Faculty Bibliography

PURPOSE/OBJECTIVE:Y radioembolization. MATERIALS AND METHODS/METHODS:for women. Survival at 90 days, 180 days, 1 year, and 3 years following initial treatment was assessed using medical and public obituary records. RESULTS:Sarcopenia was identified in 30% (25/82) of patients. Death was reported for 49% (32/65) of males and 71% (8/17) of females (mean follow-up 19.6 months, range 21 days-58 months). Patients with sarcopenia were found to have increased mortality at 180 days (31.8% vs. 8.9%) and 1 year (68.2% vs. 21.2%). Sarcopenia was an independent predictor of mortality adjusted for BCLC stage and sub-analysis demonstrated that sarcopenia independently predicted increased mortality for patients with BCLC stage B disease. CONCLUSION/CONCLUSIONS:Y radioembolization. Sarcopenia was an independent predictor of survival adjusted for BCLC stage with significant deviation in the survival curves of BCLC stage B patients with and without sarcopenia.

PURPOSE/OBJECTIVE:To evaluate the feasibility and benefits of performing yttrium-90 radioembolization in an office-based lab (OBL) compared to a hospital setting. MATERIALS AND METHODS/METHODS:A radioembolization program was established in March 2019 in an OBL that is managed by the radiology department of a tertiary care center. Mapping and treatment angiograms performed in the OBL from March 2019 through January 2020 were compared to mapping and treatment angiograms performed in the hospital during the same time period. RESULTS:One hundred seventy-six mapping and treatment angiograms were evaluated. There was no difference in the proportion of mapping versus treatment angiograms performed at each site, the proportion of lobar versus selective dose vial administrations, or the mean number of dose vials administered per treatment procedure. Procedure start delays were longer in the hospital than in the OBL (28.6 minutes vs 0.8 minutes; P < .0001), particularly for procedures that were not scheduled as the first case of the day (hospital later case delay, 38.8 minutes vs OBL later case delay, 0.5 minutes; P < .0001). Procedures performed in the hospital took longer on average than procedures performed in the OBL (2 hours, 1.8 minutes vs 1 hour, 44.4 minutes; P = .0004), particularly for procedures that were not scheduled as the first case of the day (hospital later case duration, 2 hours, 7.4 minutes vs OBL later case duration, 1 hour, 43 minutes; P = .0006). CONCLUSIONS:Establishing a radioembolization program within an OBL is feasible and might provide more efficient procedure scheduling than the hospital setting.

PURPOSE/OBJECTIVE:To assess the safety and effectiveness of yttrium-90 radioembolization and checkpoint inhibitor immunotherapy within a short interval for the treatment of unresectable hepatic metastases. MATERIALS AND METHODS/METHODS:This single-institution retrospective study included 22 patients (12 men; median age, 65 y ± 11) with unresectable hepatic metastases and preserved functional status (Eastern Cooperative Oncology Group performance status 0/1) who received immunotherapy and radioembolization within a 15-month period (median, 63.5 d; interquartile range, 19.7-178.2 d) from February 2013 to March 2018. Primary malignancies were uveal melanoma (12 of 22; 54.5%), soft tissue sarcoma (3; 13.6%), cutaneous melanoma (3; 14%), and others (4; 18.2%). Studies were reviewed to March 2019 to assess Common Terminology Criteria for Adverse Events grade 3/4 toxicities, disease progression, and death. RESULTS:There were no grade 4 toxicities within 6 mo of radioembolization. Grade 3 hepatobiliary toxicities occurred in 3 patients (13.6%) within 6 months, 2 from rapid disease progression and 1 from a biliary stricture. Two patients (9.1%) experienced clinical toxicities, including grade 4 colitis at 6 months and hepatic abscess at 3 months. Median overall survival (OS) from first radioembolization was 20 mo (95% confidence interval [CI], 12.5-27.5 mo), and median OS from first immunotherapy was 23 months (95% CI, 15.9-30.1 mo). Within the uveal melanoma subgroup, the median OS from first radioembolization was 17.0 months (95% CI, 14.2-19.8 mo). Median time to progression was 7.8 months (95% CI, 3.3-12.2 mo), and median progression-free survival was 7.8 mo (95% CI, 3.1-12.4 mo). CONCLUSIONS:Checkpoint immunotherapy around the time of radioembolization is safe, with a low incidence of toxicity independent of primary malignancy.

