OBJECTIVES:Radiologist participation in multidisciplinary tumor board can be time-consuming and demanding, requiring substantial preparation. Anecdotally radiologist participation is felt to help identify discrepancies in previous interpretations; however, there are limited data assessing the actual impact of their tumor board review on patient management. This prospective study aims to evaluate how the reinterpretation of outside imaging and review at hepatobiliary tumor board (HBTB) affects the diagnosis and management of patients with hepatobiliary neoplasms. METHODS:This prospective analysis included all patients presented at the weekly HBTB between 6/13/2023-6/25/2024. One radiologist reviewed the available reports of outside imaging, the local reinterpretation of outside imaging, the updated local imaging, and documented conclusions from discussion of the case at HBTB. HBTB included 4 radiologists who had reviewed each case. Discrepancies (presence/absence, number, and reasons for) were recorded. When discrepancies occurred, the impact on patient management (5-point Likert scale) was determined by two of the radiologists present at the HBTB in consensus, with input from clinicians if needed. A six-month follow-up was performed to confirm suspected diagnoses. RESULTS:208 cases (128 males, 104 chronic liver disease patients) were presented at HBTB. Disagreements in the detection or characterization of lesions were found in 59/208 (28.4%) of cases. A change in management occurred in 38/59 (64.6%) of these discrepant cases. In cases with recorded discrepancies in which follow-up confirmation was available, the final interpretation was confirmed in 34/41 (82.9%) of cases. CONCLUSION:Our study found a discrepant interpretation in nearly one-third of cases presented at a weekly HBTB and a resultant change in management in 65% of those cases. These findings highlight the importance of reinterpretation of prior imaging studies and the presence of radiologists at HBTB to guide optimal patient management. KEY MESSAGE:Patient care is substantially impacted by reinterpretation of prior imaging and participation of radiologists at hepatobiliary tumor board.

IMPORTANCE AND OBJECTIVE:Pancreatic cancer can lead to severe stenosis of the portomesenteric venous (PV/SMV) confluence due to extrinsic compression or direct invasion. This can result in venous hypertension associated with post-prandial abdominal pain, gastrointestinal bleeding, and ascites. In patients with unresectable tumors, transhepatic PV/SMV stenting has been reported; however, its safety and efficacy are poorly understood. DESIGN, SETTING AND PARTICIPANTS:All unresectable pancreatic cancer patients referred to Interventional Radiology to undergo palliative transhepatic PV/SMV stenting (2011-2024) were collected. Patient demographics, CT scans, transhepatic venograms, and clinical outcomes were reviewed. INTERVENTION, MAIN OUTCOMES AND RESULTS:In total, 129 patients were included; 92% had pancreatic ductal adenocarcinoma. Tumors were unresectable due to unreconstructable vascular involvement, metastatic disease, or poor performance status. Nearly 81% were symptomatic, while the remaining 24 asymptomatic patients presented with significant venous hypertensive varices and collaterals on imaging. Complete venous occlusion was seen in 39% of patients at the PV, the SMV, or the PV/SMV confluence; 97% of procedures were successful, with 4 technical failures at obtaining distal venous wire access. Adverse events occurred in 4 patients. Radiological follow-up was available in 94% of patients. Post-procedural primary stent patency was 80% at a median follow-up time of 20 months. Follow-up was available in 102 of the 105 symptomatic patients, with 85% reporting an improvement in symptoms. CONCLUSIONS AND RELEVANCE:Palliative transhepatic PV/SMV stenting is a technically feasible and safe procedure in well-selected patients. Symptoms improvement can be seen in most patients. High-volume centers should consider this technique for patients with unresectable tumors who present with symptomatic stenosis or short segment occlusion.

