Practical Considerations When Choosing Chemoembolization versus Radioembolization for Hepatocellular Carcinoma

Transarterial chemoembolization (TACE) and transarterial radioembolization (TARE) are common liver-directed therapies (LDTs) for unresectable HCC. While both deliver intra-arterial treatment directly to the site of the tumor, they differ in mechanisms of action and side effects. Several studies have compared their side effect profile, time to progression, and overall survival data, but often these lack practical considerations when choosing which treatment modality to use. Many factors can impact operator's choice for treatment, and the choice depends on treatment availability, cost, insurance coverage, operator's comfort level, patient-specific factors, tumor location, tumor biology, and disease stage. This review discusses survival data, time to progression data, as well as more practical patient and tumor characteristics for personalized LDT with TACE or TARE.

Gadolinium-based contrast agents for imaging of the central nervous system: A multicenter European prospective study

Contrast-enhanced MR (CE-MR) imaging is required to improve lesion detection and characterization and to increase diagnostic confidence. This study aims to evaluate the safety, effectiveness, and usage patterns of recently introduced ClariscanTM (gadoterate meglumine) and other macrocyclic gadolinium-based contrast agents (GBCAs) used for magnetic resonance imaging (MRI) of the central nervous system (CNS). Data was obtained from a European multicenter, prospective, observational postmarketing study that included pediatric and adult patients undergoing contrast-enhanced MRI with a GBCA used in routine clinical practice. Safety data was collected by spontaneous patient adverse event (AE) reporting. Effectiveness was assessed via changes in radiological diagnosis, diagnostic confidence, and image quality. 766 patients with CNS-related indications were included from 8 centers across 5 European countries between December 2018 and November 2019. Clariscan (gadoterate meglumine) was used in 66% (503) of exams, Dotarem® (gadoterate meglumine) in 20% (160), Gadovist® (gadobutrol) in 13% (97), and ProHance® (gadoteridol) in 1%. GBCA use increased the diagnostic confidence in 95% (724/766) of patients and a change in radiological diagnosis in 65% (501/766) of patients. The Clariscan-specific data revealed an increase in diagnostic confidence in 94% (472/503) of patients and resulted in a change in radiological diagnosis in 58% (293/503) of patients. Image quality was considered excellent or good in 95% of patients across all GBCAs and in 94% of patients who received Clariscan. No AEs were reported in this cohort including Clariscan. This data demonstrates the excellent safety and efficacy profile of Clariscan and other GBCAs used in MRI examination of the CNS.

Trimetazidine reduces contrast-induced nephropathy in patients with renal insufficiency undergoing coronary angiography and angioplasty: A systematic review and meta-analysis (PRISMA)

OBJECTIVES

This systematic review and meta-analysis assesses the utility of trimetazidine (TMZ) to prevent contrast induced nephropathy (CIN) in patients with renal insufficiency undergoing coronary angiography and angioplasty.

MATERIALS AND METHODS

This meta-analysis was formulated and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of databases was conducted by 2 researchers independently for clinical trials, comparing hydration plus TMZ vs conventional hydration alone for prevention of CIN through January 2020. All patients had renal insufficiency (defined as GFR < 89 ml/minute/1.73 m2) and the outcome of interest was the incidence of contrast induced acute kidney injury. The odds ratio (OR) was estimated with 95% confidence interval (CI). Heterogeneity was reported with the I2 statistic, using a fixed-effects model, and >50% of I2 was considered to be statistically significant.

RESULTS

Eleven studies, 1611 patients, met the inclusion/exclusion criteria: 797 patients comprised the TMZ plus hydration group and the remaining 814 patients comprised the control (hydration only) group. Heterogeneity was low I2 = 0%, P = .84, and the heterogeneity of each study was also low. The incidence of CIN in the TMZ plus hydration group was 6.6% (53/797), while the incidence of CIN in the control (hydration only) group was 20% (165/814). Pooled analysis of all studies showed TMZ reduced incidence of CIN compared to saline hydration alone (OR risk 0.30, 95% CI 0.21, 0.42, P < .0001).

CONCLUSION

TMZ added to hydration reduces CIN in renal insufficiency patients undergoing coronary angiography.

Bladder diverticuli following injection of onabotulinum toxin A in a patient with multiple sclerosis and autosomal dominant polycystic kidney disease

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Bladder diverticuli identified following Botox treatment of neurogenic bladder.

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Magnetic resonance imaging is useful to detect bladder diverticuli following Botox injections.

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Magnetic resonance imaging following Botox treatment of neurogenic bladder may be helpful.

