David R. Sopko

Small renal mass biopsy--how, what and when: report from an international consensus panel.

To discuss the use of renal mass biopsy (RMB) for small renal masses (SRMs), formulate technical aspects, outline potential pitfalls and provide recommendations for the practicing clinician. The meeting was conducted as an informal consensus process and no scoring system was used to measure the levels of agreement on the different topics. A moderated general discussion was used as the basis for consensus and arising issues were resolved at this point. A consensus was established and lack of agreement to topics or specific items was noted at this point. Recommended biopsy technique: at least two cores, sampling different tumour regions with ultrasonography being the preferred method of image guidance. Pathological interpretation: ‘non‐diagnostic samples’ should refer to insufficient material, inconclusive and normal renal parenchyma. For non‐diagnostic samples, a repeat biopsy is recommended. Fine‐needle aspiration may provide additional information but cannot substitute for core biopsy. Indications for RMB: biopsy is recommended in most cases except in patients with imaging or clinical characteristics indicative of pathology (syndromes, imaging characteristics) and cases whereby conservative management is not contemplated. RMB is recommended for active surveillance but not for watchful‐waiting candidates. We report the results of an international consensus meeting on the use of RMB for SRMs, defining the technique, pathological interpretation and indications.

Bronchial Artery Embolization for Hemoptysis

Bronchial artery angiography with embolization has become a mainstay in the treatment of hemoptysis. Major complications are rare and immediate clinical success defined as cessation of hemorrhage ranges in most series from 85% to 100%, although recurrence of hemorrhage ranges from 10% to 33%. Bronchial artery embolization offers a minimally invasive procedure for even the most compromised patient serving as first-line treatment for hemorrhage as well as providing a bridge to more definitive medical or surgical intervention focused upon the etiology of the hemorrhage. The aim of this article is to summarize the etiologies, pathophysiology, and the diagnostic and management strategies of hemoptysis as related to bronchial artery embolization. In addition, the techniques of arteriography and embolization as well as associated procedural outcomes and complications are delineated.

Percutaneous Cryoablation of Renal Lesions With Radiographic Ice Ball Involvement of the Renal Sinus: Analysis of Hemorrhagic and Collecting System Complications

OBJECTIVE The purpose of this study was to determine the incidence of collecting system and hemorrhagic complications resulting from CT-guided percutaneous cryoablation of renal tumors in which the radiographic ice ball abuts or involves the renal sinus. MATERIALS AND METHODS From November 2005 through July 2009 at our institution, we performed 129 CT-guided percutaneous cryoablation procedures on 107 patients (mean age, 64 years) with renal masses suspicious of being renal cell carcinoma. Radiographic ice balls that abutted or overlapped the renal sinus were classified as central; the other lesions were classified as noncentral. Medical records and follow-up images were retrospectively reviewed for hemorrhage requiring intervention and for evidence of collecting system injury. The mean follow-up period was 9.3 months. RESULTS The radiographic ice ball was classified as central in 67 cases. In these central ablations, the mean sinus involvement was 6.2 mm (range, 0-19 mm), 41 ice balls overlapping the renal sinus by 6 mm or more (mean, 9.4 mm). No cases of collecting system injury were identified for any ablation. Overall, there was only one hemorrhagic complication requiring intervention, and it occurred in a noncentral ablation. CONCLUSION CT-guided percutaneous cryoablation of renal masses with ice ball overlap of the renal sinus resulted in no cases of collecting system injury or serious hemorrhagic complications in our series.

Emergent ureteric stent vs percutaneous nephrostomy for obstructive urolithiasis with sepsis: patterns of use and outcomes from a 15-year experience.

To characterize the use of emergent JJ ureteric stent placement and percutaneous nephrostomy (PCN) for patients with obstructive urolithiasis with sepsis, and to determine whether outcomes differ between the two treatment methods.

