Initiative on Superselective Conventional Transarterial Chemoembolization Results (INSPIRE)

Several publications show that superselective conventional TransArterial ChemoEmbolization (cTACE), meaning cTACE performed selectively with a microcatheter positioned as close as possible to the tumor, improves outcomes, maximizing the anti-tumoral effect and minimizing the collateral damages of the surrounding liver parenchyma. Recent recommendations coming from the European Association for the Study of the Liver (EASL) and European Society of Medical Oncology (ESMO) highlighted that TACE must be used in Hepatocellular Carcinoma (HCC) "selectively targetable" and "accessible to supraselective catheterization." The goal of the manuscript is to better define such population and to standardize superselective cTACE (ss-cTACE) technique. An expert panel with extensive clinical-procedural experience in TACE, have come together in a virtual meeting to generate recommendations and express their consensus. Experts recommend that anytime cTACE is proposed, it should be ss-cTACE, preferably with a 1.5-2.0 Fr microcatheter. Ideally, ss-cTACE should be proposed to patients with less than five lesions and a maximum number of two segments involved, with largest tumor smaller than 5 cm. Angio Cone-Beam Computed Tomography (CBCT) should be used to detect enhancing tumors, tumor feeders and guide tumor targeting. Whole tumor volume should be covered to obtain the best response. Adding peritumoral margins is encouraged but not mandatory. The treatment should involve a water-in-oil emulsion, whose quality is assessable with the "drop test." Additional particulate embolization should be systematically performed, as per definition of cTACE procedure. Non-contrast CBCT or Multi-Detector Computed Tomography (MDCT) combined with angiography has been considered the gold standard for imaging during TACE, and should be used to assess tumor coverage during the procedure. Experts convene that superselectivity decreases incidence of adverse effects and improves tolerance. Experts recommend contrast-enhanced Computed Tomography (CT) as initial imaging on first follow-up after ss-cTACE, and Magnetic Resonance Imaging (MRI) if remaining tumor viability cannot be confidently assessed on CT. If no response is obtained after two ss-cTACE sessions within six months, patient must be considered unsuitable for TACE and proposed for alternative therapy. Patients are best served by multidisciplinary decision-making, and Interventional Radiologists should take an active role in patient selection, treatment allocation, and post-procedural care

A blended learning approach for teaching thoracic radiology to medical students: a proof-of-concept study

IntroductionThe best way to impart knowledge to medical students is still unclear. Therefore, we designed a blended learning course in thoracic radiology including both “traditional” in-class time as well as online learning modules. The aims were (1) to investigate students’ attitudes toward this blended learning approach; and (2) to test whether it improved their knowledge about thoracic radiology.MethodsA prospective study was conducted at the local medical center; 156 fourth-year medical students completed this study. Before and after the course, students had to complete (1) questionnaires to investigate their attitudes (7-point Likert scale); and (2) an objective test to assess their knowledge (multiple-choice/free text questions; results as % of correct answers).ResultsRegarding (1), the course led to an improvement in all items compared to baseline, exemplary: interest in thoracic radiology (precourse 4.2 vs. 5.4 postcourse) and the fulfillment of students’ expressed requirements regarding the teaching content (4.5 precourse vs. 6.2 postcourse). Furthermore, the great majority (88%) of our participants wished for more online learning offerings in the future. Regarding (2), the course led to improved knowledge on the objective test (precourse: 40% vs. postcourse: 63% correct answers).ConclusionThis feasibility study showed the successful design and implementation of a blended learning approach in thoracic radiology. Furthermore, it revealed medical students’ positive attitudes toward this approach and showed an increased knowledge in thoracic radiology. Thus, such approaches might be used to enrich the teaching armamentarium in medical education and to further enhance interest and knowledge in thoracic diseases among medical students

Textbook Outcome After Trans-arterial Chemoembolization for Hepatocellular Carcinoma

