Faculty Bibliography

PURPOSE/OBJECTIVE:To investigate the safety of yttrium-90 radioembolization in combination with checkpoint inhibitor immunotherapy for the treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS/METHODS:This single-center retrospective study included 26 consecutive patients with HCC who received checkpoint inhibitor immunotherapy within 90 days of radioembolization from April 2015 to May 2018. Patients had preserved liver function (Child-Pugh scores A-B7) and either advanced HCC due to macrovascular invasion or limited extrahepatic disease (21 patients) or aggressive intermediate stage HCC that resulted in earlier incorporation of systemic immunotherapy (5 patients). Clinical documentation, laboratory results, and imaging results at 1- and 3-month follow-up intervals were reviewed to assess treatment-related adverse events and treatment responses. RESULTS:The median follow-up period after radioembolization was 7.8 months (95% confidence interval [CI], 5.6-11.8). There were no early (30-day) mortality or grades 3/4 hepatobiliary or immunotherapy-related toxicities. Delayed grades 3/4 hepatobiliary toxicities (1-3 months) occurred in 2 patients in the setting of HCC disease progression. One patient developed pneumonitis. The median overall survival from first immunotherapy was 17.2 months (95% CI, 10.9-23.4). The median overall survival from first radioembolization was 16.5 months (95% CI, 6.6-26.4). From first radioembolization, time to tumor progression was 5.7 months (95% CI, 4.2-7.2), and progression-free survival was 5.7 months (95% CI, 4.3-7.1). CONCLUSIONS:Radioembolization combined with checkpoint inhibitor immunotherapy in cases of HCC appears to be safe and causes limited treatment-related toxicity. Future prospective studies are needed to identify the optimal combination treatment protocols and evaluate the efficacy of combination therapy.

PURPOSE/OBJECTIVE:To describe the revenue from a collaboration between a dedicated wound care center and an interventional radiology (IR) practice for venous leg ulcer (VLU) management at a tertiary care center. MATERIALS AND METHODS/METHODS:This retrospective study included 36 patients with VLU referred from a wound care center to an IR division during the 10-month active study period (April 2017 to January 2018) with a 6-month surveillance period (January 2018 to June 2018). A total of 15 patients underwent endovascular therapy (intervention group), whereas 21 patients did not (nonintervention group). Work relative value units (wRVUs) and dollar revenue were calculated using the Centers for Medicare and Medicaid Services Physician Fee Schedule. RESULTS:Three sources of revenue were identified: evaluation and management (E&M), diagnostic imaging, and procedures. The pathway generated 518.15 wRVUs, translating to $37,522. Procedures contributed the most revenue (342.27 wRVUs, $18,042), followed by E&M (124.23 wRVUs, $8,881), and diagnostic imaging (51.65 wRVUs, $10,599). Intervention patients accounted for 86.7% of wRVUs (449.48) and 80.0% of the revenue ($30,010). An average of 33 minutes (38.3 hours total) and 2.06 hours (36.8 hours total) were spent on E&M visits and procedures, respectively. CONCLUSIONS:In this collaboration between the wound center and IR undertaken to treat VLU, IR and E&M visits generated revenue and enabled procedural and downstream imaging revenue.

Familiarity with different instruments and understanding the basics of image guidance techniques are essential for interventional radiology trainees. However, there are no structured references in the literature, and trainees are left to "pick it up as they go". Puncture needles, guidewires, sheath systems, and catheters represent some of the most commonly used daily instruments by interventional radiologists. There is a large variety of instruments, and understanding the properties of each tool will allow trainees to better assess which type is needed for each specific procedure. Along with understanding the tools required to perform various interventional radiology procedures, it is important for trainees to learn how to organize the room, procedural table, and various equipment that is used during the procedure. Minimizing clutter and improving organization leads to improved efficiency and decreased errors. In addition, having a fundamental knowledge of fluoroscopy, the most commonly used imaging modality, is an integral part of beginning training in interventional radiology.

