Patel, Nihal D; Chong, Anthony T; Kolla, Avani M; Mabud, Tarub S; Kulkarni, Kopal; Masrouha, Karim; Taslakian, Bedros; Bertino, Frederic J
Venous malformations, the most common type of vascular malformation, are slow-flow lesions resulting from disorganized angiogenesis. The International Society for the Study of Vascular Anomalies (ISSVA) classification offers a categorization scheme for venous malformations based on their genetic landscapes and association with congenital overgrowth syndromes. Venous malformations present as congenital lesions and can have broad physiologic and psychosocial sequelae depending on their size, location, growth trajectory, and tissue involvement. Diagnostic evaluation is centered around clinical examination, imaging evaluation with ultrasound and time-resolved magnetic resonance imaging, and genetic testing for more complex malformations. Interventional radiology has emerged as first-line management of venous malformations through endovascular treatment with embolization, while surgery and targeted molecular therapies offer additional therapeutic options. In this review, an updated overview of the genetics and clinical presentation of venous malformations in conjunction with key aspects of diagnostic imaging and treatment are discussed.
Incorporation of a Social Virtual Reality Platform into the Residency Recruitment Season
Guichet, Phillip L; Huang, Jeffrey; Zhan, Chenyang; Millet, Alexandra; Kulkarni, Kopal; Chhor, Chloe; Mercado, Cecilia; Fefferman, Nancy
RATIONALE AND OBJECTIVES/OBJECTIVE:The Covid-19 pandemic ushered a sudden need for residency programs to develop innovative socially distant and remote approaches to effectively promote their program. Here we describe our experience using the social virtual reality (VR) platform Mozilla Hubs for the pre-interview social during the 2020-2021 radiology residency virtual recruitment season, provide results of a survey sent to assess applicants' attitudes towards the VR pre-interview social, and outline additional use-cases for the emerging technology. MATERIALS AND METHODS/METHODS:A VR Meeting Hall dedicated to the pre-interview social was designed in Mozilla Hubs. To assess applicants' impressions of the Mozilla Hubs pre-interview social, applicants were sent an optional web-based survey. Survey respondents were asked to respond to a series of eleven statements using a five-point Likert scale of perceived agreement: Strongly Agree, Agree, Neutral, Disagree, Strongly Disagree. Statements were designed to gauge applicants' attitudes towards the Mozilla Hubs pre-interview social and its usefulness in helping them learn about the residency program, particularly in comparison with pre-interview socials held on conventional video conferencing software (CVCS). RESULTS:Of the 120 residency applicants invited to the Mozilla Hubs pre-interview social, 111 (93%) attended. Of these, 68 (61%) participated in the anonymous survey. Most applicants reported a better overall experience with Mozilla Hubs compared to CVCS (47/68, 69%), with 10% (7/68) reporting a worse overall experience, and 21% (14/68) neutral. Most applicants reported the Mozilla Hubs pre-interview social allowed them to better assess residency culture than did pre-interview socials using CVCS (41/68, 60%). Seventy-two percent of applicants reported that the Mozilla Hubs pre-interview social positively impacted their decision to strongly consider the residency program (49/68). CONCLUSION/CONCLUSIONS:Radiology residency applicants overall preferred a pre-interview social hosted on a social VR platform, Mozilla Hubs, compared to those hosted on CVCS. Applicants reported the use of a social VR platform reflected positively on the residency and positively impacted their decision to strongly consider the program.
Abstract No. 507 Safety and feasibility of adjuvant liposomal bupivacaine in superior hypogastric nerve block performed during uterine fibroid embolization [Meeting Abstract]
Tria, N; Kulkarni, K
Purpose: Post embolization syndrome following uterine fibroid embolization (UFE) manifests as severe cramping pain that lasts about 5-7 days. Superior hypogastric nerve block (SHNB) with bupivacaine has been demonstrated to significantly reduce pain after UFE but has a duration of effect of only 8-12 hours. Exparel (liposomal bupivacaine, Pacira Pharm, Parsippany, NJ) is an FDA-approved formulation which is intended to provide extended release, post-surgical, regional anesthesia for up to 72 hours. Liposomal bupivacaine has not been evaluated for SHNB. The purpose of this study is to evaluate the safety and feasibility of liposomal bupivacaine as an adjuvant component to the standard bupivacaine in SHNB during UFE.
Material(s) and Method(s): A single-institution retrospective study of patients who received SHNH composed of a 0.25% bupivacaine and liposomal bupivacaine mixture from April 2021 to September 2021 was performed. Chart review was performed to determine complication, readmission and technical success rates.
Result(s): Of the 14 SHNBs performed using liposomal bupivacaine, there was a 100% (n=14) technical success rate as judged by needle position and contrast injection on AP and lateral imaging and successful delivery of bupivacaine-liposomal bupivacaine mixture. 100% (n=14) patients were discharged home the same day and 0% (n=0) were re-admitted for an overnight stay or emergency room visit. There were no documented intra- or post-operative complications per the Society of Interventional Radiology Adverse Event Classification System. This includes neurologic and cardiovascular complications commonly associated with local anesthetic systemic toxicity such as seizures, visual disturbances, cardiac dysrhythmias or hypotension as well as adverse events attributed to SHNB technique, including discitis, osteomyelitis, hemorrhage and lower extremity sensory/motor deficits.
