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Pulmonary emboli are rare occurrences in young patients, especially those who present precipitously to the emergency department. In a young unresponsive patient, recognition of thromboembolic etiology may be delayed due to atypical presenting physiology or competing diagnoses. In this report, the authors describe an initially confounding case of catastrophic bilateral pulmonary emboli in a young woman who presented to the emergency department having been found unconscious on the street. Despite severe and prolonged hypoxia as well as multi-organ failure, the patient achieved a near complete recovery. © 2012 The Author(s).

Purpose: This study was designed to assess the incidence, magnitude, and impact upon retrievability of vena caval perforation by Günther Tulip and Celect conical inferior vena cava (IVC) filters on computed tomographic (CT) imaging. Methods: Günther Tulip and Celect IVC filters placed between July 2007 and May 2009 were identified from medical records. Of 272 IVC filters placed, 50 (23 Günther Tulip, 46%; 27 Celect, 54%) were retrospectively assessed on follow-up abdominal CT scans performed for reasons unrelated to the filter. Computed tomography scans were examined for evidence of filter perforation through the vena caval wall, tilt, or pericaval tissue injury. Procedure records were reviewed to determine whether IVC filter retrieval was attempted and successful. Results: Perforation of at least one filter component through the IVC was observed in 43 of 50 (86%) filters on CT scans obtained between 1 and 880 days after filter placement. All filters imaged after 71 days showed some degree of vena caval perforation, often as a progressive process. Filter tilt was seen in 20 of 50 (40%) filters, and all tilted filters also demonstrated vena caval perforation. Transjugular removal was attempted in 12 of 50 (24%) filters and was successful in 11 of 12 (92%). Conclusions: Longer indwelling times usually result in vena caval perforation by retrievable Günther Tulip and Celect IVC filters. Although infrequently reported in the literature, clinical sequelae from IVC filter components breaching the vena cava can be significant. We advocate filter retrieval as early as clinically indicated and increased attention to the appearance of IVC filters on all follow-up imaging studies. [ABSTRACT FROM AUTHOR]

Purpose: Radiosurgery requires precise lesion localization. Fiducial markers enable lesion tracking, but complications from insertion may occur. The purpose of this study was to describe complications of fiducial marker insertion into pulmonary lesions.Materials and Methods: Clinical and imaging records of 28 consecutive patients with 32 lung nodules or masses who underwent insertion of a total of 59 fiducial markers before radiosurgery were retrospectively reviewed.Results: Eighteen patients (67%) developed a pneumothorax, and six patients (22%) required a chest tube. The rates of pneumothorax were 82% and 40%, respectively, when 18-gauge and 19-gauge needles were used for marker insertion (P = 0.01). Increased rate of pneumothorax was also associated with targeting smaller lesions (P = 0.03) and tumors not in contact with the pleural surface (P = 0.04). A total of 11 fiducials (19%) migrated after insertion into the pleural space (10 markers) or into the airway (1 marker). Migration was associated with shorter distances from pleura to the marker deposition site (P = 0.04) and with fiducial placement outside of the target lesion (P = 0.03).Conclusion: Fiducial marker placement into lung lesions is associated with a high risk of pneumothorax and a risk of fiducial migration. [ABSTRACT FROM AUTHOR]

Background and Objective: The source of tissue for genomic profiling of metastatic castration-resistant prostate cancer (mCRPC) is often limited to osseous metastases. To guide patient management, metastatic site selection and the technique for targeted bone biopsies are critical for identifying deleterious gene mutations. Our objective was to identify key parameters associated with successful large-panel DNA sequencing., Methods: We analyzed parameters for 243 men with progressing mCRPC who underwent 269 bone biopsies for genomic profiling between 2014 and 2018. Univariate and multivariate analyses were performed for clinical, imaging (bone scan; fluorodeoxyglucose [FDG] positron emission tomography [PET]; computed tomography [CT]; magnetic resonance imaging), and technical (biopsy site, number of samples, needle gauge) features associated with successful genomic profiling., Key Findings and Limitations: Overall, 159 of 269 biopsies (59%) generated sufficient tumor material for a genomic profile. Seventy (26%) of the failures were histopathologically negative for mCRPC and 40 (15%) had insufficient tumor for genomic profiling. Of 199 mCRPC samples submitted for molecular testing, 159 (80%) yielded a genomic profile. On univariate analysis, PSA, serum acid phosphatase, number of biopsy samples, FDG PET positivity, CT attenuation, and CT morphology were significantly associated with genomic profiling success. On multivariate analysis, higher FDG maximum standardized uptake value (odds ratio [OR] 7.51, 95% confidence interval [CI] 3.01-18.78; p < 0.001), higher number of biopsy samples (OR 4.73, 95% CI 1.49-15.02; p = 0.008), and lower mean CT attenuation (OR 0.4, 95% CI 0.18-0.89; p = 0.025) were significantly associated with sequencing success., Conclusions and Clinical Implications: In patients with mCRPC, bone biopsies from sites with metabolic activity and lower CT attenuation are associated with higher success rates for genomic profiling via a large-panel DNA sequencing platform., Patient Summary: We identified factors associated with successful genetic testing of bone tissue for patients with metastatic prostate cancer. Our findings may help in guiding the right scan technique and biopsy site for personalized treatment planning., (Published by Elsevier B.V.)

Our objective was to develop a technique for performing irreversible electroporation (IRE) of esophageal tumors while mitigating thermal damage to the healthy lumen wall. We investigated noncontact IRE using a wet electrode approach for tumor ablation in a human esophagus with finite element models for electric field distribution, joule heating, thermal flux, and metabolic heat generation. Simulation results indicated the feasibility of tumor ablation in the esophagus using an catheter mounted electrode immersed in diluted saline. The ablation size was clinically relevant, with substantially lesser thermal damage to the healthy esophageal wall when compared to IRE performed by placing a monopolar electrode directly into the tumor. Additional simulations were used to estimate ablation size and penetration during noncontact wet-electrode IRE (wIRE) in the healthy swine esophagus. A novel catheter electrode was manufactured and wIRE evaluated in seven pigs. wIRE was performed by securing the device in the esophagus and using diluted saline to isolate the electrode from the esophageal wall while providing electric contact. Computed tomography and fluoroscopy were performed post-treatment to document acute lumen patency. Animals were sacrificed within four hours following treatment for histologic analysis of the treated esophagus. The procedure was safely completed in all animals; post-treatment imaging revealed intact esophageal lumen. The ablations were visually distinct on gross pathology, demonstrating full thickness, circumferential regions of cell death (3.52 ± 0.89 mm depth). Acute histologic changes were not evident in nerves or extracellular matrix architecture within the treatment site. Catheter directed noncontact IRE is feasible for performing penetrative ablations in the esophagus while avoiding thermal damage., (Copyright © 2023 by ASME.)

