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Tumors involving the caudate lobe present a unique therapeutic challenge due to their complex anatomy and the safety and efficacy of locoregional therapy can be variable. The purpose of this study is to analyze the outcomes of radiation segmentectomy for primary caudate lobe tumors.Eight patients [5 women and 3 men; median age = 69 y (range 50-79)] that underwent transarterial radioembolization (TARE) using yttrium-90 (Y90) glass microspheres for primary caudate lobe tumors (hepatocellular carcinoma = 6, intrahepatic cholangiocarcinoma = 2) from August 2017 to March 2021 were retrospectively analyzed. Descriptive statistics, treatment parameters, tumor response (using modified response evaluation criteria in solid tumors), adverse events [using common terminology criteria for adverse events (CTCAE)], and survival outcomes were evaluated.Eight primary caudate lobe tumors with a median size of 2.2 cm [interquartile range (IQR), 1.7-3.3] and Child-Pugh class A liver function underwent TARE of the caudate lobe. The median radiation dose was 596 Gy (IQR 356-1585), median total activity was 0.84 GBq (IQR 0.56-1.31), median specific activity was 473 Bq/sphere (IQR 226-671), and the median number of Y90 microspheres used was 1.4 million (IQR 1.2-3.4). All complications were CTCAE grade 1, and no clinically significant hilar plate complications were observed. In targeted tumors, complete response was seen in all patients. At a median follow-up period of 16.6 months (IQR 6.6-21.6) 75% (6/8) of patients were alive with no in-field progression.Radiation segmentectomy of primary caudate lobe tumors appears effective and is well tolerated in this limited case series within the described treatment parameters.Level 4, Case Series.

Safer opioid prescribing remains a crucial issue for emergency physicians. Policy statements and guidelines recommend deliberate risk assessment for likelihood of current or future opioid use disorder prior to prescribing opioids. However, the practice patterns of emergency physicians remain underreported. We surveyed emergency physicians across Canada about their local opioid prescribing policies, their practice patterns of risk assessment prior to prescribing opioids, and which clinical risk factors they find most important. The response rate was 20.4% (n = 312/1532). 59.8% of respondents report usually or always assessing for risk. Physicians rely on gestalt (80.3%), targeted histories based on risk factors in the literature (55.6%) or their experience (57.6%), and reviewing medical (83.1%) and medication records (75.6%). Contacting primary prescribers is uncommon (16.3%). A minority routinely use opioid prescribing risk assessment tools (6.4%), have local opioid prescribing policies (27%), or make use of electronic medical record functions to assist risk stratifying (2.4%). Many Canadian emergency physicians make risk assessments based on gestalt rather than identifying literature-based risk factors. This conflicts with guidelines calling for routine comprehensive assessment. Further efforts should be directed towards education in optimizing risk assessment; and towards system-level initiatives such as clear local prescribing policies, electronic-systems functionality, and developing assessment tools for use in the ED.

John Etty, Graphic Satire in the Soviet Union: Krokodil’s Political Cartoons (Jackson, MS: University Press of Mississippi, 2019). 276 pp. ISBN: 978-1496821089 ($30)Livio Belloï and Fabrice Leroy, Pierre La Police: Une esthétique de la malfaçon (Paris: Serious Publishing, 2019). 200 pp. ISBN: 9782363200266 (30€)

Background Studies have shown that the albumin-bilirubin (ALBI) grade can be a superior prognosticator for patients undergoing Yttrium-90 (Y90) glass microsphere radioembolization for hepatocellular carcinoma (HCC) compared to the Child-Pugh (CP) scoring system. Less is known about the applicability of this score in non-hepatocellular malignancies using Y90 resin microspheres. This study evaluates the ALBI grade's ability to predict overall survival and biochemical toxicity in patients undergoing resin Y90 radioembolization and body surface area dosimetry (BSA) for non-hepatocellular primary and metastatic liver malignancies compared to the CP class and Model for End-Stage Liver Disease (MELD) score. Methods A retrospective review of patients with intrahepatic metastatic colorectal and neuroendocrine cancers and cholangiocarcinoma undergoing resin radioembolization from 2006-2015 at a single tertiary medical center was performed. ALBI, MELD, and CP scores were compared and correlated with biochemical toxicity and overall survival. Results There was a significant difference in overall survival between CP class A and class B liver function (P=0.04) for the entire patient cohort. ALBI grade (P=0.36) and MELD score (P=0.19) were not independently associated with survival. When stratified by CP class, the ALBI grade revealed a trend for survival difference in CP class B (P=0.05). Baseline ALBI grade was associated with post-procedural albumin reduction (P=0.01) and bilirubin elevation (P=0.007). Conclusions ALBI grade predicted post-procedural biochemical toxicity, but did not predict survival after resin radioembolization of non-hepatocellular liver malignancies using BSA dosimetry. Given the heterogeneity of this study population, dedicated prospective analyses are required.

