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Stent Graft Placement for the Treatment of Hepatic Artery Injury in Patients with Cancer: Primary Patency and Clinical Outcomes

Aly, Ahmed K; Yarmohammadi, Hooman; Bajwa, Raazi; Silk, Mikhail; Hsu, Meier; Moskowitz, Chaya; Santos, Ernesto; Moussa, Amgad M
PURPOSE:To evaluate the safety, primary patency, and clinical outcomes of hepatic artery stent graft (SG) placement for vascular injuries. MATERIALS AND METHODS:Patients treated with hepatic arterial SG placement for vascular injuries between September 2018 and September 2021 were reviewed. Data on demographic characteristics, indication, stent graft characteristics, antiplatelet/anticoagulant use, clinical success rate, complications, and type of follow-up imaging were collected. Follow-up images were reviewed by 2 independent reviewers to assess primary patency. A time-to-event analysis was performed. The median duration of stent graft patency was estimated using Kaplan-Meier curves. A Cox proportional hazard model was used to evaluate factors related to stent graft patency. RESULTS:Thirty-five patients were treated with hepatic arterial SG placement, 11 for postoperative bleeds and 24 for hepatic artery infusion pump catheter-related complications. Clinical success was achieved in 32 (91%) patients (95% CI, 77-98). The median primary patency was 87 days (95% CI, 73-293). Stent grafts of ≥6-mm diameter retained patency for a longer duration than that with stent grafts of smaller diameters (6 mm vs 5 mm; hazard ratio, 0.35; 95% CI, 0.14-0.88; P = .026; and 7+ mm vs 5 mm; hazard ratio, 0.27; 95% CI, 0.09-0.83; P = .023). Anticoagulation/antiplatelet regimen was not associated with increased stent graft patency duration (P > .05). Only minor complications were reported in 2 (5.7%) patients. CONCLUSIONS:Stent grafts can be used safely and effectively to treat injuries of the hepatic artery. Stent graft diameters of ≥6 mm seem to provide more durable patency.
PMID: 36265819
ISSN: 1535-7732
CID: 5505002

Real-Time Split-Dose PET/CT-Guided Ablation Improves Colorectal Liver Metastasis Detection and Ablation Zone Margin Assessments without the Need for Repeated Contrast Injection

Zirakchian Zadeh, Mahdi; Yeh, Randy; Kunin, Henry S; Kirov, Assen S; Petre, Elena N; Gönen, Mithat; Silk, Mikhail; Cornelis, Francois H; Soares, Kevin C; Ziv, Etay; Solomon, Stephen B; Sotirchos, Vlasios S; Sofocleous, Constantinos T
BACKGROUND:Real-time split-dose PET can identify the targeted colorectal liver metastasis (CLM) and eliminate the need for repeated contrast administration before and during thermal ablation (TA). This study aimed to assess the added value of pre-ablation real-time split-dose PET when combined with non-contract CT in the detection of CLM for ablation and the evaluation of the ablation zone and margins. METHODS:A total of 190 CLMs/125 participants from two IRB-approved prospective clinical trials using PET/CT-guided TA were analyzed. Based on detection on pre-TA imaging, CLMs were categorized as detectable, non-detectable, and of poor conspicuity on CT alone, and detectable, non-detectable, and low FDG-avidity on PET/CT after the initial dose. Ablation margins around the targeted CLM were evaluated using a 3D volumetric approach. RESULTS:We found that 129/190 (67.9%) CLMs were detectable on CT alone, and 61/190 CLMs (32.1%) were undetectable or of poor conspicuity, not allowing accurate depiction and targeting by CT alone. Thus, the theoretical 5- and 10-mm margins could not be defined in these tumors (32.1%) using CT alone. When TA intraprocedural PET/CT images are obtained and inspected (fused PET/CT), only 4 CLM (2.1%) remained undetectable or had a low FDG avidity. CONCLUSIONS:The addition of PET to non-contrast CT improved CLM detection for ablation targeting, margin assessments, and continuous depiction of the FDG avid CLMs during the ablation without the need for multiple intravenous contrast injections pre- and intra-procedurally.
PMID: 36551738
ISSN: 2072-6694
CID: 5430292

Evaluation of an Integrated Spectroscopy and Classification Platform for Point-of-Care Core Needle Biopsy Assessment: Performance Characteristics from Ex Vivo Renal Mass Biopsies