Purpose: To evaluate the effect of active inpatient and outpatient interventional radiology (IR) drainage catheter management on drain dwell time and percentage of drains removed by IR. Materials: Retrospective review was performed of drains placed by IR at a tertiary medical center. Exclusion criteria were no documentation of removal, dwell time less than 1 day, and pediatric, seroma, urinoma, or enteric fistula drains. Data collected for the 283 eligible drains included dwell time, IR versus referrer removal, and IR documentation. Statistical analysis was used to compare IR drain management across three phases: passive (January - June 2016), active inpatient/passive outpatient (July 2016 - February 2017) and active all patients (March 2017 - June 2019). Management was still considered passive after June 2016 if drains were lost to IR follow-up or referrer removed without IR involvement.
Result(s): Active inpatient drain management during phase 2 led to a significant 5.6 day decrease in drain dwell time compared to passive management (mean, 12.8 vs. 21.1 days, P <0.01). However, only 43% of drains were actively managed by IR. As a result, there was no significant change in the overall percentage of IR-removed drains compared to phase 1 (31 vs. 25%, P = 0.42). The inclusion of outpatients during phase 3 significantly increased overall active IR drain management (68% vs. 43%, P <0.01) and percentage of IR-removed drains (61% vs. 31%, P <0.01) compared to phase 2. There was also no significant adverse effect on dwell time with the addition of outpatients when compared to phase 2 (mean, 14.1 vs. 12.8 days, P = 0.51). For the entire 42 month analysis period, active IR drain management reduced mean drain dwell time by 4 days (13.7 vs. 17.7 days, P = 0.01) and more than doubled the percentage of IR-removed drains (61 vs. 25%, P <0.01).
Conclusion(s): Active IR drainage catheter management significantly decreases drain dwell time and increases the number of drains removed by IR. Reduction of dwell time has clear value for patients but further study is required to determine if this dwell time reduction and increased IR removal of drains have additional clinical benefits such as avoidance of surgery or recurrent infection.
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Purpose: To assess the impact of muscle mass on survival in patients with hepatocellular carcinoma undergoing yttrium-90 radioembolization. Materials: The medical records of 186 patients undergoing Yttrium-90 radioembolization for hepatocellular carcinoma between April 2014 and May 2017 were retrospectively reviewed. Fifty patients with an abdominal MRI performed within 90 days prior to treatment were identified. All patients underwent standardized abdominal and liver MRI sequence protocols. Axial T2-weighted fat-suppressed sequences were used for image analysis. The paraspinal musculature was manually segmented at the level of the origin of the superior mesenteric artery using syngo.via (Siemens Healthineers, USA) and used to calculate skeletal muscle area (cm²) and skeletal muscle index (cm²/m²). Sarcopenia was defined as skeletal muscle area < 35.23 cm² for men and < 31.53 cm² for women. Medical records were reviewed to determine patient survival following treatment. Descriptive statistics, including Mann-Whitney tests and receiver operating characteristic curves, were performed.
Result(s): Fifty patients (86% male) with mean age 64 years (range, 31-83 years) met inclusion criteria. Death was reported for 49% (21/43) of male and 57% (4/7) of female patients, with average follow-up of 21 months (range, 0.7-56 months). Sarcopenia was identified in 16% (7/43) of male and 29% (2/7) of female patients. There were statistically significant differences in skeletal muscle area (48.72 +/- 12.01 cm² vs. 42.18 +/- 15.13 cm²) (P = 0.047) and skeletal muscle index (16.26 +/- 2.69 cm²/m² vs. 14.56 +/- 5.83 cm²/m²) (P = 0.024) between men who survived and died. Differences for the seven female patients included in the study did not achieve statistical significance, likely due to small sample size. Median survival was estimated as 1403 days for nonsarcopenic men (36/43) and 243 days for sarcopenic men (7/43) (P = 0.272).
Conclusion(s): Muscle mass on pre procedure MRI predicts survival in patients with hepatocellular carcinoma undergoing Yttrium-90 radioembolization. Sarcopenia may be associated with shorter survival and ongoing analysis of additional patients will improve study power to detect significant differences.
