Publications

Many changes have occurred in the field of thoracic surgery over the last several years. In this review, we will discuss new diagnostic techniques for lung cancer, innovations in surgery, and major updates on latest treatment options including immunotherapy. All these have significantly started to change our approach toward the management of lung cancer and have great potential to improve the lives of our patients afflicted with this disease.

PURPOSE: To assess the feasibility and safety of using computed tomography (CT) guidance for ablation of prostate cancer in the salvage setting.

MATERIALS AND METHODS: This institutional review board-approved retrospective study of consecutive patients who presented with prostate cancer recurrence and underwent percutaneous CT-guided cryoablation was conducted between July 2020 and September 2022. A total of 18 patients met the inclusion criteria, and a total of 19 procedures were performed. Demographic details; preablation and postablation urinary, rectal, and erectile function assessment; procedure details; and preoperative and postoperative imaging findings and prostate-specific antigen (PSA) values were recorded.

RESULTS: The mean treated tumor size was 15.7 mm ± 6.2. Technical success was achieved in 18 of the 19 procedures (94.7%), with 1 procedure aborted due to inability to obtain a safe plane. The mean follow-up time was 10.0 months (range, 2.3-26.7 months) at the time of manuscript preparation. The mean PSA before ablation was 8.1 ng/mL ± 9.3, and postablation PSA nadir was 2.6 ng/mL ± 4.0 (P = .002). Of the 18 patients who had postoperative imaging, 16 (88.9%) had a complete response (ie, no evidence of residual disease), and 2 (11.1%) patients had residual disease. Overall, 16 (88.9%) of the 18 treated patients demonstrated a PSA and/or imaging response to ablation. Mild adverse events occurred in 4 (22%) of the 18 cases.

CONCLUSIONS: CT-guided cryoablation appears to be a technically feasible, safe option for treating locally recurrent prostate cancer.

In April 2023, the first American Roentgen Ray Society (ARRS) Wellness Summit was held in Honolulu, Hawaii. The Summit was a communal call to action bringing together professionals from the field of radiology to critically review our current state of wellness and reimagine the role of radiology and radiologists to further wellbeing. The in-person and virtual Summit was available free-of-cost to all meeting registrants and included 12 sessions with 44 invited moderators and panelists. The Summit aimed to move beyond simply rehashing the repeated issues and offering theoretical solutions, and instead focus on intentional practice evolution, identifying implementable strategies so that we as a field can start to walk our wellness talk. Here, we first summarize the thematic discussions from the 2023 ARRS Wellness Summit, and second, share several strategic action items that emerged.

PURPOSE: After intubation, a frontal chest radiograph (CXR) is obtained to assess the endotracheal tube (ETT) position by measuring the ETT tip-to-carina distance. ETT tip location changes with neck position and can be determined by assessing the position of the mandible. As the mandible is typically not visualized on standard CXRs, we developed a new protocol where the mandible is seen on the CXR, hypothesizing that it will improve the accuracy of the ETT position assessment.

PATIENTS AND METHODS: Two groups of intubated patients studied (February 9, 2021 to May 4, 2021): CXR taken in either standard or new protocol (visible mandible required). Two observers independently assessed the images for the neck position (neutral, flexed, and extended) based on the mandible position relative to the vertebral bodies. With the mandible absent (ie, neck position unknown), we established terms: "gray zone" (difficult to assess the ETT position adequately) and "clear zone" (confident recommendation to retract, advance, or maintain ETT position). We compared the rate of confident assessment of the ETT in the standard versus the new protocol.

RESULTS: Of 308 patients, 155 had standard CXRs and 153 had the new protocol. Interrater agreements for the distance between the ETT and the carina and mandible height based on vertebral bodies were 0.986 ( P < 0.001) and 0.955 ( P < 0.001), respectively. The mandible was visualized significantly more often ( P < 0.001) with the new protocol (92%; 141/153) than with the standard protocol (21%; 32/155). By visualizing the mandible or the presence of the ETT within the clear zone, a reader could confidently assess the ETT position more often using the new protocol (96.7% vs 51.6%, P < 0.001).

CONCLUSIONS: Mandible visibility on postintubation CXR is helpful for assessing the ETT position. The new protocol resulted in a significant increase in both visualizing the mandible and accurately determining ETT position on postintubation CXR.

