Search

Introduction The risk factors of breast cancer overlap with those of peripheral arterial disease (PAD), with increasing prevalence. In addition, there is under-utilization of risk factor modification measures in patients with PAD. Materials and Methods Electronic medical records of patients with breast cancer with International Classification of Diseases 9/10 codes for PAD spanning 10 years from June 1, 2009 to June 1, 2019 were reviewed. Results A total of 248 patients, 98% women, with a median age of 75 years and with a median follow-up of 76 months, were included. PAD risk factors were identified as smoking (44%), obesity (38%), hyperlipidemia (68%), hypertension (HTN) (74%), and diabetes (42%). Overall, survival was significantly impacted by smoking (P = .0301) and HTN (P = .0052). In a Cox proportion hazard ratio regression, HTN (overall death hazard ratio [HR], 3.1784; 95% CI, 1.0291-6.7490; P = .0070; cancer-related death HR, 2.6354; 95% confidence interval [CI], 1.0291-6.7490; P = .0434) and smoking (overall death HR, 1.7452; 95% CI 1.0707-2.8444; P = .0255; cancer-related death HR, 2.7432; 95% CI, 1.4190-5.3030; P = .0027) were predictors of overall death and cancer-related death. Of all patients, 48% were on statins and 54% were on antiplatelet therapies. Of the patients, 62% of current smokers were offered a smoking cessation program, 27% of obese patients were offered a nutrition consult, 42% of patients with diabetes had blood glucose controlled, and 54% of patients with HTN had blood pressure controlled. Conclusion Smoking and HTN are risk factors associated with decreased survival and predictive of overall death and cancer-related death. In this population, risk factor modification was under-utilized.

Metastatic breast cancer (MBC) remains the second cause of cancer death in women, despite improvements in early breast cancer detection and treatments, with a 5-year survival of only 27%. Patients with MBC involving the liver have a 5-year survival of only 3.8 to 12%. Systemic therapy is the cornerstone for the treatment of MBC according to the National Comprehensive Cancer Network (NCCN) guidelines. Radioembolization is not specifically prescribed by the NCCN guidelines in the treatment of MBC liver metastasis, but is an emerging therapy with some promising results. The two primary reasons to offer radioembolization would be to prolong life and to palliate and improve quality of life. We review here the indications, contraindications, technique, case examples, and unanswered questions.

Objective To identify factors associated with venous stent thrombosis in patients with cancer treated for nonthrombotic iliocaval or iliofemoral venous obstruction. Methods We performed a retrospective review of relevant imaging and medical records from 30 consecutive patients with cancer treated at a single center who underwent venous stent placement for nonthrombotic iliocaval or iliofemoral venous obstruction between 2008 and 2018. Follow-up imaging was used to assess stent patency. Variables examined included patient demographics, cancer type, stent characteristics, anticoagulant, and antiplatelet medications and complications of treatment. Results Overall primary stent patency was 83% (25/30). The median follow-up period was 44 days (range, 3-365 days). Ten percent of patients occluded owing to in-stent thrombosis and 7% owing to tumor compression of the stent without thrombosis. Therapeutic poststent anticoagulation with enoxaparin, warfarin, or a factor Xa inhibitor was initiated in 87% of the patients. Stent thrombosis occurred in one patient in the anticoagulation group (4%) at 50 days. Stent thrombosis occurred in two patients in the nonanticoagulation group (50%), one at 9 days and the other at 91 days. Anticoagulation was found to be protective against stent thrombosis in this population (hazard ratio, 0.015; P = .011). No statistically significant associations were found among the remaining variables. One patient in the anticoagulation group experienced major bleeding (1/26 [4%]). Conclusions Iliocaval and iliofemoral stent placement for nonthrombotic malignant venous obstruction is safe with favorable primary patency rates. Therapeutic anticoagulation is associated with less stent thrombosis in patients with cancer stented for nonthrombotic iliocaval and iliofemoral venous obstruction.

While much progress has been made in oncologic care, metastatic solid organ cancer still carries a poor prognosis. Immunotherapy has emerged as a promising approach, though in most patients, does not control disease when given as a monotherapy. Combining immunotherapy with locoregional therapy is one approach to boost the efficacy of treatments and potentially prolong survival. Most of the researches regarding combination therapies have involved external radiation. This review describes the immunologic effects of external radiation and radioembolization, and how these effects provide a rationale for combining hepatic radioembolization with immunotherapy.