Purpose: To compare radiation dose index distributions for fluoroscopically guided interventions in interventional radiology from the American College of Radiology (ACR) Fluoroscopy Dose Index Registry (DIR-Fluoro) pilot to those from the Radiation Doses in Interventional Radiology (RAD-IR) study., Materials and Methods: Individual and grouped ACR Common identification numbers (procedure types) from the DIR-Fluoro pilot were matched to procedure types in the RAD-IR study. Fifteen comparisons were made. Distribution parameters, including the 10th, 25th, 50th, 75th, and 95th percentiles, were compared for fluoroscopy time (FT), cumulative air kerma (K a,r ), and kerma area product (P KA ). Two derived indices were computed using median dose indices. The procedure-averaged reference air kerma rate (K a,r ¯) was computed as K a,r / FT. The procedure-averaged x-ray field size at the reference point (A r ) was computed as P KA / (K a,r  × 1,000)., Results: The median FT was equally likely to be higher or lower in the DIR-Fluoro pilot as it was in the RAD-IR study, whereas the maximum FT was almost twice as likely to be higher in the DIR-Fluoro pilot than it was in the RAD-IR study. The median K a,r was lower in the DIR-Fluoro pilot for all procedures, as was median P KA . The maximum K a,r and P KA were more often higher in the DIR-Fluoro pilot than in the RAD-IR study. K a,r ¯ followed the same pattern as K a,r , whereas A r was often greater in DIR-Fluoro., Conclusions: The median dose indices have decreased since the RAD-IR study. The typical K a,r rates are lower, a result of the use of lower default dose rates. However, opportunities for quality improvement exist, including renewed focus on tight collimation of the imaging field of view., (Copyright © 2022 SIR. All rights reserved.)

Purpose: To update normative data on fluoroscopy dose indices in the United States for the first time since the Radiation Doses in Interventional Radiology study in the late 1990s., Materials and Methods: The Dose Index Registry-Fluoroscopy pilot study collected data from March 2018 through December 2019, with 50 fluoroscopes from 10 sites submitting data. Primary radiation dose indices including fluoroscopy time (FT), cumulative air kerma (K a,r ), and kerma area product (P KA ) were collected for interventional radiology fluoroscopically guided interventional (FGI) procedures. Clinical facility procedure names were mapped to the American College of Radiology (ACR) common procedure lexicon. Distribution parameters including the 10th, 25th, 50th, 75th, 95th, and 99th percentiles were computed., Results: Dose indices were collected for 70,377 FGI procedures, with 50,501 ultimately eligible for analysis. Distribution parameters are reported for 100 ACR Common IDs. FT in minutes, K a,r in mGy, and P KA in Gy-cm 2 are reported in this study as (n; median) for select ACR Common IDs: inferior vena cava filter insertion (1,726; FT: 2.9; K a,r : 55.8; P KA : 14.19); inferior vena cava filter removal (464; FT: 5.7; K a,r : 178.6; P KA : 34.73); nephrostomy placement (2,037; FT: 4.1; K a,r : 39.2; P KA : 6.61); percutaneous biliary drainage (952; FT: 12.4; K a,r : 160.5; P KA : 21.32); gastrostomy placement (1,643; FT: 3.2; K a,r : 29.1; P KA : 7.29); and transjugular intrahepatic portosystemic shunt placement (327; FT: 34.8; K a,r : 813.0; P KA : 181.47)., Conclusions: The ACR DIR-Fluoro pilot has provided state-of-the-practice statistics for radiation dose indices from IR FGI procedures. These data can be used to prioritize procedures for radiation optimization, as demonstrated in this work., (Copyright © 2022 SIR. All rights reserved.)

Purpose: 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: 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., (Copyright © 2022 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: Oncogenic alterations of the PI3K/AKT pathway occur in >40% of patients with metastatic castration-resistant prostate cancer, predominantly via PTEN loss. The significance of other PI3K pathway components in prostate cancer is largely unknown., Experimental Design: Patients in this study underwent tumor sequencing using the MSK-IMPACT clinical assay to capture single-nucleotide variants, insertions, and deletions; copy-number alterations; and structural rearrangements, or were profiled through The Cancer Genome Atlas. The association between PIK3R1 alteration/expression and survival was evaluated using univariable and multivariable Cox proportional-hazards regression models. We used the siRNA-based knockdown of PIK3R1 for functional studies. FDG-PET/CT examinations were performed with a hybrid positron emission tomography (PET)/CT scanner for some prostate cancer patients in the MSK-IMPACT cohort., Results: Analyzing 1,417 human prostate cancers, we found a significant enrichment of PIK3R1 alterations in metastatic cancers compared with primary cancers. PIK3R1 alterations or reduced mRNA expression tended to be associated with worse clinical outcomes in prostate cancer, particularly in primary disease, as well as in breast, gastric, and several other cancers. In prostate cancer cell lines, PIK3R1 knockdown resulted in increased cell proliferation and AKT activity, including insulin-stimulated AKT activity. In cell lines and organoids, PIK3R1 loss/mutation was associated with increased sensitivity to AKT inhibitors. PIK3R1-altered patient prostate tumors had increased uptake of the glucose analogue 18F-fluorodeoxyglucose in PET imaging, suggesting increased glycolysis., Conclusions: Our findings describe a novel genomic feature in metastatic prostate cancer and suggest that PIK3R1 alteration may be a key event for insulin-PI3K-glycolytic pathway regulation in prostate cancer., (©2022 American Association for Cancer Research.)