To verify the correlation between yttrium-90 glass microsphere radiation segmentectomy treatment intensification of hepatocellular carcinoma (HCC) and complete pathologic necrosis (CPN) at liver transplantation.A retrospective, single center, analysis of patients with HCC who received radiation segmentectomy prior to liver transplantation from 2016 to 2021 was performed. The tumor treatment intensification cohort (n = 38) was prescribed radiation segmentectomy as per response recommendations identified in a previously published baseline cohort study (n = 37). Treatment intensification and baseline cohort treatment parameters were compared for rates of CPN. Both cohorts were then combined for an overall analysis of treatment parameter correlation with CPN.Sixty-three patients with a combined 75 tumors were analyzed. Specific activity, dose, and treatment activity were significantly higher in the treatment intensification cohort (all p 0.01), while particles per cubic centimeter of treated liver were not. CPN was achieved in 76% (n = 29) of tumors in the treatment intensification cohort compared to 49% (n = 18) in the baseline cohort (p = 0.013). The combined cohort CPN rate was 63% (n = 47). ROC analysis showed that specific activity ≥ 327 Bq (AUC 0.75, p 0.001), dose ≥ 446 Gy (AUC 0.69, p = 0.005), and treatment activity ≥ 2.55 Gbq (AUC 0.71, p = 0.002) were predictive of CPN. Multivariate logistic regression demonstrated that a specific activity ≥ 327 Bq was the sole independent predictor of CPN (p = 0.013).Radiation segmentectomy treatment intensification for patients with HCC prior to liver transplantation increases rates of CPN. While dose strongly correlated with pathologic response, specific activity was the most significant independent radiation segmentectomy treatment parameter associated with CPN.

Ablative treatment for hepatocellular carcinoma is standard of care in selected settings and is endorsed by international societal guidelines. Centrally located hepatocellular carcinoma are difficult to treat due to their proximity to vasculature and central bile ducts. Irreversible electroporation is a nonthermal ablation modality that has been shown to preserve the extracellular matrix and is less likely to damage structures such as bile ducts and is not susceptible to vascular heat sink. Successful irreversible electroporation requires the parallel placement of probes which can be prevented by ribs or the sternum. This case report describes the use of the coaxial bone biopsy system to enable transchondral access and facilitate parallel placement of probes during irreversible electroporation IRE for the treatment of hepatocellular carcinoma. Keywords: Irreversible electroporation, Hepatocellular carcinoma, Bonopty needle device, Transchondral access

Radiofrequency ablation (RFA) is one of the first developed minimally invasive definitive cancer therapies. The safety and efficacy of RFA is well documented and has led to its incorporation into multiple international societal guidelines. By expanding on the body of knowledge acquired during the clinical use of RFA, alternative ablative technologies have emerged and are successfully competing for locoregional therapy market share. The adaption of newer ablative technologies is leading to a rapid decline in the utilization of RFA by interventional radiologists despite the lack of proven superiority. In their 2010 article, Hong and Georgiades stated “… RFA is likely to remain the mainstay of ablations for small tumors until sufficient experience emerges for the widespread acceptance for alternative ablative modalities.” Within a decade of this publication, has this time arrived?