OBJECTIVE. The objective of our study was to determine whether there are differences in outcome of screening MRI examinations in premenopausal women as a function of the week of the menstrual cycle in which the study was performed. MATERIALS AND METHODS. The reports of consecutive screening MRI examinations performed from January 1, 2011, through December 31, 2012, of premenopausal women were reviewed. Only cases for which the 1st day of the last menstrual cycle was documented were included. Associations between the week of the menstrual cycle, degree of background parenchymal enhancement (BPE), final BI-RADS assessment, positive predictive values (PPVs), cancer detection rate (CDR), sensitivity, and specificity were noted. RESULTS. A total of 1536 MRI examinations of 1239 women were performed. Distribution of MRI examinations by menstrual cycle week was as follows: 21.8% (n = 335) in week 1, 35.4% (n = 544) in week 2, 23.4% (n = 360) in week 3, and 19.3% (n = 297) in week 4. In the overall comparison, there was no significant difference in BPE, BI-RADS assessment, PPV1, PPV2, PPV3, CDR, sensitivity, or specificity by the week of the menstrual cycle. When outcomes for cases with MRI performed in week 2 were compared with those of cases with MRI performed in weeks 1, 3, and 4 combined, there was no significant difference in the same outcome measures. CONCLUSION. There was no evidence of a difference in outcomes of screening MRI examinations as a function of the week of menstrual cycle in which the study is performed. The results of our study do not support the need for screening MRI to be performed in week 2 of the menstrual cycle.

Acute traumatic injury of the thoracic aorta is a highly lethal condition, with many afflicted patients expiring before hospital arrival. While previously these conditions were managed with open surgery, endovascular repair has rapidly evolved and is now considered the standard of care for certain patterns of aortic injury at centers with appropriate expertise. The development of newer branched devices has allowed these techniques to be utilized further and further proximally into the aorta. Through minimally invasive techniques, many aortic injuries can now be treated percutaneously with shorter recovery time and less perioperative complications.

Purpose To assess differences in outcome in an early and later time period in patients with hostile neck anatomy who underwent endovascular aneurysm repair (EVAR). Materials and Methods This single-center, institutional review board-approved retrospective study assessed patients who underwent EVAR between 2004 and 2013, divided into 2 time periods: 2004–2008 and 2009–2013. One hundred twenty-five patients had at least 1 hostile neck parameter that met inclusion criteria: 61 of 216 (28%) patients in the early period and 64 of 144 (44%) patients in the late period. Patients in the late group were younger compared to patients in the early group (late group, 74.5 ± 8.8 years vs early group, 77.5 ± 7.5 years; P = .046). No significant differences were observed in hostile neck anatomic factors between the early and late periods. Results No statistical difference was observed in periprocedural factors or outcome measures, except for abdominal aortic aneurysm (AAA) sac regression in the late period compared to the early period (late period, 73.5% vs early period, 55.7%; P = .038). A statistically significant increase was observed in type 1a endoleaks in patients in the late group with suprarenal fixation compared to patients with infrarenal fixation (suprarenal, 27.0% vs infrarenal, 7.9%; P = .025) and in the overall time studied (suprarenal, 20.3% vs infrarenal, 7.6%; P = .045). Conclusions Except for AAA sac regression, no changes were observed in periprocedural factors and outcome measures over time in patients with hostile neck who underwent EVAR.

Elective abdominal aortic aneurysm (AAA) repair is recommended for aneurysms greater than 5.5 cm, symptomatic, or rapidly expanding more than 0.5 cm in 6 months. Seventy-five percent of AAAs today are treated with endovascular aneurysm repair (EVAR) rather than open repair. This is fostered by the lower periprocedural mortality, complications, and length of hospital stay associated with EVAR. However, some studies have demonstrated EVAR to result in higher reintervention rates than with open repair, largely due to endoleaks. Type II is the most common, making up 10–25% of all endoleaks. Type II endoleaks, can potentially enlarge and pressurize the aneurysm sac with a risk of rupture. However, many type II endoleaks spontaneously resolve or never lead to sac enlargement. Imaging surveillance and approaches to management of type II endoleaks are reviewed here.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a subtype of pulmonary hypertension characterized by a mean pulmonary artery pressure ≥25 mm Hg due to obstructive fibrotic thromboembolic material in the pulmonary arteries. Malignancy is a significant risk for developing CTEPH. The option for inoperable CTEPH is largely medical with variable outcomes. Balloon pulmonary angioplasty (BPA) is a promising option for inoperable patients given distal-type CTEPH, co-morbidities, or residual pulmonary hypertension after surgery. We present a case of a patient with prostate cancer and CTEPH successfully treated with balloon pulmonary angioplasty.

