Azzam Khankan

Endoscopic extraction of vascular embolization coils that have migrated into the biliary tract in a liver transplant recipient

Hepatic artery pseudoaneurysm (HAA) is a rare vascular complication of liver transplantation. Minimally invasive radiological interventions are generally considered before seeking surgical treatment of HAA. Coil embolization of the aneurysmal sac and or exclusion of pseudoaneurysm by deploying a stent over the aneurysm are effective interventions to control hemobilia arising from the HAA. Migration of coils inside the bile duct is a rarely reported complication in post‐hepatic transplantation. Treatment options remain largely unexplored due to the rarity of its occurrence. Endoscopic retrograde cholangiographic removal of migrated vascular coils in the common bile duct following embolization of HAA has not been described in a liver transplant setting. We report a liver transplant recipient who underwent uneventful and successful endoscopic removal of migrated coils into the bile duct.

Image-guided percutaneous transthoracic biopsy in lung cancer — Emphasis on CT-guided technique

Image-guided percutaneous transthoracic core biopsy especially with CT guidance is playing an increasing role in the diagnosis and management of lung cancer. The recent advances in the specific chemotherapy and novel targeted therapy and the increasing need for specific diagnosis of tumor histopathologic subtypes have direct impact on the radiologists performing lung biopsy and important implications for the biopsy technique. Close cooperation between radiologists and referring physicians with understanding of the technical aspects of the biopsy procedure can help clinicians make appropriate referrals for this procedure and understand the significance and limitations of the results. Additionally, the appropriate management of complications can limit morbidity related to the biopsy procedure.

Diagnosis and Predictive Molecular Analysis of Non–Small-Cell Lung Cancer in the Africa-Middle East Region: Challenges and Strategies for Improvement

The identification of tumor biomarkers provides information on the prognosis and guides the implementation of appropriate treatment in patients with many different cancer types. In non-small cell lung cancer (NSCLC), targeted treatment plans based on biomarker identification have already been used in the clinic. However, such predictive molecular testing is not currently a universally used practice. This is the case, in particular, in developing countries where lung cancer is increasingly prevalent. In September 2012 and November 2013, a committee of 16 lung cancer experts from Africa and the Middle East met to discuss key issues related to diagnosis and biomarker testing in NSCLC and the implementation of personalized medicine in the region. The committee identified current challenges for effective diagnosis and predictive analysis in Africa and the Middle East. Moreover, strategies to encourage the implementation of biomarker testing were discussed. A practical approach for the effective diagnosis and predictive molecular testing of NSCLC in these regions was derived. We present the key issues and recommendations arising from the meetings.

Guidelines for multimodality radiological staging of lung cancer

Lung cancer is among the most common type of cancers and is a leading cause of cancer-related deaths with smoking representing the leading risk factor. It is classified into non-small cell lung cancer (NSCLC) representing 70-80% of cases and small cell lung cancer (SCLC) which has neuroendocrine properties with poor outcome. Staging of NSCLC is based on the TNM classification system while SCLC was usually classified into limited and extensive disease, though the use of TNM staging system for SCLC is recommended. Imaging studies are used to determine the pre-operative staging of lung cancer. Accurate radiological staging is essential to determine tumor resectability as well as to avoid futile surgeries and to assess patients outcome. Moreover, radiological examinations are used for the evaluation of tumor response to treatment. This manuscript will review the utilization of imaging studies in the management of lung cancer based on the most recent guidelines by the National Comprehensive Cancer Network (NCCN).

Gastroesophageal stenting for the management of post sleeve gastrectomy leak. A single institution experience

Objectives To retrospectively evaluate the effectiveness of gastroesophageal stenting for post sleeve gastrectomy staple line leaks using removable self-expandable stents. Methods Between April 2012 and June 2015, 12 consecutive patients (6 males) with mean age of 34 years: (21-38 years) presented with staple line leak 1-8 weeks after the operation (mean 2.8 weeks). Patients underwent gastroesophageal stenting by interventional radiology. A total of 23 stents were deployed with mean length of 17.8 cm (7-24 cm) and mean diameter 25.6 mm (18-36 mm). Stent re-insertion was needed in 7 patients (9 procedure), while 6 patients required percutaneous collection drainage and 3 patients required endoscopic glue injection with clipping. Two stent removal procedures were carried out under endoscopic visualization after failed stent capture under fluoroscopy, while the remaining stents were successfully removed by interventional radiology. Results Stent placement was technically successful in all patients. Stent migration occurred in 6 patients (50%). There is a tendency for stent migration with shorter stent length (R= -0.557, p=0.008). The mean duration of stenting was 60.5 days (14-137 days). All patients underwent stent removal and resumed oral intake with no recurrence of leak at a mean follow up time of 190 days (14-410 days). Complications included gastrointestinal bleeding (n=1), proximal esophageal stricture (n=1) and stent occlusion (n=1). Conclusion Gastroesophageal stenting as a primary measure after diagnosis of early post sleeve gastrectomy leak appears to offer a safe and effective alternative option in obviating repeat surgical interventions. Minimally invasive interventions may still be required for the management of persistent leak.

