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BACKGROUND: Examine the association of metformin use and overall survival (OS) in patients with HCC undergoing image-guided liver-directed therapy (LDT): ablation, transarterial chemoembolization (TACE), or Yttrium-90 radioembolization (Y90 RE). METHODS: Using National Cancer Institute Surveillance, Epidemiology, and End Results registry and Medicare claims databases between 2007 and 2016, we identified patients ≥ 66 years who underwent LDT within 30 days of HCC diagnosis. Patients with liver transplant, surgical resection, and other malignancies were excluded. Metformin use was identified by at least two prescription claims within 6 months before LDT. OS was measured by time between first LDT and death or last Medicare observation. Comparisons were performed between both all and diabetic patients on and not on metformin. RESULTS: Of 2746 Medicare beneficiaries with HCC undergoing LDT, 1315 (47.9%) had diabetes or diabetes-related complications. Among all and diabetic patients, 433(15.8%) and 402 (30.6%) were on metformin respectively. Median OS was greater for patients on metformin (19.6 months, 95% CI 17.1-23.0) vs those not (16.0 months, 15.0-16.9; p = 0.0238). Patients on metformin had lower risk of death undergoing ablation (HR 0.70; 0.51-0.95; p = 0.0239) and TACE (HR 0.76, 0.66-0.87; p = 0.0001), but not Y90 RE (HR1.22, 0.89-1.69; p = 0.2231). Among diabetics, OS was greater for those on metformin vs those not (HR 0.77, 0.68-0.88; p < 0.0001). Diabetic patients on metformin had longer OS undergoing TACE (HR 0.71, 0.61-0.83; p < 0.0001), but not ablation (HR 0.74, 0.52-1.04; p = 0.0886) or Y90 RE (HR 1.26, 0.87-1.85; p = 0.2217). CONCLUSION: Metformin use is associated with improved survival in HCC patients undergoing TACE and ablation.
Subject(s)
Carcinoma, Hepatocellular , Chemoembolization, Therapeutic , Liver Neoplasms , Aged , Humans , United States/epidemiology , Carcinoma, Hepatocellular/pathology , Liver Neoplasms/pathology , Chemoembolization, Therapeutic/methods , Treatment Outcome , Medicare , Registries , Retrospective StudiesABSTRACT
BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) creation remains as one of the more technically challenging endovascular procedures. Portal vein access from the hepatic vein often requires multiple needle passes, which increases procedure times, risk of complications, and radiation exposure. With its bi-directional maneuverability, the Scorpion X access kit may be a promising tool for easier portal vein access. However, the clinical safety and feasibility of this access kit has yet to be determined. MATERIALS AND METHODS: In this retrospective study, 17 patients (12 male, average age 56.6 ± 9.01) underwent TIPS procedure using Scorpion X portal vein access kits. The primary endpoint was time taken to access the portal vein from the hepatic vein. The most common indications for TIPS were refractory ascites (47.1%) and esophageal varices (17.6%). Radiation exposure, total number of needle passes, and intraoperative complications were recorded. Average MELD Score was 12.6 ± 3.39 (range: 8-20). RESULTS: Portal vein cannulation was successfully achieved in 100% of patients during intracardiac echocardiography-assisted TIPS creation. Total fluoroscopy time was 39.31 ± 17.97 min; average radiation dose was 1036.76 ± 644.15 mGy, while average contrast dose was 120.59 ± 56.87 mL. The average number of passes from the hepatic vein to the portal vein was 2 (range: 1-6). Average time to access the portal vein once the TIPS cannula was positioned in the hepatic vein was 30.65 ± 18.64 min. There were no intraoperative complications. CONCLUSIONS: Clinical utilization of the Scorpion X bi-directional portal vein access kit is both safe and feasible. Utilizing this bi-directional access kit resulted in successful portal vein access with minimal intraoperative complications. LEVEL OF EVIDENCE: Retrospective cohort.