Keshavamurthy, Krishna Nand; Dylov, Dmitry V; Yazdanfar, Siavash; Patel, Dharam; Silk, Tarik; Silk, Mikhail; Jacques, Frederick; Petre, Elena N; Gonen, Mithat; Rekhtman, Natasha; Ostroverkhov, Victor; Scher, Howard I; Solomon, Stephen B; Durack, Jeremy C
PURPOSE/OBJECTIVE:To evaluate a transmission optical spectroscopy instrument for rapid ex vivo assessment of core needle cancer biopsies (CNBs) at the point of care. MATERIALS AND METHODS/METHODS:CNBs from surgically resected renal tumors and nontumor regions were scanned on their sampling trays with a custom spectroscopy instrument. After extracting principal spectral components, machine learning was used to train logistic regression, support vector machines, and random decision forest (RF) classifiers on 80% of randomized and stratified data. The algorithms were evaluated on the remaining 20% of the data set held out during training. Binary classification (tumor/nontumor) was performed based on a decision threshold. Multinomial classification was also performed to differentiate between the subtypes of renal cell carcinoma (RCC) and account for potential confounding effects from fat, blood, and necrotic tissue. Classifiers were compared based on sensitivity, specificity, and positive predictive value (PPV) relative to a histopathologic standard. RESULTS:A total of 545 CNBs from 102 patients were analyzed, yielding 5,583 spectra after outlier exclusion. At the individual spectra level, the best performing algorithm was RF with sensitivities of 96% and 92% and specificities of 90% and 89%, for the binary and multiclass analyses, respectively. At the full CNB level, RF algorithm also showed the highest sensitivity and specificity (93% and 91%, respectively). For RCC subtypes, the highest sensitivity and PPV were attained for clear cell (93.5%) and chromophobe (98.2%) subtypes, respectively. CONCLUSIONS:Ex vivo spectroscopy imaging paired with machine learning can accurately characterize renal mass CNB at the time of tissue acquisition.
PMID: 35940363
ISSN: 1535-7732
CID: 5331382

Up to seven criteria in selection of systemic therapy for hepatocellular carcinoma

Silk, Tarik; Silk, Mikhail; Wu, Jennifer
Barcelona clinic liver cancer (BCLC) intermediate stage hepatocellular carcinoma is a heterogenous disease. Transarterial chemoembolization is offered as the first line therapy in this disease stage. Recent advances in systemic therapy have markedly improved outcomes even in advanced stage disease. The use of systemic therapy in BCLC intermediate stage disease may now be of therapeutic benefit in selected patients. We will focus on "the up to seven" criteria and its utility in selecting systemic therapy.
PMID: 35949352
ISSN: 2219-2840
CID: 5287002

Temporal and geospatial variations among the interventional radiology physician workforce in the United States

Garg, Tushar; Bajaj, Suryansh; Dayan, Michael J; Makary, Mina S; Smirniotopoulos, John B; Silk, Mikhail; Ahmed, Osman; Wadhwa, Vibhor
OBJECTIVE:To analyze the temporal trends and state-wide geospatial variations in Vascular and Interventional Radiology (VIR) workforce in the United States. METHODS:The State Physician Workforce Data from the AAMC website was accessed for years 2015, 2017, and 2019. The variables collected for each state included total number of active physicians, total number of physicians per specialty and total number of female physicians in VIR. Comparative data was obtained for vascular surgery (VS), diagnostic radiology (DR), and radiation oncology (RO). The annual growth rate for total physicians and sub-analysis of female physicians in each state was computed for each specialty. RESULTS:From 2015 to 2019, the total number of active physicians in the United States grew by 1.8% per year. Growth of active physicians in VIR grew by 8.3%, DR 0.06%, VS 4.4%, and RO 1.9% per year. Colorado and Minnesota had the highest growth rate for VIR physicians (15%). VIR physicians per 100,000 people increased from 0.84 (2015) to 1.10 (2019) in the US. In comparison, VS physicians increased from 0.99 (2015) to 1.14 (2019), DR physicians decreased from 8.61 (2015) to 8.43 (2019), and RO physicians grew from 1.48 (2015) to 1.56 (2019). Women represented 6.8% of the VIR workforce in the US in 2019 and increased by a rate of 16% annually in the US from 2015 to 2019. In comparison, the number of women in VS has grown by 21%, DR by 2%, and RO by 2.4% during the same period. The state of Maryland has the highest proportion of women in VIR at 18%. CONCLUSION/CONCLUSIONS:The number of VIR physicians is increasing at a higher rate than the national overall physician growth, and while female VIR physicians makeup a small fraction of the VIR workforce, their numbers have increased at a faster rate than overall VIR physicians.
PMID: 33773445
ISSN: 1873-4499
CID: 5333412

