Liver-Directed Therapy for Neuroendocrine Tumor Metastases in the Era of Peptide Receptor Radionuclide Therapy.

OPINION STATEMENT: The treatment of neuroendocrine neoplasm (NEN) liver metastases involves a multidisciplinary approach that includes liver-directed therapies (LDT) and systemic treatments, such as peptide receptor radionuclide therapy (PRRT). LDT has demonstrated efficacy in rapidly reducing tumor bulk, improving symptoms, and delaying disease progression. Interventional radiologists should be consulted prior to switching therapy for patients with progressive or symptomatic neuroendocrine tumor liver metastases. Long-term follow-up data on the safety of Yttrium-90 radioembolization before and after PRRT remain limited. Therefore, a more conservative approach may be to preferentially employ transarterial embolization (TAE) or transarterial chemoembolization (TACE) for patients' somatostatin receptor-avid disease who may be future candidates for PRRT. Notable exceptions where radioembolization may be a preferred treatment strategy may be patients with history of biliary tract instrumentation, asymmetric unilobar disease distribution, and rapidly progressive diffuse liver involvement. Selection of local treatment modality, sequencing, and combination of LDT with systemic therapy require further investigation.

Tunneled Peritoneal Catheter vs Repeated Paracenteses for Recurrent Ascites: A Cost-Effectiveness Analysis.

PURPOSE: To compare the cost-effectiveness of tunneled peritoneal catheter (TPC) versus serial large-volume paracenteses (LVP) for patients with recurrent ascites. MATERIALS AND METHODS: Retrospective, single-institution analysis of 100 consecutive patients undergoing LVP and eventual TPC placement (2015-2018) was performed with extraction of procedural complications and hospital admissions. LVPs were associated with 17 adverse events (AEs) while only 9 AEs occurred after TPC placement. While undergoing routine LVP, the patients had 30 hospitalizations monthly (177 days in total) and 10 hospitalizations monthly (51 days) after TPC placement. A cost-effectiveness analysis with Markov modeling was performed comparing TPC and LVP. Costs were based on Medicare reimbursement rates. Statistical analyses include base case calculation, Monte Carlo simulations, and deterministic sensitivity analyses. RESULTS: TPC placement was the dominant strategy with a comparable health benefit of 0.08060 quality-adjusted life-years (QALY) (LVP: 0.08057 QALY) at a lower cost of $4151 (LVP: $8401). Probabilistic sensitivity analysis showed TPC was superior in 97.49% of simulations. Deterministic sensitivity analysis demonstrated the superiority of TPC compared to LVP if the TPC complication rate was < 9.47% per week and the complication rate for LVP was > 1.32% per procedure. TPC was more cost-effective when its procedural cost was < $5427 (base case: 1174.5), and remained as such when the cost of LVP was varied as much as $10,000 (base case: $316.48). CONCLUSION: In this study, TPC was more cost-effective than LVP in patients with recurrent ascites due to the reduced risk of infection, emergency department visits, and length of hospitalization stays.

Cost-effectiveness of tunneled peritoneal catheters versus repeat paracenteses for recurrent ascites in gynecologic malignancies.

OBJECTIVE: To compare the cost-effectiveness of tunneled peritoneal catheter (TPC) versus repeated large-volume paracentesis (LVP) for patients with recurrent ascites secondary to gynecological malignancy. METHODS: A retrospective cohort study was performed at a single institution from 2016 through 2019 of patients with recurrent ascites from gynecologic malignancies that underwent either TPC or LVP. Data on procedural complications and hospital admissions were extracted. A cost-effectiveness analysis with Markov modeling was performed comparing TPC and LVP. Statistical analyses include base case calculation, Monte Carlo simulations and deterministic sensitivity analyses. RESULTS: There were no significant differences between the cohorts in the average number of hospital days (p = 0.21) or emergency department visits (p = 0.69) related to ascites. Palliative care was more often involved in the care of patients who had a TPC. The base case calculation showed TPC to be the more cost-effective strategy with a slightly lower health benefit (0.22980 versus 0.22982 QALY) and lower cost ($3043 versus $3868) relative to LVP (ICER of LVP compared to TPC: $44,863,103/QALY). Probabilistic sensitivity analysis showed TPC was the more cost-effective strategy in 8028/10,000 simulations. Deterministic sensitivity analysis showed TPC to be more cost-effective if its complication risk was >0.81% per 22 days or its procedural cost of TPC insertion was >$1997. When varying the cost of complications, TPC was more cost-effective if the cost of its complication was less than $49,202. CONCLUSIONS: TPC is the more cost-effective strategy when compared to LVP in patients with recurrent ascites from gynecological malignancy.

Percutaneous approach options for embolization of endoleak after iliac artery aneurysm repair: stick the sac or stick the gluteal artery.

