To evaluate the role of morbidity and mortality (M M) meetings in supporting quality improvement within interventional radiology (IR), by examining recommendations arising from meetings and their subsequent implementation. A retrospective review of M M meetings held between 2020 and 2023 within a multi-site IR service employing more than 20 consultant IRs. Cases were presented using a standardized format and open discussion encouraged. Meeting records were reviewed for procedure details, complications, morbidity or mortality and resulting recommendations. For analysis, cases were classified by their contributing factors and recommendations by their theme. Institutional guidelines and records were reviewed after at least a 12-month interval to determine whether recommendations had been successfully implemented, defined as documented adoption into institutional practice, such as protocol, policy or workflow changes. A total of 139 cases were discussed, yielding 70 recommendations, of which 45 (64.3

OBJECTIVES:Detection of thyroid nodules is increasing. The American College of Radiology Thyroid Image Reporting and Data System (ACR TI-RADS) purports to decrease unnecessary thyroid fine needle aspiration (FNA) in selected retrospective groups. Limited reports of real-world performance suggest otherwise. This large series compares our real-world outcomes pre- and post-implementation of ACR TI-RADS for thyroid ultrasound (US) reporting. METHODS:ACR TI-RADS was adopted at our tertiary institution in 2018. In this retrospective observational study, all patients undergoing thyroid US were divided into pre-TIRADS (2014-2017) and post-TIRADS (2019-2022) groups. We analyzed US, FNA, surgery rates, pathological outcomes, and cost data. A subset of post-TIRADS patients was analyzed for US findings and adherence to ACR TI-RADS recommendations. RESULTS:Our study included 13,156 patients. Post-TIRADS, the total number of thyroid US decreased (9112 vs. 10,811). Also, the post-TIRADS group had a significantly larger proportion of patients with only one US performed (70.8% vs. 62.1%, p < 0.001). Both groups had a similar number of FNAs and surgeries performed. The surgically proven malignancy rate, median tumor size, and stage were similar. The total healthcare cost of all these procedures was higher in the post-TIRADS group ($4,772,158.00) versus the pre-TIRADS group ($4,280,081.98). In the subset analysis, adherence to ACR TI-RADS was noted in 444/635 patients (69.9%, 95% CI 66.2%-73.4%). CONCLUSION:While the implementation of ACR TI-RADS has led to a reduction in follow-up thyroid US, the rate of thyroid FNAs and surgery at our institution has not reduced. Further confirmatory research in other populations in the real world is required. LEVEL OF EVIDENCE: 3:

BACKGROUND & OBJECTIVE:This prospective, single-center clinical trial evaluated the technical feasibility and clinical success of the Automatic Needle Targeting (ANT-C) patient-mounted robotic needle-guidance platform for CT-guided trans-thoracic lung biopsy under local anesthesia, incorporating an exploratory post-hoc geometric analysis of parallel artificial intelligence path planning via the NDAnalyzer software. MATERIALS & METHODS:Out of thirty-one recruited patients, one was excluded due to on-table lesion resolution, leaving a final cohort of thirty evaluable subjects with a median nodule size of 24 mm. While interventional radiologists executed target acquisition using independently planned trajectories, the automated software generated alternative paths in a parallel, blinded fashion to ensure zero clinical influence on the live procedure. RESULTS:The platform demonstrated a high technical success rate of 93.3% and a 100% clinical success rate, successfully harvesting adequate tissue cores for full histopathological and molecular profiling in all cases. Operational efficiency improved significantly as operators gained familiarity, with median procedural durations decreasing from 61.4 min in the first ten cases to 30.5 min in the final ten cases. Concurrently, median total radiation exposure significantly decreased from 427.3 mGy·cm to 303.7 mGy·cm between the early and late deciles. No major complications occurred, and minor, self-limiting Grade A adverse events were limited to asymptomatic perilesional hemorrhage and trace pneumothoraces. Furthermore, exploratory modeling revealed a median angular deviation of only 3.5° between the operator's selected path and the closest automated alternative. CONCLUSION:The robotic system is clinically viable and technically feasible for awake patients, though the AI's automated path-ranking cost-function requires further refinement prior to live workflow integration.

