Hyeon Yu

Sarcopenia as a Predictor of Complications and Survival Following Radical Cystectomy

PURPOSE Patients undergoing radical cystectomy face substantial but highly variable risks of major complications. Risk stratification may be enhanced by objective measures such as sarcopenia. Sarcopenia (loss of skeletal muscle mass) has emerged as a novel biomarker associated with adverse outcomes in many clinical contexts relevant to cystectomy. Based on these data we hypothesized that sarcopenia would be associated with increased 30-day major complications and mortality after radical cystectomy for bladder cancer. MATERIALS AND METHODS We performed a retrospective study of patients treated with radical cystectomy at our institution from 2008 to 2011. Sarcopenia was assessed by measuring cross-sectional area of the psoas muscle (total psoas area) on preoperative computerized tomography. Cutoff points were developed and evaluated using ROC curves to determine predictive ability in men and women for outcomes of major complications and survival. RESULTS Of 224 patients with bladder cancer 200 underwent preoperative computerized tomography within 1 month of surgery. Total psoas area was calculated with a mean score of 712 and 571 cm2/m2 in men and women, respectively. A clear association was noted between major complications and lower total psoas area in women using a cutoff of 523 cm2/m2 to define sarcopenia (AUC 0.70). Sarcopenia was not significantly associated with complications in men. There was a nonsignificant trend of sarcopenia with worse 2-year survival. CONCLUSIONS Sarcopenia in women was a predictor of major complications after radical cystectomy. Further research confirming sarcopenia as a useful predictor of complications would support the development of targeted interventions to mitigate the untoward effects of sarcopenia before cancer surgery.

Management of pleural effusion, empyema, and lung abscess

Pleural effusion is an accumulation of fluid in the pleural space that is classified as transudate or exudate according to its composition and underlying pathophysiology. Empyema is defined by purulent fluid collection in the pleural space, which is most commonly caused by pneumonia. A lung abscess, on the other hand, is a parenchymal necrosis with confined cavitation that results from a pulmonary infection. Pleural effusion, empyema, and lung abscess are commonly encountered clinical problems that increase mortality. These conditions have traditionally been managed by antibiotics or surgical placement of a large drainage tube. However, as the efficacy of minimally invasive interventional procedures has been well established, image-guided small percutaneous drainage tubes have been considered as the mainstay of treatment for patients with pleural fluid collections or a lung abscess. In this article, the technical aspects of image-guided interventions, indications, expected benefits, and complications are discussed and the published literature is reviewed.

Prevalence of sarcopenia in older patients with colorectal cancer

OBJECTIVE Sarcopenia is the age-related loss of muscle mass, strength, and function. It is a common finding in older patients and is associated with decreased life expectancy and potentially higher susceptibility to chemotherapy toxicity. This study describes the prevalence of sarcopenia in older adults with early stage colorectal cancer. MATERIALS AND METHODS Patients ≥70 years old who underwent surgical resection for stage I-III colorectal cancer between 2008 and 2013 were identified from the medical record. Sarcopenia was assessed by measuring the total muscle area on computerized tomography (CT) images obtained prior to surgery. Total muscle area was measured at the level of L3 and normalized using each patients height to produce a skeletal muscle index (SMI). Sarcopenia was defined using sex- and body mass index (BMI)-specific threshold values of SMI. RESULTS Eighty-seven patients were included, with a median age of 77 years (70-96). Twenty-five men (60% of 42) and 25 women (56% of 45) had sarcopenia. Sarcopenic patients had significantly lower BMI (p=0.03) compared to non-sarcopenic patients. There was a positive correlation between BMI and SMI for both men (r=0.44) and women (r=0.16). CONCLUSION Sarcopenia is highly prevalent among older patients with early stage colorectal cancer. BMI alone is a poor indicator of lean body mass and improved methods of screening for sarcopenia are necessary. CT scans are a viable option for identifying sarcopenic patients in whom timely interventions may improve survival, quality of life, and functional outcomes.

Comparison of percutaneous ablation technologies in the treatment of malignant liver tumors.

