- hypoplastic uterine arteries. The patient had complete resolution of symptoms from her uterine fibroids after treatment with bilateral ovarian artery embolization with no ovarian failure findings on the follow-up.

Sour cherry (Prunus cerasus L.) vinegars produced from fresh fruit or juice concentrate: Bioactive compounds, volatile aroma compounds and antioxidant capacities.

In this study, it was aimed to determine the bioactive compounds and volatile aroma compounds of the sour cherry vinegar, and to investigate the usability of concentrated juice instead of the fresh fruit juice in vinegar production. And, two sour cherry vinegars were produced using juices prepareted fresh fruit (FSCJ) and concentrate juice (CSCJ), analyzed for functional and organoleptic aspects. The finding shown that both vinegars produced have rich functional compounds (gallic and chlorogenic acids) and volatile aroma compounds, and sour cherry is ideal for vinegar production. However, the vinegar produced using the CSCJ was more prominent, according to aromatic aspect. These aroma compounds were 3-methyl-1-butanol and eugenol, phenethyl alcohol, 2-phenethyl acetate, acetic, isobutyric, isovaleric, hexanoic and octanoic acids. Within this study, a new way for sour cherry usage, independently of the season were proposed. And, aromatic and functional aspects of sour cherry vinegar were revealed for the first time.

Acute Headache in the Emergency Setting.

Acute headache is a common symptom and is reported by approximately 2%-4% of patients who present to the emergency department. Many abnormalities manifest with headache as the first symptom, and it is crucial to obtain a patient's complete clinical history for correct diagnosis. Headache onset, duration, and severity; risk factors such as hypertension, immunosuppression, or malignancy; and the presence of focal neurologic deficits or systemic symptoms may aid the radiologist in deciding whether imaging is appropriate and which modality to choose. Imaging findings are more likely to be abnormal in patients with a "thunderclap" headache than in those with headaches of lesser severity. The causes of headache in the emergency setting are various. They may manifest at imaging as subarachnoid hemorrhage (ruptured aneurysm, reversible vasoconstriction syndrome, or pituitary apoplexy), parenchymal hemorrhage (hypertension, ruptured arteriovenous malformation, cerebral amyloid angiopathy, dural arteriovenous fistula, or sinus thrombosis), or parenchymal edema (posterior reversible encephalopathy syndrome, reversible cerebral vasoconstriction syndrome, sinus thrombosis, or encephalitis). Alterations in intracranial pressure that are related to idiopathic intracranial hypertension or spontaneous intracranial hypotension and prior lumbar puncture or epidural injection may manifest with specific imaging findings. With accumulating knowledge of disease pathophysiology, radiologists have started to play a more central role in making the correct diagnosis. This article reviews multiple causes of acute headache and their characteristic appearances at multimodality imaging and familiarizes the reader with current concepts in imaging.Online supplemental material is available for this article.©RSNA, 2019.

Value of follow-up angiography: additional interventions in patients undergoing catheter-directed thrombolysis for massive and submassive pulmonary embolism.

PURPOSE: Catheter-directed thrombolysis (CDT) is an emerging, minimally invasive treatment for patients with massive and submassive pulmonary embolism (PE). The value of follow-up pulmonary angiography for evaluating improvement after CDT is limited by a paucity of large studies assessing its utility and role for additional intervention. The purpose of our study was to assess the role of next-day pulmonary angiography for CDT in patients with acute massive and submassive PE undergoing continuous pulmonary arterial pressure monitoring, and secondarily, determine factors that are correlated with a need for further therapy. METHODS: Patients who underwent CDT from 2006 to 2016 for massive and submassive PE were reviewed. Patient demographics, comorbidities, preprocedural lab results, noninvasive hemodynamic studies, and technical variables were recorded. Among patients receiving next-day angiography, those requiring further therapy, defined as continued CDT beyond the standard 24 hours (with or without catheter repositioning or exchange) and/or mechanical or suction thrombectomy were contrasted with those not requiring additional therapy to assess for the role of angiography and patient factors that correlate with need for further therapy. RESULTS: Thirty-two patients underwent CDT for massive (n=14) and submassive (n=18) PE. Eighteen (56.3%) were male, 14 (43.7%) were Caucasian, 18 (56.3%) were African-American, with a mean age of 66.2 years (range, 26-87 years). Of the 27 (84.4%) patients that underwent next-day pulmonary angiography, 16 (59.3%) did not require additional therapy and 11 (40.7%) did require additional therapy. Additional therapy included extended CDT beyond 24 hours (n=4), mechanical/suction thrombectomy (n=5), or both extended CDT and mechanical/suction thrombectomy (n=2). Younger age (50.1 vs. 62.2 years, P = 0.039) was correlated with a need for further therapy. Initial (40.7 vs. 34.8 mmHg, P = 0.248), next-day (31.5 vs. 26.3 mmHg, P = 0.259), and interval change (4.6 vs. 8.0 mmHg, P = 0.669) in pulmonary artery pressures were not statistically significant between patient subsets. Preprocedural right ventricular/left ventricular ratio (RV/LV) also did not differ significantly (1.74 vs. 1.75, P = 0.961). Thirty-day mortality was comparable (2 vs. 1, P = 0.332). CONCLUSION: Next-day pulmonary angiography is a useful method to identify patients needing additional therapy including extended CDT and/or mechanical or suction thrombectomy in acute PE management. Pulmonary arterial pressures and preprocedural RV/LV ratios were not found to be predicative of those requiring further intervention.