Thermal ablation is widely regarded as definitive therapy for early-stage hepatocellular carcinoma, but its efficacy decreases in tumors greater than 3 cm. Extensive clinical studies have supported improved outcomes provided through combining transarterial embolic therapy with ablation in the treatment of larger tumors. This article will provide a survey of the science and data for combination therapy in both thermal and nonthermal ablation modalities, as well as describe emerging applications.

David Kunzle, Cham: The Best Comic Strips and Graphic Novelettes, 1839–1862 (Jackson: University Press of Mississippi, 2019). 566 pp. ISBN: 978-1-4968-1618-4 ($90)Tatiana Prorokova and Nimrod Tal, eds, Cultures of War in Graphic Novels: Violence, Trauma, and Memory (New Brunswick, NJ: Rutgers University Press, 2018). 237 pp. ISBN: 978-0-8135-9095-0 ($29.95)Stephen E. Tabachnick, ed., The Cambridge Companion to The Graphic Novel (Cambridge: Cambridge University Press, 2017). 244 pp. ISBN: 978-1-107-51971-8 (£21.99)Louie Dean Valencia-García, Antiauthoritarian Youth Culture in Francoist Spain: Clashing with Fascism (London: Bloomsbury Academic, 2018). 248 pp. ISBN: 978-1-350-03847-9 ($114)

Cynthia De la Garza-Ramos,1,&ast; Cameron J Overfield,1,&ast; S Ali Montazeri,1 Harris Liou,2 Ricardo Paz-Fumagalli,1 Gregory T Frey,1 J Mark McKinney,1 Charles A Ritchie,1 Zlatko Devcic,1 Andrew R Lewis,1 Denise M Harnois,3 Tushar Patel,3 Beau B Toskich1 1Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA; 2Alix School of Medicine, Mayo Clinic Arizona, Scottsdale, AZ, USA; 3Department of Transplant, Mayo Clinic Florida, Jacksonville, FL, USA&ast;These authors contributed equally to this workCorrespondence: Beau B ToskichDivision of Interventional Radiology, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USATel +1 904-953-1496Email Toskich.Beau@mayo.eduPurpose: Transarterial radioembolization can serve as an ablative therapy for early-stage hepatocellular carcinoma (HCC). Given the volumetric variability of liver segments, this study aimed to characterize the safety of ablative radioembolization by determining percent liver treated (%LT) thresholds associated with biochemical toxicity.Patients and Methods: Patients with HCC receiving a single ablative radioembolization treatment using glass microspheres from 2017 through 2020 were reviewed. %LT was calculated as treatment angiosome volume divided by whole liver volume. Biochemical toxicities were defined as increases in Albumin-Bilirubin (ALBI) grade or Child-Pugh (CP) class compared to baseline and albumin or bilirubin adverse events (AEs) per the Common Terminology Criteria for Adverse Events. Receiver operating characteristic curves and multivariate logistic regression analyses were performed to assess the impact of %LT on toxicities.Results: Of 141 patients analyzed, 53% (n=75) were ALBI 1, 45% (n=64) ALBI 2, 79% (n=111) CP-A, and 21% (n=30) CP-B. A %LT ≥ 14.5% was associated with grade/class increases in ALBI 2 (p≤ 0.01) and CP-B patients (p=0.026). In multivariate analysis, a %LT ≥ 14.5% was an independent predictor of increases in the ALBI 2 and CP-B groups (p< 0.01). No significant %LT threshold was found for ALBI 1 and CP-A patients. No grade 3/4 albumin or bilirubin AEs were reported, while grade 2 AEs were related to an initial whole liver volume < 1.3 L (p≤ 0.01).Conclusion: Patients with ALBI 2 and CP-B liver function are less likely to have an increase in their respective grade/class when treating < 14.5% of the liver using glass microspheres. ALBI 1 and CP-A patients showed no definitive %LT threshold for biochemical toxicity within the range of this study.Keywords: hepatocellular carcinoma, radioembolization, Y-90, adverse events

