Publications

BACKGROUND AND PURPOSE: Neuromix is a fast, motion robust multi-contrast sequence capable of providing all diagnostic contrasts in ∼3.5 minutes. However, more evaluation is needed across the various contrasts compared to gold standard, optimized sequences routinely used in the clinic. The goal of this study was to prospectively determine how NeuroMix performs in the clinical setting compared to routine clinical MRI.

METHODS: NeuroMix and routine clinical MRI sequences were acquired on a 3 Tesla clinical scanner for 39 patients clinically indicated for brain MRI. Three radiologists were asked to assess the diagnostic confidence of NeuroMix compared to the routine MRI using a series of questions. Signal-to-noise and contrast-to-noise ratios (SNR and CNR) were assessed for NeuroMix. Fleiss' free-marginal multirater kappa was calculated for the qualitative assessment performed by the radiologists.

RESULTS: Radiologists were comfortable substituting or reading some of the NeuroMix sequences in place of the corresponding conventional sequence for some contrasts, including diffusion-weighted imaging, single-shot T2, and susceptibility-weighted imaging. The image quality, SNR, and CNR allowed the radiologists to visualize anatomy and pathology on NeuroMix images. There was no significant difference between coefficient of variation for the apparent diffusion coefficient maps (p = .084).

CONCLUSIONS: Analysis revealed both positives and some pitfalls of NeuroMix. However, these results indicate Neuromix as having the capability to be a backup sequence in case artifacts are present in routine sequences, or potentially a replacement for some contrasts altogether.

Hepatocellular carcinoma is a leading and increasing contributor to cancer-related death worldwide. Recent advancements in both liver-directed therapies in the form of yttrium-90 (90Y) radioembolization (RE) and systemic therapy in the form of immune checkpoint inhibitors (ICI) have expanded treatment options for patients with an otherwise poor prognosis. Despite these gains, ICIs and 90Y-RE each have key limitations with low objective response rates and persistent hazard of out-of-field recurrence, respectively, and overall survival remains low. However, each therapy's strength may mitigate the other's weakness, making them potentially ideal partners for combination treatment strategies. This review discusses the scientific and clinical rationale for combining 90Y-RE with ICIs, highlights early clinical trial data on its safety and effectiveness, and proposes key issues to be addressed in this emerging field. With optimal strategies, combination therapies can potentially result in increasing likelihood of durable and curative outcomes in later stage patients.

BACKGROUND: Lymphatic drainage from the arm may be altered after axillary lymph node dissection (ALND). Understanding these alterations is important as they may change standard surgical and radiation treatment in recurrent breast cancer or upper extremity skin cancers, including melanoma.

METHODS: Utilizing a single-institution planar and single photon emission computed tomography/computed tomography lymphoscintigraphy database, we identified patients with a diagnosis of upper extremity cutaneous melanoma from 2008 to 2023 who previously underwent ALND for cancer treatment and did not develop upper extremity cancer-related lymphedema. ALND patients were matched to control patients presenting with cutaneous melanomas at the same anatomic sites. Sentinel lymph nodes (SLNs) were compared between both groups.

RESULTS: Of 3628 upper extremity melanoma cutaneous patients, 934 met inclusion criteria, including 22 ALND and 912 control patients. Level I axillary SLN drainage was observed in 98% of controls and 27% of ALND patients (p < 0.001). Level II axillary SLN drainage was observed in 3% of controls and 27% of ALND patients (p < 0.001). Level III axillary SLN drainage was observed in 1% of controls and 32% of ALND patients (p < 0.001). Epitrochlear SLN drainage was observed in 9% of controls and 32% of ALND patients, respectively (p < 0.046). Brachial SLN drainage was observed in 4% of controls and 23% of ALND patients (p < 0.001).

CONCLUSIONS: Distinct changes in functional lymphatic drainage were seen between the arms of patients who previously underwent ALND versus control patients. Levels II and III axillary, epitrochlear, and brachial nodes are possible sites of metastatic disease that should be considered in patients with a prior ALND.