Background: Men with grade group 2 or 3 prostate cancer are often considered ineligible for active surveillance; some patients with grade group 2 prostate cancer who are managed with active surveillance will have early disease progression requiring radical therapy. This study aimed to investigate whether MRI-guided focused ultrasound focal therapy can safely reduce treatment burden for patients with localised grade group 2 or 3 intermediate-risk prostate cancer., Methods: In this single-arm, multicentre, phase 2b study conducted at eight health-care centres in the USA, we recruited men aged 50 years and older with unilateral, MRI-visible, primary, intermediate-risk, previously untreated prostate adenocarcinoma (prostate-specific antigen ≤20 ng/mL, grade group 2 or 3; tumour classification ≤T2) confirmed on combined biopsy (combining MRI-targeted and systematic biopsies). MRI-guided focused ultrasound energy, sequentially titrated to temperatures sufficient for tissue ablation (about 60-70°C), was delivered to the index lesion and a planned margin of 5 mm or more of normal tissue, using real-time magnetic resonance thermometry for intraoperative monitoring. Co-primary outcomes were oncological outcomes (absence of grade group 2 and higher cancer in the treated area at 6-month and 24-month combined biopsy; when 24-month biopsy data were not available and grade group 2 or higher cancer had occurred in the treated area at 6 months, the 6-month biopsy results were included in the final analysis) and safety (adverse events up to 24 months) in all patients enrolled in the study. This study is registered with ClinicalTrials.gov, NCT01657942, and is no longer recruiting., Findings: Between May 4, 2017, and Dec 21, 2018, we assessed 194 patients for eligibility and treated 101 patients with MRI-guided focused ultrasound. Median age was 63 years (IQR 58-67) and median concentration of prostate-specific antigen was 5·7 ng/mL (IQR 4·2-7·5). Most cancers were grade group 2 (79 [78%] of 101). At 24 months, 78 (88% [95% CI 79-94]) of 89 men had no evidence of grade group 2 or higher prostate cancer in the treated area. No grade 4 or grade 5 treatment-related adverse events were reported, and only one grade 3 adverse event (urinary tract infection) was reported. There were no treatment-related deaths., Interpretation: 24-month biopsy outcomes show that MRI-guided focused ultrasound focal therapy is safe and effectively treats grade group 2 or 3 prostate cancer. These results support focal therapy for select patients and its use in comparative trials to determine if a tissue-preserving approach is effective in delaying or eliminating the need for radical whole-gland treatment in the long term., Funding: Insightec and the National Cancer Institute., Competing Interests: Declaration of interests BE attends the medical advisory board of Insightec as an unpaid consultant, and has previously received consulting funds from Myriad Genetics. CMT reports consulting funds from Profound. DDS reports consulting funds from OPKO Health and Steba. ASK is on the medical advisory board of Insightec, Profound, and Janssen, and has received consulting funds from Advantagene DSMC, Bristol Myers Squibb, Merck, Bayer, and General Electric. Q-DT reports consulting funds from Astellas, Bayer, Intuitive Surgical, and Janssen. JCD is the Chief Clinical Officer for Ajax Health and Cordis Accelco and has equity interests in Cordis; is on the advisory board and has ownership or equity interests in Serpex Health and Adient Medical; and serves as the past chair of the Society of Interventional Radiology Foundation. OA has ownership or equity interests in Ezra AI. AJV is named on a patent for a statistical method to detect prostate cancer that has been commercialised by OPKO Health (from which he receives royalties and stock options) and has received consulting funds from Insightec and Steba. PTS is named on a patent for a statistical method to detect prostate cancer that has been commercialised by OPKO Health (from which he receives royalties and stock options) and chairs the medical advisory board of Insightec as an unpaid consultant. DS is the medical director and founder of Sperling Prostate Center, a private facility for prostate cancer treatment in Delray Beach, FL, USA. LAM has collaborative and research agreements with Philips Healthcare and Biobot Surgical. GAS is on the medical advisory board of miR Scientific. PG is on the medical advisory boards of Insightec and SonALASense and has ownership or equity interests in SonALASense. All other authors declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Immune checkpoint inhibitor therapy improves survival in patients with metastatic renal cell carcinoma (RCC) but has not been studied well preoperatively in patients with localized disease undergoing nephrectomy. We conducted a single-center study to evaluate the safety and feasibility of neoadjuvant nivolumab in patients undergoing nephrectomy for localized RCC. Eligible patients had a >20% risk of recurrence, as estimated by a preoperative nomogram. Patients received nivolumab every 2 wk for four treatments prior to surgery. The primary endpoints were feasibility, defined as completing at least three treatments without significant surgical delay, and safety, defined as the rate of surgical complications. Treatment effects were assessed by radiomics and immunohistochemistry. A total of 18 patients (11 men; median age 60 yr) with clear cell RCC were enrolled. All received at least one dose of nivolumab and proceeded to nephrectomy without delay; 16/18 patients completed all four doses. Two patients discontinued nivolumab for immune-related adverse events, and four had surgical complications as per the Clavien-Dindo classification. Integrated pathology plus radiomic analysis demonstrated an association between post-treatment immune infiltration and low entropy apparent diffusion coefficient on magnetic resonance imaging. Nivolumab prior to nephrectomy was safe and feasible, without significant surgical delays and with an expected rate of immune-related adverse events. PATIENT SUMMARY: We evaluated the outcomes for patients with localized kidney cancer who received immunotherapy prior to surgery to remove their kidney tumor. In a small group of patients who had cancer confined to the kidney, this approach appeared safe and feasible., (Copyright © 2022 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Innovative catheter-based therapies are increasingly being used for the treatment of patients with submassive pulmonary embolism. These patients may be monitored in the intensive care unit following insertion of specialized pulmonary artery catheters. However, the infusion catheters utilized in catheter-based therapies differ greatly from traditional pulmonary artery catheters designed for hemodynamic monitoring. As such, the critical care team will have to be familiar with the monitoring and management of these novel catheters. Important distinctions between the catheters are illustrated using a clinical case report., Competing Interests: The authors have no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: We report our experience with next-generation sequencing to characterize the landscape of actionable genomic alterations in renal cell carcinoma (RCC)., Experimental Design: A query of our institutional clinical sequencing database (MSK-IMPACT) was performed that included tumor samples from 38,468 individuals across all cancer types. Somatic variations were annotated using a precision knowledge database (OncoKB) and the available clinical data stratified by level of evidence. Alterations associated with response to immune-checkpoint blockade (ICB) were analyzed separately; these included DNA mismatch repair (MMR) gene alterations, tumor mutational burden (TMB), and microsatellite instability (MSI). Data from The Cancer Genome Atlas (TCGA) consortium as well as public data from several clinical trials in metastatic RCC were used for validation purposes. Multiregional sequencing data from the TRAcking Cancer Evolution through Therapy (TRACERx) RENAL cohort were used to assess the clonality of somatic mutations., Results: Of the 753 individuals with RCC identified in the MSK-IMPACT cohort, 115 showed evidence of targetable alterations, which represented a prevalence of 15.3% [95% confidence interval (CI), 12.7%-17.8%). When stratified by levels of evidence, the alterations identified corresponded to levels 2 (11.3%), 3A (5.2%), and 3B (83.5%). A low prevalence was recapitulated in the TCGA cohort at 9.1% (95% CI, 6.9%-11.2%). Copy-number variations predominated in papillary RCC tumors, largely due to amplifications in the MET gene. Notably, higher rates of actionability were found in individuals with metastatic disease (stage IV) compared with those with localized disease (OR, 2.50; 95% CI, 1.16-6.16; Fisher's P = 0.01). On the other hand, the prevalence of alterations associated with response to ICB therapy was found to be approximately 5% in both the MSK-IMPACT and TCGA cohorts and no associations with disease stage were identified (OR, 1.35; 95% CI, 0.46-5.40; P = 0.8). Finally, multiregional sequencing revealed that the vast majority of actionable mutations occurred later during tumor evolution and were only present subclonally in RCC tumors., Conclusions: RCC harbors a low prevalence of clinically actionable alterations compared with other tumors and the evidence supporting their clinical use is limited. These aberrations were found to be more common in advanced disease and seem to occur later during tumor evolution. Our study provides new insights on the role of targeted therapies for RCC and highlights the need for additional research to improve treatment selection using genomic profiling., (©2021 American Association for Cancer Research.)

Purpose: Prostate specific membrane antigen-targeted positron emission tomography/computerized tomography has the potential to improve the detection and localization of prostate cancer. OSPREY was a prospective trial designed to determine the diagnostic performance of 18 F-DCFPyL-positron emission tomography/computerized tomography for detecting sites of metastatic prostate cancer., Materials and Methods: Two patient populations underwent 18 F-DCFPyL-positron emission tomography/computerized tomography. Cohort A enrolled men with high-risk prostate cancer undergoing radical prostatectomy with pelvic lymphadenectomy. Cohort B enrolled patients with suspected recurrent/metastatic prostate cancer on conventional imaging. Three blinded central readers evaluated the 18 F-DCFPyL-positron emission tomography/computerized tomography. Diagnostic performance of 18 F-DCFPyL-positron emission tomography/computerized tomography was based on imaging results compared to histopathology. In cohort A, detection of pelvic nodal disease (with specificity and sensitivity as co-primary end points) and of extrapelvic metastases were evaluated. In cohort B, sensitivity and positive predictive value for prostate cancer within biopsied lesions were evaluated., Results: A total of 385 patients were enrolled. In cohort A (252 evaluable patients), 18 F-DCFPyL-positron emission tomography/computerized tomography had median specificity of 97.9% (95% CI: 94.5%-99.4%) and median sensitivity of 40.3% (28.1%-52.5%, not meeting prespecified end point) among 3 readers for pelvic nodal involvement; median positive predictive value and negative predictive value were 86.7% (69.7%-95.3%) and 83.2% (78.2%-88.1%), respectively. In cohort B (93 evaluable patients, median prostate specific antigen 11.3 ng/ml), median sensitivity and positive predictive value for extraprostatic lesions were 95.8% (87.8%-99.0%) and 81.9% (73.7%-90.2%), respectively., Conclusions: The primary end point for specificity was met while the primary end point for sensitivity was not. The high positive predictive value observed in both cohorts indicates that 18 F-DCFPyL-positive lesions are likely to represent disease, supporting the potential utility of 18 F-DCFPyL-positron emission tomography/computerized tomography to stage men with high-risk prostate cancer for nodal or distant metastases, and reliably detect sites of disease in men with suspected metastatic prostate cancer.