Internal iliac artery aneurysms (IIAAs), isolated or associated with abdominal aortic aneurysms, are at rupture risk with growth. Treatment is recommended when symptomatic or greater than 3 cm. Surgical or endovascular therapy should exclude the arterial origin and outflow branches. If all outflow branches are not completely embolized, an endoleak can develop, pressurizing the sac leading to growth and rupture. Accessing the arteries involved can be technically challenging and understanding potential targets is critical. We describe two percutaneous approaches for treatment: percutaneously accessing the sac from an anterior trans-iliopsoas approach and percutaneously accessing the gluteal artery from a posterior approach.

Perceptions of Futility in Interventional Radiology: A Multipractice Systematic Qualitative Analysis.

PURPOSE: To characterize perceptions of palliative versus futile care in interventional radiology (IR) as a roadmap for quality improvement. METHODS: Interventional radiologists (IRs) and referring physicians were recruited for anonymous interviews and/or focus groups to discuss their perceptions and experiences related to palliative verse futile care in IR. Sessions were recorded, transcribed, and systematically analyzed using dedicated software, content analysis, and grounded theory. Data collection and analysis continued simultaneously until additional interviews stopped revealing new themes: 24 IRs (21 males, 3 females, 1-39 years of experience) and 7 referring physicians (3 males, 4 females, 6-14 years of experience) were analyzed. RESULTS: Many IRs (75%) perceived futility as an important issue. Years of experience (r = 0.60, p = 0.03) and being in academics (r = 0.62, p = 0.04) correlated with greater perceived importance. Perceptions of futility and whether a potentially inappropriate procedure was performed involved a balance between four sets of factors (patient, clinician, procedural, and cultural). These assessments tended to be qualitative in nature and are challenged by a lack of data, education, and consistent workflows. Referring clinicians were unaware of this issue and assumed IR had guidelines for differentiating between palliation and futility. CONCLUSION: This study characterized the complexity and qualitative nature of assessments of palliative verses futile care in IR while highlighting potential means of improving current practices. This is important given the number of critically ill patients referred to IR and costs of potentially inappropriate interventions.

Role of Interventional Procedures in Obstetrics and Gynecology.

Radiological guided intervention techniques are discussed in obstetric and gynecologic patients. Fallopian tube recanalization, postpartum hemorrhage control, techniques of treating uterine leiomyomas, pelvic congestion treatment, and the use of percutaneous and transvaginal ultrasonography-guided aspirations and biopsy are covered. These techniques use basic radiological interventional skills and show how they are adapted for use in the female pelvis.

Percutaneous Vertebral Augmentation for Vertebral Compression Fractures: National Trends in the Medicare Population (2005-2015).

STUDY DESIGN: Retrospective analysis of Medicare data OBJECTIVE.: To analyze trends of vertebral augmentation in the elderly Medicare population in the context of evolving evidence and varied medical society opinions. SUMMARY OF BACKGROUND DATA: Percutaneous vertebral augmentation offers a minimally invasive therapy for vertebral compression fractures. Numerous trials have been published on this topic with mixed results. The impact of these studies and societal recommendations on physician practice patterns is not well understood. METHODS: The Centers for Medicare and Medicaid Services annual Medicare Physician Supplier Procedure Summary database was examined for kyphoplasty and vertebroplasty procedures from 2005 through 2015. Top provider specialties were determined based on annual procedural volume, and grouped into the three broad categories of radiology, surgery, and anesthesia/pain medicine. Data entries were independently analyzed by provider type, site of service, submitted charges, and reimbursement rates for interventions during the study period. RESULTS: Between 2005 and 2015 total annual claims for vertebral augmentation procedures in the Medicare population increased from 108.11% (37,133-77,276) peaking in 2008 and declining by 15.56% in 2009. Radiology is the largest provider of vertebral augmentation by specialty with declining market shares from 71% in 2005 to 43% in 2015. The frequency of vertebroplasty declined by 61.7% (35,409-13,478) from 2005 to 2015 with reduction in Medicare reimbursement. Annual volume of kyphoplasty grew by 18.3% (48,725-57,646) with significant increase in reimbursement for office-based procedures ($728.50/yr, P < 0.001, R = 0.69). CONCLUSION: The annual volume of vertebral augmentation declined in 2009 following two negative trials on vertebroplasty. Although these publications had a persistent negative impact on practice of vertebroplasty, the overall frequency of vertebral augmentation in the Medicare population has not changed significantly between 2005 and 2015. Instead, there has been a significant shift in provider practice patterns in favor of kyphoplasty in increasingly outpatient and office-based settings. LEVEL OF EVIDENCE: 3.

Hemodialysis Access Maintenance in the Medicare Population: An Analysis Over a Decade of Trends by Provider Specialty and Site of Service.