PURPOSE: To study the experiences of patients with hepatocellular carcinoma (HCC) contributing to treatment discrepancy in the United States.

MATERIALS AND METHODS: Using Surveillance, Epidemiology, and End Results data from National Cancer Institute (NCI), Medicare (2002-2015) beneficiaries with HCC who completed a Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey were included. Six CAHPS items (3 global scores: global care rating [GCR], primary doctor rating [PDR], and specialist rating [SR]; 3 composite scores: getting needed care [GNC], getting care quickly [GCQ], and doctor communication [DC]) assessed patient experience. Covariates assessed between treated and nontreated groups included patient, disease, hospital, and CAHPS items.

RESULTS: Among 548 patients with HCC, 211 (39%) received treatment and 337 (61%) did not receive treatment. Forty-two percent (GCR), 29% (PDR), 30% (SR), 36% (GNC), 78% (GCQ), and 35% (DC) of patients reported less-than-excellent experiences on the respective CAHPS items. Chronic liver disease (CLD) was present in 52% and liver decompensation (LD) in 60%. A minority of the hospitals were NCI-designated cancer centers (47%), transplant centers (27%), and referral centers (9%). On univariable analysis, patients with at least a high school degree (odds ratio [OR], 1.9), admittance to a ≥400-bed hospital (OR, 2.7), CLD (OR, 3.0), or LD (OR, 1.7) were more likely to receive treatment, whereas older patients (≥75 years) (OR, 0.5) were less likely to receive treatment. On multivariable, patients with CLD (OR, 6.8) and an excellent experience in GNC with a specialist (OR, 10.6) were more likely to receive treatment.

CONCLUSIONS: HCC treatment discrepancy may be associated with patient-related factors, such as lack of specialist care (GNC), and disease-related factors, such as absence of underlying CLD.

PURPOSE: After a slow and challenging transition period, peer learning and improvement (PLI) is now being more widely adopted by practices as an option for continuous personal and practice performance improvement. In addition to gaps that exist in the understanding of what PLI is and how it should be practiced, wide variation exists in how the process is implemented, administered, how outcomes are measured, and what strategies are employed to engage radiologists. This report aims to describe lessons learned from our 20-year experience with the design, implementation, and continuous improvements of a PLI program in a large academic program.

METHODS: Since initial implementation in 2004, an oversight team prospectively documented iterative process improvements and data submission trends in our PLI process. Process data included strategies for engaging radiologists in the PLI process (fostering case submission, PLI meeting participation), steps for achieving regulatory compliance, and template content for facilitating the value and impact of PLI meetings (case analysis, review of contributing factors, identification of improvement opportunities).

RESULTS: Submission trends, submitted case content, and improvement opportunities varied by clinical section. Process improvements that fostered engagement included closing the loop with participants, expanding criteria for case submission beyond interpretive disagreements (e.g., great pickups, near misses), minimizing impacts to workflow, and using evidence-based templates for case and contributor categorization, bias analysis, and identification of improvement opportunities.

CONCLUSION: Implementing an effective PLI program requires sustained communication, education, and continuous process improvement. While PLI can certainly lead to process and individual performance improvement, the program requires trained champions, designated time, effort, resources, education, and patience to be effectively implemented.

Approach to imaging ischemia in women Coronary artery disease in women tends to have a worse short- and long-term prognosis relative to men and remains the leading cause of mortality worldwide. Both clinical symptoms and diagnostic approach remain challenging in women due to lesser likelihood of women presenting with classic anginal symptoms on one hand and underperformance of conventional exercise treadmill testing in women on the other. Moreover, a higher proportion of women with signs and symptoms suggestive of ischemia are more likely to have nonobstructive coronary artery disease (CAD) that requires additional imaging and therapeutic considerations. New imaging techniques such as coronary computed tomography (CT) angiography, CT myocardial perfusion imaging, CT functional flow reserve assessment, and cardiac magnetic resonance imaging carry substantially better sensitivity and specificity for the detection of ischemia and coronary artery disease in women. Familiarity with various clinical subtypes of ischemic heart disease in women and with the major advantages and disadvantages of advanced imaging tests to ensure the decision to select one modality over another is one of the keys to successful diagnosis of CAD in women. This review compares the 2 major types of ischemic heart disease in women - obstructive and nonobstructive, while focusing on sex-specific elements of its pathophysiology.