BACKGROUNDAmino acid (AA) concentrations are increased in prediabetes and diabetes. Since AAs stimulate glucagon secretion, which should then increase hepatic AA catabolism, it has been hypothesized that hepatic resistance (associated with hepatic fat content) to glucagon's actions on AA metabolism leads to hyperglucagonemia and hyperglycemia.METHODSTo test this hypothesis, we therefore studied lean and obese individuals, the latter group with and without hepatic steatosis as defined by proton density fat fraction (PDFF) > 5%. After an overnight fast, femoral vein, femoral artery, and hepatic vein catheters were placed. [3-3H] glucose and l-[1-13C,15N]-leucine were used to measure glucose turnover and leucine oxidation, respectively. During a hyperglycemic clamp, an AA mixture was infused together with insulin and glucagon (1.5 ng/kg/min 0-120 minutes; 3.0 ng/kg/min 120-240 minutes). Tracer-based measurement of hepatic leucine oxidation in response to rising glucagon concentrations and splanchnic balance (measured using arteriovenous differences across the liver) of the other AAs were the main outcomes measured.RESULTSThe presence of hepatic steatosis did not alter hepatic glucose metabolism and leucine oxidation in response to insulin and rising concentrations of glucagon. Splanchnic balance of a few AAs and related metabolites differed among the groups. However, across-group differences of AA splanchnic balance in response to glucagon were unaffected by the presence of hepatic steatosis.CONCLUSIONThe action of glucagon on hepatic AA metabolism is unaffected by hepatic steatosis in humans.TRIAL REGISTRATIONClinical Trials.gov: NCT05500586.FUNDINGNIH National Institute of Diabetes and Digestive and Kidney Diseases DK116231, DK78646, DK116231, DK126206, and DK116231.

Hepatic artery pseudoaneurysm is a rare complication that may occur in the setting of liver transplantation and other traumatic instrumentation of the hepatobiliary system. This condition poses a significant morbidity and mortality risk and must be diagnosed and intervened upon emergently. Herein we present a case of hepatic artery pseudoaneurysm complicated by hemorrhagic shock in the setting of a post-liver transplant biliary leak. In this case, the patient was ultimately diagnosed via hepatic angiogram, treated with hepatic artery embolization, and required subsequent retransplantation. The objective of this case was to demonstrate the importance of maintaining a high clinical suspicion for hepatic artery pseudoaneurysm in the post-transplant setting, emphasize the use of computed tomography angiography as a primary diagnostic tool, and involving interventional radiology early in the treatment course.

Post-operative pancreatic fluid collections (POPFCs) can be drained using percutaneous or endoscopic approaches. The primary aim of this study was to compare rates of clinical success between endoscopic ultrasound-guided drainage (EUSD) with percutaneous drainage (PTD) in the management of symptomatic POPFCs after distal pancreatectomy. Secondary outcomes included technical success, total number of interventions, time to resolution, rates of adverse events (AEs), and POPFC recurrence. Adults who underwent distal pancreatectomy from January 2012 to August 2021 and developed symptomatic POPFC in the resection bed were retrospectively identified from a single academic center database. Demographic data, procedural data, and clinical outcomes were abstracted. Clinical success was defined as symptomatic improvement and radiographic resolution without requiring an alternate drainage modality. Quantitative variables were compared using a two-tailed t-test and categorical data were compared using Chi-squared or Fisher’s exact tests. Of 1046 patients that underwent distal pancreatectomy, 217 met study inclusion criteria (median age 60 years, 51.2

BACKGROUND:Arterial resection (AR) for pancreatic adenocarcinoma is increasingly considered at specialized centers. We aimed to examine the incidence, risk factors, and outcomes of hepatic artery (HA) occlusion after revascularization. METHODS:We included patients undergoing HA resection with interposition graft (IG) or primary end-to-end anastomoses (EE). Complete arterial occlusion (CAO) was defined as "early" (EO) or "late" (LO) before/after 90 days respectively. Kaplan-Meier and change-point analysis for CAO was performed. RESULTS:HA resection was performed in 108 patients, IG in 61% (66/108) and EE in 39% (42/108). An equal proportion (50%) underwent HA resection alone or in combination with celiac and/or superior mesenteric artery. CAO was identified in 18% of patients (19/108) with arterial IG least likely to occlude (p=0.019). Hepatic complications occurred in 42% (45/108) and correlated with CAO, symptomatic patients, venous resection, and postoperative portal venous patency. CAO-related operative mortality was 4.6% and significantly higher in EO vs LO (p = 0.046). Median CAO occlusion was 126 days. With change-point analysis, CAO was minimal beyond postoperative day 158. CONCLUSION:CAO can occur in up to 18% of patients and the first 5-month post-operative period is critical for surveillance. LO is associated with better outcomes compared to EO unless there is inadequate portal venous inflow.