Safety and efficacy of arterially directed liver therapies in treatment of hepatic metastatic ovarian cancer: A retrospective single-institution study

Lacayo, Eduardo A; Velayati, Sara; Elsakka, Ahmed; Brody, Lynn; Erinjeri, Joseph P; Ziv, Etay; Boas, Franz E; Sofocleous, Constantinos T; Silk, Mikhail; Makker, Vicky; Tew, William P; Yarmohammadi, Hooman
PURPOSE/OBJECTIVE:To evaluate the safety and efficacy of two locoregional therapies (LRT) including hepatic artery embolization (HAE) and transarterial radioembolization (TARE) in treating patients with metastatic ovarian cancer to the liver. METHODS:From October 2010 to May 2019, the data of 15 consecutive patients (median age, 54 ± 9.8; range, 35-78) with hepatic metastatic ovarian cancer that were treated with either HAE (n = 6, 40%) or TARE (n = 9, 60%) were reviewed. Most common histopathologic type was epithelial ovarian carcinoma (80%). Most common chemotherapy regimens used prior to embolization included carboplatin, paclitaxel, cisplatin, and bevacizumab. Patients received a mean of 4 ± 3 (range 1-9) lines of chemotherapy. All patients with serous carcinoma were platinum-resistant at the time of embolization. Indications for embolization were progression of disease in the liver while receiving chemotherapy in 14 (93.3%) and palliative pain control in 1 patient. RESULTS:Overall response rate at 1, 3, and 6 months was 92.4%, 85.6%, and 70%. The median overall survival from the time of LRT was 9 months (95% confidence interval [CI], 4-14 months). Median local tumor progression was 6.4 ± 5.03 months (95% CI, 3.3-9.5). No grade 3-5 adverse events were detected in either group. CONCLUSION/CONCLUSIONS:HAE and TARE were well tolerated in patients with metastatic ovarian cancer to the liver and possibly prolong disease control in heavily treated, predominately platinum-resistant patients. Larger numbers are needed to verify these data.
PMID: 33636309
ISSN: 1535-7732
CID: 4795152

Prospective Evaluation of Unprocessed Core Needle Biopsy DNA and RNA Yield from Lung, Liver, and Kidney Tumors: Implications for Cancer Genomics

Silk, Mikhail T; Mikkilineni, Nina; Silk, Tarik C; Zabor, Emily C; Ostrovnaya, Irina; Hakimi, Ari A; Hsieh, James J; Ziv, Etay; Rekhtman, Natasha; Solomon, Stephen B; Durack, Jeremy C
CONTEXT/BACKGROUND:Targeted needle biopsies are increasingly performed for the genetic characterization of cancer. While the nucleic acid content of core needle biopsies after standard pathology processing (i.e., formalin fixation and paraffin embedding (FFPE)) has been previously reported, little is known about the potential yield for molecular analysis at the time of biopsy sample acquisition. OBJECTIVES/OBJECTIVE:Our objective was to improve the understanding of DNA and RNA yields from commonly used core needle biopsy techniques prior to sample processing. METHODS:We performed 552 ex vivo 18 and 20G core biopsies in the lungs, liver, and kidneys. DNA and RNA were extracted from fresh-frozen core samples and quantified for statistical comparisons based on needle gauge, biopsy site, and tissue type. RESULTS:< 0.001). CONCLUSIONS:Core needle biopsy techniques for cancer diagnostics yield a broad range of DNA and RNA for molecular pathology, though quantities are greater than what has been reported for FFPE processed material. Since non-formalin-fixed DNA is advantageous for molecular studies, workflows that optimize core needle biopsy yield for molecular characterization should be explored.
PMID: 30652067
ISSN: 2210-7185
CID: 5333402

Feasibility of a Modified Biopsy Needle for Irreversible Electroporation Ablation and Periprocedural Tissue Sampling

Wimmer, Thomas; Srimathveeravalli, Govindarajan; Silk, Mikhail; Monette, Sebastien; Gutta, Narendra; Maybody, Majid; Erinjery, Joseph P; Coleman, Jonathan A; Solomon, Stephen B; Sofocleous, Constantinos T
OBJECTIVES:To test the feasibility of modified biopsy needles as probes for irreversible electroporation ablation and periprocedural biopsy. METHODS:Core biopsy needles of 16-G/9-cm were customized to serve as experimental ablation probes. Computed tomography-guided percutaneous irreversible electroporation was performed in in vivo porcine kidneys with pairs of experimental (n = 10) or standard probes (n = 10) using a single parameter set (1667 V/cm, ninety 100 µs pulses). Two biopsy samples were taken immediately following ablation using the experimental probes (n = 20). Ablation outcomes were compared using computed tomography, simulation, and histology. Biopsy and necropsy histology were compared. RESULTS:; P = .29) indicated ablations with experimental probes were not significantly different from the standard. Histopathology indicated similar morphological changes in both groups. Biopsies from the ablation zone yielded at least 1 core with sufficient tissue for analysis (11 of the 20). CONCLUSIONS:A combined probe for irreversible electroporation ablation and periprocedural tissue sampling from the ablation zone is feasible. Ablation outcomes are comparable to those of standard electrodes.
PMID: 26443800
ISSN: 1533-0338
CID: 5333392