To investigate the outcomes of radiation segmentectomy (RS) versus standard-of-care surgical resection (SR).A multisite, retrospective analysis of treatment-naïve patients who underwent either RS or SR was performed. The inclusion criteria were solitary hepatocellular carcinoma ≤8 cm in size, Eastern Cooperative Oncology Cohort performance status of 0-1, and absence of macrovascular invasion or extrahepatic disease. Target tumor and overall progression, time to progression (TTP), and overall survival rates were assessed. Outcomes were censored for liver transplantation.A total of 123 patients were included (RS, 57; SR, 66). Tumor size, Child-Pugh class, albumin-bilirubin score, platelet count, and fibrosis stage were significantly different between cohorts (P ≤ .01). Major adverse events (AEs), defined as grade ≥3 per the Clavien-Dindo classification, occurred in 0 patients in the RS cohort vs 13 (20%) patients in the SR cohort (P .001). Target tumor progression occurred in 3 (5%) patients who underwent RS and 5 (8%) patients who underwent SR. Overall progression occurred in 19 (33%) patients who underwent RS and 21 (32%) patients who underwent SR. The median overall TTP was 21.9 and 29.4 months after RS and SR, respectively (95% confidence interval [CI], 15.5-28.2 and 18.5-40.3, respectively; P = .03). Overall TTP subgroup analyses showed no difference between treatment cohorts with fibrosis stages 3-4 (P = .26) and a platelet count of150 × 10RS and SR were performed in different patient populations, which limits comparison. RS approached SR outcomes, with a lower incidence of major AEs, in patients who were not eligible for hepatectomy.

Background This study evaluates preliminary results of image-guided percutaneous direct pancreatic duct intervention in the management of pancreatic fistula after surgery or pancreatitis when initially ineligible for surgical or endoscopic therapy. Methods Between 2001 and 2018 the medical records of all patients that underwent percutaneous pancreatic duct intervention for radiographically confirmed pancreatic fistula initially ineligible for surgical or endoscopic repair were reviewed for demographics, clinical history, procedure details, adverse events, procedure related imaging and laboratory results, ability to directly catheterized the main pancreatic duct, and whether desired clinical objectives were met. Results In 10 of 11patients (6 male and 5 female with mean age 60.5, range 39–89) percutaneous pancreatic duct cannulation was possible. The 10 duct interventions included direct ductal suction drainage in 7, percutaneous duct closure in 3 and stent placement in 1. Pancreatic fistulas closed in 7 of 10, 2 were temporized until elective surgery, and 1 palliated until death from malignancy. The single patient with failed duct cannulation resolved the fistula with prolonged catheter drainage of the peri-pancreatic cavity. There were no major adverse events related to intervention. Conclusion In patients with pancreatic fistulas initially ineligible for endoscopic therapy or elective surgery, direct percutaneous pancreatic duct interventions are possible, can achieve improvement without major morbidity or mortality, and can improve and maintain the medical condition of patients in preparation for definitive surgery.

Purpose To evaluate the natural history of incidental enhancing nodules (IENs) on contrast-enhanced cone-beam computed tomography (CT) during transarterial treatment of hepatocellular carcinoma (HCC). Material and Methods A single-center retrospective analysis of 100 patients with HCC who underwent contrast-enhanced cone-beam CT prior to transarterial treatment from August 2015 to June 2019 was performed. Inclusion criteria were patients with segmental distribution sublobar HCC, contrast-enhanced cone-beam CT of the target lesion and nontarget liver parenchyma, and follow-up cross-sectional imaging. Patients with IENs ≥3 mm that did not meet imaging criteria for HCC were analyzed. Exclusion criteria included biphenotypic tumors and IEN present inside the treated area of the liver. Results Fifty-six patients demonstrated 154 IENs on contrast-enhanced cone-beam CT, of which 13 IENs (8.5%) progressed to HCC. The mean primary tumor size was 29 mm (range: 10.2–189 mm). Ten patients had ≥4 IENs, and 46 patients had 1–3 IENs. The mean IEN size was 6.8 mm (range: 3.0–16.3 mm). The median follow-up interval after contrast-enhanced cone-beam CT was 282 days (interquartile range: 143–522). Increased alpha-fetoprotein before treatment (≥15.5 ng/mL, P = .035), having ≥4 IENs (P = .020), and hepatitis C virus (P = .015) were significantly correlated with IEN progression to HCC. No statistically significant differences were identified in baseline neutrophil-to-lymphocyte ratio, targeted HCC characteristics (size, macrovascular invasion, infiltrative pattern, enhancement pattern, and satellite lesions), and IEN size between those with IEN progression to HCC and those without. Conclusions Most IENs of ≥3 mm on contrast-enhanced cone-beam CT in patients with segmental distribution sublobar HCC do not progress to HCC. Patients with segmental distribution sublobar HCC with ≥4 IENs, alpha-fetoprotein elevation (≥15.5 ng/mL), or hepatitis C virus have an increased risk of IEN progression to HCC.

