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Comparison of Non-Tumoral Portal Vein Thrombosis Management in Cirrhotic Patients: TIPS Versus Anticoagulation Versus No Treatment

Zhan, Chenyang; Prabhu, Vinay; Kang, Stella K; Li, Clayton; Zhu, Yuli; Kim, Sooah; Olsen, Sonja; Jacobson, Ira M; Dagher, Nabil N; Carney, Brendan; Hickey, Ryan M; Taslakian, Bedros
BACKGROUND:There is a lack of consensus in optimal management of portal vein thrombosis (PVT) in patients with cirrhosis. The purpose of this study is to compare the safety and thrombosis burden change for cirrhotic patients with non-tumoral PVT managed by transjugular intrahepatic portosystemic shunt (TIPS) only, anticoagulation only, or no treatment. METHODS:This single-center retrospective study evaluated 52 patients with cirrhosis and non-tumoral PVT managed by TIPS only (14), anticoagulation only (11), or no treatment (27). The demographic, clinical, and imaging data for patients were collected. The portomesenteric thrombosis burden and liver function tests at early follow-up (6-9 months) and late follow-up (9-16 months) were compared to the baseline. Adverse events including bleeding and encephalopathy were recorded. RESULTS:= 0.007). No bleeding complications attributable to anticoagulation were observed. CONCLUSION/CONCLUSIONS:TIPS decreased portomesenteric thrombus burden compared to anticoagulation or no treatment for cirrhotic patients with PVT. Both TIPS and anticoagulation were safe therapies.
PMID: 34073236
ISSN: 2077-0383
CID: 4891422

Combination Therapies of Radioembolization and Systemic Agents for Primary and Secondary Liver Tumors

Hickey, R M
This review provides an overview of studies in which radioembolization was combined with systemic agent(s). Several reports in the literature provide retrospective evaluation of the use of concomitant radioembolization with systemic agents; however, in an effort to limit the scope of this review to the highest levels of evidence available, the studies discussed are restricted to prospective phase 2 and 3 clinical trials of combination therapy.
EMBASE:635097632
ISSN: 2472-873x
CID: 4904652

Yttrium-90 Radioembolization in the Office-Based Lab

Hickey, Ryan M; Maslowski, John M; Aaltonen, Eric T; Horn, Jeremy Cash; Patel, Amish; Sista, Akhilesh K; Gross, Jonathan S
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.
PMID: 32800662
ISSN: 1535-7732
CID: 4572972

Safety and Effectiveness of Yttrium-90 Radioembolization around the Time of Immune Checkpoint Inhibitors for Unresectable Hepatic Metastases

Ruohoniemi, David M; Zhan, Chenyang; Wei, Jason; Kulkarni, Kopal; Aaltonen, Eric T; Horn, Jeremy C; Hickey, Ryan M; Taslakian, Bedros
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.
PMID: 32741550
ISSN: 1535-7732
CID: 4552662

Comparative Analysis of Safety and Efficacy of Transarterial Chemoembolization for the Treatment of Hepatocellular Carcinoma in Patients with and without Pre-Existing Transjugular Intrahepatic Portosystemic Shunts

Ruohoniemi, David M; Taslakian, Bedros; Aaltonen, Eric A; Hickey, Ryan; Patel, Amish; Horn, Jeremy C; Chiarello, Matthew; McDermott, Meredith
PURPOSE/OBJECTIVE:To compare the safety and efficacy of transarterial chemoembolization for hepatocellular carcinoma (HCC) in patients with and without transjugular intrahepatic portosystemic shunts (TIPS). MATERIALS AND METHODS/METHODS:This single-institution study included a retrospective review of 50 patients who underwent transarterial chemoembolization for HCC between January 2010 and April 2017. Twenty-five patients had preexisting TIPS, and 25 patients were selected to control for age, sex, and target tumor size. Baseline median Model for End-Stage Liver Disease (MELD; 13 TIPS, 9 control; P < .001) and albumin-bilirubin (ALBI; 3 TIPS, 2 control; P < .001) differed between groups. Safety was assessed on the basis of Common Terminology Criteria for Adverse Events (CTCAE) and change in MELD and ALBI grade assessed between 3 and 6 months. Efficacy was assessed by tumor response and time to progression (TTP). RESULTS:There was 1 severe adverse event (CTCAE grade >2) in the TIPS group. There was no difference in the change in MELD or ALBI grade. Although there was no difference in tumor response (P = .19), more patients achieved a complete response in the control group (19/25, 76%) than in the TIPS group (13/25, 52%). There was no difference in TTP (P = .82). At 1 year, 2 patients in the control group and 3 patients in the TIPS group received a liver transplant. Seven patients died in the TIPS group. CONCLUSIONS:Transarterial chemoembolization is as safe and effective in patients with TIPS as in patients without TIPS, despite worse baseline liver function. Severe adverse events are rare and may be transient.
PMID: 31982313
ISSN: 1535-7732
CID: 4293742

Muscle mass on magnetic resonance imaging predicts hepatocellular carcinoma survival following Yttrium-90 radioembolization [Meeting Abstract]

Guichet, P; Taslakian, B; Aaltonen, E; Farquharson, S; Hickey, R; Horn, C; Gross, J
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.
Copyright
EMBASE:2004990344
ISSN: 1535-7732
CID: 4326232

Management of portal vein thrombosis in cirrhotic patients [Meeting Abstract]

Carney, B; Zhan, C; Li, C; Zhu, Y; Weinberger, H; Horn, C; Aaltonen, E; Dagher, N; Laville, M; Olsen, S; Sista, A; Hickey, R; Taslakian, B
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.
EMBASE:2004990557
ISSN: 1535-7732
CID: 4325612

Descriptive revenue analysis of 100 patients in an interventional oncology service line: understanding revenue sources in interventional radiology [Meeting Abstract]

Ruohoniemi, D; Taslakian, B; Chong, A; Aaltonen, E; Horn, C; Sista, A; Hickey, R
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.
Copyright
EMBASE:2004990468
ISSN: 1535-7732
CID: 4325632

Safety of Combined Yttrium-90 Radioembolization and Immune Checkpoint Inhibitor Immunotherapy for Hepatocellular Carcinoma

Zhan, Chenyang; Ruohoniemi, David; Shanbhogue, Krishna P; Wei, Jason; Welling, Theodore H; Gu, Ping; Park, James S; Dagher, Nabil N; Taslakian, Bedros; Hickey, Ryan M
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.
PMID: 31422022
ISSN: 1535-7732
CID: 4046512

Interventional Radiology in the Era of Immuno-Oncology: Impact and Opportunity

Chiarello, M A; Hickey, R M
EMBASE:2002094532
ISSN: 2589-8701
CID: 4986902