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., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: Tumor-associated macrophages correlate with increased invasiveness, growth, and immunosuppression. Activation of the colony-stimulating factor-1 receptor (CSF-1R) results in proliferation, differentiation, and migration of monocytes/macrophages. This phase I study evaluated the immunologic and clinical activity, and safety profile of CSF-1R inhibition with the mAb LY3022855., Patients and Methods: Patients with advanced refractory metastatic breast cancer (MBC) or metastatic castration-resistant prostate cancer (mCRPC) were treated with LY3022855 intravenously in 6-week cycles in cohorts: (A) 1.25 mg/kg every 2 weeks (Q2W); (B) 1.0 mg/kg on weeks 1, 2, 4, and 5; (C) 100 mg once weekly; (D)100 mg Q2W. mCRPC patients were enrolled in cohorts A and B; patients with MBC were enrolled in all cohorts. Efficacy was assessed by RECIST and Prostate Cancer Clinical Trials Working Group 2 criteria., Results: Thirty-four patients (22 MBC; 12 mCRPC) received ≥1 dose of LY3022855. At day 8, circulating CSF-1 levels increased and proinflammatory monocytes CD14 DIM CD16 BRIGHT decreased. Best RECIST response was stable disease in five patients with MBC (23%; duration, 82-302 days) and three patients with mCRPC (25%; duration, 50-124 days). Two patients with MBC (cohort A) had durable stable disease >9 months and a third patient with MBC had palpable reduction in a nontarget neck mass. Immune-related gene activation in tumor biopsies posttreatment was observed. Common any grade treatment-related adverse events were fatigue, decreased appetite, nausea, asymptomatic increased lipase, and creatine phosphokinase., Conclusions: LY3022855 was well tolerated and showed evidence of immune modulation. Clinically meaningful stable disease >9 months was observed in two patients with MBC., (©2020 American Association for Cancer Research.)

Purpose: We investigated the efficacy and analyzed the complication risk factors of peritoneovenous shunt in treating refractory chylous ascites following retroperitoneal lymph node dissection in patients with urological malignancies., Materials and Methods: From April 2001 to March 2019 all patients with refractory chylous ascites after retroperitoneal lymph node dissection treated with peritoneovenous shunt were reviewed. Demographic characteristics, technical success, efficacy, patency period and complications were studied. Univariate and multivariate logistic regression analysis was performed to identify predictors of complications., Results: Twenty patients were included in this study. Testicular cancer was the most common malignancy (85%). The mean number of days from surgery to detection of chylous ascites was 21 days (SD 15, range 4 to 65). Ascites permanently resolved after peritoneovenous shunt in 18 patients (90%), leading to shunt removal in 17 patients (85%) between 46 and 481 days (mean 162, SD 141). The mean serum albumin level increased 24% after shunt placement (mean 3.0±0.6 gm/dl before, 3.9±0.8 gm/dl after, p <0.05). The most common complication was occlusion (30%). Relative risk of complications increased significantly when shunt placement was more than 70 days after surgery and in patients with more than 5 paracenteses before peritoneovenous shunt placement (AR 0.71% vs 0.25%, RR 2.9, p <0.048 and AR 0.6% vs 0.125%, RR 4.8, p <0.04, respectively)., Conclusions: Peritoneovenous shunt permanently treated chylous ascites in 90% of patients after retroperitoneal lymph node dissection. Peritoneovenous shunt was removed in 85% of patients. Shunt placement is an effective and safe treatment option for refractory chylous ascites. These patients might benefit from earlier intervention, after 4 to 6 weeks of conservative management as opposed to 2 to 3 months.

Our purpose was to evaluate the performance of 11 C-choline PET/CT in detecting biochemically recurrent prostate cancer (PCa) in a large non-European cohort (in the context of emerging evidence for prostate-specific membrane antigen PET in this setting) and to map patterns of PCa recurrence. Methods: We retrospectively analyzed 11 C-choline PET/CT scans from 287 patients who were enrolled in an imaging protocol based on rising prostate-specific antigen (PSA) levels (mean, 3.43 ng/mL; median, 0.94 ng/mL; range, 0.15-89.91 ng/mL) and suspected recurrent PCa. A total of 187 patients had undergone primary radical prostatectomy (RP) (79/187 had secondary radiotherapy), 30 had undergone primary radiotherapy, and 70 had a persistent PSA elevation after receiving initial treatment (69 after RP, 1 after radiotherapy). The level of suspicion for recurrence on 11 C-choline PET/CT was scored (0, negative; 1, equivocal; 2, positive) by 2 readers. The correlation between 11 C-choline PET/CT positivity and initial treatment, Gleason score, National Comprehensive Cancer Network stage, PSA level, PSA doubling time, PSA velocity, and time between initial treatment and PET imaging was evaluated. Prostate Cancer Molecular Imaging Standardized Evaluation (PROMISE) criteria were used to map 11 C-choline recurrence patterns. Results: Considering scores 1 and 2 as positives, consensus between the 2 readers deemed 66% of the 11 C-choline PET/CT scans as positive. When sorted by PSA level, 45% of patients with a PSA of less than 0.5 ng/mL, 56% of patients with a PSA of 0.5-0.99 ng/mL, 70% of patients with a PSA of 1.0-1.99 ng/mL, and 90% of patients with a PSA of at least 2.0 ng/mL scored either 1 or 2 on 11 C-choline PET/CT scans. When considering scores of 2 only, 11 C-choline PET/CT positivity was 54% (28%, 46%, 62%, and 81%, respectively, for patients with PSA < 0.5 ng/mL, 0.5-0.99 ng/mL, 1.0-1.99 ng/mL, and ≥ 2.0 ng/mL). In multivariate analysis, only PSA level was significantly associated with scan positivity. Pattern analysis showed that pelvic lymph nodes were the most common site of recurrence, and 28% of patients had 11 C-choline-positive suspected recurrences outside the initial treatment field. Conclusion: 11 C-choline PET/CT can detect PCa recurrence even among patients with low PSA levels when interpretation accounts for the clinical context, providing a certain pretest probability. Until prostate-specific membrane antigen agents are fully approved for PCa, choline PET/CT may provide clinical utility., (© 2020 by the Society of Nuclear Medicine and Molecular Imaging.)

Thermal ablation of small renal masses is increasingly accepted as an alternative to partial nephrectomy, particularly in patients with multiple comorbidities. Many professional societies support this alternate treatment with updated guidelines. Before performing thermal ablation, it is important to stratify risk and assess technical feasibility by evaluating tumor imaging features such as size, location, and centrality. Routine postablation imaging with CT or MRI is necessary for assessment of residual or recurrent tumor, evidence of complications, or new renal masses outside the ablation zone. The normal spectrum and evolution of findings at CT and MRI include a halo appearance of the ablation zone, ablation zone contraction, and ablation zone calcifications. Tumor recurrence frequently manifests at CT or MRI as new nodular enhancement at the periphery of an expanding ablation zone, although it is normal for the ablation zone to enlarge within the first few months. Recognizing early tumor recurrence is important, as small renal masses are often easily treated with repeat ablations. Potential complications of thermal ablation include vascular injury, urine leak, ureteral stricture, nerve injury, and bowel perforation. The risk of these complications may be related to tumor size and location. © RSNA, 2019.