OBJECTIVE:The objective of this study was to evaluate the role of adrenal venous sampling (AVS) in guiding the management of patients with corticotropin (ACTH)-independent glucocorticoid secretory autonomy and bilateral adrenal masses. DESIGN AND PATIENTS:A cohort with 25 patients underwent AVS and surgical management. MEASUREMENTS:Cortisol was measured from the adrenal veins (AVs) and inferior vena cava (IVC). AV/IVC cortisol ratio and cortisol lateralization ratio (CLR) (dominant AV cortisol concentration divided by the nondominant AV cortisol concentration) were calculated. Posthoc receiver-operating characteristic curves were generated to determine the specificity of revised AV/IVC cortisol ratio and CLR in differentiating unilateral from bilateral disease. RESULTS:Patients underwent unilateral (n = 21) or bilateral (n = 4) adrenalectomy. The mean AV/IVC cortisol ratio for unilateral adrenalectomy was 12.1 ± 9.6 (dominant) and 4.7 ± 3.8 (contralateral) with a mean CLR of 3.6 ± 3.5. The mean AV/IVC cortisol ratio for bilateral adrenalectomy was 7.5 ± 2.1, with a mean CLR of 1.1 ± 0.6. At a mean follow-up of 22 months, one patient who underwent unilateral adrenalectomy for the predicted bilateral disease developed recurrent mild autonomous cortisol secretion. Posthoc analyses demonstrated a specificity of 95%-100% for unilateral disease with AV/IVC cortisol ratio >9 for one side, <2.0 for the opposite side and a CLR > 2.3. The specificity was 80%-90% for bilateral disease with AV/IVC cortisol ratio >5.1 bilaterally and a CLR < 1.1. CONCLUSIONS:Among patients with bilateral adrenal masses and ACTH-independent autonomous cortisol secretion, AVS can distinguish between unilateral and bilateral disease with high specificity and may guide surgical management.

Background and Objectives: Percutaneous transhepatic biliary drainage (PTBD) and EUS-guided choledochoduodenostomy (EUS-CD) are alternate therapies to endoscopic retrograde cholangiopancreatography with stent placement for biliary decompression. The primary outcome of this study is to compare the technical and clinical success of PTBD to EUS-CD in patients with distal biliary obstruction. Secondary outcomes were adverse events (AEs), need for reintervention, and survival. Methods: A multicenter retrospective cohort study from three different centers was performed. Cox regression was used to compare time to reintervention and survival and logistic regression to compare technical and clinical success and AE rates. Subgroup analysis was performed in patients with malignant biliary obstruction (MBO). Results: A total of 86 patients (58 PTBD and 28 EUS-CD) were included. The two groups were similar with respect to age, gender, and cause of biliary obstruction, with malignancy being the most common etiology (80.2%). EUS-CD utilized lumen-apposing metal stents in 15 patients and self-expandable metal biliary stents in 13 patients. Technical success was similar been EUS-CD (100%) and PTBD (96.6%; P = 0.3). EUS-CD was associated with higher clinical success compared to PTBD (84.6% vs. 62.1%; P = 0.04). There was a trend toward lower rates of AEs with EUS-CD 14.3% versus PTBD 29.3%, odds ratio: 0.40 (95% confidence interval [CI]: 0.12-1.33, P = 0.14). The need for reintervention was significantly lower among patients who underwent EUS-CD (10.7%) compared to PTBD (77.6%) (hazard ratio: 0.07, 95% CI: 0.02-0.24; P < 0.001). A sensitivity analysis of only patients with MBO demonstrated similar rate of reintervention between the groups in individuals who survived 50 days or less after the biliary decompression. However, reintervention rates were lower for EUS-CD in those with longer survival. Conclusion: EUS-CD is a technically and clinically highly successful procedure with a trend toward lower AEs compared to PTBD. EUS-CD minimizes the need for reintervention, which may enhance end-of-life quality in patients with MBO and expected survival longer than 50 days.