Acute and delayed bleeding requiring embolization after image-guided liver biopsy in patients with cancer

Sag, Alan A; Brody, Lynn A; Maybody, Majid; Erinjeri, Joseph P; Wang, Xiaodong; Wimmer, Thomas; Silk, Mikhail; Petre, Elena N; Solomon, Stephen B
PURPOSE/OBJECTIVE:To report incidence of acute versus delayed presentations of bleeding requiring embolization after focal liver biopsy, in correlation with angiographic findings and treatment success rates. The available literature will be reviewed as well. MATERIALS AND METHODS/METHODS:Health Insurance Portability and Accountability Act-compliant institutional review board approved retrospective review of 2180 consecutive patients undergoing 2335 targeted liver biopsies at a tertiary-care cancer center. Hepatic arterial embolization episodes within 30days from biopsy were identified via radiology PACS. Electronic medical record review was performed for indication of embolization and postembolization clinical course. RESULTS:The incidence of postbiopsy bleeding requiring embolization was 0.5% (12/2335 biopsies). In those with bleeding, 1/12 (8%) had no hepatic arterial findings at angiography. Angiographic hepatic arterial findings resolved after embolization in 11/11 patients (100% technical success). Bleeding ceased after embolization in 10/12 patients (83% clinical success). Complications were seen in 2/12 (17%) patients: cholecystitis and hepatic infarct, respectively. Delayed presentation of bleeding (defined as >24h postbiopsy) occurred in 5/12 (42%) patients; the longest latency was 12days. CONCLUSION/CONCLUSIONS:The overall incidence of bleeding requiring embolization in our population was 0.5%. This complication rate compares favorably to the 0-4.2% (median: 0.29%) rate quoted in the available, heterogeneous, literature on this topic. Delayed presentation occurred in almost half of patients. Arterial embolization carries excellent technical and clinical success rates.
PMID: 27133700
ISSN: 1873-4499
CID: 3102762

Feasibility of catheter-directed intraluminal irreversible electroporation of porcine ureter and acute outcomes in response to increasing energy delivery

Srimathveeravalli, Govindarajan; Silk, Mikhail; Wimmer, Thomas; Monette, Sebastien; Kimm, Simon; Maybody, Majid; Solomon, Stephen B; Coleman, Jonathan; Durack, Jeremy C
PURPOSE/OBJECTIVE:To evaluate the feasibility of focal intraluminal irreversible electroporation (IRE) in the ureter with a novel electrode catheter and to study the treatment effects in response to increasing pulse strength. MATERIALS AND METHODS/METHODS:Five IRE treatment settings were each evaluated twice for the ablation of normal ureter in 5 Yorkshire pigs (n = 1-4 ablations per animal; total of 10 ablations) with the use of a prototype device under ultrasound and fluoroscopic guidance. Animals received unilateral or bilateral treatment, limited to a maximum of 2 ablations in any 1 ureter. Treatment was delivered with increasing pulse strength (from 1,000 V to 3,000 V in increments of 500 V) while keeping the pulse duration (100 μs) and number of pulses (n = 90) constant. Ureter patency was assessed with antegrade ureteropyelography immediately following treatment. Animals were euthanized within 4 hours after treatment, and treated urinary tract was harvested for histopathologic analysis with hematoxylin and eosin and Masson trichrome stains. RESULTS:IRE was successfully performed in all animals, without evidence of ureteral perforation. Hematoxylin and eosin analysis of IRE treatments demonstrated full-thickness ablation at higher field strengths (mucosa to the adventitia). Masson trichrome stains showed preservation of connective tissue at all field strengths. CONCLUSIONS:Intraluminal catheter-directed IRE ablation is feasible and produces full-thickness ablation of normal ureters. There was no evidence of lumen perforation even at the maximum voltages evaluated.
PMID: 25769212
ISSN: 1535-7732
CID: 5333382