The purpose of this paper is to evaluate whether meteorological variables influence rates of pneumothorax and chest tube placement after percutaneous transthoracic needle biopsy (PTNB) of pulmonary nodules. A retrospective review of 338 consecutive PTNBs of pulmonary nodules at a single institution was performed. All procedures implemented a coaxial approach, using a 19-gauge outer guide needle for access and a 20-gauge core biopsy gun with or without a small-gauge aspiration needle for tissue sampling. Correlation between age, sex, smoking history, lesion size, meteorological variables, and frequency of complications were evaluated. Fisher exact, trend and t tests were used to evaluate the relationship between each factor and rates of pneumothorax and chest tube placement. A p value of less than 0.05 was considered to indicate a statistically significant difference. Pneumothorax occurred in 115 of 338 patients (34%). Chest tube placement was required in 30 patients (8.9%). No significant relationship was found between pneumothorax rate and age (p = 0.172), sex (p = 0.909), smoking history (p = 0.819), or lesion location (p = 0.765). The presence or absence of special weather conditions did not correlate with the rate of pneumothorax (p = 0.241) or chest tube placement (p = 0.213). The mean atmospheric temperature (p = 0.619) and degree of humidity (p = 0.858) also did not correlate with differences in the rate of pneumothorax. Finally, mean atmospheric pressure on the day of the procedure demonstrated no correlation with the rate of pneumothorax (p = 0.277) or chest tube placement (p = 0.767). In conclusion, no correlation is demonstrated between the occurrence of pneumothorax after PTNB of pulmonary nodules and the studied meteorological variables.

PHACES is the acronym describing the phenotypic association of posterior fossa anomalies, facial hemangioma, cardiac and eye anomalies, and sternal defects. To date, more than 300 cases of PHACE(S) have been reported. We present the case of a newborn girl who was born with a variant of the PHACES syndrome. Although the sternal cleft and the small facial hemangioma were evident clinically at birth, magnetic resonance imaging of the brain provided additional information to establish the diagnosis. In addition, the patient manifested later with hemihypertrophy, an association that has not been described previously.

Purpose: As Y90 radioembolization has been shown to activate an immune response, synergistic effects with check-point inhibitor immunotherapy have been proposed. However, the safety of concurrent Y90 and immunotherapy has not been reported. This study retrospectively evaluated the safety of Y90 with concurrent immunotherapy in patients with primary or metastatic liver cancer. Materials: The retrospective study was conducted with IRB approval. Patients who received Y90 treatment within 30 days of immunotherapy were considered to have concurrent therapy. Baseline laboratory values obtained within one month prior to Y90 and at 1 and 3 months after Y90 were evaluated. Hepatobiliary and immunotherapy-related adverse events were characterized according to NCI CTCAE v5.0. Patient survival was estimated using Kaplan-Meier analysis.
Result(s): Between June 2015 and March 2018, 18 patients received concurrent therapy. 14 patients had hepatocellular carcinoma (3 BCLC B, and 11 BCLC C), and 4 had metastatic disease to the liver (3 melanoma, 1 gastric cancer). The median interval between Y90 and immunotherapy was 7 days. Grade >=3 hepatobiliary toxicity occurred in 1 patient at 1 month (6%) and in 3 patients at 3 months (17%) after Y90. Grade >=3 toxicities occurred only in patients with advanced HCC (BCLC C). No grade >=3 immune-associated toxicities occurred at 1 or 3 months in any patients. Median overall survival from first Y90 was 27.4 months for patients with HCC and 13.7 months for patients with metastatic disease to the liver.
Conclusion(s): Concurrent Y90 radioembolization and checkpoint-inhibitor immunotherapy appears to be safe with a low incidence of toxicity. Toxicities were limited to patients with advanced HCC and may be confounded by disease progression.
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Purpose: The abscopal effect refers to the immune mediated regression of distant tumor after localized therapy and is typically enhanced by administration of immunotherapy agents such as check-point inhibitors. There are emerging case reports of the abscopal effect after Y90 radioembolization to hepatic malignancy, but systematic investigations are lacking. Here, we investigated the response of extra-hepatic tumors in patients who received both hepatic Y90 radioembolization and systemic immunotherapy. Materials: This single-center retrospective study includes patients with concomitant intra-and extra-hepatic tumor burden who received both Y90 radioembolization and immunotherapy within a 6 month time period between 6/2015-3/2018. The overall survival was evaluated by Kaplan-Meier analysis. The treatment responses of extra-hepatic malignancy at 1 month, 3 months and 6 months intervals were evaluated according to RECIST 1.1 criteria. Result(s): Of 136 total Y90 patients, 26 patients were eligible for analysis. 11 patients (7 HCC, 1 cholangiocarcinoma, and 3 metastatic liver cancer) had Y90 prior to initiation of immunotherapy and 15 patients (7 HCC, 8 metastatic liver cancer) had Y90 after immunotherapy. Objective response at 6-month follow up includes 1 partial response (3.8%), 8 stable disease (30.8%), and 16 progressive disease (61.5%). The median survival time for patients with metastatic hepatic malignancy cannot be determined (2/11 died), and the median survival time for patients with primary liver cancer is 27 months (9/15 died). Conclusion(s): In this systematic, large institutional review, no patients displayed complete regression in distant sites after receiving Y90 and immunotherapy, suggesting that the type of clear abscopal regression reported anecdotally is uncommon. Interestingly, multiple patients demonstrated unexpectedly long-term stable metastatic disease, which could be related to the abscopal effect and motivates subsequent dedicated studies of the immune environment of stable distant tumors.