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Purpose: To evaluate the technical success, clinical efficacy, and safety of gonadal vein embolization in men presenting with symptomatic varicoceles. Materials: A retrospective study of 83 consecutive male patients who had varicocele embolization between January 2008 and December 2018 was conducted. 39 patients (mean age, 33.8 years; range, 18-70 years) met the inclusion criteria of symptomatic varicocele (scrotal pain and/or heaviness) and had complete clinical records. The primary outcome was symptomatic improvement. Secondary outcomes were technical success rate defined as successful catheterization and embolization of the gonadal vein(s) and adverse events.
Result(s): Of the 39 patients, 33 (84.6%) presented had scrotal pain, 3 (7.7%) had heaviness, and 3 (7.7%) had pain and heaviness. Nine (23.1%) had prior varicocelectomy. 32 patients had complete preprocedural ultrasound; of those 12 (37.5%) had testicular asymmetry, 22 (68.8%) had left varicocele, 1 (3.1%) had right varicocele, and 9 (28.1%) had bilateral varicoceles. Procedural approach was transfemoral in 34 (87.2%) and transjugular in 5 (12.8%) patients. Only symptomatic sides were treated; of the 39 patients, 8 (20.5%) had bilateral, 1 (2.6%) had right, and 30 (76.9%) had left embolization. Embolic agents used were coils + Sodium tetradecyl sulfate (STS) in 3 (7.7%), coils + n-Butyl cyanoacrylate (n-BCA) glue in 8 (20.5%), n-BCA glue alone in 20 (51.3%), and a combination of different embolization material in the remainder of the patients (STS, vascular plugs, n-BCA, Gelfoam, and/or coils). The mean time to follow-up was 8.3 months. The overall technical success rate was 94.9%; of those, 28 (75.7%) indicated an improvement in their preprocedural symptoms. In patients with symptomatic improvement, the recurrence rate was 7.1%, with a mean time to recurrence of 7.5 months. There were no recorded complications. Conclusion(s): GVE is safe, has high technical success rate, and is effective in improving scrotal pain and heaviness

Purpose: To identify clinical, procedural, and logistical factors that influence time to inpatient interventional radiology (IR) procedures. Materials: All inpatient IR procedures performed at two tertiary care academic medical centers in January 2018 were retrospectively reviewed. Procedures were included if a complete consult note (with an associated time), and procedure start time were available. Time to procedure (TTP) was defined as the interval from consult note entry to procedure start time in hours. Clinical and procedure data which may influenced TTP were analyzed, including day of week, time of consult, procedure urgency and complexity, availability of imaging and laboratory values, requesting clinical service, patient vital signs, and procedural urgency. Consult time of day was divided into four time periods: early day (08:00-12:00), late day (12:00-16:00), evening (16:00-20:00), and overnight (20:00 - 08:00).
Result(s): A total of 127 inpatient procedures were performed on 116 patients (mean age, 59 years; 43% male). Procedures performed on Wednesdays and Fridays had the longest TTP (mean, 32 and 21 hours respectively, P = 0.010). Procedures performed during the weekend and on Mondays had the shortest TTP (mean, 2.9 and 10.8 hours, respectively, P = 0.010). The time of day the consult was completed correlated significantly with TTP (P = 0.038), with the shortest TTP for consults requested in the early day (mean, 11.4 hours) and overnight (mean, 11.5 hours) and the longest TTP for those requested in the afternoon (mean, 27.4 hours). Lack of appropriate imaging resulted in longer TTP (mean, 35 vs. 17 hours, P = 0.029). High urgency procedures had significantly shorter TTP (P = 0.038). There was no significant correlation between TTP and fasting status (P = 0.073), anticoagulation (P = 0.073), availability of appropriate labs (0.225), procedure category (P = 0.086), bed location (P = 0.094), and requesting service (P = 0.100).
Conclusion(s): Overnight, early day, and urgent procedures had the shortest TTP, whereas afternoon and later week consults had the longest TTP. Examining the underlying reasons for these trends may offer opportunities to reduce TTP for inpatient IR procedures.