Conclusion(s): This 6-month interim data suggests liposomal bupivacaine is a safe adjuvant to bupivacaine as a SHNB in patients undergoing UFE. Given the high technical success and safety profile, SHNB with liposomal bupivacaine should be further evaluated for efficacy in extending pain relief and decreasing opioid consumption in UFE recovery.
Essentials of Insulinoma Localization with Selective Arterial Calcium Stimulation and Hepatic Venous Sampling
Zhao, Ken; Patel, Nihal; Kulkarni, Kopal; Gross, Jonathan S; Taslakian, Bedros
Insulinomas are the most common functional pancreatic neuroendocrine tumor. Most insulinomas can be localized non-invasively with cross-sectional and nuclear imaging. Selective arterial calcium stimulation and hepatic venous sampling is an effective and safe minimally-invasive procedure for insulinoma localization that may be utilized when non-invasive techniques are inconclusive. The procedure's technical success and proper interpretation of its results is dependent on the interventional radiologist's knowledge of normal and variant pancreatic arterial perfusion. Accurate pre-operative localization aids in successful surgical resection. Technical and anatomic considerations of insulinoma localization with selective arterial calcium stimulation and hepatic venous sampling are reviewed.
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 Â± 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.
A Descriptive Revenue Analysis of a Wound-Center IR Collaboration to Treat Lower Extremity Venous Ulcers
Ruohoniemi, David M; Ross, Frank L; Chiu, Ernest S; Taslakian, Bedros; Horn, Jeremy C; Aaltonen, Eric A; Kulkarni, Kopal; Browning, Alexa; Patel, Amish; Sista, Akhilesh K
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.
03:00 PM Abstract No. 325 Extra-hepatic response of primary and metastatic hepatic malignancy to Y90 radioembolization in the setting of immunotherapy [Meeting Abstract]
Zhan, C; Ruohoniemi, D; Martirosyan, K; Hickey, R; Taslakian, B; Kulkarni, K
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.
03:54 PM Abstract No. 437 Safety and toxicity of concurrent Y90 radioembolization and checkpoint-inhibitor immunotherapy [Meeting Abstract]
Zhan, C; Ruohoniemi, D; Kulkarni, K; Martirosyan, K; Welling, T; Gu, P; Taslakian, B; Hickey, R
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.
Concordance Between Aspiration Detected on Upper Gastrointestinal Series and Videofluoroscopic Swallow Study in Bottle-Fed Children
Flax-Goldenberg, Renee; Kulkarni, Kopal S; Carson, Kathryn A; Pinto, Jeanne M; Martin-Harris, Bonnie; Lefton-Greif, Maureen A
The increasing incidence of pediatric dysphagia has raised questions about how to identify children at risk for aspiration. Multiple investigative imaging modalities are considered in diagnostic algorithms, since dysphagia may involve any or all phases of swallowing. Although upper gastrointestinal (UGI) series and videofluoroscopic swallow study (VFSS) are common procedures, the utility of UGI for detection of aspiration and the impact of oropharyngeal imaging during UGI on radiation exposure have not been well described. We hypothesized that diagnosis of aspiration on UGI would be predictive of aspiration on VFSS and screening swallows during UGI would increase radiation exposure. A retrospective review was completed of bottle-fed children undergoing UGI series within 1 month before/after standardized VFSS. UGI was imaged at 3 frames per second (fps) pulsed and VFSS at 30 fps continuous fluoroscopy. Cumulative radiation dose (CD) and dose area product (DAP) were recorded. VFSS and UGI were performed in 49 patients; however, only 21 (43 %) had documentation of swallow function on an UGI series. All children with aspiration on UGI demonstrated thin liquid aspiration on VFSS; however, 53 % without aspiration on UGI aspirated on VFSS. CD for UGI with versus without swallowing documentation was significantly higher (median = 0.33 vs. 0.21 mGy, p = 0.02) but within variability ranges reported for fluoroscopy equipment. DAP was not significantly higher for UGI with documentation of swallowing compared to without documentation of swallowing (median = 4.11 vs. 3.02 muGy cm(2), p = 0.09). UGI findings are specific but not sensitive markers for aspiration on VFSS. Imaging of swallowing on UGI may have an appreciable increase on radiation exposure.
Metastatic Disease to the Breast From Extramammary Malignancies: A Multimodality Pictorial Review
Sippo, Dorothy A; Kulkarni, Kopal; Carlo, Philip Di; Lee, Bonmyong; Eisner, David; Cimino-Mathews, Ashley; Harvey, Susan C
This pictorial review demonstrates imaging features of extramammary malignancies metastatic to the breast seen with multiple modalities, including mammography, ultrasound, computed tomography (CT), positron emission tomography, and magnetic resonance imaging. Although rare, metastases to the breast may have a distinct imaging appearance from the appearance of primary breast cancers. They are important to identify because they can mimic benign breast disease and their treatment differs from that of primary breast cancer. Metastatic disease to the breast most commonly appears as a single round or oval mass with circumscribed margins. Sonographically it is usually hypoechoic, and with CT or magnetic resonance imaging it usually enhances. In contrast with primary breast cancer, breast metastases do not demonstrate spiculated margins and rarely have associated calcifications. A variety of clinical presentations of breast metastases are reviewed, including presentation with a palpable mass, detection at screening mammography, and detection with CT or positron emission tomography.