BACKGROUND. Patients who undergo bland hepatic artery embolization (HAE) for the treatment of hepatic malignancy may undergo routine overnight postprocedure hospitalization to monitor for postembolization syndrome (PES) given the potential for ischemic injury from HAE to lead to rapid onset of PES. In our experience, PES after HAE is more frequent in patients without cirrhosis. OBJECTIVE. The purpose of this study was to investigate the utility of cirrhosis and other patient and procedural characteristics in predicting the development of PES after bland HAE performed for the treatment of hepatic malignancy. METHODS. This retrospective study included 167 patients (122 men and 45 women; mean age, 63.5 ± 13.1 [SD] years) who underwent a total of 248 bland HAE procedures to treat primary or secondary hepatic malignancy. All patients were hospitalized for 24 hours of observation after HAE to monitor for and manage PES symptoms. PES severity was graded using the Southwest Oncology Group's toxicity coding scale. Patient and procedural characteristics were recorded. Associations with the development of PES were explored. A risk model to predict the risk of PES was constructed using independent predictors of PES in multivariable analysis. RESULTS. PES developed after 51.2% (127/248) of procedures; 23 cases were mild, 50 were moderate, and 54 were severe. PES developed in 32.1% (45/140) of patients with cirrhosis versus 75.9% (82/108) of patients without cirrhosis, whereas severe PES developed in 10.0% (14/140) versus 37.0% (40/108) of such patients, respectively. In multivariable analysis (which controlled for primary versus secondary malignancy, comorbidities, pre-procedure laboratory values, size and multiplicity of treated lesions, lobar vs segmental embolization, embolized artery, and embolic material used), independent predictors of lower likelihood of PES were older age (OR = 0.95 [95% CI, 0.92-0.99]), cirrhosis (OR = 0.26 [95% CI, 0.11-0.64]), and primary hepatic malignancy (OR = 0.34 [95% CI, 0.13-0.93]); the only independent predictor of a higher likelihood of PES was embolization of 50% or more of liver volume (OR = 4.29 [95% CI, 1.89-10.18]). A risk model using these factors had sensitivity of 75.6% and specificity of 76.0% for predicting PES. CONCLUSION. Cirrhosis was associated with a decreased risk of PES after bland HAE performed for the treatment of hepatic malignancy. A risk model combining cirrhosis and other factors had good performance in predicting the risk of PES. CLINICAL IMPACT. These findings may be applied to the selection of patients for early discharge after bland HAE, to avoid the need for overnight inpatient monitoring.

Introduction: Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HG) provides endoscopic biliary drainage when conventional techniques are not feasible. Access to the biliary tree can be obtained under EUS-guided puncture of the gastric wall into the left intrahepatic ducts. In the absence of dilation, the procedure can be technically challenging. Case Description/Methods: We present the case of a 43-year-old female with a history of total pancreatectomy for chronic pancreatitis followed by surgical revision including Roux-en-Y reconstruction and hepaticojejunostomy (HJ). The patient developed recurrent episodes of ascending cholangitis in the setting of diffuse biliary strictures and afferent limb dysmotility. She underwent placement of a percutaneous transhepatic biliary drain (PTBD) which was complicated by repeated hospitalizations for dehydration in the setting of high drain output (1-2L/day) and progressive malnutrition with marked deficiency in fat soluble vitamins. After a multidisciplinary discussion, it was felt that internalizing drainage would address these issues by promoting physiologic flow of bile. An EUS-guided HG was performed using the existing percutaneous drain tract to aid in identification and access of the left biliary tree (Video). The biliary drain was exchanged over a wire to a sheath with balloon catheter. Under fluoroscopic guidance, the percutaneous balloon catheter was advanced into the left hepatic duct and an occlusion cholangiogram was performed to opacify and distend the target ducts. The left hepatic duct was punctured under EUS-guidance with a 19-gauge needle. A 0.025” angled guidewire was then advanced into the left hepatic duct and across the HJ. After dilating the tract with a 4mm balloon, a 10mm x 8cm fully-covered self-expandable metal stent was deployed with the distal end in the left hepatic duct and proximal in the stomach. A guidewire was then used to access the right hepatic duct and a plastic double-pigtail catheter was deployed across the HG. The patient did well post-procedurally with no additional hospitalizations for cholangitis and improvement in nutrition parameters. (Figure) Discussion: Visualization of the intrahepatic ducts is critical for successful completion of EUS-HG. Here we report a creative, collaborative approach to the procedure which unencumbered the patient from external hardware and improved her nutrition through more physiologic bile circulation. Watch the video at https://tinyurl.com/ACGAbstractS353Figure 1.: (A) Balloon-occlusion (arrow) cholangiogram of left hepatic duct performed through transcutaneous catheter and (B) completion fluoroscopy showing fully-covered self-expandable metal stent bridging hepaticogastrostomy with plastic stent draining the right biliary tree.