AIM:Asia-Pacific guidelines recommend selective internal radiation therapy (SIRT) as an alternative to transarterial chemoembolization for patients with intermediate or advanced hepatocellular carcinoma (HCC) and, in more limited circumstances, for metastatic colorectal cancer (mCRC). This multicenter, single-arm, prospective, observational registry evaluated safety and efficacy of SIRT with 90Y resin microspheres for HCC or mCRC in Asia. PATIENTS & METHODS:Adults (n = 202) with HCC or mCRC eligible for, and scheduled to receive, SIRT with 90Y resin microspheres at participating centers were recruited. Dosimetry methods used were body surface area or partition model at the physician's discretion. The primary endpoints were overall response rate (ORR), frequency of treatment-emergent adverse events (TEAEs) and serious adverse events (SAEs), and liver function baseline changes. RESULTS:ORR at 3 or 6 months was 56% (HCC) and 33% (mCRC). 491 TEAEs were reported in 125 patients and 71 SAEs were reported in 29 patients. Performance status was maintained or improved in most patients 6 months after SIRT. CONCLUSION:SIRT may offer clinicians a targeted, single-use approach for HCC or mCRC palliative care or for tumor down-sizing or down-staging in Asia. Controlled trials of SIRT using personalized dosimetry could further define a role for SIRT in these populations.

Purpose: To investigate the feasibility of a robotic system with artificial intelligence-based lesion detection and path planning for computed tomography (CT)-guided biopsy compared with the conventional freehand technique. Materials and Methods: Eight nodules within an abdominal phantom, incorporating the simulated vertebrae and ribs, were designated as targets. A robotic system was used for lesion detection, trajectory generation, and needle holder positioning. Four interventional radiologists with more than 5 years of experience and 4 with 5 years of experience or less performed 96 robot-assisted insertions encompassing both in-plane and out-of-plane trajectories. Additionally, 32 CT fluoroscopy single-rotation scan-guided freehand needle insertions were performed along the in-plane trajectories. The 3-dimensional (3D), lateral, depth deviations, and insertion time were quantified using post-needle insertion CT scans. Statistical analysis was performed using the unpaired t-test or 1-way analysis of variance, with a significance level of P < .05. Results: The system detected all target lesions and generated appropriate needle paths. Robot-assisted insertions exhibited significantly smaller 3D and depth deviations than freehand insertions (3.8 mm +/- 1.3 vs 4.7 mm +/- 1.6, P = .001, and 1.8 mm +/- 1.2 vs 2.6 mm +/- 1.8, P = .005, respectively). No significant difference was observed in lateral deviations (3.0 mm +/- 1.5 vs 3.5 mm +/- 1.5, P = .118). Robotic assistance significantly reduced insertion time compared with freehand insertion (17.3 s +/- 7.8 vs 78.6 s +/- 38.1, P < .001). The same trends were observed between the 2 groups of radiologists. Conclusions: The robotic system has the potential to shorten puncture time while maintaining sufficient accuracy in CT-guided procedures.

PURPOSE:To investigate the feasibility of robot-assisted computed tomography (CT)-guided percutaneous needle placement compared with the conventional technique. MATERIALS AND METHODS:This single-center, open-label, randomized clinical trial included 70 patients with indications for CT-guided intervention, randomly assigned to conventional or robot-assisted groups. A table-mounted robotic system, automated needle-targeting device for CT, was utilized. Needle insertion time, technical success, diagnostic accuracy, procedure duration, needle angle adjustments, number of CT fluoroscopic acquisitions, radiation dose, and adverse event rates were compared. RESULTS:Seventy patients were enrolled, and 65 patients (33 robot-assisted) were analyzed. Lesion sizes were 44.3 mm (SD ± 26.7) and 43.0 mm (SD ± 28.4) in the conventional and robot-assisted groups, respectively (P = .845). There was no significant difference in the needle insertion time between the 2 groups (175.6 seconds [SD ± 211.8] vs 218.2 seconds [SD ± 242.1], P = .452). Technical success was 100% in both groups. Diagnostic accuracy was 87.0% in the conventional group and 93.3% in the and robot-assisted group (P = .671). Procedure duration was longer in the robot-assisted group (21.4 minutes [SD ± 5.6] vs 33.4 minutes [SD ± 10.3], P < .001). Needle adjustments (2.1 times [SD ± 1.8] vs 0.3 times [SD ± 0.7], P < .001), CT fluoroscopic acquisitions (10.0 times [SD ± 4.9] vs 7.7 times [SD ± 3.4], P = .027), and volume CT dose index (11.2 mGy [SD ± 5.9] vs 8.5 mGy [SD ± 4.7], P = .049) were lower in the robot-assisted group. Dose length product (667.4 mGy·cm [SD ± 247.2] vs 578.5 mGy·cm [SD ± 232.5], P = .143) and adverse event rates (28.1% vs 24.2%, P = .885) were not significant difference between groups. CONCLUSIONS:The robotic system may allow accurate needle insertion across multiple sites, although with prolonged procedure time.