Background: Lung adenocarcinoma histologic subtype is an important indicator of patient outcomes, so preoperative knowledge of subtype may be helpful to guide surgical planning. We evaluated the sensitivity and prognostic efficacy of specimens from computed tomography-guided core needle biopsies to predict histologic subtype and patient outcome after surgery., Methods: We retrospectively identified 221 patients with lung adenocarcinoma who underwent computed tomography-guided lung biopsy and subsequent surgical resection. Concordance, accuracy, specificity, and sensitivity of histologic subtypes from core biopsy specimens were compared with surgically resected specimens. Tumor characteristics and biopsy procedural factors were analyzed to determine impact on diagnostic sensitivity. Histologic subtype based on biopsy specimen, clinical, tumor, and treatment variables were also examined in relation to time to progression., Results: Overall concordance of biopsy samples with the predominant subtype from surgical specimens was 77%. Specificity (sensitivity) of detecting a nonaggressive and aggressive subtype were 86% (93%) and 95% (48%), respectively. Length of core specimen and percentage subtype composition in the surgically resected specimen were correlated with improved sensitivity but to a lesser extent with aggressive subtypes. Presence of an aggressive subtype in biopsy specimens was an independent predictor of progression after surgery (subdistribution hazard ratio, 2.51; 95% confidence interval, 1.28-4.94; p = 0.0075)., Conclusions: Specimens from computed tomography-guided core biopsies can predict lung adenocarcinoma progression after surgical resection. Future prospective studies should address the role of core biopsy in preoperative planning., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Iatrogenic injury to the healthy ureter during ureteroscope-guided ablation of malignant or nonmalignant disease can result in ureteral stricture. Transforming growth factor (TGF)-β 1 -mediated scar formation is considered to underlie ureteral stricture, but the cellular sources of this cytokine and the sequelae preceding iatrogenic stricture formation are unknown. Using a swine model of ureteral injury with irreversible electroporation (IRE), we evaluated the cellular sources of TGF-β 1 and scar formation at the site of injury and examined in vitro whether the effects of TGF-β 1 could be attenuated by pirfenidone. We observed that proliferation and α-smooth muscle actin expression by fibroblasts were restricted to injured tissue and coincided with proliferation of macrophages. Collagen deposition and scarring of the ureter were associated with increased TGF-β 1 expression in both fibroblasts and macrophages. Using in vitro experiments, we demonstrated that macrophages stimulated by cells that were killed with IRE, but not LPS, secreted TGF-β 1 , consistent with a wound healing phenotype. Furthermore, using 3T3 fibroblasts, we demonstrated that stimulation with paracrine TGF-β 1 is necessary and sufficient to promote differentiation of fibroblasts and increase collagen secretion. In vitro, we also showed that treatment with pirfenidone, which modulates TGF-β 1 activity, limits proliferation and TGF-β 1 secretion in macrophages and scar formation-related activity by fibroblasts. In conclusion, we identified wound healing-related macrophages to be an important source of TGF-β 1 in the injured ureter, which may be a paracrine source of TGF-β 1 driving scar formation by fibroblasts, resulting in stricture formation.

The Appropriate Use Criteria Program, enacted by the Centers for Medicare & Medicaid Services in response to the Protecting Access to Medicare Act of 2014 (PAMA), aims to reduce inappropriate and unnecessary imaging by mandating use of clinical decision support (CDS) by all providers who order advanced imaging examinations (magnetic resonance imaging; computed tomography; and nuclear medicine studies, including positron emission tomography). Beginning 1 January 2020, documentation of an interaction with a certified CDS system using approved appropriate use criteria will be required on all Medicare claims for advanced imaging in all emergency department patients and outpatients as a prerequisite for payment. The Appropriate Use Criteria Program will initially cover 8 priority clinical areas, including several (such as headache and low back pain) commonly encountered by internal medicine providers. All providers and organizations that order and provide advanced imaging must understand program requirements and their options for compliance strategies. Substantial resources and planning will be needed to comply with PAMA regulations and avoid unintended negative consequences on workflow and payments. However, robust evidence supporting the desired outcome of reducing inappropriate use of advanced imaging is lacking.

Purpose: The goal of this study was to develop and evaluate a volumetric three-dimensional (3D) approach to improve the accuracy of ablation margin assessment following thermal ablation of hepatic tumors., Methods: The 3D margin assessment technique was developed to generate the new 3D assessment metrics: volumes of insufficient coverage (VICs) measuring volume of tissue at risk post-ablation. VICs were computed for the tumor and tumor plus theoretical 5- and 10-mm margins. The diagnostic accuracy of the 3D assessment to predict 2-year local tumor progression (LTP) was compared to that of manual 2D assessment using retrospective analysis of a patient cohort that has previously been reported as a part of an outcome-centered study. Eighty-six consecutive patients with 108 colorectal cancer liver metastases treated with radiofrequency ablation (2002-2012) were used for evaluation. The 2-year LTP discrimination power was assessed using receiver operating characteristic area under the curve (AUC) analysis., Results: A 3D assessment of margins was successfully completed for 93 out of 108 tumors. The minimum margin size measured using the 3D method had higher discrimination power compared with the 2D method, with an AUC value of 0.893 vs. 0.790 (p = 0.01). The new 5-mm VIC metric had the highest 2-year LTP discrimination power with an AUC value of 0.923 (p = 0.004)., Conclusions: Volumetric semi-automated 3D assessment of the ablation zone in the liver is feasible and can improve accuracy of 2-year LTP prediction following thermal ablation of hepatic tumors., Key Points: • More accurate prediction of local tumor progression risk using volumetric 3D ablation zone assessment can help improve the efficacy of image-guided percutaneous thermal ablation of hepatic tumors. • The accuracy of evaluation of ablation zone margins after thermal ablation of colorectal liver metastases can be improved using a volumetric 3D semi-automated assessment approach and the volume of insufficient coverage assessment metric. • The new 5-mm volume-of-insufficient-coverage metric, indicating the volume of tumor plus 5-mm margin that remained untreated, had the highest 2-year local tumor progression discrimination power.

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.

Context: 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: 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: Median tumor DNA yields from all 18G and 20G samples were 5880 ng and 2710 ng, respectively. Median tumor RNA yields from all 18G and 20G samples were 1100 ng and 230 ng, respectively. A wide range of DNA and RNA quantities (1060-13,390 ng and 370-6280 ng, respectively) were acquired. Median DNA and RNA yields from 18G needles were significantly greater than those from 20G needles across all organs ( p < 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.

Human epidermal growth factor receptor 2 (HER2) gene amplification and/or protein overexpression in tumors is a prerequisite for initiation of trastuzumab therapy. Although HER2 is a cell membrane receptor, differential rates of endocytosis and recycling engender a dynamic surface pool of HER2. Since trastuzumab must bind to the extracellular domain of HER2, a depressed HER2 surface pool hinders binding. Using in vivo biological models and cultures of fresh human tumors, we find that the caveolin-1 (CAV1) protein is involved in HER2 cell membrane dynamics within the context of receptor endocytosis. The translational significance of this finding is highlighted by our observation that temporal CAV1 depletion with lovastatin increases HER2 half-life and availability at the cell membrane resulting in improved trastuzumab binding and therapy against HER2-positive tumors. These data show the important role that CAV1 plays in the effectiveness of trastuzumab to target HER2-positive tumors.