PurposeTextbook Outcome (TO) is inclusive of quality indicators and it not been provided for trans-arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC).Materials and methodsData on treatment-naïve HCC patients receiving TACE from 10 centers were reviewed. TO was defined as "no post-TACE grade 3-4 complications, no prolonged hospital stay (defined as a post-procedure stay ≤ 75th percentile of the median values from the total cohort), no 30-day mortality/readmission and the achievement of an objective response (OR) at post-TACE imaging." Grade of adverse event was classified according to the Common Terminology Criteria for Adverse Events and short-term efficacy was assessed by response. Pooled estimates were calculated to account for hospital's effect and risk-adjustment was applied to allow for diversity of patients in each center.ResultsA total of 1124 patients (2014-2018) fulfilling specific inclusion criteria were included. Baseline clinical features showed considerable heterogeneity (I2 > 0.75) across centers. TACE-related mortality was absent in 97.6%, readmission was not required after 94.9% of procedures, 91.5% of patients had no complication graded 3-4, 71.8% of patients did not require prolonged hospitalization, OR of the target lesion was achieved in 68.5%. Risk-adjustment showed that all indicators were achieved in 43.1% of patients, and this figure was similar across centers. The median overall survival for patients who achieved all indicators was 33.1 months, 11.9 months longer than for patients who did not.ConclusionsA useful benchmark for TACE in HCC patients has been developed, which provides an indication of survival and allows for a comparison of treatment quality across different hospitals

The Effect of a New Angiographic Imaging Technology on Radiation Dose in Visceral Embolization Procedures

PURPOSE To evaluate the impact of a new angiographic imaging technology on radiation dose during visceral embolization procedures involving both fluoroscopy and digital subtraction angiography. MATERIAL AND METHODS A retrospective analysis from a single-center consecutive series of patients was performed comparing 2 angiographic imaging systems. The AlluraClarity (CIQ; Philips Healthcare, Best, the Netherlands) was used in 100 patients (n = 59 male, mean age: 70.6 years) from July 2013 to April 2014 and compared to the former AlluraXper (AX) technology used in 139 patients (n = 71 male, mean age: 70.1 years) from May 2011 to June 2013. Patients were categorized according to body mass index (BMI [kg/m])-group 1: BMI <25, group 2: BMI ≥25 and <30, and group 3: BMI ≥30. Fluoroscopy time, the total dose of iodinated contrast administered, and procedural AirKerma (Ka, r [mGy]) were obtained. RESULTS Mean BMI was 26.4 ± 5.0 kg/m in the CIQ and 26.4 ± 7.1 kg/m in the AX group ( P = .93). Fluoroscopy time and the amount of contrast media were equally distributed. Ka, r was 1342.9 mGy versus 2214.8 mGy ( P < .001, t test) when comparing CIQ to AX. Comparing CIQ to AX, BMI subgroup analysis revealed a mean Ka, r of 970.1 to 1586.1 mGy ( P = .003, t test), 1484.7 to 2170.1 mGy ( P = .02, t test), and 1848.8 to 3348.9 mGy ( P = .001, t test) in BMI groups 1, 2, and 3, respectively. CONCLUSION The CIQ technology significantly reduced mean radiation dose by 39.4% for visceral embolization procedures when compared to fluoroscopy time and contrast media dose. This dose relationship was consistent across all BMI groups

Pregnancy management for a woman with extensive vulvar and pelvic malformations caused by Klippel–Trénaunay syndrome

Abstract Klippel–Trénaunay syndrome (KTS) is a rare congenital disorder defined by a triad of capillary malformation, venous malformation, and soft tissue or bone hypertrophy most commonly affecting unilateral lower limbs. Due to the rarity of KTS, evidence‐based guidelines for the management of pregnancy in people with KTS are still lacking. A 34‐year‐old woman (gravidity 1; parity 0) presented at 25 weeks of gestation with malformations of the right side of her body. The extent of the KTS affecting the vulva, pelvis, and right leg was remarkable. As the prenatal MRI showed massive vascular malformations of the pelvis and vulva, we performed an elective cesarean section to avoid severe perinatal hemorrhage during a vaginal delivery. Intraoperatively, we observed varices on the parietal peritoneum within the vesico‐uterine pouch and the isthmocervical transition of the uterus, which were not identifiable in the preoperative MRI. Although KTS patients have been discouraged from pregnancy in the past because of a high risk for complications, successful and uncomplicated pregnancies are possible. For this purpose, we believe a multidisciplinary strategy that is crucial