Video 1Narrated case of an EUS-guided hepaticogastrostomy facilitated by opacification and distention of the left intrahepatic ducts using an existing percutaneous drain tract.

Prostate‐specific membrane antigen (PSMA) is a validated target for molecular diagnostics and targeted radionuclide therapy. Our purpose was to evaluate PSMA expression in hepatocellular carcinoma (HCC), cholangiocarcinoma (CCA), and hepatic adenoma (HCA); investigate the genetic pathways in HCC associated with PSMA expression; and evaluate HCC detection rate with 68Ga‐PSMA‐11 positron emission tomography (PET). In phase 1, PSMA immunohistochemistry (IHC) on HCC (n = 148), CCA (n = 111), and HCA (n = 78) was scored. In a subset (n = 30), messenger RNA (mRNA) data from the Cancer Genome Atlas HCC RNA sequencing were correlated with PSMA expression. In phase 2, 68Ga‐PSMA‐11 PET was prospectively performed in patients with treatment‐naïve HCC on a digital PET scanner using cyclotron‐produced 68Ga. Uptake was graded qualitatively and semi‐quantitatively using standard metrics. On IHC, PSMA expression was significantly higher in HCC compared with CCA and HCA (P < 0.0001); 91% of HCCs (n = 134) expressed PSMA, which principally localized to tumor‐associated neovasculature. Higher tumor grade was associated with PSMA expression (P = 0.012) but there was no association with tumor size (P = 0.14), fibrosis (P = 0.35), cirrhosis (P = 0.74), hepatitis B virus (P = 0.31), or hepatitis C virus (P = 0.15). Overall survival tended to be longer in patients without versus with PSMA expression (median overall survival: 4.2 vs. 1.9 years; P = 0.273). FGF14 (fibroblast growth factor 14) mRNA expression correlated positively (rho = 0.70; P = 1.70 × 10‐5) and MAD1L1 (Mitotic spindle assembly checkpoint protein MAD1) correlated negatively with PSMA expression (rho = −0.753; P = 1.58 × 10‐6). Of the 190 patients who met the eligibility criteria, 31 patients with 39 HCC lesions completed PET; 64% (n = 25) lesions had pronounced 68Ga‐PSMA‐11 standardized uptake value: SUVmax (median [range] 9.2 [4.9‐28.4]), SUVmean 4.7 (2.4‐12.7), and tumor‐to‐liver background ratio 2 (1.1‐11). Conclusion: Ex vivo expression of PSMA in neovasculature of HCC translates to marked tumor avidity on 68Ga‐PSMA‐11 PET, which suggests that PSMA has the potential as a theranostic target in patients with HCC.

Salivary gland adenoid cystic carcinoma (ACC) is a rare malignancy accounting for less than 1%–10% of head and neck malignant tumors ( 1 Ouyang D.Q. Liang L.Z. Zheng G.S. et al. Risk factors and prognosis for salivary gland adenoid cystic carcinoma in southern china: a 25-year retrospective study. Medicine (Baltimore). 2017; 96: e5964 Crossref PubMed Scopus (35) Google Scholar ). It usually demonstrates indolent, slow growth but has the potential to metastasize years after initial diagnosis. Hepatic metastasis from salivary gland ACC carries a poor prognosis, with limited conventional treatment options ( 2 Spiro R.H. Distant metastasis in adenoid cystic carcinoma of salivary origin. Am J Surg. 1997; 174: 495-498 Abstract Full Text PDF PubMed Scopus (307) Google Scholar ). Salivary gland ACC may be radiosensitive, making hepatic radioembolization a potential option ( 3 Lee A. Givi B. Osborn V.W. Schwartz D. Schreiber D. Patterns of care and survival of adjuvant radiation for major salivary adenoid cystic carcinoma. Laryngoscope. 2017; 127: 2057-2062 Crossref PubMed Scopus (42) Google Scholar ). This report describes transarterial radioembolization (TARE) for palliation of hepatic metastases in 4 patients with salivary gland ACC. Hepatic TARE was performed as previously described ( 4 Padia S.A. Lewandowski R.J. Johnson G.E. et al. Radioembolization of hepatic malignancies: background, quality improvement guidelines, and future directions. J Vasc Interv Radiol. 2017; 28: 1-15 Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar ). The primary outcome measure was tumor response following the modified Response Evaluation Criteria in Solid Tumors. Institutional review board exemption was obtained.

