Value of Interventional Radiology: Past, Present, and Future.

Interventional radiology (IR) has had immense growth in importance and value over the last several decades from its founding in the mid-20th century. IR procedures have been widely adopted and an era of IR clinical expertise is upon us. Despite this, there is a perception that IR is simply an imaging study to be ordered and that IR physicians are expendable. This article attempts to explore that. Questionnaires were sent to other specialties and administrators asking key questions regarding the value of IR as a specialty, both for procedural and consultative expertise as well as their thoughts on the future of IR. Answers varied, but consistent opinions were observed that IR is extremely valuable, both procedurally and consultatively, and that expansion of IR services is likely. IR is extremely valuable given its impact on healthcare (lessening morbidity, decreasing length of stay, improving cost) and although there is some misperception of this value, other specialties and administrators understand it well. Newer generations of IR physicians are poised to become even more impactful if they continue to expand their clinical presence.

Is there a role for Ytrrium-90 in the treatment of unresectable and metastatic intrahepatic cholangiocarcinoma?

BACKGROUND: Selective internal radiation therapy (SIRT) with Ytrrium-90 (Y-90) has been used to treat hepatic malignancies with success. This study focuses on the efficacy and safety of Y-90 in the treatment of unresectable and metastatic intrahepatic cholangiocarcinoma (ICC). METHODS: A single-institution retrospective case review was performed for patients with unresectable and metastatic ICC treated with Y-90 between 2006 and 2016. RESULTS: Seventeen patients with ICC underwent 21 Y-90 treatments. Four patients had undergone prior liver resection, and six patients had extrahepatic disease at the time of treatment. Five year overall survival was 26.8%, with a median survival of 33.6 months. One patient underwent margin negative liver resection after a single treatment. Complications were appreciated in two cases. Ninety-day mortality was 0%. CONCLUSION: Treatment of ICC using Y-90 is a safe and promising procedure. Further research is needed to clarify its role in the treatment of unresectable and metastatic ICC.

Liver Resection After Selective Internal Radiation Therapy with Yttrium-90 is Safe and Feasible: A Bi-institutional Analysis.

BACKGROUND: Treatment with yttrium-90 (Y90) microspheres has emerged as a viable liver-directed therapy for patients with unresectable tumors and those outside transplantation criteria. A select number of patients demonstrate a favorable response and become candidates for surgical resection. METHODS: Patients who underwent selective internal radiation therapy (SIRT) with Y90 microspheres at two institutions were reviewed. Patients who underwent liver resection were included in the study. The data gathered included demographics, tumor characteristics, response to Y90, surgical details, perioperative outcomes, and survival. RESULTS: The inclusion criteria were met by 12 patients. The diagnoses included metastatic disease from colorectal adenocarcinoma (n = 6), neuroendocrine tumor (n = 1), and ocular melanoma (n = 1) in addition to hepatocellular carcinoma (n = 4). The median time from liver disease diagnosis to Y90 treatment was 5.5 months (range 2-92 months). The median time from Y90 treatment to surgery was 9.5 months (range 3-20 months). The surgical approach included right hepatectomy (n = 3), extended right hepatectomy (n = 5), extended left hepatectomy (n = 1), segmentectomy with ablation (n = 2), and segmentectomy with isolated liver perfusion (n = 1). The hospital stay was 7 days (range 4-31 days), and 67% of the patients were discharged home. The readmission rate was 42%. The 90-day morbidity and mortality rates were respectively 42 and 8%. At this writing, the median overall survival has not been reached at 25 months. CONCLUSION: Liver resection after Y90 SIRT is a challenging surgical procedure with high rates of perioperative morbidity and hospital readmission. However, for properly selected patients, potential exists for extending disease-free and overall survival in the current era of multimodal therapy for malignant liver disease.

Sarcopenia and survival in patients undergoing pancreatic resection.