Safer opioid prescribing remains a crucial issue for emergency physicians. Policy statements and guidelines recommend deliberate risk assessment for likelihood of current or future opioid use disorder prior to prescribing opioids. However, the practice patterns of emergency physicians remain underreported.We surveyed emergency physicians across Canada about their local opioid prescribing policies, their practice patterns of risk assessment prior to prescribing opioids, and which clinical risk factors they find most important.The response rate was 20.4% (n = 312/1532). 59.8% of respondents report usually or always assessing for risk. Physicians rely on gestalt (80.3%), targeted histories based on risk factors in the literature (55.6%) or their experience (57.6%), and reviewing medical (83.1%) and medication records (75.6%). Contacting primary prescribers is uncommon (16.3%). A minority routinely use opioid prescribing risk assessment tools (6.4%), have local opioid prescribing policies (27%), or make use of electronic medical record functions to assist risk stratifying (2.4%).Many Canadian emergency physicians make risk assessments based on gestalt rather than identifying literature-based risk factors. This conflicts with guidelines calling for routine comprehensive assessment. Further efforts should be directed towards education in optimizing risk assessment; and towards system-level initiatives such as clear local prescribing policies, electronic-systems functionality, and developing assessment tools for use in the ED.RéSUMé: CONTEXTE: La prescription sûre d'opioïdes reste un enjeu essentiel pour les médecins d'urgence. Avant de prescrire des opioïdes, les énoncés de politique et les lignes directrices recommandent une évaluation des risques bien réfléchie pour la probabilité d’un abus d'opiacé actuel ou éventuel. Cependant, les modalités de pratique des médecins urgentistes font l’objet d’une documentation et d’une information insuffisante. MéTHODES: Nous avons mené une enquête auprès des médecins urgentistes partout au Canada au sujet de leurs politiques locales de prescription des opioïdes, de leurs modalités de pratique d'évaluation des risques avant de prescrire des opioïdes, et des facteurs de risque cliniques qu'ils jugent les plus importants. RéSULTATS: Le taux de réponse était de 20.4% (n = 312/1532). 59.8% des répondants déclarent évaluer habituellement ou toujours le risque. Les médecins dépendent du gestalt (80.3%), des antécédents ciblés basés sur des facteurs de risque de la littérature (55.6%) ou de leur expérience (57.6%) et d’une examination des dossiers médicaux (83.1%) et des dossiers pharmaceutiques (75.6%). Il est rare de contacter les principaux prescripteurs (16.3%). Une minorité utilise régulièrement des outils d'évaluation des risques liés à la prescription des opioïdes (6.4%), dispose de politiques locales de prescription d'opiacés (27%) ou utilise les fonctions de dossier médical électronique pour aider à la stratification des risques (2.4%). CONCLUSION: De nombreux médecins urgentistes canadiens évaluent les risques en se basant sur la gestalt plutôt que sur l’identification des facteurs de risque documentés. Cela est en contradiction avec les directives exigeant une évaluation complète de routine. Des efforts supplémentaires devraient être dirigés vers l'éducation pour optimiser l’évaluation des risques; et vers des initiatives au niveau du système telles que des politiques de prescription locales claires, la fonctionnalité des systèmes électroniques et l'élaboration d’outils d'évaluation à utiliser aux urgences.