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Purpose: To compare the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) to anticoagulation and no treatment in cirrhotic patients with portal vein thrombosis (PVT). Materials: This single-center retrospective study evaluated 64 consecutive cirrhotic patients with imaging diagnosis of PVT between November 2005 and July 2019. 15 patients were excluded due to lack of adequate follow-up imaging. Of the remaining 49 patients, 11 (22%) were female. The median age was 61.5 (range, 24-80) years. 9 (18%) patients were treated with TIPS, 12 (24%) with anticoagulation, and 28 (57%) received no treatment. Demographic and clinical data were collected by reviewing the electronic medical record. PVT was evaluated using contrast-enhanced CT or MRI. Thrombus burden in the main portal (MPV), superior mesenteric (SMV), and splenic (SV) vein was graded as follows: grade 1, < 25%; grade 2, 26-50%; grade 3, 51-75%; and grade 4, > 75% of the luminal diameter. Yerdel scoring system was also used to evaluate the extent of portomesenteric thrombus. Thrombus burden at 6 and 12 months was compared to baseline imaging. Patient survival was estimated using Kaplan-Meier analysis. The extent of baseline thrombus was compared using Kruskal-Wallis test. Treatment response was analyzed by chi square test.
Result(s): There was no statistically significant difference in baseline thrombus burden between the 3 groups (MPV, P = 0.345; SMV, P = 0.244; SV, P = 0.541; Yerdel grade, P = 0.230). At 6 months, 87.5%, 58.3%, and 4.8% patients demonstrated complete or partial recanalization in the TIPS, anticoagulation, and no treatment groups respectively (TIPS/no treatment, P <0.0001; TIPS/anticoagulation, P = 0.163). At 12 months, 100%, 57.1%, 11.1% patients demonstrated complete or partial recanalization in the TIPS, anticoagulation, and no treatment groups respectively (TIPS/no treatment, P <0.0001; TIPS/ anticoagulation, P = 0.051). The overall survival between the 3 groups was not significantly different (P = 0.788) Conclusion(s): TIPS has significantly higher recanalization rate compared to no treatment and has a trend towards higher recanalization rate than that of anticoagulation at 6 and 12 months in cirrhotic patients with PVT.

Purpose: As interventional radiology (IR) transitions to a clinical model and reimbursement patterns change, quantifying revenue may help emphasize IR's value. This study sought to quantify the total and relative contributions of evaluation and management (E&M), diagnostic imaging, and procedural services to total revenue and work relative value units (wRVU) within an academic interventional oncology service line. Materials: This study included a retrospective review of 100 consecutive interventional oncology patients with an index procedure between July 1, 2017, and December 30, 2017. Patient charts were reviewed for the 3 months prior to the first procedure and 6 months beyond the final procedure to capture pre- and postprocedural revenue. Patient demographics and current procedural terminology (CPT) codes associated with each IR encounter were collected. The wRVU and total revenue based on the national payment amount were extracted from the 2019 Centers for Medicare and Medicaid Services (CMS) Physician Fee Schedule database.
Result(s): The 100 patients (66% male, mean age 65.6 years) underwent a total of 230 procedures, most often for treatment of hepatocellular carcinoma (71%). Procedures included radioembolization (39.1%), MAA mapping (32.6%), hepatic ablation (17.8%), TACE/bland embolization (9.1%), and renal ablation (1.3%). Of the 254 office visits generated, most were coded as level 3 (15.3%), 4 (44.9%), or 5 (39.0%). Mean office visit length was 37 min +/- 13 min. A total of 445 imaging studies were generated, including pre/postprocedural (260 MRI and 66 CT) and nuclear medicine (119) imaging. The service line generated a total of 5584 wRVU from procedures (4336, 77.6%), office visits (480, 8.6%), and imaging (767, 13.7%). Assuming CMS reimbursement, these wRVUs translated to a total of $388,665 from procedures ($225,463, 58.0%), imaging ($129,473, 33.3%), and office visits ($33,728, 8.7%). Individual patient wRVU 49.8 (25-75% IQR 30.8-72.0) and revenue $3457 ($2381-$4924) varied considerably.
Conclusion(s): In an academic interventional oncology service line, wRVU and revenue are generated primarily by procedural work. However, non-procedural work contributes a substantial portion (~40%) of the revenue.
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