The objective of this study was to measure the contemporary patency rates and frequency of interventions required for arteriovenous fistula (AVF) care in a representative US population of patients with end-stage kidney disease, including by age, race, and gender. All Medicare beneficiaries aged >20 years who underwent AVF graft creation for end-stage kidney disease between 2017 and 2019 were included for analysis. The primary end points included primary patency, primary assisted patency, postintervention patency, and fistula functionality up to 1 year after AVF placement. The secondary end point included admission for an associated adverse event after AVF creation. Multivariate analysis of patency rates was also assessed. Of 43,457 patients included in the analysis, the cumulative primary patency at 90 days was 68.4% and at 1 year, 31.5%. At 1 year, the primary assisted patency rate, postintervention patency, and fistula use were 70.4%, 30.2%, and 59.1%, respectively. There was no difference in primary patency rates when comparing age groups (age 40 to 59 years: hazard ratio [HR] 1.01, 95% confidence interval [CI] 0.95 to 1.06, p = 0.84 or age ≥60 years: HR 0.99, 95% CI 0.93 to 1.04, p = 0.61) with the reference of age group 20 to 39 years. Women were at greater risk of experiencing primary patency failure than were men (HR 1.16, 95% CI 1.14 to 1.20, p <0.001), and Black patients were at greater risk of experiencing primary patency failure than were White patients (HR 1.34, 95% CI 1.31 to 1.38, p <0.001). The cumulative incidence of admissions for adverse events was 32.6% at 1 year. In conclusion, our findings suggest that the real-world AVF patency rates remain low, with disproportionately low rates in women and Black patients.

Our study presents cases demonstrating the technique and safety of percutaneous occlusion of adult patients with partial anomalous pulmonary venous return (PAPVR). PAPVR is a rare condition that is traditionally treated surgically. Percutaneous interventions are rarely reported. Most patients with PAPVR present in youth and are surgical candidates. In nonsurgical candidates or those who prefer a percutaneous approach, there are little available data to guide therapy. Patients with PAPVR and indications for intervention were treated with percutaneous techniques to occlude anomalous venous return and relieve the hemodynamic effects of these anomalies. Several different percutaneous techniques were used, sometimes in tandem to achieve occlusion. Percutaneous closure was achieved successfully in 3 cases, with improvement in symptoms and in hemodynamic status. A total of 2 patients achieved positive remodeling in right chamber sizes. In conclusion, percutaneous occlusion of PAPVR is feasible, with a multitude of transcatheter options available. This represents a novel approach to the adult patient with PAPVR, specifically, those without a surgical option. Condensed Abstract: Partial anomalous pulmonary venous return is a rare congenital condition, which is traditionally treated surgically. Adult patients with congenital heart disease are potentially nonsurgical candidates and, as such, benefit from percutaneous approaches. Our study describes the safety and feasibility of percutaneous closure of partial anomalous pulmonary venous return and the positive impact on hemodynamic and chamber measures.

PURPOSE: Ultrasound-guided fine needle aspiration (FNA) is a very low-risk procedure. Despite this, there remains great variability in the use of protective equipment. Given the monetary and environmental costs of protective equipment, the difference in infection rates with full versus limited protective equipment was assessed.

METHODS: A total of 857 consecutive patients were retrospectively reviewed after undergoing thyroid FNAs at the main hospital and outpatient clinic site performed from 12/1/2020 to 11/30/2023. The hospital site operated with full protective equipment (bouffant, sterile gown, sterile gloves, and full body sterile drape), and the outpatient site with limited (sterile gloves, limited sterile paper drape) protective equipment. Two patients were excluded as no procedure was performed. Review for signs of infection within 30 days of procedure was performed using medical records, which was blinded to the extent of protective equipment utilization.

RESULTS: No infections were identified in either group, with 0/629 (0%, 95%CI 0-1%) in the full protective equipment group vs. 0/226 (0%, 95%CI 0-2%) in the limited protective equipment group. There was no statistically significant difference in infection rate between full and limited protective equipment use in thyroid FNA in the included 855 procedures (95%CI 0-1%). Two patients out of 629 (0.3%) in the full protective equipment group developed mild allergic reaction to topical antiseptic. The 226 procedures with limited protective equipment represent a saving of at least 204,530 g of CO2 equivalents, equivalent to driving a car for almost 3000 miles.

