Safety and efficacy of repeat Y90 radioembolization to the same hepatic arterial territory.

OBJECTIVE: To study the efficacy and safety of repeat transarterial radioembolization (TARE) to similar hepatic arterial territories. METHODS: Between 3/2011 and 4/2019, 26 patients (25 males and 1 Female, Mean Age: 65 yo, SD: 11.7 yo, Range: 18-83.0 yo) received TARE with Y90 glass microspheres to treat recurrent or residual primary disease in similar hepatic arterial lobe or segments. Tumor response was evaluated by imaging using the modified-RECIST criteria. Incidence of RILD and adverse events were categorized by a standardized scale using the Common Terminology Criteria for Adverse Events (CTCAE) v.4.0. RESULTS: Mean cumulative activity after the first treatment was 2.50 GBq (SD:1.04 GBq, Range:0.61-4.93 GBq) and second treatment was 2.27 GBq (SD:1.01 GBq, Range:0.92-5.46 GBq). Mean interval time between initial and repeat treatments was 9.6 months (Range: 1-53 months). Tumor responses were complete, partial, or progression in 73% (n = 19/26), 23% (n = 6/26), and 4% (n = 1/26) in repeat treatment patients, respectively. The incidence of RILD was 0%. Toxicity after first and second treatment was seen in 19% (n = 5/26) & 23% (n = 6/26) patients, respectively, and were all of CTCAE Grade 2. No significant predictors of treatment toxicity for repeat treatment were identified except increased MELD score (p = 0.04). Kaplan-Meier survival analysis in patients with repeat treatment showed a median survival of 15.0 months (95% CI 8.8-21.1 months) and 19.0 months (95% CI 8.1-29.9 months) in patients who only received one treatment with a p value of 0.485. CONCLUSION: Repeat TARE with glass microspheres was an effective and safe treatment strategy for disease management in patients with residual or recurrent disease to the similar hepatic arterial territories without any major treatment related toxicity. ADVANCES IN KNOWLEDGE: Although safety and efficacy of repeat radioembolism has been studied, no study has focused on repeat treatment to similar hepatic arterial territories. The current study shows that repeat treatment to the same hepatic arterial territory is as safe as single treatment to the same territory.

Lung and Abdominal Biopsies in the Age of Precision Medicine.

Image-guided percutaneous needle biopsies (PNBs) are one of the most common procedures performed in radiology departments today. Rapid developments in precision medicine, which identifies molecular and genomic biomarkers in cancers, have ushered a new paradigm of oncologic workup and treatment. PNB has conventionally been used to establish a benign or malignant nature of a lesion during initial diagnosis or in suspected metastatic or recurrent disease. However, increasing amounts of tissue are being required to meet the demands of molecular pathologic analysis, which are now being sought at multiple time points during the course of the disease to guide targeted therapy. As primary providers of biopsy, radiologists must be proactive in these developments to improve diagnostic yield and tissue acquisition in PNB. Herein, we discuss the important and expanding role of PNB in the age of precision medicine and review the technical considerations of percutaneous lung and intra-abdominal biopsy. Finally, we examine promising state-of-the-art techniques in PNB that may safely increase tissue acquisition for optimal molecular pathologic analysis.

Inability of conventional imaging findings to predict response to laparoscopic release of the median arcuate ligament in patients with celiac artery compression.