Purpose To describe ablation of bone, liver, lung, and soft tissue tumors from oligometastatic breast cancer and to define predictors of local progression and progression-free survival (PFS). Materials and Methods A total of 33 women (mean age 52 ± 12 years old; range, 28–69 years), underwent 46 thermal ablations of liver (n = 35), lung (n = 7), and bone/soft tissue (n = 4) metastases. Mean tumor diameter was 18 ± 15 mm (range, 6–50 mm). Ablations were performed to eradicate all evident sites of disease (n = 24) or to control growing sites in the setting of other stable or responding sites of disease (n = 22). Patient characteristics, ablation margins, imaging responses, and cases of PFS were assessed. Follow-up imaging was performed using contrast-enhanced computed tomography (CT), magnetic resonance (MR) imaging, or positron-emission tomography/ CT. Results Median PFS was 10 months (95% confidence interval [CI], 6.2 –14.5 months), and time to local progression was 11 months (95% CI, 5–16 months). Eight patients (24%) maintained no evidence of disease during a median follow-up period of 39 months. Ablation margin ≥5 mm was associated with no local tumor progression. Longer PFS was noted in estrogen receptor-positive patients (12 vs 4 months; P = .037) and younger patients (12 vs 4 months; P = .039) treated to eradicate all sites of disease (13 vs 5 months; P = .05). Eighteen patients (55%) developed new metastases during study follow-up. Conclusions Thermal ablation of oligometastatic pulmonary, hepatic, bone, and soft tissue tumors can eliminate local tumor progression if margins are ≥5 mm. Longer PFS was observed in patients who were estrogen receptor-positive and patients who were younger and in whom all sites of disease were eradicated.

Desmoid tumors are locally aggressive tumors that have a high rate of reoccurrence, even after resection. Percutaneous cryoablation is an effective alternative treatment with less associated risk. A patient in the fifth decade of life with a history of ductal carcinoma-in-situ, status post bilateral mastectomy and silicone implant placement, presented with a palpable mass in the left breast, core biopsy proven to be a desmoid tumor underneath the implant. The patient underwent two cryoablation procedures in a six-month period. During both procedures part of the implant was included in the ablation zone without any negative effects on the implant. Cryoablation is a feasible treatment option for desmoid tumors adjacent to silicone breast implants.

Pulmonary embolus (PE) is the third most common cause of cardiovascular death with more than 600,000 cases occurring in the USA per year. About 45% of patients with acute PE will have acute right ventricular failure, and up to 3.8% of patients will develop chronic thromboembolic pulmonary hypertension (CTEPH) with progressive, severe, chronic heart failure. The right ventricle (RV) is constructed to accommodate a low-resistance afterload. Increases in afterload from acute massive and submassive PE and CTEPH may markedly compromise the RV function leading to hemodynamic collapse and death. The purpose of this educational manuscript is to instruct on the pathophysiology of RV failure in massive and submassive PE and CTEPH. It is important to understand the pathophysiology of these diseases as it provides the rationale for therapeutic intervention by the Interventional Radiologist. We review here the pathophysiology of right ventricular (RV) failure in acute massive and submassive PE and CTEPH.

Seventy-five percent of abdominal aortic aneurysms are now treated by endovascular aneurysm repair (EVAR) rather than open repair, given the decreased periprocedural mortality, complications, and length of hospital stay for EVAR compared to the surgical counterpart. An endoleak is a potential complication after EVAR, characterized by continued perfusion of the aneurysm sac after stent graft placement. Type II endoleak is the most common endoleak, and often has a benign course with spontaneous resolution, occurring in the first 6 months after repair. However, these type II endoleaks may result in pressurization of the aneurysm sac and potentially sac rupture. They occur from retrograde collateral blood flow into the aneurysm sac, typically from a lumbar artery or the inferior mesenteric artery. Alternative sources include accessory renal, gonadal, median sacral arteries, and the internal iliac artery. We will discuss our protocol for post-EVAR imaging surveillance and potential type II endoleak treatment strategies, including transarterial, translumbar, transcaval, and perigraft approaches, as well as open surgery.

PURPOSE: To compare the effect of autologous blood patch injection (ABPI) with that of a hydrogel plug on the rate of pneumothorax at CT-guided percutaneous lung biopsy. MATERIALS AND METHODS: In this prospective randomized controlled trial (https://ClinicalTrials.gov, NCT02224924), a noninferiority design was used for ABPI, with a 10% noninferiority margin when compared with the hydrogel plug, with the primary outcome of pneumothorax rate within 2 hours of biopsy. A type I error rate of 0.05 and 90% power were specified with a target study population of 552 participants (276 in each arm). From October 2014 to February 2017, all potential study participants referred for CT-guided lung biopsy (n = 2052) were assessed for enrollment. RESULTS: The data safety monitoring board recommended the trial be closed to accrual after an interim analysis met prespecified criteria for early stopping based on noninferiority. The final study group consisted of 453 participants who were randomly assigned to the ABPI (n = 226) or hydrogel plug (n = 227) arms. Of these, 407 underwent lung biopsy. Pneumothorax rates within 2 hours of biopsy were 21% (42 of 199) and 29% (60 of 208); chest tube rates were 9% (18 of 199) and 13% (27 of 208); and delayed pneumothorax rates within 2 weeks after biopsy were 1.4% (three of 199) and 1.5% (three of 208) in the ABPI and hydrogel plug arms, respectively. CONCLUSION: Autologous blood patch injection is noninferior to a hydrogel plug regarding the rate of pneumothorax after CT-guided percutaneous lung biopsy. © RSNA, 2018 Online supplemental material is available for this article.