Urinary incontinence due to neurogenic detrusor overactivity is common in patients with disorders of lower motor neurons controlling the bladder. Multiple sclerosis is a major cause of neurogenic detrusor overactivity, which negatively impacts quality of life. Bladder wall injection of onabotulinum toxin A can diminish spontaneous bladder contraction, urinary urgency, and urge incontinence. Herein we report a 61-year-old woman with multiple sclerosis and autosomal dominant polycystic kidney disease with bladder trabeculation developing after repeated injections of onabotulinum toxin A.

Relationship of Seminal Megavesicles, Prostate Median Cysts, and Genotype in Autosomal Dominant Polycystic Kidney Disease

BACKGROUND

Autosomal dominant polycystic kidney disease (ADPKD) can involve prostate and seminal vesicles but the potential interrelationship of these findings and associations with PKD gene mutation locus and type is unknown.

PURPOSE

To determine the interrelationship of seminal megavesicles (seminal vesicles with lumen diameter > 10mm) and prostatic cysts in ADPKD and to determine whether there are associations with PKD gene mutations.

STUDY TYPE

Retrospective, case control.

POPULATION

Male ADPKD subjects (n = 92) with mutations in PKD1 (n = 71; 77%) or PKD2 (n = 21; 23%), and age/gender-matched controls without ADPKD (n = 92).

FIELD STRENGTH/SEQUENCE

1.5T, axial/coronal T₂ -weighted MR images.

ASSESSMENT

Reviewers blinded to genotype independently measured seminal vesicle lumen diameter and prevalence of cysts in prostate, kidney, and liver.

STATISTICAL TESTS

Nonparametric tests for group comparisons and univariate and multivariable logistic regression analyses to identify associations of megavesicles and prostate median cysts with mutations and renal/hepatic cyst burden.

RESULTS

Seminal megavesicles were found in 23 of 92 ADPKD (25%) subjects with PKD1 (22/71, 31%) or PKD2 (n = 1/21, 5%) mutations, but in only two control subjects (P < 0.0001). Prostate median cysts were found in 17/92 (18%) ADPKD subjects, compared with only 6/92 (7%) controls (P = 0.01), and were correlated with seminal vesicle diameters (ρ = 0.24, P = 0.02). Nonmedian prostate cyst prevalence was identical between ADPKD and controls (7/92, 8%). After adjusting for age, estimated glomerular filtration rate, and height-adjusted total kidney volume, ADPKD subjects with megavesicles were 10 times more likely to have a PKD1 than a PKD2 mutation. Among PKD1 subjects, seminal megavesicles occurred more frequently with nontruncating mutations with less severe kidney involvement.

DATA CONCLUSION

ADPKD is associated with prostate median cysts near ejaculatory ducts. These cysts correlate with seminal megavesicles (dilated to >10 mm) which predict a 10-fold greater likelihood of PKD1 vs. PKD2 mutation. Cysts elsewhere in the prostate are not related to ADPKD.

LEVEL OF EVIDENCE

2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:894-903.

Applications of PET/CT and PET/MR Imaging in Primary Bone Malignancies

Primary bone malignancies are characterized with anatomic imaging. However, in recent years, there has been an increased interest in PET/computed tomography scanning and PET/MRI with fludeoxyglucose F 18 for evaluating and staging musculoskeletal neoplasms. These hybrid imaging modalities have shown promise largely owing to their high sensitivity, ability to perform more thorough staging, and ability to monitor treatment response. This article reviews the current role of PET/computed tomography scanning and PET/MRI in primary malignancies of bone, with an emphasis on imaging characteristics, clinical usefulness, and current limitations.

Dentate Nucleus Signal Intensity Decrease on T1-weighted MR Images after Switching from Gadopentetate Dimeglumine to Gadobutrol

Purpose To determine if the increased dentate nucleus signal intensity following six or more doses of a linear gadolinium-based contrast agent (GBCA) (gadopentetate dimeglumine) changes at follow-up examinations performed with a macrocyclic GBCA (gadobutrol). Materials and Methods This retrospective study included 13 patients with increased dentate nucleus signal intensity following at least six (range, 6-18) gadopentetate dimeglumine administrations who then underwent at least 12 months of follow-up imaging with multiple (range, 3-29) gadobutrol-enhanced magnetic resonance (MR) examinations. Dentate nucleus-to-pons and dentate nucleus-to-cerebellar peduncle signal intensity ratios were measured by two radiologists blinded to all patient information, and changes were analyzed by using the paired t test and linear regression. Results The mean dentate nucleus-to-pons and dentate nucleus-to-cerebellar peduncle signal intensity ratios increased after gadopentetate dimeglumine administration, from 0.98 ± 0.03 to 1.10 ± 0.03 (P < .0001) and from 0.98 ± 0.030 to 1.09 ± 0.02 (P < .0001), respectively. With gadobutrol, the mean dentate nucleus-to-pons and dentate nucleus-to-cerebellar peduncle signal intensity ratios decreased to 1.03 ± 0.03 and 1.02 ± 0.04, respectively (P < .0001). With use of a mixed effects model linear regression allowing for each patient to have a different y intercept, mean dentate nucleus-to-pons and dentate nucleus-to-cerebellar peduncle signal intensity ratios decreased with follow-up time (dentate nucleus-to-pons: slope = -0.2% per month [95% confidence interval: -0.0024, -0.0015], R² = 0.58, P < .0001 for nonzero slope; dentate nucleus-to-cerebellar peduncle: slope = -0.2% per month [95% confidence interval: -0.0024, -0.0015], R² = 0.61, P < .0001 for nonzero slope). Conclusion Dentate signal intensity increased with at least six gadopentetate dimeglumine-enhanced MR examinations and decreased after switching from a linear (gadopentetate dimeglumine) to a macrocyclic (gadobutrol) GBCA. ^© RSNA, 2018 Online supplemental material is available for this article.