Radiation dose from 3D rotational X-ray imaging: organ and effective dose with conversion factors

The purpose of this study was to measure organ doses and the effective dose (ED) using a three-dimensional rotational X-ray (3D-RX) system and to determine the ED conversion factor from the dose area product (DAP) for skull, spine and biliary protocols. A commercial 3D-RX imaging system was used to simulate the protocols with the adult female anthropomorphic phantom. Twenty MOSFET detectors were used to measure the absorbed doses at various organ locations. The ED was calculated for each protocol and the corresponding DAP was obtained. The skin dose was the highest for all the protocols. The second highest organ doses were those of the brain for the skull, the intestine for the spine and the kidney for the biliary protocol. The ED was 0.4-0.9, 4.2-8.4 and 3.2-4.6 mSv, and the ED conversion factor was 0.06-0.09, 0.18-0.31 and 0.13-0.23 mSv Gy(-1) cm(-2) for each protocol, respectively. This data may be used to estimate the patient ED for those protocols in the 3D-RX.

Percutaneous interventions on the hemodialysis reliable outflow vascular access device.

PURPOSE To determine the outcomes of percutaneous interventions for prolonging the patency of the Hemodialysis Reliable Outflow (HeRO) device. MATERIALS AND METHODS Between January 2007 and August 2011, 73 percutaneous interventions were performed on 26 HeRO devices in 25 patients. The graft was implanted in the upper arm with the outflow catheter tip in the superior vena cava or right atrium. Procedural reports, angiographic images, and clinical notes were retrospectively reviewed. The primary and secondary patency rates after intervention were calculated using the Kaplan-Meier method. RESULTS The mean time from HeRO implantation to initial dysfunction or thrombosis was 171 days. In 60 (82%) procedures, the HeRO device was thrombosed. An intragraft stenosis was the most common lesion identified (59%; n = 43) followed by an arterial anastomosis stenosis identified in 18% (n = 13). In 22% (n = 16) of procedures in which the HeRO device was thrombosed, an underlying cause was not identified after thrombectomy. The 3-, 6-, and 12-month primary patency rates after intervention were 47%, 37%, and 26% for first-time interventions. The secondary patency rates were 80%, 70%, and 64%. The only complication was pulmonary embolism resulting in death 2 days after HeRO thrombectomy. CONCLUSIONS Percutaneous interventions on thrombosed and failing HeRO devices yielded acceptable primary and secondary patency rates after intervention in these patients with few, if any, alternatives for hemodialysis access.

Hepatic Venous Pressure Measurements: Comparison of End-Hole and Balloon Catheter Methods

PURPOSE To determine the difference in hepatic venous pressures measured with the use of an end-hole diagnostic catheter versus a balloon catheter. MATERIALS AND METHODS A total of 92 patients underwent transjugular hepatic venous pressure measurements with a 5-F diagnostic end-hole catheter and a balloon catheter, with the catheter type used initially determined randomly. With both catheters, free and wedged systolic, diastolic, and mean pressures were collected. Hepatic venous pressure gradients were calculated from each pressure set. Eighty-five patients (92%) also underwent concurrent transjugular biopsy after pressures were recorded. Demographic, histologic, and specific procedural information were also collected. RESULTS The study included 47 men and 45 women, with a mean age of 52.7 years (range, 19-84 y). For the entire population, there were statistically significant differences in mean measurements between the two catheters in wedged systolic (P = .004), diastolic (P = .021), and mean (P = .036) pressures. However, the differences between the means were only 0.783, 0.609, and 0.207 mm Hg, respectively. A subanalysis based on histologic stage revealed no difference between catheter types for normal or cirrhotic livers, but a significant (P = .017) difference in systolic wedged pressure (absolute difference of 0.67 mm Hg) in patients with mild to moderate fibrosis (stages 1-3). In all differences, the balloon catheter had the greater pressure reading. CONCLUSIONS There was a significant difference in wedged pressure measurements between the two catheter systems in the overall population and among patients with a histologic grade indicating fibrosis. However, the absolute value differences between the two systems were comparatively small (< 1 mm Hg).