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PURPOSE: To evaluate the differences in safety, effectiveness, and dosimetry between glass-based and resin-based ablative yttrium-90 (90Y) transarterial radioembolization (TARE) of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Using the modified Response Evaluation Criteria in Solid Tumors and Common Terminology Criteria for Adverse Events, both tumor response and adverse events (AEs) were assessed at 3 months after 90Y-TARE. Post procedure 90Y-bremsstrahlung single-photon emission computed tomography/computed tomography voxel-based dosimetry analysis was used to create tumor dose (TD) and normal tissue dose (NTD) volume histograms, and to calculate tumor particle loading and specific activity. The TD and NTD receiver operating characteristic curves evaluated the dose threshold able to predict objective (partial or complete) and complete tumor responses in addition to any-grade and grade ≥3 AE incidences. The chi-square test and Student t-test were used to assess variable differences where appropriate. RESULTS: Between 2019 and 2020, 81 patients with HCC (20 in the resin-based cohort and 61 in the glass-based cohort) underwent ablative 90Y-TARE. The resin-based cohort had more males (89% vs 65%, P = .03), lower tumor-to-normal ratio (1.81 ± 0.39 vs 2.22 ± 0.94, P = .03), higher tumor particle loading (40,172 particles/mL ± 28,039 vs 17,081 particles/mL ± 12,555, P = .0001), lower specific activity (158 Bq/particle ± 3 vs 1,058 Bq/particle ± 331, P = .001), and lower mean TD (308 Gy ± 210 vs 794 Gy ± 523, P = .0002) than the glass-based cohort. No significant differences in baseline characteristics or posttreatment AEs were noted. The overall objective and complete response rates were 85% (95% resin-based vs 82% glass-based; P = .1) and 65% (95% resin-based vs 56% glass-based; P = .003), respectively. The mean TD thresholds able to predict the objective and complete responses were 176 Gy and 247 Gy for resin-based radioembolization and 290 Gy and 481 Gy for glass-based radioembolization, respectively. A maximum NTD of 999 Gy predicted any-grade AEs in glass-based ablative 90Y-TARE. CONCLUSIONS: Compared with glass-based ablative 90Y-TARE, resin-based ablative 90Y-TARE can offer comparable safety and effectiveness profiles for patients with HCC. The impact of the significantly different tumor particle loading, particle specific activities, and delivered TDs on tumor response outcomes merits further investigation.
Subject(s)
Carcinoma, Hepatocellular , Embolization, Therapeutic , Liver Neoplasms , Male , Humans , Carcinoma, Hepatocellular/diagnostic imaging , Carcinoma, Hepatocellular/radiotherapy , Carcinoma, Hepatocellular/drug therapy , Liver Neoplasms/diagnostic imaging , Liver Neoplasms/radiotherapy , Liver Neoplasms/drug therapy , Microspheres , Pneumonectomy , Yttrium Radioisotopes/adverse effects , Embolization, Therapeutic/adverse effects , Embolization, Therapeutic/methods , Retrospective StudiesABSTRACT
PURPOSE: To evaluate the relationship between non-tumor liver (NTL) dose and adverse events (AE) in patients with hepatocellular carcinoma (HCC) treated with glass-based Yttrium-90 radioembolization (Y90-RE). MATERIALS AND METHODS: A retrospective analysis of patients with HCC treated with Y90-RE between 2013 and 2018 was performed. Baseline characteristics including demographics and Y90-RE treatment approach were captured. Common Terminology Criteria for Adverse Events v5 was assessed at months 3 and 6 post-treatment. Using voxel-based dosimetry with MIM Software V. 6.9, dose-volume histograms of treated area of liver were created. Receiver operator characteristic curve was used to determine NTL dose threshold predicting AEs. Multivariate analysis was used to determine independent clinical factors of predicting severe AEs. Chi-square analysis was used to compare proportions. RESULTS: Two hundred and twenty-nine consecutive patients (115(50.2%) lobar and 114(49.8%) segmental) were included. At 3 months, there was a lower rate of any grade AE (55(46%) segmental and 36(31%) lobar, p = 0.009) and increased rate of severe AEs for lobar compared to segmental (2(2%) segmental and 9(8%) lobar, p = 0.029). At 6 months, severe AEs were greater for lobar than segmental (1(1%) segmental vs 10(9%) lobar, p = 0.005). For lobar Y90-RE, mean NTL dose of 112 Gy predicted severe AE (89% sensitivity and 91% specificity (AUC = 0.95, p = < 0.0001) at 3 and 6 months. For the segmental group, no significant association was found between NTL dose and severe treatment-related AE at 3 and 6 months. CONCLUSION: In patients with HCC undergoing glass-based lobar Y90-RE, NTL dose of > 112 Gy is associated with severe treatment-related AEs at 3-6 months.