Purpose: To evaluate the feasibility and preliminary evidence of the efficacy of combined cutting balloon and drug-coated balloon angioplasty for the treatment of arteriovenous fistula stenoses resistant to conventional balloon angioplasty. Material and Methods: From August 2018 to January 2019, 19 patients (mean age = 64.9 +/- 8.6 years; males = 63%) with resistant arteriovenous fistula stenosis, defined as >30% residual stenosis after conventional balloon angioplasty, were enrolled into this single-center prospective pilot study. The resistant arteriovenous fistula stenoses were treated with a cutting balloon followed by a drug-coated balloon. The primary outcome measure was 6-month target lesion patency. Results: The degree of residual stenosis after conventional balloon angioplasty was 48.8 +/- 11.3%, decreasing to 18.7 +/- 10.4% after combined cutting and drug-coated balloon angioplasty. Technical success, defined as < 30% residual stenosis, was achieved in 94.7% (18 of 19 stenoses). The 6-month target lesion patency was 100%, while the 6-month access circuit primary patency was 94.7% (n = 18/19) due to recurrent non-target lesion stenosis. No venous rupture or major complication was encountered. Conclusions: This pilot study provides evidence to support the conduct of a phase 3 randomized clinical trial to prove the superiority of a cutting balloon and drug-coated balloon combination for resistant arteriovenous fistula stenoses.

PurposeTo validate the sensitivity and specificity of a 3-Dimensional Convolution Neural Network (3D-CNN) AI software for lung lesion detection, and to establish concordance between AI-generated needle paths and those used in actual biopsy procedures.Materials and MethodsThis was a retrospective study utilizing CT scans from three hospitals. Inclusion criteria were scans with 1-5 nodules of diameter ≥5mm; exclusion criteria were poor-quality scans or those with nodules measuring <5mm. In the lesion detection phase, 2147 nodules from 219 scans were used to develop and train the deep learning 3D-CNN to detect lesions. The 3D-CNN was validated with 235 scans (354 lesions) for sensitivity, specificity, and area-under-the-curve (AUC) analysis. In the path planning phase, Bayesian optimization was utilized to propose possible needle trajectories for lesion biopsy while avoiding vital structures. Software-proposed needle trajectories were compared against actual biopsy path trajectories from intraoperative CT scans in 150 patients, with a match defined as angular deviation of <5 degrees between the two.ResultsThe model achieved an overall AUC of 97.4% (95%CI=96.3-98.2%) for lesion detection, with mean sensitivity of 93.5% and mean specificity of 93.2%. 85.3% of software-proposed needle trajectories were feasible, with 82% matching actual paths, and similar performance between supine and prone/oblique patient orientations (p=0.311). Average angular deviation between matching trajectories was 2.30±1.22o; average path deviation was 2.94±1.60mm.ConclusionsSegmentation, lesion detection and path-planning for CT-guided lung biopsy using an AI-guided software showed promising results. Future integration with automated robotic systems may pave the way towards fully automated biopsy procedures.

Biliary atresia (BA) is a severe hepatobiliary condition requiring Kasai portoenterostomy (KP) during infancy to facilitate biliary flow. However, post-KP, patients frequently develop complications such as recurrent cholangitis, biliary stricture, and cystic intrahepatic dilatation. These complications often progress to biliary cirrhosis and end-stage liver disease, necessitating liver transplantation. In this context, we explore the application of Percutaneous Transhepatic Biliary Drainage (PTBD) for treating biliary complications in post-KP BA patients. PTBD in these cases is technically challenging due to the presence of biliary strictures and intrahepatic bile duct dilatation, and its effectiveness has been a subject of debate. This paper presents two technically challenge cases where we treated adult BA patients who developed late-onset biliary strictures following successful KP. Both of the required first direct puncture of a cystic region of biliary dilatation, followed by successful puncture (one patient was punctured on CT-guidance) and wire cannulation and successful PTBD insertion. Following the procedure, both patients achieved short-term and long-term clinical improvement. The significant findings from these cases include: resolution of acute cholangitis, normalization of liver enzymes, no evidence of biliary cirrhosis in subsequent ultrasound, and removal of both patients from the liver transplantation list.