Pilot Evaluation of Angiogenesis Signaling Factor Response after Transcatheter Arterial Embolization for Hepatocellular Carcinoma

Purpose To identify changes in a broad panel of circulating angiogenesis factors after bland transcatheter arterial embolization (TAE), a purely ischemic treatment for hepatocellular carcinoma (HCC). Materials and Methods This prospective HIPAA-compliant study was approved by the institutional review board. Informed written consent was obtained from all participants prior to entry into the study. Twenty-five patients (21 men; mean age, 61 years; range, 30-81 years) with Liver Imaging Reporting and Data System category 5 or biopsy-proven HCC and who were undergoing TAE were enrolled from October 15, 2014, through December 2, 2015. Nineteen plasma angiogenesis factors (angiopoietin 2; hepatocyte growth factor; platelet-derived growth factor AA and BB; placental growth factor; vascular endothelial growth factor A and D; vascular endothelial growth factor receptor 1, 2, and 3; osteopontin; transforming growth factor β1 and β2; thrombospondin 2; intercellular adhesion molecule 1; interleukin 6 [IL-6]; stromal cell-derived factor 1; tissue inhibitor of metalloproteinases 1; and vascular cell adhesion molecule 1 [VCAM-1]) were measured by using enzyme-linked immunosorbent assays at 1 day, 2 weeks, and 5 weeks after TAE and were compared with baseline levels by using paired Wilcoxon tests. Tumor response was assessed according to modified Response Evaluation Criteria in Solid Tumors (mRECIST). Angiogenesis factor levels were compared between responders and nonresponders by mRECIST criteria by using unpaired Wilcoxon tests. Results All procedures were technically successful with no complications. Fourteen angiogenesis factors showed statistically significant changes following TAE, but most changes were transient. IL-6 was upregulated only 1 day after the procedure, but showed the largest increases of any factor. Osteopontin and VCAM-1 demonstrated sustained upregulation at all time points following TAE. At 3-month follow-up imaging, 11 patients had responses to TAE (complete response, n = 6; partial response, n = 5) and 11 patients were nonresponders (stable disease, n = 9; progressive disease, n = 2). In nonresponders, the percent change in IL-6 on the day after TAE (P = .033) and the mean percent change in osteopontin after TAE (P = .024) were significantly greater compared with those of responders. Conclusion Multiple angiogenesis factors demonstrated significant upregulation after TAE. VCAM-1 and osteopontin demonstrated sustained upregulation, whereas the rest were transient. IL-6 and osteopontin correlated significantly with radiologic response after TAE.

Randomized Controlled Trial of Octyl Cyanoacrylate Skin Adhesive versus Subcuticular Suture for Skin Closure after Implantable Venous Port Placement

PURPOSE To compare early outcomes of skin closure with octyl cyanoacrylate skin adhesive versus subcuticular suture closure. MATERIALS AND METHODS Over a 7-month period, 109 subjects (28 men and 81 women; mean age, 58.6 y) scheduled to undergo single-lumen implantable venous port insertion for chemotherapy were randomly assigned to skin closure with either octyl cyanoacrylate skin adhesive or absorbable subcuticular suture after suturing the deep dermal layer. Subjects were followed for episodes of infection or dehiscence within 3 months of port implantation. At 3 months, photographs of the healed incision were obtained and reviewed by a plastic surgeon in a blinded fashion who rated cosmetic scar appearance based on a validated 10-point cosmesis score. RESULTS Of subjects, 54 were randomly assigned to skin adhesive, and 55 were randomly assigned to subcuticular suture. No subjects had incision dehiscence. Infection rates at 3 months were similar between groups (2.1% vs 4.0%; P = 1.0). The mean cosmesis scores were 4.40 for skin adhesive and 4.46 for subcuticular suture (P = .898). The superficial skin closure time was 8.6 minutes for suture versus 1.4 minutes for skin adhesive (P < .001). CONCLUSIONS Scar cosmesis and patient outcomes did not significantly vary between skin adhesive versus subcuticular suture, although skin closure time was significantly less with skin adhesive.