BACKGROUND: Recent studies have suggested that lean core muscle area may predict outcomes from major abdominal surgeries. Pancreatic resections have been independently analyzed less frequently. METHODS: Pancreatic resections from 2005 to 2012 were reviewed. Sarcopenia was defined as the lowest tertile for lean psoas muscle area (LPMA). Preoperative risk factors, including comorbidities, albumin, weight loss, age and gender, were analyzed with a primary endpoint of overall survival. Secondary endpoints included complications, discharge destination and readmission. RESULTS: The study sample of 270 patients had complications in 42% of patients, with 26% developing serious complication. The majority (80%) were discharged home, and 1.9% died in the peri-operative period. The mean length of follow up was 31.2 months (range 0-94), and 37% required at least one readmission. LPMA was predictive of discharge destination for females (p = 0.038). Sarcopenia was predictive of readmission in males, compared to subjects in the second LPMA tertile (HR 0.3; 95% CI: 0.1-0.9). In all male subjects, including a subset with adenocarcinoma, patients with sarcopenia were more likely to die than males in the highest LPMA tertile (HR: 2.6; 95% CI: 1.4-4.8 and HR: 2.4; 95% CI: 1.2-4.9, respectively). In all patients with pancreatic ductal adenocarcinoma, transfusion (HR: 1.9; 95% CI: 1.1-3.4) and positive margins (HR: 2.0; 95% CI: 1.2-3.3) were the only factors predictive of overall survival. CONCLUSIONS: Sarcopenia appears to be a predictor of overall survival in male patients undergoing pancreatic resections, but not specifically for patients with pancreatic ductal adenocarcinoma. As prospective data in future studies are identified, sarcopenia may become a useful tool in predicting outcomes.

Abdominal findings in hereditary hemorrhagic telangiectasia: pictorial essay on 2D and 3D findings with isotropic multiphase CT.

The rapid evolution in multidetector computed tomographic (CT) technology has produced improvements in temporal and spatial resolution, leading to greater recognition of the spectrum of abdominal findings in hereditary hemorrhagic telangiectasia (HHT). In this multisystem vascular disorder, the abdominal findings are predominantly within the liver. Hepatic vascular lesions in HHT range from tiny telangiectases to transient perfusion abnormalities and large confluent vascular masses. Focal hepatic lesions are often associated with arteriovenous, arterioportal, or portovenous shunts. Pancreatic, splenic, and other vascular abnormalities are also observed because they are included in the field of view. By taking advantage of the increased z-axis spatial resolution and faster scanning times, and by using a bolus tracking technique, multiphase CT can be used to identify hepatic and extrahepatic lesions in HHT and to characterize the associated vascular shunts. Coronal maximum intensity projection images are particularly helpful in depiction of small hepatic vascular lesions.

Adventitial remodeling with increased matrix metalloproteinase-2 activity in a porcine arteriovenous polytetrafluoroethylene grafts.

BACKGROUND: We hypothesized the source of early proliferating cells contributing to venous stenosis formation in a porcine hemodialysis grafts is the adventitia and media, and migration of these cells is greatest within the first two weeks following graft placement, resulting in increased matrix metalloproteinase-2 (MMP-2) activity. METHODS: Polytetrafluoroethylene grafts from the iliac artery to the ipsilateral iliac vein were placed in 23 pigs and 5-Bromo-2'-deoxyuridine (BrdU) was given at 24 and 48 hours after surgery to assess cell proliferation and migration. Angiography and magnetic resonance angiography was performed. Animals were euthanized on day three (N= 6), day seven, (N= 5), day 14 (N= 6), and days 19 to 26 (N= 6) after graft placement, and stenotic tissue and unaffected contralateral iliac vein were removed for zymography and immunostaining. RESULTS: Migration of cells derived from the adventitia and media peaked at day 14. Adventitial diameter of the stenotic vein decreased, while the intima to media ratio increased. MMP-2 activity peaks at day seven in the adventitia and days 19 to 26 in the intima. CONCLUSION: These results confirm our hypothesis that the source of cells resulting in venous stenosis formation is derived from the adventitia and media, with cell migration being greatest within the first two weeks after graft placement with translocation of these cells into the intima at four weeks. MMP-2 activity peaks at day seven in the adventitia and again at days 19 to 26 in the intima. A key to limiting venous stenosis formation may lie in inhibiting MMP-2 by adventitial and medial targeting.