AIM: To compare the effectiveness and safety of pharmacological thrombolysis and mechanical thrombectomy. MATERIAL AND METHODS: This review was conducted in accordance with the PRISMA guidelines. Pooled proportions and subgroup analysis were calculated for primary and secondary patency rates, technical success, clinical success, major and minor complications rates. RESULTS: This systematic review identified a total of 6,492 studies of which 17 studies were included for analysis. A total of 1,089 patients comprising 451 (41.4 %) and 638 (58.6 %) patients who underwent thrombolysis and mechanical thrombectomy procedures, respectively, were analysed. No significant differences were observed between thrombolysis and mechanical thrombectomy procedures in terms of technical success, clinical success, major and minor complications rates, primary and secondary patency rates; however, subgroup analysis of overall arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) demonstrated a signifi- cantly higher rate of major complications within the AVF group (p1/40.0248). CONCLUSION: The present meta-analysis suggests that pharmacological thrombolysis and mechanical thrombectomy procedures are similarly effective and safe; however, AVFs are subject to higher major complications compared to AVGs. (c) 2024 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Introduction: Transarterial radioembolisation (RE) using yttrium-90 (Y-90) microspheres is a widely used locoregional therapy for a broad spectrum of hepatocellular carcinoma (HCC) given its favourable safety profile. We evaluated the real-world outcomes of unresectable HCC treated with resin Y-90 RE and the relationship between tumour absorbed dose and subsequent curative therapy with survival. Methods: Included were consecutive patients treated with Y-90 resin microspheres RE for unresectable HCC between January 2008 and May 2019 at the National Cancer Centre Singapore/Singapore General Hospital. The outcomes were stratified by tumour burden, distribution, presence of portal vein invasion (PVI) and liver function to improve prognostication. Results: The median overall survival (OS) evaluated on 413 included patients was 20.9 months (95% CI: 18.2-24.0). More than half of the patients (214/413, 51.8%) had HCC beyond up-to-seven criteria, and 37.3% had portal vein invasion (154/413, 37.3%). Majority (71.7%) had dosimetry calculated based on the partition model. Patients who received >= 150 Gy to tumour had significantly better outcomes (OS 32.2 months, 95% CI: 18.3-46.4) than those who did not (OS 17.5 months, 95% CI: 13.7-22.7, p < 0.001). Seventy patients (17%) received curative therapies after tumour was downstaged by Y-90 RE and had better OS of 79.7 months (95% CI: 40.4 - NE) compared to those who did not receive curative therapies (OS 17.1 months; 95% CI: 13.5-20.4, p < 0.001). RE-induced liver injury was observed in 5.08% of the patients while 3.2% of the patients had possible radiation pneumonitis but none developed Grade 3-4 toxicity. For HCC without PVI, OS differed significantly with performance status, albumin-bilirubin grade, tumour distribution, and radiation dose; for HCC with PVI, Child-Pugh class and AFP were significant predictors of survival. Conclusions: Treatment outcomes for unresectable HCC using Y-90 RE were favourable. Incorporating tumour burden and distribution improved prognostication. Patients who received tumour absorbed dose above 150 Gy had better OS. Patients who subsequently received curative therapies after being downstaged by Y-90 RE had remarkable clinical outcomes.

Background: Pre-operative assessment of non-melanoma skin cancers via advanced ultrasound techniques may potentially provide additional information to tumour margins and morphology compared to current assessment via dermoscopy or optical coherence tomography. In this case series, the findings of multimodal ultrasonography of non-melanoma skin cancer are described, with histological correlation. Methods: Consecutive patients with clinical suspicion of malignant skin lesions underwent multimodal ultrasonography, comprising B-mode, colour Doppler imaging, superb microvascular imaging, strain elastography, and shear-wave elastography, followed by surgical excision. Images were reviewed by two radiologists. Results: There were 8 female and 3 male patients, whose age ranged from 66 to 98 years. A total of 11 malignant skin tumours (basal cell carcinoma, n = 6; squamous cell carcinoma, n = 5) were reviewed. Tumour depth measured via ultrasound assessment ranged from 1.20 to 7.00 mm (mean ± standard deviation: 4.35 ± 1.99 mm). Tumours were located within dermis (n = 1) and abutting subcutaneous layer (n = 10) sonographically. Where corresponding histological reports for tumour depth were available, ultrasound correlated well with histology. Ultrasound also correctly predicted the deepest layer of involvement for all lesions. The sonographic features observed in all malignant skin tumours (11/11:100%) are solid, hypoechoic, with abundant neovascularity on colour Doppler imaging and superb microvascular imaging, and appeared stiff on strain elastography and shear-wave elastography. In some cases, the microvascular network of intra-tumoural flow were better demonstrated on superb microvascular imaging. Conclusion: Multimodal ultrasound can potentially be a useful and quick adjunctive tool for the pre-operative assessment of skin cancer by delineating the tumour depth and deepest skin layer involvement, ensuring complete excision of tumour.