OBJECTIVE: The objective of this study was to identify duplex ultrasound (DUS) or computed tomography angiography (CTA) imaging findings that can predict clinical response to laparoscopic release of the median arcuate ligament (MAL) in patients with celiac artery compression. METHODS: There were 299 patients who were evaluated for MAL syndrome (MALS) between January 2009 and November 2015. Of these, 29 underwent laparoscopic MAL release and completed 1-year follow-up. The patients' preoperative and postoperative symptoms, use of analgesics, and body mass index were recorded. Patients' demographics and DUS and CTA findings were reviewed. Fisher exact and Student t-tests were used to identify correlation between patient or imaging variables and clinical outcomes. RESULTS: There were 19 patients (66%) who reported improvement in symptoms, and 18 (62%) decreased their use of analgesics; average body mass index increased by 0.2 (standard deviation, 1.97; range, -3.35 to 5.11). No celiac artery DUS finding (peak celiac artery velocity, angle of deflection, or change in preoperative to postoperative velocity) was predictive of successful clinical outcomes (P > .05). Similarly, no CTA finding (characteristic morphology, cross-sectional area, diameter, or location of the focal stenosis of the celiac artery) was associated with clinical outcomes (P > .05). CONCLUSIONS: Clinical response to laparoscopic MAL release was favorable in two-thirds of patients; however, no specific imaging finding of stenosis was predictive of this response. Given that the severity of stenosis on conventional imaging had no impact on treatment efficacy, vascular compromise may not be the primary cause of pain in patients presenting with this syndrome. Future investigation incorporating the neurogenic basis of MALS pain, such as with diagnostic celiac ganglion blockade, would be helpful in further elucidating the enigmatic pathophysiologic process of MALS.

Comparison between whole-body and head and neck neurovascular coils for 3-T magnetic resonance proton resonance frequency shift thermography guidance in the head and neck region.

The purpose of this study is to compare the image quality of magnetic resonance (MR) treatment planning images and proton resonance frequency (PRF) shift thermography images and inform coil selection for MR-guided laser ablation of tumors in the head and neck region. Laser ablation was performed on an agar phantom and monitored via MR PRF shift thermography on a 3-T scanner, following acquisition of T1-weighted (T1W) planning images. PRF shift thermography images and T2-weighted (T2W) planning images were also performed in the neck region of five normal human volunteers. Signal-to-noise ratios (SNR) and temperature uncertainty were calculated and compared between scans acquired with the quadrature mode body integrated coil and a head and neck neurovascular coil. T1W planning images of the agar phantom produced SNRs of 4.0 and 12.2 for the quadrature mode body integrated coil and head and neck neurovascular coil, respectively. The SNR of the phantom MR thermography magnitude images obtained using the quadrature mode body integrated coil was 14.4 versus 59.6 using the head and neck coil. The average temperature uncertainty for MR thermography performed on the phantom with the quadrature mode body integrated coil was 1.1 versus 0.3 °C with the head and neck coil. T2W planning images of the neck in five human volunteers produced SNRs of 28.3 and 91.0 for the quadrature mode body integrated coil and head and neck coil, respectively. MR thermography magnitude images of the neck in the volunteers obtained using the quadrature mode body integrated coil had a signal-to-noise ratio of 8.3, while the SNR using the head and neck coil was 16.1. The average temperature uncertainty for MR thermography performed on the volunteers with the body coil was 2.5 versus 1.6 °C with the head and neck neurovascular coil. The quadrature mode body integrated coil provides inferior image quality for both basic treatment planning sequences and MR PRF shift thermography compared with a neurovascular coil, but may nevertheless be adequate for clinical purposes.

Ureteroenteric Strictures After Open Radical Cystectomy and Urinary Diversion: The University of Southern California Experience.

OBJECTIVE: To evaluate the risk factors, management, and outcomes of benign ureteroenteric strictures (UES) in patients undergoing open radical cystectomy (RC) and urinary diversion for urothelial bladder carcinoma. MATERIALS AND METHODS: Using our institutional review board-approved institutional bladder cancer database, we identified 1964 patients who underwent RC for urothelial bladder carcinoma between 1971 and 2008. Patients underwent a uniform refluxing ureteroenteric anastomosis technique to ileum. In patients with UES, we reviewed clinicopathologic, management, and outcome variables. A multivariate logistic regression model was used to identify independent UES predictors. RESULTS: Forty-nine patients and 51 renal units were retrospectively identified with benign UES (2.6%). Median follow-up was 12.4 years (0.2-27.3 years) and median time from RC to UES diagnosis was 10 months (2 months-10 years). Although one-third were asymptomatic, common presentations included flank pain (22%) and urinary tract infection (9%). Thirty-one patients underwent primary endoscopic treatments, including dilatation and stenting, of whom, 13 patients (42%) underwent secondary endoscopic treatment and 9 patients (29%) underwent open revision. Three patients underwent primary open management. Median glomerular filtration rate did not change after management (49-48 mL/min); however, imaging showed improvement in 50% of cases. A multivariate logistic regression model revealed no association with age, body mass index, Charlson comorbidity index, perioperative radiation or chemotherapy, or preoperative serum albumin in predicting UES. CONCLUSION: Benign UES are uncommon after RC and urinary diversion using a consistent meticulous surgical approach. More commonly on the left, UES generally present a few months after RC. Although no specific predisposing factor was determined, surgical technique plays an important role.