Screening mammography reduces breast cancer mortality in average-risk women. However, adverse consequences include false-positive findings possibly leading to benign breast biopsies and patient anxiety. There is also potential for overdiagnosis and overtreatment. Differences in how to balance benefits and harms have led to varying recommendations by the U.S. Preventive Services Task Force, the American Cancer Society, the National Comprehensive Cancer Network and the American College of Radiology/Society of Breast Imaging. These recommendations differ with respect to what age to start, what age to stop, and frequency of screening in average-risk women. Most recently, the American College of Obstetricians and Gynecologists have issued updated clinical management guidelines for breast cancer risk assessment and screening in average-risk women that aim to maximize the benefits of screening while keeping in mind the potential harms of false-positive results. This commentary summarizes the clinical management guidelines of the American College of Obstetricians and Gynecologists Practice Bulletin July 2017 for breast cancer risk assessment and screening in average-risk women. We review evidence of the benefits and adverse consequences of screening mammography and briefly discuss new advances in breast cancer screening with recent technologies such digital breast tomosynthesis and risk-adapted screening.

Acute dissection of the thoracic aorta is a potentially life-threatening condition which requires collaborative treatment from multiple specialties for optimal patient outcomes. Dissections involving the ascending aorta and aortic arch have traditionally been managed entirely by surgery, while dissections beyond the arch vessels have most commonly been relegated to medical management. This algorithm has been undergoing a paradigm shift over the past two decades due to improvements in stent graft technology, better understanding of the hemodynamic interactions of the true and false lumen and their influence on organ and limb perfusion, and improvements in medical management and long term surveillance for dissection-related complications. This manuscript includes a brief discussion of the pathogenesis and etiology of dissection, followed by an in-depth review of the medical and endovascular techniques utilized to treat patients afflicted by this condition.

592 Background: Checkpoint inhibition (CPI) combined with local strategies that cause local tumor destruction, such as cryo may augment tumor specific immunity and improve survival. We previously demonstrated in 18 ESBC patients (pts) that pre-operative (pre-op) cryo with ipilimumab (ipi) is not only safe but also generates robust local and systemic immune responses (NCT01502592). Given the added activity of dual CPI in other tumors, we undertook a second pilot study of pre-op ipi/nivolumab (nivo)/cryo to confirm the safety of this combination and the impact on immune biomarkers. Methods: In both pilot studies, eligible pts had operable ≥1.5cm invasive HER2 negative ESBC. CPI was administered 8-15d prior to, and cryo was performed 7-10d prior to, standard-of-care (SOC) surgery. Toxicity evaluation continued for 12wks after drug administration. Blood for immune correlates was obtained at baseline, cryo, surgery and 2-4 weeks thereafter. Tumor samples were obtained at cryo and surgery. Flow-cytometry of peripheral lymphocytes was compared to previously reported ipi/cryo responses. Results: After a median follow-up of 66 months all 18 ESBC ipi/cryo pts, including 3 TNBC pts, are recurrence free. In the ipi/nivo/cryo study, the safety primary endpoint was met when 5 pts underwent SOC surgery without delay. Ipi/nivo/cryo was well tolerated overall. One pt on an aromatase inhibitor had grade 4 liver toxicity 8 weeks after surgery. One pt, 3 weeks after her SOC surgery, developed grade 1 hyperthyroidism, preventing a secondary axillary dissection from proceeding as scheduled. Robust activation of peripheral CD4+ and CD8+ T cells peaked at week 2 post ipi/nivo with the majority of activated CD8+ T cells expressing PD1. Comparing the correlatives of the ipi/nivo/cryo study with the prior ipi/cryo study, we observed higher expression of activation markers (Ki-67, ICOS, CTLA-4, LAG-3) on peripheral T cells and downregulation of suppressor cells. Conclusions: Ipi/cryo-treated pts, including 3 TNBC pts, remain recurrence free after > 5y. Combining cryo with ipi/nivo preop is feasible, safe, and associated with greater T cell activation than ipi/cryo alone. These results informed an ongoing randomized phase 2 study of pre-op ipi/nivo/cryo versus SOC in women with residual TNBC after neoadjuvant chemotherapy (NCT03546686). Clinical trial information: NCT02833233.