The role of Shear-Wave elastography in the differentiation of benign and malign non-mass lesions of the breast.

AIM: The aim of this study is to retrospectively assess the additional diagnostic value of shear wave elastography (SWE) added to ultrasound (US) versus US alone in differentiating malignant and benign non-mass lesions (NMLs) of the breast by readers with different experience levels and to assess interreader agreement. MATERIAL AND METHODS: This retrospective study enrolled 53 NMLs (31 benign, 22 malignant). Two radiologists (readers 1 and 2 had 15 years and 1 year of experience in breast imaging, respectively) independently reviewed each study and determined the BI-RADS category using US alone and again after adding SWE to US. Diagnostic performances of US alone and US combined with SWE were compared for both readers. Areas under receiver operating characteristic curves (AUCs) were estimated. The levels of interobserver agreement were determined by the calculated kappa coefficient. RESULTS: With the addition of SWE to US, AUCs for differentiation of benign and malignant lesions increased significantly for the less experienced reader (0.56 vs. 0.79; p=0.028), but not for the more experienced reader (0.60 vs. 0.75; p=0.170). While evaluating US alone, the interobserver agreement was moderate, and the interobserver variability among the readers was statistically significant (k=0.493, p<0.001). After adding SWE, the agreement increased to 0.773, and the interobserver variability among the readers became non-significant (k=0.773, p=0.688) CONCLUSIONS: SWE increased the diagnostic performance of relatively less experienced reader significantly. SWE improved interobserver agreement of two readers with different levels of experience and reduced the interobserver variability in differentiating benign and malignant NMLs of the breast. KEY WORDS: Breast, Elastography, Ultrasound.

Is there a correlation between the severity of Idiopathic Granulomatous Mastitis and pre-treatment Shear-Wave Elastography Findings? Original research.

AIM: The aim of this study was to analyze the correlation between the severity of idiopathic Garulomatous Mastitis (IGM) and the pre-treatment Shear-Wave Elastography (SWE) findings. MATERIAL AND METHODS: A total of 39 patients diagnosed with granulomatous mastitis were included in the study between the dates of December 2014 and February 2017. The patients were divided into two groups. Group 1 was treated using a conservative protocol and steroids. Group 2 was treated surgically. Pre-treatment SWE findings of both groups were compared. RESULTS: The mean ages of the patients in group 1 and 2 were 38.44±9.6 and 36.05±7.44 years, respectively. There were not any significant differences between the groups with regard to frequency of BI-RADS categories and Virtual touch tissue imaging (VTI) patterns. The mean Shear-Wave Spead (SWS) were 1.98 ± 1.02 m/sec and 2.82± 1.66 m/sec in group 1 and 2 respectively. The difference was not significant (p ≥ 0.05). The BI-RADS categories and VTI patterns did not show significant difference when the recurrent and non-recurrent patients were compared. CONCLUSION: There may not be a correlation with the pre-treatment SWE findings and severity of the IGM. KEY WORDS: Breast, Elasticity Imaging Techniques, Granulomatous mastitis, Ultrasonography.