Subject(s)
Carcinoma, Hepatocellular , Embolization, Therapeutic , Liver Neoplasms , Humans , Carcinoma, Hepatocellular/pathology , Liver Neoplasms/pathology , Retrospective Studies , Yttrium Radioisotopes/adverse effects , Embolization, Therapeutic/adverse effects , Treatment Outcome , MicrospheresABSTRACT
INTRODUCTION: Non-small cell lung cancer (NSCLC) makes up the majority of lung cancer cases. Currently, surgical resection is the gold standard of treatment. However, as patients are becoming medically more complex presenting with advanced disease, minimally invasive image-guided percutaneous ablations are gaining popularity. Therefore, comparison of surgical, ablative and second-line external beam therapies will help clinicians, as management of NSCLC changes. We will conduct a meta-analysis, reviewing literature investigating these therapies in adult patients diagnosed with stage 1 NSCLC, with neither hilar nor mediastinal nodal involvement, confirmed either through cytology or histology regardless of type. METHODS AND ANALYSIS: We will search electronic databases (MEDLINE, Embase, Web of Science, Scopus, ClinicalTrials.gov, Cochrane) from their inception to January 2021 to identify randomised controlled trials (RCTs), cluster RCTs and cohort studies comparing survival and clinical outcomes between any two interventions (lobectomy, wedge resection, video-assisted thoracoscopic surgery/robot-assisted thoracoscopic surgery, radiofrequency ablation, microwave ablation, cryoablation and consolidated radiation therapies (external beam radiation therapy, stereotactic body radiation therapy, and 3D conformal radiation therapy). The primary outcomes will include cancer-specific survival, lung disease-free survival, locoregional recurrence, death, toxicity and non-target organ injury. We will also search published and unpublished studies in trial registries and will review references of included studies for possible inclusion. Risk of bias will be assessed using tools developed by the Cochrane collaboration. Two reviewers will independently assess the eligibility of studies and conduct the corresponding risk of bias assessments. For each outcome, given enough studies, we will conduct a network meta-analysis. Finally, we will use the Confidence in Network Meta-Analysis tool to assess quality of the evidence for each of the primary outcomes. ETHICS AND DISSEMINATION: We aim to share our findings through high-impact peer review. As interventional techniques become more popular, it will be important for providers in multidisciplinary teams caring for these patients to receive continuing medical education related to these interventions. Data will be made available to readers. PROSPERO REGISTRATION NUMBER: CRD42021276629.