Percutaneous Approach for Removal of a Migrated Cystogastric Stent from a Pancreatic Pseudocyst: A Case Report and Review of the Literature

Stent migration into pancreatic pseudocysts during endosonographic (EUS) cystogastrostomy is a relatively rare complication. The migrated stent may induce, if it remains within the body, infection and perforation. Therefore, retrieval and/or re-stenting is necessary. Endoscopic retrieval is commonly attempted first. However, it is technically challenging and largely dependent on the skill of the endoscopists; if retrieval is unsuccessful, surgery is usually carried out. We report a case of stent migration into a pancreatic pseudocyst that was retrieved with a percutaneous approach under imaging guidance using a simple technique with available devices. A technique that enhances the role of interventional radiology in the management of this rare complication.

Common Complications of Nonvascular Percutaneous Thoracic Interventions: Diagnosis and Management

Percutaneous thoracic interventions are among the most common procedures in todays medical practice. From the simple placement of a pleural drain to the ablation of lung tumors, the advent of image guidance has revolutionized minimally invasive procedures and has allowed for the introduction of new techniques and widened the range of indications. It is therefore imperative to understand the complications associated with these interventions and their management. This article illustrates the common complications associated with these interventions and highlights the relative safety of these interventions.

Demystifying Cyberknife stereotactic body radiation therapy for interventional radiologists

Stereotactic body radiation therapy (SBRT) using CyberKnife system is a relatively new radiation therapy that has demonstrated feasibility, safety, and efficacy with a high local control of various extracranial unresectable primary cancer and oligometastasis. It involves accurate delivery of very high dose of radiation to the target or tumor volume with high precision and conformity, while minimizing the radiation exposure of nontargeted tissue. Radiopaque fiducial markers (FMs) implantation in and around the tumors is required to track the selected tumor during CyberKnife SBRT, especially in those organs moving with respiration. They act as internal radiographic landmarks that maintain a fixed relationship within the tumor and with each other. Although their implantation can be technically demanding, it can be performed using various techniques with varying success; however, percutaneous implantation under image guidance by interventional radiologists is the most common method. Close collaboration between interventional radiologists and radiation oncologists with understanding of the technical aspects of CyberKnife SBRT and FMs implantation has important implications for optimal delivery of therapy and direct impact on the interventional radiology practice in selected patients proposed for CyberKnife SBRT.

Interventional oncology: A snapshot of expanding practice

Interventional oncology (IO) was a minor part of interventional radiology. However, with the development of novel technologies and introduction of innovative therapeutics with dramatic transformations in the practice of oncology, IO is facing challenges in adopting and responding to these new changes to maintain its integral role and maximize its potentials in the efficient management of patients with cancer. In this snapshot, some of the novel therapeutic approach principles relevant to IO practice will be explained briefly.

Adequacy of Transthoracic Needle Biopsy Samples in the Diagnosis of a Peripheral Lung Lesion – Comparing Success Rates of Various Imaging Modalities

The aim of the study was to test whether a difference in the imaging modality (CT, Fluoroscopy, or Ultrasound) would result in a higher biopsy success rate for the diagnosis of lung cancer. A total of 144 transthoracic needle biopsies performed under guidance of different imaging modalities were retrospectively reviewed at King Abdulaziz Medical city in Riyadh between 2008 and 2012. A biopsy was counted a success whenever a definitive diagnosis could be achieved. CT guided biopsies revealed 51 successes out of 86 total samples, fluoroscopy guided biopsies revealed 8 successes out of 20 total samples, while for ultrasound guided biopsies, 30 successes out of 38 biopsies gave a definitive diagnosis. Comparing CT guided biopsies vs. Fluoroscopy guided biopsies, we got a p-value of 0.1884 which is clinically insignificant, 95% Confidence Interval [-0.07628, 0.46233]. On comparison of CT guided biopsies vs. ultrasound guided biopsies the p-value was 0.05558 which is also clinically insignificant, 95% Confidence Interval [-0.38150, -0.011399]. When ultrasound guided biopsies were compared to the fluoroscopy guided biopsies a p-value of 0.007461 < 0.025 was achieved which is clinically highly significant, 95% Confidence Interval [-0.38150, -0.011399]. It was determined with 95% confidence that there is a clinically significant difference (p-value of 0.007461) between success rates of Fluoroscopy guided biopsies and ultrasound guided biopsies, but not between the other pairs of modalities. Further investigations with larger sample size are warranted to compare the efficacy of fluoroscopy and ultrasound based imaging modalities for transthoracic needle biopsy.