Background: Next-generation sequencing (NGS) studies of matched pairs of primary and metastatic tumors in renal cell carcinoma (RCC) have been limited to small cohorts., Objective: To evaluate the discordance in somatic mutations between matched primary and metastatic RCC tumors., Design, Setting, and Participants: Primary tumor (P), metastasis (M), and germline DNA from 60 patients with RCC was subjected to NGS with a targeted exon capture-based assay of 341 cancer-associated genes. Somatic mutations were called using a validated pipeline., Outcome Measurements and Statistical Analysis: Mutations were classified as shared (S) or private (Pr) in relation to each other within individual P-M pairs. The concordance score was calculated as (S-Pr)/(S+Pr). To calculate enrichment of Pr/S mutations for a particular gene, we calculated a two-sided p value from a binomial model for each gene with at least ten somatic mutation events, and also implemented a separate permutation test procedure. We adjusted p values for multiple hypothesis testing using the Benjamini-Hochberg procedure. The mutation discordance was calculated using Mann-Whitney U tests according to gene mutations or metastatic sites., Results and Limitations: Twenty-one pairs (35%) showed Pr mutations in both P and M samples. Of the remaining 39 pairs (65%), 14 (23%) had Pr mutations specific to P samples, 12 (20%) had Pr mutations to M samples, and 13 (22%) had identical somatic mutations. No individual gene mutation was preferentially enriched in either P or M samples. P-M pairs with SETD2 mutations demonstrated higher discordance than pairs with wild-type SETD2. We observed that patients who received therapy before sampling of the P or M tissue had higher concordance of mutations for P-M pairs than patients who did not (Mann-Whitney p=0.088)., Conclusions: Our data show mutation discordance within matched P-M RCC tumor pairs. As most contemporary precision medicine trials do not differentiate mutations detected in P and M tumors, the prognostic and predictive value of mutations in P versus M tumors warrants further investigation., Patient Summary: In this study we evaluated the concordance of mutations between matched primary and metastatic tumors for 60 kidney cancer patients using a panel of 341 cancer genes. Forty-seven patients carried nonidentical cancer gene mutations within their matched primary-metastatic pair. The mutation profile of the primary tumor alone could compromise precision in selecting effective targeted therapies and result in suboptimal clinical outcomes., (Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Aim: To evaluate arterial cone-beam computed tomography (A-CBCT) automated analysis software for identification of vessels supplying tumours during transarterial hepatic embolisation (TAE)., Materials and Methods: This study was approved by the institutional review board, with waiver of consent. Consecutive TAE procedures using arterial mapping software (AMS), and performed between February 2014 and August 2014, were reviewed. Hepatic arteries were imaged using digital subtraction angiography (DSA) as well as A-CBCT processed with AMS. Interventional radiologists reported 1 potential embolisation target vessels computed using AMS versus DSA alone, 2 modification of the embolisation plan based on AMS, and 3 operator confidence related to technical success. Imaging set-up, processing time, radiation dose, and contrast media volume were recorded., Results: Thirty of 34 consecutive procedures were evaluated retrospectively. At least one additional embolisation target vessel was identified using AMS in 13 procedures (43%, 95% confidence interval [CI]: 26-61%) and embolisation plan modified in 11 (37%, 95% CI: 19-54%). Radiologists reported AMS increased operator confidence and reduced the number of DSA acquisitions in 25 (83%, 95% CI: 70-97%) and 15 cases (50%, 95% CI: 32-68%), respectively. The average A-CBCT acquisition and processing time was 4 minutes 53 seconds and 3 minutes 45 seconds, respectively. A-CBCT contributed to 11% of the radiation dose and 18% of the contrast media volume., Conclusion: Physicians report increased tumour supplying vessel detection and intraprocedural confidence using AMS during TAE without substantial impact on radiation dose, contrast media volume, and procedure time., (Copyright © 2018 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

The aim of this study was to determine whether intraprocedural 18 F-FDG PET/CT can be used as a predictor of local tumor progression after percutaneous ablation of colorectal liver metastases. Methods: In this institutional review board-approved prospective study, 39 patients (19 men and 20 women; median age, 56 y) underwent split-dose 18 F-FDG PET/CT-guided ablation followed by immediate biopsy and contrast-enhanced CT imaging of the ablation zone. Binary categorization of biopsy tissues was performed on the basis of the presence of only nonviable coagulation necrosis or viable tumor cells. Minimum ablation margin measurements from contrast-enhanced CT imaging were categorized as 0 mm, 1-4 mm, 5-9 mm, or greater than or equal to 10 mm. SUVs were obtained from PET/CT imaging, and SUV ratios were calculated from 3-dimensional regions of interest located in the ablation zone and surrounding normal liver. All predictive variables (biopsy, minimum margin distance, and SUV ratio) were evaluated as predictors of time to local tumor progression identified on imaging using competing-risks regression models (uni- and multivariate analyses). Results: A total of 62 consecutive ablations were evaluated. The mean SUV ratio was significantly higher for viable tumor-positive immediate postablation biopsies ( n = 10) than for tumor-negative biopsies ( n = 52) (85.8 ± 92.2 vs. 42.3 ± 45.5) ( P = 0.03) and for a minimum margin size of less than 5 mm ( n = 15) than for a minimum margin size of greater than or equal to 5 mm ( n = 47) (78.5 ± 99.1 vs. 38.3 ± 78.5) ( P = 0.01). After a median follow-up period of 22.5 (range, 7-52) months, 23 of 62 ablated tumors showed local tumor progression (37.1%). The local tumor progression rate was significantly higher for viable tumor-positive biopsies (8/10) than for negative biopsies (15/52) (80% vs. 29%) ( P = 0.001) and for a minimum margin size of less than 5 mm (9/15) than for a minimum margin size of greater than or equal to 10 mm (2/15) (60% vs. 13%) ( P = 0.02) but not 5-9 mm (37.5%; 12/32) ( P = 0.5). In a competing-risks analysis, biopsy results ( P = 0.07) and the minimum margin size ( P = 0.08) were borderline significant, but the SUV ratio was not ( P = 0.22). However, for negative biopsy ablations, the minimum margin size and SUV ratio were predictive imaging factors for local tumor progression; subdistribution hazard ratios were 0.564 (0.325-0.978) ( P = 0.04) and 1.005 (1.001-1.009) ( P = 0.005), respectively. Conclusion: The SUV ratio and minimum margin size can independently predict colorectal metastasis local tumor progression after liver ablation when there are no viable tumor cells on immediate postablation biopsies., (© 2018 by the Society of Nuclear Medicine and Molecular Imaging.)

Objective: Long indwelling times for inferior vena cava (IVC) filters that are used to prevent venous thromboembolism can result in complications. To improve care for patients receiving retrievable IVC filters, we developed and evaluated an informatics-based initiative to facilitate patient tracking, clinical decision-making, and care coordination., Materials and Methods: A semiautomated filter-tracking application was custom-built to query our radiology information system to extract and transfer key data elements related to IVC filter insertion procedures into a database. A web-based interface displayed key information and facilitated communication between the interventional radiology clinical team and referring physicians. A set of filter management options was provided depending on each patient's clinical condition. The system was launched in April 2016. Using retrospective observational cohort methods, we compared filter retrieval rates during a test period from July through December 2016 with a control period of the same 6 months in 2015., Results: System development required approximately 100 hours of development time. Two hundred ninety-three IVC filter placements and 83 filter retrievals were tracked during the study periods. The overall filter retrieval rate was 23% in the control period and 34% in the test period. Mean times from filter placement to retrieval in the control and test periods were not significantly different (88.9 and 102.7 days, respectively; p = 0.32)., Conclusion: A semiautomated approach to tracking patients with IVC filters can facilitate care coordination and clinical decision-making for a device with known potential complications. Similar applications designed to improve provider communication and documentation of filter management plans, including appropriateness for retrieval, can be replicated.