OBJECTIVES: To determine the factors that affect successful ultrasound-guided biopsy of liver lesions and build a model predicting feasibility of US-guided liver biopsy.

METHODS: This is IRB-approved HIPAA-compliant retrospective review of consecutive ultrasound-guided targeted liver biopsies performed or attempted between 1/2018 and 9/2020 at a single tertiary academic institution with a total of 501 patients included. Mann-Whitney and chi-square tests were used to compare continuous and categorical variables, respectively. Logistic regression model was built to predict feasibility of successful ultrasound-guided biopsy.

RESULTS: Liver lesion biopsy was successfully performed with US guidance in 429/501 (86%) patients. Lesions not amenable for US biopsy were smaller (median size 1.6 cm vs 3.3 cm, p < 0.0001) and deeper within the liver (median depth 9.0 cm vs 5.8 cm, p < 0.0001). The technical success rate was lowest for lesions in segment II (40/53, 75%), while lesions in segment IVb (87/91, 96%) had highest success rate (p < 0.003). US targeting in patients with 1 or 2 lesions was less feasible than in patients with 3 or more lesions, 126/180 (70%) vs. 303/321 (94%), (p < 0.0001). Model including lesion size, depth, location, and number of lesions predicts feasibility of US-guided biopsy with Area under the ROC curve (AUC) = 0.92.

CONCLUSIONS: Linear logistic regression model that includes lesion size, depth and location, and number of lesions is highly successful in predicting feasibility of ultrasound-guided biopsy for liver lesions. Smaller lesions, deeper lesions, and lesions in segment II and VIII in patients with less than 3 lesions were less feasible for ultrasound-guided biopsy of liver lesions.

PURPOSE: To characterize intratumoral immune cell trafficking in ablated and synchronous tumors following combined radiofrequency ablation (RFA) and systemic liposomal granulocyte-macrophage colony stimulation factor (lip-GM-CSF).

METHODS: Phase I, 72 rats with single subcutaneous R3230 adenocarcinoma were randomized to 6 groups: a) sham; b&c) free or liposomal GM-CSF alone; d) RFA alone; or e&f) combined with blank liposomes or lip-GM-CSF. Animals were sacrificed 3 and 7 days post-RFA. Outcomes included immunohistochemistry of dendritic cells (DCs), M1 and M2 macrophages, T-helper cells (Th1) (CD4+), cytotoxic T- lymphocytes (CTL) (CD8+), T-regulator cells (T-reg) (FoxP3+) and Fas Ligand activated CTLs (Fas-L+) in the periablational rim and untreated index tumor. M1/M2, CD4+/CD8+ and CD8+/FoxP3+ ratios were calculated. Phase II, 40 rats with double tumors were randomized to 4 groups: a) sham, b) RFA, c) RFA-BL and d) RFA-lip-GM-CSF. Synchronous untreated tumors collected at 7d were analyzed similarly.

RESULTS: RFA-lip-GMCSF increased periablational M1, CTL and CD8+/FoxP3+ ratio at 3 and 7d, and activated CTLs 7d post-RFA (p<0.05). RFA-lip-GMSCF also increased M2, T-reg, and reduced CD4+/CD8+ 3 and 7d post-RFA respectively (p<0.05). In untreated index tumor, RFA-lip-GMCSF improved DCs, M1, CTLs and activated CTL 7d post-RFA (p<0.05). Furthermore, RFA-lip-GMSCF increased M2 at 3 and 7d, and T-reg 7d post-RFA (p<0.05). In synchronous tumors, RFA-BL and RFA-lip-GM-CSF improved DC, Th1 and CTL infiltration 7d post-RFA.

CONCLUSION: Systemic liposomal GM-CSF combined with RFA improves intratumoral immune cell trafficking, specifically populations initiating (DC, M1) and executing (CTL, FasL+) anti-tumor immunity. Moreover, liposomes influence synchronous untreated metastases increasing Th1, CTL and DCs infiltration.