Local and Regional Therapies for Hepatocellular Carcinoma and Future Combinations

Background: Hepatocellular carcinoma (HCC) can be treated by local and regional methods of percutaneous interventional radiological techniques. Indications depend on tumor size, type and stage, as well as patient&rsquo;s condition, liver function and co-morbidities. According to international classification systems such as Barcelona Clinic Liver Cancer (BCLC) classification, very early, early or intermediate staged tumors can be treated either with ablative methods or with transarterial chemoembolization (TACE), depending on tumor characteristics. The combination of both allows for individualized forms of treatment with the ultimate goal of improving response and survival. In recent years, a lot of research has been carried out in combining locoregional approaches with immune therapy. Although recent developments in systemic treatment, especially immunotherapy, seem quite promising and have expanded possible combined treatment options, there is still not enough evidence in their favor. The aim of this review is to provide a comprehensive up-to-date overview of all these techniques, explaining indications, contraindications, technical problems, outcomes, results and complications. Moreover, combinations of percutaneous treatment with each other or with immunotherapy and future options will be discussed. Use of all those methods as down-staging or bridging solutions until surgery or transplantation are taken into consideration will also be reviewed. Conclusion: Local and regional therapies remain a mainstay of curative and palliative treatment of patients with HCC. Currently, evidence on potential combination of the local and regional treatment options with each other as well as with other treatment modalities is growing and has the potential to further individualize HCC therapy. To identify the most suitable treatment option out of these new various options, a repeated interdisciplinary discussion of each case by the tumor board is of utmost importance

Validation and implementation of artificial intelligence in radiology Quo vadis in 2022?

Background: The hype around artificial intelligence (AI) in radiology continues and the number of approved AI tools is growing steadily. Despite the great potential, integration into clinical routine in radiology remains limited. In addition, the large number of individual applications poses a challenge for clinical routine, as individual applications have to be selected for different questions and organ systems, which increases the complexity and time required.Objectives: This review will discuss the current status of validation and implementation of AI tools in clinical routine, and identify possible approaches for an improved assessment of the generalizability of results of AI tools.Materials and methods: A literature search in various literature and product databases as well as publications, position papers, and reports from various stakeholders was conducted for this review.Results: Scientific evidence and independent validation studies are available for only a few commercial AI tools and the generalizability of the results often remains questionable.Conclusions: One challenge is the multitude of offerings for individual, specific application areas by a large number of manufacturers, making integration into the existing site-specific IT infrastructure more difficult. Furthermore, remuneration for the use of AI tools in clinical routine by health insurance companies in Germany is lacking. But in order for reimbursement to be granted, the clinical utility of new applications must first be proven. Such proof, however, is lacking for most applications

Guidelines Regarding 16 of the German Transplantation Act - Initial Experiences with Structured Reporting

Purpose To transfer the report sheet from the guidelines regarding the German Transplantation Act to a standards-compliant report template and to evaluate it in the clinical routine. Materials and Methods The template was developed using the freely available software brackets.io. It was implemented in the clinical routine using a reporting platform developed in-house. Interfaces to the department RIS and PACS allowed for integration into the usual reporting workflow. The evaluation period was 70 days. Results Developing the template for implementation of the guidelines was possible without any difficulties. The content of the report sheet provided in the guidelines was transferred one to one. Additionally, a text field was included to allow for further remarks. In the period under review, 7 radiologists performed 44 evaluations in line with 16 of the German Transplantation Act. Users of the template, referring physicians and the employees of the transplantation office reported a high degree of satisfaction. Conclusion Implementing report sheets that are required by law (e.g. in the guidelines regarding 16 of the German Transplantation Act) in the clinical routine electronically is easy and achieves a high degree of acceptance. The standard supported by the German Radiological Society (IHE - Management of radiology report templates) allows for a quick response to the growing demand for structured and standardized reporting