INTRODUCTION Complications resulting from clinically significant portal hypertension, such as ascites, acute variceal bleeding (AVB), and HE cause significant morbidity and mortality:1 Interventional radiology plays a significant role in the diagnosis and treatment of these complications. HVPG measurement The BAVENO VII guidelines indicate the measurement of the HVPG as the gold standard for the diagnosis of clinically significant portal hypertension.2 There are many technical nuances that can affect the HVPG reading and prognosis.3 For example, the free hepatic vein pressure or IVC pressure should be used as the systemic pressure component of the reading instead of the right atrial pressure.1 A balloon occlusion catheter should be used to measure wedged hepatic venous pressures instead of end-hole catheter (because insufficient wedging leads to artificially low wedged hepatic venous pressures),4 and ree hepatic vein pressure should be measured within 2 cm of the IVC confluence where the hepatic vein is largest (because damping of the waveform due to presence of a large catheter in a small vein results in artificially high ree hepatic vein pressure).5 Angiography should be routinely performed to exclude venovenous and venoportal shunts, which can significantly alter the HVPG readings—if shunts are present, a different vein should be used, or direct portal pressure measurements performed.5 TIPS TIPS procedure TIPS was first described by Josef Rösch in 1969.6 Since then, the technique has been refined and is now considered the standard of care for secondary prevention of AVB (ie, failed medical and endoscopic therapy) with a reported technical success rate of over 95%.7 Briefly, a directional metallic cannula with a puncture needle is advanced into the hepatic vein by means of jugular access. Under fluoroscopy, the portal vein is punctured, traversing the parenchyma between the hepatic and portal veins. The tract is dilated and lined with a stent to maintain its patency. The initially used bare metal stents were fraught with early occlusions and have been largely replaced by hybrid self-expanding metallic stent grafts, which combine covered and uncovered portions.8 The original 8 or 10 mm Viatorr TIPS stent graft (Gore, Flagstaff, Arizona) has recently been replaced by the variable (8–10 mm) diameter Viatorr CX graft,9 which allows the procedurist to adjust the diameter to 8, 9, or 10 mm depending on the desired pressure gradient. The advancing liver therapeutic approaches consortium provides multidisciplinary evidence-based recommendations for TIPS.1 Ultrasound-guided TIPS creation The transhepatic portal vein puncture is considered the most difficult part of the TIPS procedure because the traditional method of puncture relies on anatomical landmarks and 2-dimensional imaging of the portal vein on fluoroscopy acquired through a wedged transhepatic portogram. This may require multiple needle passes, increasing the risk of hemorrhage due to extrahepatic portal vein puncture.10 The use of intravascular or transabdominal ultrasound has significantly improved this step, as described in several articles.7,11 Transabdominal ultrasound is the preferred guidance used in our institution as it avoids the high cost of intravascular ultrasound, and portal punctures can be successfully achieved with 1 or 2 needle passes. Preemptive or “early” TIPS Preemptive TIPS (pTIPS) is defined as a TIPS procedure within 72 hours from admission for AVB.12,13 TIPS management of AVB has seen a significant shift in recent years from late rescue therapy to pTIPS, especially in high-risk patients.14 The BAVENO VI consensus statement15 first adopted the use of pTIPS in patients with AVB who are at high risk of treatment failure, and much discussion in the literature has focused on the definition of this “high-risk group.” Child-Pugh C (score 10–13) patients show clear-cut benefits from pTIPS with over 20% improved mortality without increased HE.16 Note that the highest risk category of Child-Pugh C patients (score 14) is excluded for medical futility.14,16 The benefit in Child-Pugh B (score 7–9) patients are more varied, and a recent large meta-analysis16 has provided further stratification of this heterogenous population. The subgroup of Child-Pugh B patients with scores of 8–9 and with active bleeding showed clear mortality benefit with pTIPS compared with drug + endoscopic therapy. The Child-Pugh-B7 with active bleeding score subgroup did not see a survival benefit with pTIPS, although there was a signal toward improved ascites control and/or reduced rebleeding. Primary constrained TIPS HE is a major drawback of TIPS, reportedly occurring in 5%–35% of cases and remaining refractory to medical therapy in 3%–7% of cases.17,18 Prediction of portosystemic gradient post-shunt creation is not very reliable.19 There can be significant differences in gradient measured immediately after shunt creation versus during a subsequent procedure.18 In several instances, patients require shunt reduction due to refractory encephalopathy to 6–7 mm diameters.20 Due to this, several authors19,21,22 have proposed the primary constriction of TIPS stents so as to allow for controlled gradual dilatation of the shunt over time (“dial-a-TIPS approach”). The technique we prefer at our institution is to place a short (6 mm diameter × 19 mm length) balloon expandable stent in the hepatic parenchymal tract before insertion of the TIPS stent to form a “belt” around the covered portion of the Viatorr stent graft (Figure 1). The main indication for this is refractory ascites—an initial diameter of 6 mm is accepted regardless of gradient. The patient is monitored clinically for improvement and then brought back for subsequent TIPS dilatation procedures over several weeks or months, depending on clinical need. At each interval, the shunt is gradually expanded by 1 mm until the desired clinical effect is achieved. This approach may prevent the onset of refractory encephalopathy due to drastic changes in portosystemic gradient but remains to be validated by larger patient numbers. Others have suggested under-dilation of the TIPS at the initial creation (ie, without the constraining stent, but balloon dilatation only to 6 or 7 mm).23 However, given that the Viatorr is a self-expanding stent graft comprising of shape-memory Nitinol (nickel-titanium alloy)24 scaffold, this strategy does not reliably prevent stent expansion to its nominal diameter over time. With the new Viatorr Cx now available, we place a constraining stent only when diameters below 8 mm are required.FIGURE 1: (A) US-guided constrained TIPS performed in a 78 year old with refractory ascites HE. Arrows show the needle pass into the right portal vein. (B) Angiogram of portal vein(*) through the TIPS puncture set. (C) Post-TIPS venogram shows a TIPS stent with a mid-segment narrowing (arrow) due to the constrainging stent restricting the shunt diameter to 6 mm. This can be progressively dilated as needed. (D) Coronal CT shows the TIPS stent and constraining stent (arrow) more clearly.Balloon occluded retrograde (or antegrade) transvenous obliteration, BRTO (or BATO) Variants include plug-assisted retrograde transvenous obliteration of varices and coil-assisted retrograde transvenous obliteration of varices techniques.13 These local occlusive therapies require access to the variceal network, which is most commonly achieved by means of the left renal vein. BAVENO VII guidelines support balloon occluded retrograde transvenous obliteration of varices as an alternative to endoscopic treatment and TIPS for type 1 isolated gastric varices, type 2 gastroesophageal varices, and ectopic varices2; however, any accessible variceal network is potentially suitable. Occluding the variceal inflow allows for better visualization and filling of the ectatic system to obliterate as much of the structure as possible using sclerosants and/or liquid agents, for example, cyanoacrylate glue. Without the occlusion, the embolic agents tend to only block off a small portion of the variceal network allowing recanalization and risk of rebleeding. These methods have the advantage of obliterating potential sites of bleeding even in patients who may be poor candidates for TIPS (eg, poor liver function or encephalopathy), and therapeutic effects can be achieved even without excessive portal gradient reduction (Figure 2).25FIGURE 2: (A) Coronal CT image of a 58-year-old woman with variceal bleeding shows large GOV2 and PGV. (B) Balloon occluded retrograde venogram shows GV and PGV (white arrow). Note coil embolization (arrowhead) of the left inferior phrenic vein. This allows the GV to be better visualized and prevents reflux of sclerosant into the inferior phrenic vein (C) Post-BRTO showing complete angiographic sclerosis of the GOV2. (D) Post-BRTO CT shows disappearance of the GOV2 and PGV. Abbreviations: BRTO, balloon occluded retrograde transvenous obliteration of varices; GOV2, gastro-esophageal varices.Partial splenic arterial embolization (PSAE) PSAE is performed by catheter-directed introduction of embolic agents into portions of the spleen resulting in controlled tissue infarction of at least 50%. PSAE is established for improving the platelet count in patients with hypersplenism. However, recent evidence suggests a role in secondary prevention of variceal hemorrhage, particularly in patients who cannot receive the TIPS procedure. Sun et al, comparing endoscopic therapy with and without PSAE in 102 patients, reported a significantly lower 2-year rebleeding rate of 22% versus 67% (p < 0.001) when PSAE was added.26 Wan et al reported markedly improved 5-year patency of TIPS when combined with PSAE.27 However, PSAE should be weighed against postembolic adverse events such as abdominal pain and fever. Variceal and shunt embolization With or without TIPS, embolization of symptomatic varices can be explored for improvement of HE, intrahepatic portal venous flow, and synthetic liver function.28 Access to these varices may be obtained by means of direct puncture (eg, in parastomal varices), a transhepatic puncture for rectal varices, or in combination with a standard TIPS approach.29 Arterial portal shunts may be the primary cause of portal hypertension and should be embolized where possible.30 Prehepatic portal hypertension, for example, due to splenic or portal vein stenosis, requires stenting of these segments and is, therefore unlikely to improve with TIPS alone.13 Summary Interventional radiology procedures are well established for the diagnosis and management of portal hypertension. Recent revisions to guidelines based on emerging evidence have placed greater emphasis on HVPG and TIPS earlier in the patient journey. Combination therapies should be explored in a multidisciplinary manner for optimal outcomes.