Development and Validation of a Novel Robotic Procedure Specific Simulation Platform: Partial Nephrectomy.

PURPOSE: We developed a novel procedure specific simulation platform for robotic partial nephrectomy. In this study we prospectively evaluate its face, content, construct and concurrent validity. MATERIALS AND METHODS: This hybrid platform features augmented reality and virtual reality. Augmented reality involves 3-dimensional robotic partial nephrectomy surgical videos overlaid with virtual instruments to teach surgical anatomy, technical skills and operative steps. Advanced technical skills are assessed with an embedded full virtual reality renorrhaphy task. Participants were classified as novice (no surgical training, 15), intermediate (less than 100 robotic cases, 13) or expert (100 or more robotic cases, 14) and prospectively assessed. Cohort performance was compared with the Kruskal-Wallis test (construct validity). Post-study questionnaire was used to assess the realism of simulation (face validity) and usefulness for training (content validity). Concurrent validity evaluated correlation between virtual reality renorrhaphy task and a live porcine robotic partial nephrectomy performance (Spearman's analysis). RESULTS: Experts rated the augmented reality content as realistic (median 8/10) and helpful for resident/fellow training (8.0-8.2/10). Experts rated the platform highly for teaching anatomy (9/10) and operative steps (8.5/10) but moderately for technical skills (7.5/10). Experts and intermediates outperformed novices (construct validity) in efficiency (p=0.0002) and accuracy (p=0.002). For virtual reality renorrhaphy, experts outperformed intermediates on GEARS metrics (p=0.002). Virtual reality renorrhaphy and in vivo porcine robotic partial nephrectomy performance correlated significantly (r=0.8, p <0.0001) (concurrent validity). CONCLUSIONS: This augmented reality simulation platform displayed face, content and construct validity. Performance in the procedure specific virtual reality task correlated highly with a porcine model (concurrent validity). Future efforts will integrate procedure specific virtual reality tasks and their global assessment.

A novel interface for the telementoring of robotic surgery.

OBJECTIVE: To prospectively evaluate the feasibility and safety of a novel, second-generation telementoring interface (Connect(™) ; Intuitive Surgical Inc., Sunnyvale, CA, USA) for the da Vinci robot. MATERIALS AND METHODS: Robotic surgery trainees were mentored during portions of robot-assisted prostatectomy and renal surgery cases. Cases were assigned as traditional in-room mentoring or remote mentoring using Connect. While viewing two-dimensional, real-time video of the surgical field, remote mentors delivered verbal and visual counsel, using two-way audio and telestration (drawing) capabilities. Perioperative and technical data were recorded. Trainee robotic performance was rated using a validated assessment tool by both mentors and trainees. The mentoring interface was rated using a multi-factorial Likert-based survey. The Mann-Whitney and t-tests were used to determine statistical differences. RESULTS: We enrolled 55 mentored surgical cases (29 in-room, 26 remote). Perioperative variables of operative time and blood loss were similar between in-room and remote mentored cases. Robotic skills assessment showed no significant difference (P > 0.05). Mentors preferred remote over in-room telestration (P = 0.05); otherwise no significant difference existed in evaluation of the interfaces. Remote cases using wired (vs wireless) connections had lower latency and better data transfer (P = 0.005). Three of 18 (17%) wireless sessions were disrupted; one was converted to wired, one continued after restarting Connect, and the third was aborted. A bipolar injury to the colon occurred during one (3%) in-room mentored case; no intraoperative injuries were reported during remote sessions. CONCLUSION: In a tightly controlled environment, the Connect interface allows trainee robotic surgeons to be telementored in a safe and effective manner while performing basic surgical techniques. Significant steps remain prior to widespread use of this technology.