Background: Stage T1a renal cell carcinoma (RCC) (tumors <4 cm) is usually curable. Nephron-sparing partial nephrectomy (PN) has replaced radical nephrectomy (RN) as the standard of care for these tumors. Radical nephrectomy remains the first alternative treatment option, whereas percutaneous ablation (PA), a newer, nonsurgical treatment, is recommended less strongly because of the relative paucity of comparative PA data., Objective: To compare PA, PN, and RN outcomes., Design: Observational cohort analysis using inverse probability of treatment-weighted propensity scores., Setting: Population-based SEER (Surveillance, Epidemiology, and End Results) cancer registry data linked to Medicare claims., Patients: Persons aged 66 years or older who received treatment for T1a RCC between 2006 and 2011., Interventions: PA versus PN and RN., Measurements: RCC-specific and overall survival, 30- and 365-day postintervention complications., Results: 4310 patients were followed for a median of 52 months for overall survival and 42 months for RCC-specific survival. After PA versus PN, the 5-year RCC-specific survival rate was 95% (95% CI, 93% to 98%) versus 98% (CI, 96% to 99%); after PA versus RN, 96% (CI, 94% to 98%) versus 95% (CI, 93% to 96%). After PA versus PN, the 5-year overall survival rate was 77% (CI, 74% to 81%) versus 86% (CI, 84% to 88%); after PA versus RN, 74% (CI, 71% to 78%) versus 75% (CI, 73% to 77%). Cumulative rates of renal insufficiency 31 to 365 days after PA, PN, and RN were 11% (CI, 8% to 14%), 9% (CI, 8% to 10%), and 18% (CI, 17% to 20%), respectively. Rates of nonurologic complications within 30 days after PA, PN, and RN were 6% (CI, 4% to 9%), 29% (CI, 27% to 30%), and 30% (CI, 28% to 32%), respectively. Ten percent of patients in the PN group had intraoperative conversion to RN. Seven percent of patients in the PA group received additional PA within 1 year of treatment., Limitations: Analysis of observational data may have been affected by residual confounding by provider or from selection bias toward younger, healthier patients in the PN group. Findings from this older study population are probably less applicable to younger patients. Use of SEER-Medicare linked files prevented analysis of patients who received treatment after 2011, possibly reducing generalizability to the newest PA, PN, and RN techniques., Conclusion: For well-selected older adults with T1a RCC, PA may result in oncologic outcomes similar to those of RN, but with less long-term renal insufficiency and markedly fewer periprocedural complications. Compared with PN, PA may be associated with slightly shorter RCC-specific survival but fewer periprocedural complications., Primary Funding Source: Association of University Radiologists GE Radiology Research Academic Fellowship and Society of Interventional Radiology Foundation.

Introduction: The practice of positioning patients' arms above the head during catheter-injected hepatic arterial phase cone beam CT (A-CBCT) imaging has been inherited from standard CT imaging due to image quality concerns, but interrupts workflow and extends procedure time. We sought to assess A-CBCT image quality and artifacts with arms extended above the head versus down by the side., Methods: We performed an IRB approved retrospective evaluation of reformatted and 3D-volume rendered images from 91 consecutive A-CBCTs (43 arms up, 48 arms down) acquired during hepatic tumor arterial embolization procedures. Two interventional radiologists reviewed all A-CBCT imaging and assigned vessel visualization scores (VVS) from 1 to 5, ranging from non-diagnostic to optimal visualization. Streak artifacts across axial images were rated from 1 to 3 based on resulting image quality (none to significant). Presence of respiratory or cardiac motion during acquisition, body mass index and radiation dose area product (DAP) were also recorded and analyzed. Univariate and multivariate analyses were used to assess the impact of arm position on VVS and imaging artifacts., Results: VVS were not significantly associated with arm position during A-CBCT imaging. One reader reported more streak artifacts across axial images in the arms down group (p = 0.005). DAP was not statistically different between the groups (23.9 Gy cm 2 [6.1-73.4] arms up, 26.1 Gy cm 2 [4.2-102.6] arms down, p = 0.54)., Conclusion: A-CBCT angiography performed with the arms above the head is not superior for clinically relevant hepatic vascular visualization compared to imaging performed with the arms by the patient's side.

Purpose: To investigate the effects of pirfenidone (PFD) on post-cryoablation inflammation in a mouse model., Materials and Methods: In this IACUC-approved study, eighty Balb/c mice were randomly divided into four groups (20/group): sham + vehicle, sham + PFD, cryoablation + vehicle, and cryoablation + PFD. For cryoablation groups, a 20% freeze rate cryoablation (20 s to less than -100 °C) was used to ablate normal muscle in the right flank. For sham groups, the cryoprobe was advanced into the flank and maintained for 20 s without ablation. PFD or vehicle solution was intraperitoneally injected (5 mg/kg) at days 0, 1, 2, 3, and then every other day until day 13 after cryoablation. Mice were euthanized at days 1, 3, 7, and 14. Blood samples were used for serum IL-6, IL-10, and TGFβ1 analysis using electrochemiluminescence and ELISA assays, respectively. Immunohistochemistry-stained ablated tissues were used to analyze macrophage infiltration and local TGFβ1 expression in the border region surrounding the cryoablation-induced coagulation zone., Results: Cryoablation induced macrophage infiltration and increased TGFβ1 expression in the border of the necrotic zone, and high levels of serum IL-6, peaking at days 7 (70.5 ± 8.46/HPF), 14 (228 ± 18.36/HPF), and 7 (298.67 ± 92.63), respectively. Animals receiving PFD showed reduced macrophage infiltration (35.5 ± 16.93/HPF at day 7, p < 0.01) and cytokine levels (60.2 ± 7.6/HPF at day 14, p < 0.01). PFD also significantly reduced serum IL-6 levels (p < 0.001 vs. all non-PFD groups)., Conclusions: PFD mitigates cryoablation induced muscle tissue macrophage infiltration, increased IL-6 levels, and local TGFβ1 expression in a small animal model., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The rationale for this study was to evaluate the feasibility of within-suite 89 Zr-labeled radiotracer PET/CT-guided biopsy performed without reinjection. Methods: From 2013 to 2016, 12 patients (7 men, 5 women; mean age, 61 y; range, 40-75 y) with metastatic prostate or breast carcinoma suspected either on imaging or because of biochemical progression underwent 14 percutaneous biopsies after diagnostic PET/CT using 89 Zr-labeled radiotracers (mean dose, 180 MBq; range, 126-189 MBq) targeting prostate-specific membrane antigen ( n = 7) or human epidermal growth factor receptor 2 ( n = 5). Biopsy was performed within a PET/CT suite without radiotracer reinjection. Results: There were no complications in any biopsies, which were performed a mean of 6.2 d (range, 0-13 d) after injection of the radiotracer. The biopsy sites were bone ( n = 7), pleura ( n = 3), lymph nodes ( n = 2), and liver ( n = 2). On pathologic examination of the biopsy samples, all were positive for malignancy. The initial diagnostic imaging findings were concordant with the biopsy results. The additional radiation (mean dose-length product) due to the CT procedures was 1,581 mGy/cm (range, 379-2,686 mGy/cm). Conclusion: PET/CT-guided biopsy using 89 Zr-labeled radiotracers is safe and effective without tracer reinjection., (© 2018 by the Society of Nuclear Medicine and Molecular Imaging.)