REILD is a rare but potentially life-threatening adverse event of Y90-SIRT, with a previously reported incidence of 0-8%. To date, risk factors for REILD remain poorly defined. We aim to define risk factors for REILD in a large cohort of patients treated with Y90-SIRT for HCC from a single institution. This is a retrospective study of consecutive patients treated with Y90 for locally advanced HCC from 2007 to 2019 at the National Cancer Centre Singapore and Singapore General Hospital. Excluded were patients lost to follow-up and those with other concomitant cancer. REILD was defined by the presence of ascites and jaundice between 4-8 weeks post-Y90-SIRT in the absence of tumor progression or bile duct obstruction. Patient demographics, clinical history, pertinent laboratory values and radiological findings were collected. Ethical approval was granted by the Institutional Review Board (IRB 2017/2541). 593 patients received Y90 during the study period, of which 472 met the inclusion/exclusion criteria. 12 patients (2.54%) developed REILD. Risk factors for REILD included baseline grade 2 ALBI score (P=0.039), BCLC C HCC (P=0.003), AFP ≥400 pre-Y90 (P=0.005), and radiological ascites (P=0.003). T/N ratio and total administered Y90 dose did not correlate with REILD development. No patients demised from REILD. However, median overall survival (OS) post-Y90 was shorter for REILD patients (22.3 weeks) compared to non-REILD patients (49.1 weeks) (P=0.017).Table: 157PBaseline characteristicsREILDNon-REILDPN = 12N = 460ALBI grade10 (0.00%)130 (28.3%)0.039212 (100%)297 (64.6%)30 (0.00%)33 (7.17%)BCLC stageA0 (0.00%)77 (16.7%)0.003B0 (0.00%)171 (37.2%)C12 (100%)208 (45.2%)D0 (0.00%)4 (0.87%)AFP Pre-Y90<4002 (20.0%)267 (63.9%)0.005≥4008 (80.0%)151 (36.1%)NA242Radiological ascitesN9 (75.0%)424 (92.2%)0.003Y3 (25.0%)36 (7.8%)T/N ratioMean (SD)3.67 (2.17)4.30 (4.14)0.369Median (IQR)3.46 (2.15-5.37)3.12 (2.07-5.31)Y90 dose (Gbq)Mean (SD)1.73 (1.03)1.70 (0.955)0.454Median (IQR)1.50 (1.33-1.90)1.47 (0.980-2.30) Open table in a new tab Risk factors for REILD are varied and multifactorial. HCC stage and underlying liver function are major determinants of REILD risk. The risk of REILD is not dependent on factors related to Y90-SIRT delivery such as median T/N ratio and radiation dose delivered.