To evaluate prognostic factors associated with peri-procedural (30 days) and short-term (90 days) mortality in the United States cohort of patients following emergent transarterial embolization for ruptured hepatocellular carcinoma. Patients with ruptured hepatocellular carcinoma treated with emergent TAE between January 2001 and December 2019 were retrospectively identified (n = 24). Average age was 62 years (range, 23–78 year); 15 (62.5%) were men. Univariate and Cox proportional hazard modeling were used to determine independent predictors of overall survival (OS) following TAE. OS stratified by Model for End-Stage Liver Disease-Sodium score was assessed using Kaplan–Meier analysis. Twenty-one patients (88%) died during a mean clinical follow-up period of 328 ± 139 days. MELD-Na score (HR 1.22 per 1-unit increase; 95% CI 1.06–1.46; p = 0.005) and pre-rupture ECOG PS score (HR 8.1; 95% CI 1.28–51.2; p = 0.026) were independent predictors of decreased overall survival. There was no significant association between overall survival and presence of cardiovascular co-morbidities (p = 0.60), hemorrhagic shock on presentation (p = 0.16), portal vein thrombus (p = 0.08), vasopressor support required (p = 0.79), intubation required (p = 0.40), acute kidney injury (p = 0.58), and number of packed red blood cell transfusions (p = 0.22). The median OS was 64 days. Median OS was significantly greater in patients with a MELD-Na score ≤ 16 as compared to those with a MELD-Na score > 16 (166.5 days vs 9 days, p = 0.011). Cumulative OS rates in those with a MELD-Na score ≤ 16 at 30, 60, 90, and 360 days were 79%, 64%, 64%, and 25%, respectively, vs 33%, 33%, 11%, and 0%, respectively, in those with a MELD-Na score > 16. MELD-Na > 16 is associated with very high peri-procedural (67% at 30 days) and short-term (89% at 90 days) mortality in patients with ruptured HCC treated with emergent transarterial embolization. A better understanding of these prognostic factors may help guide treatment decisions and provide realistic expectations when counseling patients and their families.

Abstract Context Insulinoma is a pancreatic neuroendocrine tumor that causes hyperinsulinemic hypoglycemia. Symptomatic hypoglycemia related to hepatic insulinoma metastases may be addressed with liver-directed therapies such as hepatic artery embolization. Objective This work aimed to determine the safety and effectiveness of bland hepatic artery embolization (HAE) for palliation of symptomatic hypoglycemia in patients with hepatic insulinoma metastases refractory to medical management. Methods An institutional review board–approved retrospective review was undertaken of all patients with a tissue (n = 18) or imaging (n = 2) diagnosis of hepatic insulinoma metastases and symptomatic hyperinsulinemic hypoglycemia refractory to medical management who underwent bland HAE at a single center between January 1, 1998 and November 1, 2020. Twenty patients (10 women, 10 men; mean age, 56 years; range, 18-84 years) were identified who individually underwent 1 (n = 7), 2 (n = 5), 3 (n = 5), 4 (n = 2), or 5 (n = 1) HAEs, for an overall total of 45 HAEs. Post-HAE hypoglycemia recurrence was defined as onset of adrenergic symptoms (eg, sweating, weakness, tremor), neuroglycopenic symptoms (eg, confusion, loss of consciousness), and/or documented serum glucose of less than 50 mg/dL, in the absence of an alternative explanation. Median time to first hypoglycemia recurrence, hypoglycemia-free survival (HFS), and overall survival (OS) were calculated using Kaplan-Meier method. Results Before HAE, all patients experienced adrenergic or neuroglycopenic symptoms alleviated by glucose intake, and 60% (n = 12) of patients had documented serum glucose of less than 50 mg/dL within 1 week of the first treatment. Median post-HAE follow-up was 9.4 months (mean, 26 months; range, 0.1-190 months). Postprocedural hypoglycemic symptom relief after the first HAE was reported in 100% (n = 20) of patients before discharge or at follow-up. Post-HAE hypoglycemia recurrence occurred in 60% (n = 12) of patients with a median time to first hypoglycemia recurrence of 2 months (mean, 14 months; range, 0.2-60 months). After the first HAE, median HFS was 14.5 months, and median OS was 16 months. One patient experienced labile postprocedure blood glucose levels requiring intensive care unit admission for intravenous dextrose. Otherwise, no major procedure-related complications occurred. Conclusion Bland HAE is a safe, effective, and repeatable procedure for palliation of symptomatic hypoglycemia in patients with hepatic insulinoma metastases refractory to medical management.