Keywords: pulmonary embolism; submassive; survey.

OBJECTIVES/OBJECTIVE:To determine whether use of a stylus user input device (UID) would be superior to a mouse for CMR segmentation. METHODS:Twenty-five consecutive clinical cardiac magnetic resonance (CMR) examinations were selected. Image analysis was independently performed by four observers. Manual tracing of left (LV) and right (RV) ventricular endocardial contours was performed twice in 10 randomly assigned sessions, each session using only one UID. Segmentation time and the ventricular function variables were recorded. The mean segmentation time and time reduction were calculated for each method. Intraclass correlation coefficients (ICC) and Bland-Altman plots of function variables were used to assess intra- and interobserver variability and agreement between methods. Observers completed a Likert-type questionnaire. RESULTS:The mean segmentation time (in seconds) was significantly less with the stylus compared to the mouse, averaging 206±108 versus 308±125 (p<0.001) and 225±140 versus 353±162 (p<0.001) for LV and RV segmentation, respectively. The intra- and interobserver agreement rates were excellent (ICC≥0.75) regardless of the UID. There was an excellent agreement between measurements derived from manual segmentation using different UIDs (ICC≥0.75), with few exceptions. Observers preferred the stylus. CONCLUSION/CONCLUSIONS:The study shows a significant reduction in segmentation time using the stylus, a subjective preference, and excellent agreement between the methods. KEY POINTS/CONCLUSIONS:• Using a stylus for MRI ventricular segmentation is faster compared to mouse • A stylus is easier to use and results in less fatigue • There is excellent agreement between stylus and mouse UIDs.

Acute pulmonary embolism (PE) is the third most common cause of death among hospitalized patients. Treatment escalation beyond anticoagulation therapy is necessary in patients with cardiogenic shock and may be of benefit in select normotensive patients with right heart strain. Percutaneous catheter-based techniques (catheter-directed mechanical thrombectomy, clot maceration, and/or pharmacologic thrombolysis) as an alternative or adjunct to systemic thrombolysis can rapidly debulk central clot in patients with shock. Catheter-directed thrombolysis, which uses a low-dose intraclot prolonged thrombolytic infusion, is a promising but insufficiently studied therapy for patients presenting with acute intermediate-risk PE.