Lung cancer is one of the leading causes of cancer-related mortality in Singapore and globally, with majority of patients diagnosed in the advanced stage where the disease is incurable. Intervention by screening to detect pre or early-stage cancer may potentially provide the best tool to improve mortality and morbidity. The cornerstone of lung cancer screening studies thus far has been low-dose computed tomography (LDCT), with majority of recommendations for implementation in high risk individuals defined by smoking status and age.

Introduction:Sorafenib was historically the standard of care for advanced hepatocellular carcinoma (aHCC) until it was superseded by the combination of atezolizumab and bevacizumab. Thereafter, several novel first-line combination therapies have demonstrated favorable outcomes. The efficacies of these treatments in relation to current and previous standards of care are unknown, necessitating an overarching evaluation. Methods:A systematic literature search was conducted on PubMed, EMBASE, Scopus, and the Cochrane Controlled Register of Trials for phase III randomized controlled trials investigating first-line systemic therapies for aHCC. Kaplan-Meier curves for overall survival (OS) and progression-free survival (PFS) were graphically reconstructed to retrieve individual patient-level data. Derived hazard ratios (HRs) for each study were pooled in a random-effects network meta-analysis (NMA). NMAs were also conducted using study-level HRs for various subgroups, according to viral etiology, Barcelona Clinic Liver Cancer (BCLC) staging, alpha-fetoprotein (AFP) levels, macrovascular invasion, and extrahepatic spread. Treatment strategies were ranked using p scores. Results:Among 4,321 articles identified, 12 trials and 9,589 patients were included for analysis. Only two therapies showed OS benefit over sorafenib: combined anti-programmed-death and anti-VEGF pathway inhibitor monoclonal antibodies (Anti-PD-(L)1/VEGF Ab), including atezolizumab-bevacizumab and sintilimab-bevacizumab biosimilar (HR = 0.63, 95% CI = 0.53-0.76) and tremelimumab-durvalumab (HR = 0.78, 95% CI = 0.66-0.92). Anti-PD-(L)1/VEGF Ab showed OS benefit over all other therapies except tremelimumab-durvalumab. Low heterogeneity (I2 = 0%) and inconsistency (Cochran's Q = 0.52, p = 0.773) was observed. p scores for OS ranked Anti-PD-(L)1/VEGF Ab as the best treatment in all subgroups, except hepatitis B where atezolizumab-cabozantinib ranked highest for both OS and PFS, as well as nonviral HCC and AFP ≥400 μg/L where tremelimumab-durvalumab ranked highest for OS. Conclusion:This NMA supports Anti-PD-(L)1/VEGF Ab as the first-line therapy for aHCC and demonstrates a comparable benefit for tremelimumab-durvalumab which also extends to certain subgroups. Results of the subgroup analysis may guide treatment according to baseline characteristics, while pending further studies.