Background: Public awareness of inferior vena cava (IVC) filter-related controversies has been elevated by the Food and Drug Administration (FDA) safety communication in 2010., Objectives: To examine population level trends in IVC filter utilization, complications, retrieval rates, and subsequent pulmonary embolism (PE) risk., Design: A retrospective cohort study., Subjects: Patients receiving IVC filters during 2005-2014 in New York State., Measures: IVC filter-specific complications, new PE occurrences and IVC filter retrievals were evaluated as time-to-event data using Kaplan-Meier analysis. Estimated cumulative risks were obtained at various timepoints during follow-up., Results: There were 91,873 patients receiving IVC filters between 2005 and 2014 in New York State included in the study. The average patient age was 67 years and 46.6% were male. Age-adjusted rates of IVC filter placement increased from 48 cases/100,000 in 2005 to 52 cases/100,000 in 2009, and decreased afterwards to 36 cases/100,000 in 2014. The estimated risks of having an IVC filter-related complication and filter retrieval within 1 year was 1.5% [95% confidence interval (CI), 1.4%-1.6%] and 3.5% (95% CI, 3.4%-3.6%). One-year retrieval rate was higher post-2010 when compared with pre-2010 years (hazard ratio, 2.70; 95% CI, 2.50-2.91). Among the 58,176 patients who did not have PE events before or at the time of IVC filter placement, the estimated risk of developing subsequent PE at 1 year was 2.0% (95% CI, 1.9%-2.1%)., Conclusions: Our findings suggest that FDA communications may be effective in modifying statewide clinical practices. Given the 2% observed PE rate following prophylactic IVC filter placement, large scale pragmatic studies are needed to determine contemporary safety and effectiveness of IVC filters.

Background: To investigate whether histologic subtyping from biopsies can predict local recurrence after thermal ablation for lung adenocarcinoma., Methods: Patients treated with CT-guided thermal ablation for lung adenocarcinoma that had pre-ablation needle biopsy with analysis of histologic components were identified. Age, gender, smoking status, treatment indication (primary stage 1 tumor versus salvage), histologic subtype, ground-glass radiographic appearance, tumor size, ablation modality, and ablation margin were evaluated in relation to time to local recurrence (TTLR). Cumulative incidence of recurrence (CIR) was calculated using competing risks analysis and compared across groups using Fine and Grey method with clustering. Multivariate analysis was conducted with stepwise regression., Results: There were 53 patients with 57 tumors diagnosed as adenocarcinoma on pre-ablation biopsy and with histologic subtype analysis. Of these, 19% (11) had micropapillary components, 14% (8) had solid components, and 26% (15) had micropapillary and/or solid components. In the univariate analysis, solid (subdistribution hazard ratio [SHR] = 4.04, p = 0.0051, 95% confidence interval [CI] = 1.52-10.7), micropapillary (SHR = 3.36, p = 0.01, CI = 1.33-8.47), and micropapillary and/or solid components (SHR = 5.85, p = 0.00038, CI = 2.21-15.5) were significantly correlated with shorter TTLR. On multivariate analysis, the presence of micropapillary and/or solid component (SHR = 11.4, p = 0.00021, CI: 3.14-41.3) was the only independent predictor of TTLR. The 1-, 2-, and 3-year CIR in patients with micropapillary and/or solid components was 33, 49, and 66% compared to 5, 14, and 18% in patients with no micropapillary or solid components on biopsy specimens., Conclusion: Micropapillary and/or solid histologic components identified in pre-ablation biopsy are associated with shorter TTLR after thermal ablation of lung adenocarcinoma.

Background and Aims: The aim of this study was to evaluate the feasibility and early safety of catheter-directed irreversible electroporation (IRE) of the normal common bile duct (CBD) in swine., Methods: IRE (2000 V, 90 pulses, 100 μs pulse) was performed in the CBD of 6 Yorkshire pigs using a catheter electrode under endoscopic guidance. Ductal patency was assessed with immediate retrograde cholangiography and contrast-enhanced CT imaging at 1 or 7 days after treatment. Animals were killed at either 1 day (n = 4, 2 ablations/animal) or 7 days (n = 2, 1 ablation/animal) after treatment. The biliary tract was extracted en bloc and the length of the ablation along the CBD mucosa was measured. The depth of ablation was quantified using cross-sections of the treated CBD wall stained with hematoxylin and eosin. Single-sample hypothesis testing was performed to verify whether the depth of ablation in the CBD was a representative outcome of IRE treatment., Results: IRE of the CBD did not result in perforation or obstruction of the organ at 1 or 7 days after treatment. The length of ablation along the CBD mucosa was 17.27 ± 5.55 mm on day 1 samples, and transmural ablation of the CBD wall was a representative outcome of the treatment (7/8 samples, P < .05). Day 1 samples demonstrated loss of epithelium, transmural necrosis, with preservation of lumen integrity. Day 7 samples demonstrated re-epithelialization, with diffuse transmural fibrosis of the CBD wall. These findings were absent from sham tissue samples., Conclusions: Intraluminal catheter-directed IRE is feasible and safe for full-thickness ablation of the normal porcine CBD without affecting lumen patency up to 1 week after treatment., (Copyright © 2018 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Aims: To evaluate the accuracy of contrast-enhanced ultrasound (CEUS) for monitoring tumor necrosis following WST-11 vascular targeted photodynamic therapy (VTP) using imaging-pathology correlation., Methods: Renal adenocarcinoma cells were injected into the hindlimb of 13 BalB/c mice resulting in tumors ranging from 9.8 to 194.3mm 3 . US guidance was used to place a laser fiber into the tumor, and VTP was performed. CEUS was performed prior to animal sacrifice, 24h post-VTP. Whole tumors were extracted for histopathologic analysis using H&E and TUNEL staining. Pathology samples corresponding to the CEUS imaging plane were prepared in order to compare the size and extents of tumor necrosis., Results: Tumor necrosis following VTP appeared as a central region of non-enhancement on CEUS, while viable tumor appeared as patchy regions of enhancement in the tumor periphery. The region of tumor necrosis measured in mean 66% and 64.8% of total tumor area on CEUS and pathology respectively (p=0.2). The size and location of the necrosis on CEUS images and pathology samples were found correlative with no inter-observer difference (weighted kappa of 0.771 and 0.823, respectively)., Conclusion: CEUS allows accurate monitoring of VTP induced tumor necrosis in a small animal model., (Copyright © 2017 Elsevier B.V. All rights reserved.)

PET/CT-guided interventions using specific radiotracers are promising for detecting avid lesions not well visualized with other imaging methods. A 72-year-old man who initially presented with prostate cancer Gleason 5 + 4 (prostate-specific antigen [PSA] = 7.9 ng/mL) underwent radical prostatectomy and node dissection. Three years after radiation, a rising PSA was observed over 6 months with PSA level reaching 1.08 ng/mL. He was evaluated with prostate-specific membrane antigen-based (PSMA) F-DCFPyL PET/CT, conventional CT, F-FDG PET/CT, and C-choline PET/CT. The PSMA F-DCFPyL PET/CT successfully targeted oligometastatic prostate cancer, whereas the other imaging studies were not correct in assessing disease extent.