Tumor ablation is a minimally invasive technique used to deliver chemical, thermal, electrical, or ultrasonic damage to a specific focal tumor in an attempt to achieve substantial tumor destruction or complete eradication. As the technology continues to advance, several image-guided tumor ablations have emerged to effectively manage primary and secondary malignancies in the liver. Percutaneous chemical ablation is one of the oldest and most established techniques for treating small hepatocellular carcinomas. However, this technique has been largely replaced by newer modalities including radiofrequency ablation, microwave ablation, laser-induced interstitial thermotherapy, cryoablation, high-intensity-focused ultrasound ablation, and irreversible electroporation. Because there exist significant differences in underlying technological bases, understanding each mechanism of action is essential for achieving desirable outcomes. In this article, the authors review the current state of each ablation method including technological and clinical considerations.

Temporary balloon tamponade for managing subclavian arterial injury by inadvertent central venous catheter placement.

PURPOSE To evaluate the feasibility, efficacy, and safety of a temporary balloon tamponade technique for managing subclavian arterial injury secondary to inadvertent central venous catheter placement. MATERIALS AND METHODS Patients with subclavian arterial injury caused by inadvertent placement of a central venous catheter (size range 7-F to 7.5-F) who were treated only with temporary balloon tamponade between February 2002 and October 2009 were included. A temporary balloon tamponade technique was used to treat 13 patients (6 men and 7 women; mean age 56.7 years; age range 28-80 years). Technical success, total balloon inflation time, and complications were evaluated. RESULTS Technical success was achieved with the temporary balloon tamponade technique in 13 cases (100%). Eight patients were treated with one balloon inflation, and five patients with two inflations (mean inflations 1.4). The mean total balloon inflation time was 14 minutes ± 13. There was no recurrent bleeding, hematoma, or pseudoaneurysm that required additional interventional procedures or surgical repair. A thrombus was identified in the subclavian arterial lumen after removal of the balloon catheter in one case; however, the thrombus was nonocclusive and asymptomatic. CONCLUSIONS Temporary balloon tamponade seems to be technically feasible and effective with a good safety profile in the management of subclavian arterial injury caused by inadvertent central venous catheter placement. Intraluminal thrombus can be an associated complication of the procedure.

Prostatic Artery Embolization Using Embosphere Microspheres for Prostates Measuring 80–150 cm3: Early Results from a US Trial

Between November 2014 and October 2015, 12 patients with prostates measuring 80-150 cm(3) and lower urinary tract symptoms (LUTSs) were enrolled in a prospective single-center US trial to evaluate Embosphere Microspheres for use in prostatic artery embolization (PAE). At 3 months, mean improvements in International Prostate Symptom Score and quality of life score were 18.3 points (range, 5-27) and 3.6 points (range, 1-6), respectively. One-month cystoscopies and anoscopies demonstrated no ischemic injuries. There were no major complications. In this cohort, Embosphere Microspheres, when used for PAE, were safe and effective in reducing LUTSs in the early follow-up period.

Comparison of Type II Endoleak Embolizations: Embolization of Endoleak Nidus Only versus Embolization of Endoleak Nidus and Branch Vessels

PURPOSE To compare outcomes of type II endoleak embolization involving embolization of the endoleak nidus only vs embolization of the endoleak nidus and branch vessels in patients treated with endovascular repair of abdominal aortic aneurysms. MATERIALS AND METHODS Twenty-nine consecutive patients (mean age, 77.9 y; range, 63-88 y) with type II endoleak who underwent embolization from 2004 to 2015 were retrospectively reviewed. Patients were divided into 2 groups: embolization of endoleak nidus only (group A) and embolization of endoleak nidus and branch vessels (group B). Mean follow-up intervals were 20.5 months ± 14.7 in group A and 24.3 months ± 18.5 in group B. Outcomes were compared between groups by Mann-Whitney U and Pearson χ2 tests. RESULTS Mean interval from endovascular aneurysm repair to embolization was 47.6 months ± 42.9, and mean presentation time of endoleak before embolization was 23.1 months ± 25.8. Coils (n = 28) and liquid embolic agents (n = 23) were used for embolization. There were no significant differences in rates of residual endoleak (50% vs 53.8%; P = .96) or sac decrease/stabilization (62.5% vs 61.5%; P = .64). Procedure time and radiation exposure in group B (132.3 min ± 78.1; 232.4 Gy·cm2 ± 130.7) were greater than in group A (63.4 min ± 11.9; 61.5 Gy·cm2 ± 35.5; P < .01). There were no procedure-related complications. CONCLUSIONS Embolization of the endoleak nidus and branch vessels is not superior to embolization of only the nidus in terms of occlusion of type II endoleak and change in sac size despite requiring longer procedure times and resulting in greater patient radiation exposure.