To determine long-term renal function outcomes following renal cryoablation complicated by hemorrhage requiring post-ablation transarterial embolization A retrospective review identified 23 patients who underwent CT-guided renal cryoablation complicated by hemorrhage requiring ipsilateral transarterial embolization (TAE) and a control group of 23 patients who underwent uncomplicated renal cryoablation matched by age, gender and nephrometry score at a single institution from 2005 to 2019. Primary outcome parameters included change in creatinine (mg/dL), estimated glomerular filtration rate (mL/min/1.73 m2; eGFR) and chronic kidney disease (CKD) stage from baseline to most-recent follow-up. Overall survival was estimated using Kaplan-Meier method. There was no significant difference in baseline age (P = 0.75), gender (P = 0.76), median nephrometry score (8 v. 8; P = 1.0), Charlson co-morbidity index (7.0 ± 3.0 v. 5.8 ± 2.3; P = 0.13), creatinine (1.0 ± 0.4 v. 1.1 ± 0.3; P = 0.56), eGFR (56.9 ± 7.9 v. 57.9 ± 4.6; P = 0.60) or CKD stage (P = 0.85) between the TAE and control group. There was a significantly higher proportion of patients on pre-ablation anticoagulation in the TAE v. control group (30% v. 4%; P = 0.047), but all patients were off anticoagulation and with normal coagulation parameters at the time of cryoablation. No significant difference in cryoablation parameters between the TAE and control group including number of cryoprobes (P = 0.72), freeze-thaw duration (P = 0.37) or ice-ball fracture (P = 0.49). Most bleeding was detected at immediate post-ablation imaging (70%) and patients underwent TAE of 1 (61%), 2 (26%) or 3 (13%) renal artery branches, predominantly 3rd or 4th order branches (83%) with 100% technical success. At a mean follow-up of 42.7 months, there was no significant difference between the TAE and control group in creatinine (1.3 ± 0.8 v.1.2 ± 0.3; P = 0.68), eGFR (52.6 ± 13.2 v. 54.2 ± 8.2; P = 0.60) or change from baseline in creatinine (0.3 ± 0.6 v. 0.1 ± 0.2; P = 0.28), eGFR (-4.3 ± 10.0 v. -3.7 ± 6.1; P = 0.80) or CKD stage (22% v. 30%; P = 0.74). Median overall survival was significantly longer in the control v. TAE group (53.5 months v. not reached; P = 0.005). Selective transarterial embolization for post renal cryoablation hemorrhage does not significantly affect long-term renal function compared to cryoablation alone. Pre-ablation anticoagulation despite normal coagulation at time of ablation may be a risk factor for post-ablation hemorrhage and warrants further evaluation when considering pre-ablation embolization.