MRI and CT contrast media extravasation: A systematic review

BACKGROUND

This systematic review combines data from multiple papers on contrast media extravasation to identify factors contributing to increased extravasation risk.

METHODS

Data were extracted from 17 papers reporting 2191 extravasations in 1,104,872 patients (0.2%) undergoing computed tomography (CT) or magnetic resonance imaging (MRI).

RESULTS

Extravasation rates were 0.045% for gadolinium-based contrast agents (GBCA) and nearly 6-fold higher, 0.26% for iodinated contrast agents. Factors associated with increased contrast media extravasations included: older age, female gender, using an existing intravenous (IV) instead of placing a new IV in radiology, in-patient status, use of automated power injection, high injection rates, catheter location, and failing to warm up the more viscous contrast media to body temperature.

CONCLUSION

Contrast media extravasation is infrequent but nearly 6 times less frequent with GBCA for MRI compared with iodinated contrast used in CT.

Comparison of MRI segmentation techniques for measuring liver cyst volumes in autosomal dominant polycystic kidney disease

PURPOSE

To compare MRI segmentation methods for measuring liver cyst volumes in autosomal dominant polycystic kidney disease (ADPKD).

METHODS

Liver cyst volumes in 42 ADPKD patients were measured using region growing, thresholding and cyst diameter techniques. Manual segmentation was the reference standard.

RESULTS

Root mean square deviation was 113, 155, and 500 for cyst diameter, thresholding and region growing respectively. Thresholding error for cyst volumes below 500ml was 550% vs 17% for cyst volumes above 500ml (p<0.001).

CONCLUSION

For measuring volume of a small number of cysts, cyst diameter and manual segmentation methods are recommended. For severe disease with numerous, large hepatic cysts, thresholding is an acceptable alternative.

Preventing Allergic Reactions to Gadolinium-Based Contrast Agents

Although the low incidence of immediate-type gadolinium-based contrast agent (GBCA) allergic reactions is widely known, preventing these reactions and properly managing them to reduce their adverse sequel can improve the already exceedingly favorable GBCA safety profile. This review article should help those who order, supervise, or administer GBCA contrast agents, including recognizing and handling allergic reaction risks intrinsic to their use. Areas of focus include factors indicating increased allergic reaction risk, patient selection strategies, skin testing, premedication, and treatment of adverse events.

Obesity and urologic complications after renal transplantation

Although obesity has been associated with improved survival on dialysis, its short-and long-term effects on renal transplantation outcomes remain unclear. Herein, we evaluate the short-term and intermediate long-term effects of obesity on first-time renal transplant patients. A retrospective analysis was performed on 180 consecutive renal transplant recipients from living unrelated donors during 2006-2008 in a major transplantation center in Tehran, Iran. Among these, 34 (18%) patients were found to be obese (body mass index ≥30 kg/m 2 ). Obese patients were more likely to develop post-transplant renal artery stenosis (RAS) (17.6% vs. 2.8%, P <0.001), hematoma (47.9% vs. 17.6, P = 0.009), surgical wound complications (64.7% vs. 9.6%, P <0.001) and renal vein thrombosis (2% vs. 0%, P <0.001). However, the incidence of delayed graft function, lymphocele, urologic complications of ureterovesical junction stenosis or urinary leakage, surgical complications of excessive bleeding or renal artery thrombosis and duration of hospitalization were similar between the two groups. The two-year patient and graft survival were also statistically not different. Renal transplantation in obese recipients is associated with a higher incidence of post-transplant RAS, hematoma, surgical wound complications and renal vein thrombosis, but similar two-year patient and graft survival.