Factors that predict increased catheter tip movement in left internal jugular vein implantable venous access ports upon standing

Purpose To determine the characteristics that predict catheter tip movement with positional changes in patients with left-sided, internal jugular vein (IJV) implantable venous access ports. Methods A retrospective review revealed 264 patients with left IJV ports placed at one academic institution from 2008 to 2013 with follow-up upright chest radiographs. Demographic information was recorded and anatomic measurements were made on both procedural fluoroscopic imaging and upright chest radiographs. Multivariate regression analysis was performed to determine which factors had statistically significant relationships with catheter tip movement distance. Results Mean catheter tip movement was 1.49 ± 1.97 cm. There was a statistically significant positive relationship between catheter tip movement distance and age (p = 0.03), body mass index (BMI) (p = 0.02), innominate vein angle (p<0.01) and dual- compared to single-lumen ports (p = 0.02). Port pocket location, venous access site and gender did not demonstrate statistical significance. Conclusions The factors associated with increased positional catheter tip movement for left IJV ports include patient age, BMI, innominate vein angle and dual- vs single-lumen port. This information can be useful in determining initial placement position and avoiding complications associated with catheter malposition.

The role of interventional radiology in management of benign and malignant gynecologic diseases.

&NA; This article focuses on the role of interventional radiology in the therapeutic and diagnostic management of benign and malignant gynecologic conditions. The subspecialty of interventional radiology utilizes minimally invasive advanced image-guided percutaneous techniques in gynecology that include central venous catheter placement, fluid aspiration, drainage catheter placement, tissue biopsy, inferior vena cava filter placement, and pelvic arterial embolization. Central venous catheters, such as ports, peripherally inserted central catheters, and tunneled catheters, are placed for intermediate to long-term intravenous chemotherapy or total parental nutrition or antibiotics. Patients with refractory malignant ascites or pleural effusion from seeding of advanced gynecologic cancers may benefit by percutaneous aspiration of fluid collections or placement of drainage catheters. Postoperative fluid collections including abscess, seroma, or lymphocele are managed by percutaneous drainage catheter insertion. Pelvic, peritoneal, or retroperitoneal masses can be sampled by image-guided percutaneous biopsy or aspiration of fluid to determine a pathologic diagnosis. Certain patients are at risk for deep venous thrombosis with pulmonary embolism and may benefit from an inferior vena cava filter. Patients with uncontrolled postoperative or postpartum bleeding can be effectively managed with emergent transarterial pelvic embolization. Each of the aforementioned interventions with indications, expected benefits, and complications is described including a published literature. Target Audience Obstetricians and gynecologists, family physicians, interventional radiologists Learning Objectives After completing this CME activity, physicians should be better able to identify the role of each type of interventional procedure in the management of patients with benign and malignant gynecologic conditions and to discuss the techniques, relevant imaging modalities, indications, contraindications, and potential complications of interventional radiology.

Interventional Radiologic Placement of Denver Pleuroperitoneal Shunt for Refractory Chylothorax

demonstrated an effusion with large-volume chylous fluid draining from his thoracostomy tube, with daily output ranging from 0.5 to 3.5 L (Fig. 1). The chylothorax did not improve after a fat-restricted diet, total parenteral nutrition, repeat surgical thoracic duct ligation, and pleurodesis. Additional procedures, including intranodal lymphangiography with cisterna chyli embolization (postoperative days 16 and 17) and thoracic duct needle disruption with alcohol ablation (postoperative day 31), were also performed, without resolution of the effusion. Forty-nine days after the initial surgery and hospitalization, a consensus decision was made to percutaneously create a pleuroperitoneal shunt. The procedure was performed under general anesthesia in the interventional radiology suite. Preprocedural ampicillin/sulbactam (Unasyn; Pfizer, New York, New York) was administered. A 3-cm transverse incision was made over the ninth to 11th ribs in the right lateral chest