CONCLUSION: Reducing the extent of protective equipment does not adversely affect the infection rate in thyroid FNAs. Given the inherent costs involved in the procurement and waste of protective equipment, reducing protective equipment use is warranted to reduce both the monetary and environmental impacts of waste.

BACKGROUND: Quantitative susceptibility mapping (QSM) is an emerging MRI technique with multiple clinical applications. As tissue susceptibility cannot be directly measured using MRI, QSM imaging techniques must indirectly compute susceptibility values, requiring regularization methods. CSF is a popular choice for regularization due to its near water susceptibility in healthy controls. However, the impact of pus, elevated protein, or blood dissolved in CSF on QSM regularization is not well defined.

OBJECTIVE: This study aimed to investigate the effects of intracranial hemorrhage (ICH) on selecting CSF as reference for QSM imaging.

MATERIALS AND METHODS: A total of 87 subjects, 53 with ICH (5 intraventricular, 19 subarachnoid, 27 both, and 2 intraparenchymal only) and 37 without hemorrhage (27 with MS, 10 without MS), were included in this study. Imaging was performed using 3D multiecho gradient echo, FLAIR, and multiecho complex total field inversion (mcTFI) at 3 T. McTFI with and without CSF zero-referencing regularization was generated from the 3DMEGRE data and reviewed with FLAIR images. Regions of hemorrhagic (H+) and nonhemorrhagic (H-) CSF were manually selected in reference to head CT and FLAIR images by a PGY III diagnostic radiology resident and Certificate of Added Qualification-certified neuroradiologist with 10 years' experience. Paired Student t test and one-way ANOVA were used with post hoc multicomparisons. A P value <0.05 was considered statistically significant.

RESULTS: Areas of H- CSF were noted to have higher regularized QSM values in subjects with ICH relative to subjects without. Unregularized H- QSM values were also noted to have a systematically higher value in ICH subjects relative to subjects without blood. Subjects with MS and without ICH did not show significant difference in H- CSF regularized or unregularized QSM values.

CONCLUSIONS: QSM values of areas suggested to not have hemorrhage on other imaging showed significantly higher QSM values in ICH subjects relative to subjects without ICH. Additionally, areas of hemorrhage did not show significant QSM value difference between regularized and unregularized QSM images. These findings suggest that, in subjects with any area of ICH, QSM values for no-hemorrhagic areas may be significantly altered using CSF regularization relative to subjects without ICH, with implications for intra- and intersubject QSM value analysis.

PURPOSE: To evaluate the representation of women as speakers at U.S. radiology annual scientific meetings (ASM).

METHODS: This retrospective study analyzed speaker demographic data from the Society of Interventional Radiology (SIR) and American Roentgen Ray Society (ARRS) ASM between 2019 and 2022. Speaker gender was identified through publicly available profiles, and the percentage of female speakers was calculated for each year. Statistical significance of trends was determined using chi-squared tests, and linear regression analysis was employed to assess trends and to predict future representation.

RESULTS: At the SIR ASM, female representation increased from 20.0 % (67 of 334 speakers) in 2019 to 26.5 % (90 of 340 speakers) in 2022. Chi-squared tests showed a statistically significant increase when adjusted for the percentage of female membership. At the ARRS ASM, female representation fluctuated, dropping from 36.6 % (104 of 284 speakers) in 2019 to 17.7 % (43 of 243 speakers) in 2020, then rising to 48.5 % (190 of 392 speakers) in 2022. A chi-squared test revealed significant variation in female representation across the years (p < 0.0001).

CONCLUSION: While both ASM showed an overall positive trend in female speaker representation, SIR demonstrated consistent increases, whereas ARRS exhibited significant fluctuations. Continued efforts in advocacy and targeted interventions are needed to sustain progress and address the gender gap in radiology.

This summary of the proceedings of the 2023 ACR Intersociety Meeting discusses the seven most important challenges facing radiology today: declining reimbursement, corporatization and consolidation, inadequate labor force, imaging appropriateness, burnout, turf wars with nonphysicians, and workflow efficiency. Participants in the Intersociety Summer Conference-2023 focused their effort on identifying potential solutions given how critical these topics are to the sustainability of the profession.