PURPOSE: To evaluate annual national trends in hemodialysis access maintenance procedures in the Medicare population by specialty and setting. METHODS: Medicare Physician Supplier Procedure Summary Master Files between 2005 and 2015 were analyzed for procedure codes of hemodialysis access angiography and percutaneous thrombectomy. Using physician specialty codes, component procedure volume for endovascular services were queried for radiology, medicine, and surgery. Data entries were analyzed by provider specialty and place of service. Average submitted and allowed charges per intervention were extracted. Linear regression modeling was used to identify trends in number of and allowed charges by specialty and practice setting. RESULTS: Between 2005 and 2015, the frequency of dialysis access angiography for Medicare fee-for-service beneficiaries increased by a total of 74.71% (211,181 to 368,955). Specialty-specific analysis demonstrated volume increases of 220.21% (22,128 to 101,109) for surgery, 249.02% (32,690 to 114,094) for medicine, and 2.81% (135,564 to 139, 367) for radiology. By 2015, an increased trend from hospital-based to non-hospital-based procedures associated with significantly higher reimbursement rates to providers (+18,798 non-hospital-based cases/year, $46.95/year, P ≤ .001) was also observed, with medicine performing the highest volume of non-hospital-based procedures. In this period, there was also a modest total overall increase of percutaneous thrombectomy procedures by 7.75% (61,485 to 66,250). CONCLUSIONS: The frequency of endovascular hemodialysis access maintenance procedures in the Medicare fee-for-service program has increased from 2005 to 2015, with the majority market share transitioning from radiologists to non-radiologists. Similarly, most access maintenance in this time period changed from hospital-based to non-hospital-based interventions.

AMPA Receptor Plasticity in Accumbens Core Contributes to Incubation of Methamphetamine Craving.

BACKGROUND: The incubation of cue-induced drug craving in rodents provides a model of persistent vulnerability to craving and relapse in human addicts. After prolonged withdrawal, incubated cocaine craving depends on strengthening of nucleus accumbens (NAc) core synapses through incorporation of Ca2+-permeable alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid receptors (CP-AMPARs). Through metabotropic glutamate receptor 1 (mGluR1)-mediated synaptic depression, mGluR1 positive allosteric modulators remove CP-AMPARs from these synapses and thereby reduce cocaine craving. This study aimed to determine if similar plasticity accompanies incubation of methamphetamine craving. METHODS: Rats self-administered saline or methamphetamine under extended-access conditions. Cue-induced seeking tests demonstrated incubation of methamphetamine craving. After withdrawal periods ranging from 1 to >40 days, rats underwent one of the following procedures: 1) whole-cell patch clamp recordings to characterize AMPAR transmission, 2) intra-NAc core injection of the CP-AMPAR antagonist 1-naphthyl acetyl spermine followed by a seeking test, or 3) systemic administration of a mGluR1 positive allosteric modulator followed by a seeking test. RESULTS: Incubation of methamphetamine craving was associated with CP-AMPAR accumulation in NAc core, and both effects were maximal after ~1 week of withdrawal. Expression of incubated craving was decreased by intra-NAc core 1-naphthyl acetyl spermine injection or systemic mGluR1 positive allosteric modulator administration. CONCLUSIONS: These results are the first to demonstrate a role for the NAc in the incubation of methamphetamine craving and describe adaptations in synaptic transmission associated with this model. They establish that incubation of craving and associated CP-AMPAR plasticity occur much more rapidly during withdrawal from methamphetamine compared with cocaine. However, a common mGluR1-based therapeutic strategy may be helpful for recovering cocaine and methamphetamine addicts.

A critical role of lateral hypothalamus in context-induced relapse to alcohol seeking after punishment-imposed abstinence.

In human alcoholics, abstinence is often self-imposed, despite alcohol availability, because of the negative consequences of excessive use. During abstinence, relapse is often triggered by exposure to contexts associated with alcohol use. We recently developed a rat model that captures some features of this human condition: exposure to the alcohol self-administration environment (context A), after punishment-imposed suppression of alcohol self-administration in a different environment (context B), provoked renewal of alcohol seeking in alcohol-preferring P rats. The mechanisms underlying context-induced renewal of alcohol seeking after punishment-imposed abstinence are unknown. Here, we studied the role of the lateral hypothalamus (LH) and its forebrain projections in this effect. We first determined the effect of context-induced renewal of alcohol seeking on Fos (a neuronal activity marker) expression in LH. We next determined the effect of LH reversible inactivation by GABAA + GABAB receptor agonists (muscimol + baclofen) on this effect. Finally, we determined neuronal activation in brain areas projecting to LH during context-induced renewal tests by measuring double labeling of the retrograde tracer cholera toxin subunit B (CTb; injected in LH) with Fos. Context-induced renewal of alcohol seeking after punishment-imposed abstinence was associated with increased Fos expression in LH. Additionally, renewal was blocked by muscimol + baclofen injections into LH. Finally, double-labeling analysis of CTb + Fos showed that context-induced renewal of alcohol seeking after punishment-imposed abstinence was associated with selective activation of accumbens shell neurons projecting to LH. The results demonstrate an important role of LH in renewal of alcohol seeking after punishment-imposed abstinence and suggest a role of accumbens shell projections to LH in this form of relapse.