Subject(s)
Carcinoma, Non-Small-Cell Lung , Catheter Ablation , Lung Neoplasms , Adult , Carcinoma, Non-Small-Cell Lung/radiotherapy , Carcinoma, Non-Small-Cell Lung/surgery , Catheter Ablation/methods , Humans , Lung Neoplasms/radiotherapy , Lung Neoplasms/surgery , Meta-Analysis as Topic , Neoplasm Recurrence, Local/surgery , Network Meta-Analysis , Systematic Reviews as TopicSubject(s)
Adrenal Gland Neoplasms , Catheter Ablation , Cushing Syndrome , Adrenal Gland Neoplasms/diagnostic imaging , Adrenal Gland Neoplasms/pathology , Adrenal Gland Neoplasms/surgery , Adrenal Glands/diagnostic imaging , Adrenal Glands/surgery , Catheter Ablation/methods , Cushing Syndrome/diagnostic imaging , Cushing Syndrome/pathology , Cushing Syndrome/surgery , Humans , Hyperplasia/pathology , Tomography, X-Ray Computed/methodsABSTRACT
OBJECTIVE: The objective of this study is to introduce cooled radiofrequency ablation technical feasibility as an alternative percutaneous image-guided treatment of chronic pain and stiffness in the setting of uncomplicated total knee arthroplasty. MATERIAL AND METHOD: This retrospective pilot study includes a total of 19 consecutive patients experiencing persistent chronic pain after total knee arthroplasty, without underlying hardware complications who had failed conservative care. Patients initially underwent anesthetic blocks of the genicular nerve branches to determine C-RFA candidacy. After adequate response to the anesthetic blocks (> 50% immediate pain relief), patients were subjected to cooled radiofrequency ablations 2-3 weeks later. Treatment response was evaluated utilizing clinically validated questionnaires (KOOS, the Knee Injury and Osteoarthritis Outcome Score) and visual analog scale (VAS) to assess pain severity, stiffness, functional activities of daily living, and use of pain medication. Follow-up outcome scores were collected up to 1 year after C-RFA procedure. RESULT: A total of 21 knees were treated consecutively between 4/2019 and 1/2020 (mean age 70.5 years; 5 M:14F). The mean total KOOS score improved significantly from baseline at 35.0 ± 14.0 to 64.2 ± 14.7 at a mean of 10.2 months after treatment (p < 0.0001), with significant improvement in mean stiffness score from 44.8 ± 16.7 to 68.8 ± 20 (p < 0.0001). The mean VAS score improved significantly from baseline at 8.30 ± 1.1 to 2.45 ± 1.8 (p < 0.0001). No major complications were encountered. No patients went on to receive re-treatment, surgical revision, or other intervention. CONCLUSION: Image-guided genicular nerve cooled radiofrequency ablation offers a promising alternative in treating chronic pain/stiffness in the setting of uncomplicated TKA.
Subject(s)
Arthroplasty, Replacement, Knee , Chronic Pain , Osteoarthritis, Knee , Radiofrequency Ablation , Activities of Daily Living , Aged , Chronic Pain/diagnostic imaging , Chronic Pain/surgery , Humans , Knee Joint/surgery , Osteoarthritis, Knee/complications , Osteoarthritis, Knee/diagnostic imaging , Osteoarthritis, Knee/surgery , Pilot Projects , Radiofrequency Ablation/adverse effects , Radiofrequency Ablation/methods , Retrospective Studies , Treatment OutcomeABSTRACT
Artificial intelligence (AI) and deep learning (DL) remains a hot topic in medicine. DL is a subcategory of machine learning that takes advantage of multiple layers of interconnected neurons capable of analyzing immense amounts of data and "learning" patterns and offering predictions. It appears to be poised to fundamentally transform and help advance the field of diagnostic radiology, as heralded by numerous published use cases and number of FDA-cleared products. On the other hand, while multiple publications have touched upon many great hypothetical use cases of AI in interventional radiology (IR), the actual implementation of AI in IR clinical practice has been slow compared with the diagnostic world. In this article, we set out to examine a few challenges contributing to this scarcity of AI applications in IR, including inherent specialty challenges, regulatory hurdles, intellectual property, raising capital, and ethics. Owing to the complexities involved in implementing AI in IR, it is likely that IR will be one of the late beneficiaries of AI. In the meantime, it would be worthwhile to continuously engage in defining clinically relevant use cases and focus our limited resources on those that would benefit our patients the most.
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Inferior vena cava filter (IVCF) placement is indicated in patients with acute venous thromboembolism who cannot be adequately anticoagulated or have failed anticoagulation. Prompt IVCF retrieval decreases the risk of complications associated with longer dwell times including fracture, penetration, and further thromboembolic events. Endovascular IVCF retrieval has been performed despite penetration into adjacent structures including the aorta; however, penetration into the false lumen of an aortic dissection is rarely seen. This case report describes endovascular management of an 11 year old IVCF that caused iliocaval thrombosis and penetrated the false lumen of a chronic type B aortic dissection.