Abstract Background and Aims TPDI is the treatment of choice for patients with severe hyperparathyroidism who have failed medical therapy in our centre. The auto-transplantation of parathyroid tissue in the deltoid reduces the risk of permanent hypoparathyroidism. However, there is a risk of recurrent hyperparathyroidism from the implanted parathyroid tissue. Traditionally, these autografts are removed surgically in the event of recurrent hyperparathyroidism exposing the patients to the risk of permanent hypoparathyroidism. We attempted radiologically guided ablation of the implanted tissue to allow near but not complete ablation of the tissue. We aim to report our experience in using this technique to treat patients with recurrent hyperparathyroidism following TPDI. Method This is a single centre retrospective study of 9 patients who are on regular dialysis and underwent ablation of their deltoid parathyroid implants at Singapore General Hospital between May 2020 to July 2022. Baseline demographic data, as well as biochemistry results including intact parathyroid hormone (iPTH), serum calcium, phosphorus and alkaline phosphatase (ALP) levels were retrieved from electronic medical records and analysed. We define successful procedure as achieving 2 out of the following 3 criteria: i. >50% drop in iPTH level at 3 months, ii. correction of hypercalcemia at 3 months, iii. off calcimimetic at 3 months Results A total of 9 patients underwent ablation of their parathyroid deltoid implants, of which 8 (89%) had thermal ablation and 1 (11%) had cryoablation. 1 patient required a repeat procedure within 3 month as only 50% of the implanted tissue were targeted instead of the intended 80% and another patient had a repeat procedure >3 month after initial unsuccessful procedure. The median age of patients undergoing this procedure was 60 years (IQR 60, 66) and majority were female (5/9, 55.5%). 8 out of 9 patients were on haemodialysis. 7 out of 9 patients (78%) had a successful procedure based on our definition. 6 patients (67%) had a >50% reduction of iPTH at 3 month, 6 patients (67%) were off calcimimetic at 3 months and out of the 5 patients who were hypercalcemic pre procedure, 4(80%) patients had normalisation of hypercalcemia at 3 months. 3 patients (33%) had iPTH < 2x upper limit of normal with only 1 out of the 3 patient requiring high dose oral calcium replacement at 3 months. Pre ablation levels of PTH decreased from 191.87 ± 93.52 pmol/L to 99.77 ± 111.007 pmol/L (P = 0.773) 1 day after ablation and 92.450 ± 70.235 pmol/L (P = .0450) at 1 month and 91.25 ± 81.25 (P = .024) pmol/L at 3 months. Serum calcium levels decreased from 2.48 mmol/L ± 0.286 pre ablation to 2.11 mmol/L ± 0.322 1 day post ablation (P = 0.007) and remained 2.28 mmol/L ± 0.403 (P = .122) at 3 months post ablation. Serum ALP levels decreased from 478 ± 292.00 pre ablation to 238 ± 157 at 3 months post ablation. There were no re-admissions and no immediate post procedure complications in all patients. 4 out of 9 patients (44%) required intravenous calcium replacement post- procedure during the same admission. Limitations of this study are the relatively short follow-up duration and the small number of patients. 2 out of the 9 patients were lost to follow up at 3 months. Conclusion Ablation of deltoid parathyroid autografts may be a safe and effective minimally invasive procedure to manage recurrent hyperparathyroidism and minimising the risk of permanent hypoparathyroidism. However, further studies with larger sample sizes and longer follow up duration would be prudent to confirm our findings