To determine long-term renal function outcomes after renal cryoablation complicated by major hemorrhage requiring transarterial embolization compared to patients who underwent uncomplicated renal cryoablation without major hemorrhage. Utilizing a matched cohort study design, retrospective review identified 23 patients who underwent percutaneous image-guided renal cryoablation complicated by major hemorrhage requiring ipsilateral transarterial embolization (TAE group) and a control group of 23 patients who underwent uncomplicated renal cryoablation matched 1:1 by age, gender and RENAL Nephrometry score at a single institution from 1/1/2005 to 12/31/2019. Primary outcome parameters included change in creatinine (mg/dl) and estimated glomerular filtration rate (ml/min/1.73 m2; eGFR) from baseline and were compared between TAE and control group using a paired t-test. There was a significantly higher proportion of patients on pre-ablation anticoagulation in the TAE v. control group (30% v. 4%; p = 0.047), but all patients were off anticoagulation and with normal coagulation parameters at the time of cryoablation. Otherwise there were no significant differences in clinical, renal tumor, Charlson co-morbidity index, baseline renal function or cryoablation parameters between the TAE and control group. In the post-ablation period, there was trend toward greater increase in creatinine from baseline to worst post-ablation creatinine in the TAE v. the control group (+ 0.5 ± 0.7 mg/dl v. 0.2 ± 0.1 mg/dl; p = 0.056). However, at a mean follow-up of 42.7 ± 35.7 months, there was no significant difference between the TAE and control group in creatinine (p = 0.68), eGFR (p = 0.60) or change from baseline in creatinine (p = 0.28), eGFR (p = 0.80) or CKD stage (p = 0.74). No patient required initiation of hemodialysis. Selective transarterial embolization for post-renal cryoablation hemorrhage does not significantly affect long-term renal function compared to cryoablation alone. Pre-ablation anticoagulation despite normal coagulation at time of ablation may be a risk factor for post-ablation hemorrhage, and warrants further evaluation when considering pre-ablation embolization.

To evaluate adrenal venous sampling (AVS) in guiding surgical management of patients with adrenocorticotropic hormone (ACTH) independent Cushing syndrome (CS) and bilateral adrenal masses 28 patients with bilateral adrenal masses and ACTH independent autonomous cortisol secretion who underwent AVS from January 1, 2008, to August 1, 2020, were identified. Methodology and data interpretation were performed as previously described. Cortisol and epinephrine levels were measured from each adrenal vein (AV) and the inferior vena cava (IVC). AVS was technically successful if plasma epinephrine concentration in AV-IVC was > 100 pg/mL. AV/IVC cortisol ratio for each adrenal gland and cortisol lateralization ratio (CLR) were calculated. Previously described parameters were utilized for interpretation: AV/IVC cortisol ratio of > 6.5 on one side and ≤3.3 on the contralateral side with CLR ≥ 2.3 was consistent with a unilateral cortisol-secreting adenoma whereas bilateral AV/IVC cortisol ≥ 4.1 with CLR < 2 was consistent with bilateral cortisol hypersecretion. Clinical, imaging, laboratory, pathology and follow-up data were collected. Primary outcome measure was hypercortisolism recurrence. 28 patients underwent AVS. Patients underwent subsequent right (n = 12) or left (n = 9) total, right total and left partial (n = 1) or bilateral total (n = 3) adrenalectomy. 3 patients were recommended adrenalectomy but were lost to follow up and not included in outcome analysis. Initial presentation included incidental adrenal masses (12%), subclinical CS (64%), overt CS (24%). Sequela included hypertension (88%), osteoporosis/osteopenia (38%), diabetes mellitus (36%), hyperlipidemia (56%), weight gain (76%), depression (52%). AVS was successful in all 28 patients. Data were interpreted as described above to guide laterality of adrenalectomy. Mean AV/IVC cortisol for unilateral adrenalectomies was 12 with mean CLR 3.7. Mean AV/IVC for bilateral adrenalectomies was 8.67 right and 6.33 left with CLR 0.76. Among 29 resected adrenal glands, pathology demonstrated benign adrenocortical adenomas (52%) and macronodular hyperplasia (48%) and mean dominant nodule maximum diameter of 2.7cm and mean weight of 18.2g. At a mean follow-up of 21.8 months, there was no clinical or biochemical recurrence of ACTH-independent hypercortisolism with most recent cortisol of 12.8 ± 7.5 mcg/dL and ACTH of 19.7 ± 13.1 pg/mL. AVS can be used to guide surgical management in patients with ACTH independent Cushing syndrome and bilateral adrenal masses, with favorable midterm outcomes.