Tinnitus: an epidemiologic study in Iranian population

A wide range of population, 4% to 30%, suffers from tinnitus that is defined as perception of sound without apparent acoustic stimulus. We conducted the present study to determine the prevalence of tinnitus in Iranian population; Tehran province. This cross-sectional study was conducted from January 2009 to December 2009, recruiting 3207 individuals (age range, 7-98) who were residing in Tehran province, Iran. Participants were asked to fill two questionnaires; the validated Persian version of Tinnitus Questionnaire (TQ) and another one that was specifically designed for this study. Prevalence of tinnitus and its association factors were evaluated. 3207 participants enrolled into our study comprising 1429 (44.7%) male and 1765 (55.3%) female with mean age of 55.01±17.85. Of total of 3207 participants, 146 (4.6%) had tinnitus consisting of 80 male (54.8%) and 66 (45.2%) female participants. It showed a rising trend with increasing age that was especially significant after the sixth decade of life (P=0.001). The analysis showed mean TQ global score of 35.96±25.52 that was significantly different between male and female participants (P=0.051) and had no significant correlation with increasing age (Spearman's r=0.1, P=0.10). The tinnitus intensity was moderate to very severe in 95 (56.1%) of the participants. Its severity level was not significantly different between men and women (P=0.09). Tinnitus intensity had no significant association with increasing age (Spearman's r=0.1, P=0.31). Patients with higher TQ global score had higher tinnitus intensities (P=0.001). The annoyance level was significantly different between men and women (P=0.04) and its impact on the participants daily routine functions were significantly higher in men (P=0.003). Given the results of the study, demonstrating that prevalence of tinnitus in Iranian population (Tehran province) was lower than the other countries and had a direct correlation with increasing age only after the sixth decade. TQ global score had significant correlation with tinnitus intensity, annoyance and impact on the participants' daily routine functions. However, none of the above had correlation with increasing age. Tinnitus TQ global score and intensity were not different between men and women; however annoyance of tinnitus and its impact on participants' daily routine functions were significantly higher in men.

Use of image guidance in endoscopic endonasal surgeries: a 5-year experience

PROBLEMS/OBJECTIVES

Endoscopic endonasal surgery (EES) is standard practice in sinonasal disease and is becoming more accepted in the performance of anterior skull base resections. We report our experience with image-guided surgery (IGS) in difficult cases of paranasal sinus (PNS) and skull base pathologies and discuss advantages and disadvantages of this technique.

METHODOLOGY

A retrospective chart review was performed for the period 2004-2009. Degree of PNS involvement, indication for IGS, incidence of major complications, need for revision surgery, and technical data regarding the system were gathered.

RESULTS

Sixty-two of 86 patients were followed for at least one year and therefore included in the analysis. Indications for IGS were mostly revision surgery for polyposis (42%), chronic rhinosinusitis (CRS) of frontal and/or sphenoid sinuses (14.5%), skull base tumours (30.6%), and foreign body removal (4.8%). Revision rates after IGS in polyposis, CRS, and benign skull base tumours were 7.7%, 11.11%, and 7.1%, respectively.

CONCLUSIONS

IGS is of particular benefit in the management of sinonasal polyposis, benign skull base tumours, palliative surgery, and foreign body removal. IGS may avoid trauma to the orbit and anterior skull base and reduces the rate of revision surgeries rendering more meticulous and complete operations possible. We also think it could be helpful for foreign body removal.

Folic acid efficacy as an alternative drug added to sodium valproate in the treatment of acute phase of mania in bipolar disorder: a double-blind randomized controlled trial

OBJECTIVE

The purpose of this study was to evaluate the efficacy of adding folic acid to sodium valproate in the acute phase of mania.

METHOD

Following a double-blind randomized controlled trial, 88 clinically manic patients with diagnosis of type I bipolar disorder (BID) were divided randomly into two groups (case and control). The case group was treated with folic acid and sodium valproate and the control group with sodium valproate and placebo. The severity of mania was assessed using the Young Mania Rating Scale (YMRS) at the beginning and end of the first, second and third weeks of the study.

RESULTS

The case group's mean manic YMRS measurements (SD) before the initiation of therapy and in the first, second and third weeks of treatment were 34.0 +/- 7.7, 26.7 +/- 2.1, 18.1 +/- 2.1 and 7.1 +/- 0.9 respectively. The control group's measurements were 34.7 +/- 3.8, 27.3 +/- 2.3, 20.7 +/- 2.5 and 10.1 +/- 1.1. There was a statistically significant difference in YMRS scaling results between the case and control groups after 3 weeks of treatment (7.1 +/- 0.9 vs. 10.1 +/- 1.1, P = 0.005).

CONCLUSION

Based on our findings, folic acid seems to be an effective adjuvant to sodium valproate in the treatment of the acute phase of mania in patients with bipolar disorder.