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Postpartum hemorrhage (PPH) affects approximately 14 million women yearly, accounts for 25% of delivery-related deaths in the world and is the main cause of emergency peripartum hysterectomy. Traditionally, PPH is defined as at least 500 mL of blood loss after vaginal delivery or 1000 mL of blood loss after cesarean-section. However, several authors have suggested a simpler definition to include women who experience hemodynamic instability after birth regardless of amount of blood loss. Secondary PPH is defined as bleeding that occurs after 24 hours to 12 weeks from delivery, and can fail medical management. It is imperative that the clinical team recognize the signs and symptoms of secondary PPH and, if necessary, consult the interventional radiology service for a minimally invasive option of uterine artery embolization, which has shown up to 95% success rate.
Subject(s)
Postpartum Hemorrhage/therapy , Radiography, Interventional , Uterine Artery Embolization , Female , Humans , Postpartum Hemorrhage/diagnostic imaging , Pregnancy , Radiography, Interventional/adverse effects , Treatment Outcome , Uterine Artery Embolization/adverse effectsABSTRACT
PURPOSE: To identify factors associated with radiologist donations to radiology political action committees (PACs). MATERIALS AND METHODS: A survey was emailed to 4474 radiologists. Factors investigated include demographics, donor history, and knowledge of the federal advocacy process. Logistic regression analysis was performed to determine factors associated with donor behavior. RESULTS: In total, 336 radiologists completed the survey. Overall, 152 (46.2%) radiologists reported donating to a radiology PAC in the past year. Those with annual personal income ≥$450,000 had greater odds to donate than those with annual personal income <$450,000 (odds ratio [OR]: 2.58, 95% confidence interval [CI]: 1.47-4.52; p < 0.001). More than three-quarters (77.2%, nâ¯=â¯254) reported limited or no knowledge of the federal advocacy process. Those with good or excellent knowledge of the federal advocacy process had greater odds to donate than those with no knowledge (OR: 2.63, 95% CI: 1.01-6.84; pâ¯=â¯0.047). Those with awareness that membership dues and foundation funds do not fund Society of Interventional Radiology Political Action Committee had greater odds to donate (OR: 3.54, 95% CI: 2.00, 6.25; p < 0.001). CONCLUSIONS: Radiologists' personal income and knowledge of the federal advocacy process were identified as key factors influencing donations. PAC donation may benefit from raising awareness of the federal advocacy process, as well as from targeted fundraising strategies aimed at higher earners.
Subject(s)
Radiology , Adult , Aged , Female , Humans , Male , Middle Aged , Radiology/legislation & jurisprudence , Societies, Medical , Surveys and QuestionnairesABSTRACT
Nonoperative management of traumatic splenic hemorrhage includes the targeted administration of embolic agents. In certain instances where computed tomography angiography cannot exclude a bleed, prophylactic embolization with absorbable gelatin sponge has been used. In this retrospective case series review, we characterized the demographic data and clinical outcomes associated with 4 patients who underwent prophylactic transarterial splenic artery embolization after blunt abdominal trauma. Embolization was employed in cases where computed tomography angiography findings suggested at least a moderate splenic injury, and simultaneously where hemorrhage was not apparent during fluoroscopic angiography. Periprocedural hemodynamic status, technical success, and postoperative complications are discussed. The goal of this report was to discuss the safety and efficacy of prophylactic gelatin sponge embolization for occult splenic hemorrhage. In cases where a hemorrhagic site might be occult, this approach has the potential to minimize bleeding complications and the need for further intervention.
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Benign parotid lesions can grow to be a cosmetic deformation with psychological sequelae for a patient. Although surgical resection is the treatment of choice, cyst aspiration has also been attempted. This, however, has been shown to recur, requiring repeat intervention. An alternative therapeutic method not as widely recognized, but which has been reported to be both effective and less invasive than surgery for treating parotid cyst lesions, is sclerotherapy. Here we describe a report of a patient with a benign, localized, cystic neck mass refractory to 2 trials of fine needle aspiration. After the patient refused surgical resection, a trial of sterile ethanol sclerotherapy was performed. Our patient tolerated the procedure well with a significant reduction in the size of the lesion.