Zeina Abirached, a Lebanese and French cartoonist, has published several graphic novels exploring possibilities for creative self-expression amid and against violence. Four conceptual metaphors are used to analyze Abirached’s diversionary art in her graphic novel Le piano oriental (The Oriental Piano, 2015), which offers a model for evading monocultural constraints and (post) colonial exclusion. One is from the author of this chapter (affrontier), one is from literary history (clinamen), and two are from Abirached (déhanchement and tricotage). It is argued here that déhanchement (hip swaying) is an apt metaphor for transcultural alternation between the Eastern and Western cultural poles in her book. Tricotage (knitting) offers a powerful variation on, or substitute for, tressage (braiding), a metaphor through which Thierry Groensteen theorized exceptional repetition of images in comics. The chapter also shows how Abirached deftly combines fiction with auto-/biography to escape constraints of the latter on her artistic creativity.

Some contemporary French cartoonists have published comics that either themselves serve as post-colonial lieux de mémoire in place of disappeared colonial people, places, events or objects, or that otherwise recall colonial lieux de mémoire. The graphic novel Cannibale (2009), adapted by Emmanuel Reuzé from Didier Daeninckx's eponymous prose novel (1998), returns to the International Colonial Exhibition in Paris, which has become a post-colonial lieu de mémoire. The 1931 event, staged at the zenith of French imperial rule, and overseen by Maréchal Lyautey, was grandiose in conception, size and scope, and racist too, in fact. Both versions of Cannibale feature a Kanak narrator sent to perform as a New Caledonian cannibal in the Parisian exhibition. This essay analyzes how Reuzé uses cartooning techniques such as visual symbolism, subjective viewpoints, visual and verbal narration, inset images, and visual rhymes to critique French colonialism and to commemorate its victims.

Santiago García (trans. Bruce Campbell), On the Graphic Novel (Jackson: University Press of Mississippi, 2015). 375 pp. ISBN: 978-1-49681-318-3 ($30)Jan-Noël Thon, Transmedial Narratology and Contemporary Media Culture, Frontiers of Narrative (Lincoln: University of Nebraska Press, 2016). 527 pp. ISBN: 978-0-80-327720-5 (€50.99)Thierry Bellefroid, ed., L’Âge d’Or de la bande dessinée belge: La Collection du Musée des Beaux-Arts de Liège (Brussels: Les Impressions Nouvelles, 2015). 96 pp. ISBN: 978-2-87-449232-7 (€19.50)Philippe Delisle, Petite histoire politique de la BD belge de langue française: Années 1920–1960 (Paris: Karthala, 2016). 199 pp. ISBN: 978-2-81- 111717-7 (€15)

Background and aim The aim of this study was to assess the effectiveness of yttrium-90 (90 Y) microspheres for the treatment of unresectable metastatic liver neuroendocrine tumors (NET). Methods From February 2006 to September 2015, 36 patients (19 male and 17 female, age 63.6 ± 9.4 years) who underwent 90 Y therapy for unresectable liver metastases of NET were included and analyzed retrospectively. All patients received a variety of treatments before 90 Y therapy. The radiological response, symptoms improvement of carcinoid syndrome, tumor marker changes, complications, side effects/toxicity, survival, and factors related to survival were evaluated and analyzed. Results Of the 36 patients, the mean delivered dose of 90 Y was 1.8 ± 0.7 GBq with a total of 40 treatments. Overall disease control rate was 88.9% (32/36) at 3 months following therapy. In 16 patients with carcinoid syndrome, 15 (93.8%) patients had symptomatic improvement. Tumor marker response (5-hydroxyindoleacetic acid [n = 7] and chromogranin A [n = 13]) at 3 months after treatment were as follows: none (n = 0, 4), partial (n = 6, 7), and complete (n = 1, 2). Radiation-induced gastrointestinal ulcers (n = 2, 5.6%) were identified. Side effects included fatigue (n = 31, 86.1%), anorexia (n = 26, 72.2%), nausea (n = 15, 41.7%), vomiting (n = 14, 38.9%), abdominal pain (n = 10, 27.8%), and fever (n = 8, 22.2%). The mean follow-up was 27.0 ± 16.4 months, with a median survival of 41.0 months. Child-Pugh classification (P = 0.008) and lymph node metastases (P = 0.045) had statistically significant influence on overall survival. Conclusions Yttrium-90 radioembolization can be effective in the treatment of unresectable liver metastases of NET who failed to respond to other treatments.