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Percutaneous management of cholangiocarcinoma

Key points In general, the higher the cholangiocarcinoma (type 3 and type 4) and the more multifocal the disease/obstruction, the more likely the patient is to require percutaneous therapy/drainage rather than endoscopic drainage. The two chief indications for preoperative biliary drainage are (1) the presence of preoperative cholangitis and (2) estimated FLR <30%. The goal of percutaneous biliary drainage is hepatic reserve optimization by improving coagulopathy…

Cholangiocarcinoma: Diagnosis, management, and prognosis

Key points Although relatively rare, cholangiocarcinoma is the second most common primary hepatobiliary malignancy in the United States, and its incidence is increasing. Surgical treatment remains the cornerstone of curative therapy. Resection frequently requires a major procedure but can be done with relatively low morbidity and near zero mortality. Locoregional therapies have an important role in the management of cholangiocarcinoma, with radiation therapy more commonly used…

Systemic therapy in advanced hepatocellular carcinoma

Key points Cytotoxic chemotherapy has not proven effective in hepatocellular carcinoma (HCC). Sorafenib is the only approved agent for advanced, unresectable disease. Current studies are evaluating a wide range of targeted agents covering the spectrum of molecular aberrations in HCC. Currently, there are no effective alternatives for sorafenib-refractory HCC. The combination of sorafenib and chemoembolization has not been shown to improve clinical outcomes. Combined systemic and…

Interventional management of hepatocellular carcinoma

Key points Image guided techniques are the most common invasive therapy for unresectable hepatocellular carcinoma (HCC). Level 1 evidence supports survival benefit chemoembolization. New embolic devices may offer benefits not currenlty realized. Background Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the third most common cause of cancer-related death. Although the highest prevalence is still in sub-Saharan Africa and Asia, the incidence in…

Surgical management of hepatocellular carcinoma

Key points Patients with cirrhosis are at highest risk of developing hepatocellular carcinoma (HCC) and screening with sonography every 6 months is recommended. Early-stage HCC should be treated by resection, liver transplantation, or ablation. The best modality depends on tumor size and location, number of tumors, liver function status, future liver remnant, organ availability, as well as patient’s fitness for surgery. Curative anatomic liver resection is…

Trends in basic science research in interventional radiology: NANOTECHNOLOGY, STEM CELL, RNAi, AND RADIOGENOMICS

Introduction Research in interventional radiology has historically been driven by innovation and technological development leading to the conceptualization, investigation, validation, and application of a myriad of novel procedures into clinical practice. The development of new techniques and therapies is critical to ensuring the continued success and relevance of interventional radiology as a subspecialty. This has been reflected in the vision statement of the Society of Interventional…

Tumor response for image-guided interventions: ASSESSMENT AND VALIDATION

Key points The pathologic endpoint for percutaneous thermal or ethanol treatment of unresectable tumors is coagulation necrosis. Similarly, the goals of transarterial therapy are cell necrosis and apoptosis. Although specific follow-up imaging protocols differ among practitioners and institutions, contrast-enhanced computed tomography (CT), positron emission tomography (PET), and magnetic resonance imaging (MRI) are the primary imaging modalities used. Because tumors can recur months or years after treatment,…

Principles of radiotherapy

Key points The clinical application of radiation oncology balances the dual goals of improved tumor control with reduced treatment-related morbidity. Over time, technological and biological advances have offered many opportunities to further reduce normal tissue complications and improve tumor control with radiotherapy. More recent and emerging technologies promise further improvements in the therapeutic ratio. Rational application and critical appraisal of these new technologies will remain essential…

Principles of isolated regional perfusion of the extremity or liver

Key points Regional perfusion is a method of delivering high-dose chemotherapy to a region burdened with cancer. Isolated limb perfusion and hepatic perfusion are traditional open surgical methods of regional therapy in treating melanoma confined to an extremity or the liver. Newer hybrid methods employ percutaneous techniques by interventional radiologists to gain access to the afferent and efferent blood flow of the limb or liver. Introduction…

Principles of percutaneous ablative therapies

Key points Percutaneous image-guided tumor ablation uses the cytotoxic properties of thermal energy or electric field strength to cause cell death. The thermal ablative effect due to coagulation necrosis is generated by the Radiofrequency probe, which acts as the cathode in an electrical circuit closed by attaching grounds pads to the patient. Cytotoxicity of Cryoablation results from denaturation of protein structures, and cellular membrane disruption caused…

Principles of embolization

Key points Properly identify the indications and goals for the procedure to guide selection of embolic material. Become familiar with available embolic agents and common uses for each. A clear understanding of the relevant anatomy will allow for a safe and efficient embolization. Introduction Transcatheter and percutaneous embolization therapies are a large part of the Interventional Radiologists’ armamentarium. Embolotherapy has a wide array of applications such…

Sports Medicine

In the United States, more than than 30 million (approximately one-third) of school-aged children participate in organized sports. Sports-related injuries occur more frequently in the lower extremities compared with the upper extremities. This section will review acute and chronic sports injury patterns with an emphasis on entities that are unique in children as well as cover multimodality imaging with an emphasis on important magnetic resonance imaging…

Child Abuse

Overview Radiology played a major role in defining child abuse as a medical entity, most notably with the landmark publications by Caffey (1946) and Silverman (1953). Silverman also contributed to Kempe's 1962 paper, “The Battered Child,” which demonstrated the prevalence of severe injury and death from child abuse and brought widespread public awareness to the diagnosis. In the ensuing years, an enormous experience base and wealth…

Skeletal Trauma

General Overview The dictum “Children are not small adults” is especially true regarding skeletal trauma. Fracture patterns, fracture healing, and fracture complications differ between children and adults. Fortunately, fracture complications are relatively uncommon. In healthy children, the process of fracture healing and remodeling is rapid, particularly in the vascularized metaphysis. Most posttraumatic deformities readily correct with healing and remodeling. The composition of a child's bones and…

Skeletal Manifestations of Systemic Disease

Normal Bone Marrow Overview Bone marrow is one of the largest and most dynamic tissues in the body. Its functions include the production of red blood cells, white blood cells, and platelets for tissue oxygenation, cellular immunity, and blood coagulation, respectively. Bone marrow occupies approximately 85% of the medullary cavity and is supported by a network of trabecular bone. In addition to hematopoietic elements, it contains…

Endocrine Disorders

Several endocrine glands have significant effects on skeletal growth, maturation, and modeling, and understanding these effects facilitates correct radiographic interpretation. Renal osteodystrophy is also included in this chapter because of the importance of hyperparathyroidism (HPTH) in its pathophysiology, as are other related conditions causing disorders of bone physiology. Hyperparathyroidism and Renal Osteodystrophy Etiology. The parathyroid glands help maintain a normal circulating calcium concentration by releasing parathyroid…

Metabolic Bone Disease

Skeletal ossification and mineralization are influenced by many metabolic factors, with sometimes arbitrary distinctions between metabolic bone disorders, endocrine bone disorders, and inherited skeletal dysplasias. Accurate diagnosis is essential because many of these disorders require specific therapy for both their skeletal and extraskeletal effects. Abnormalities of Mineralization Bone Mineral Physiology In the process of bone formation, osteoblasts produce organic bone matrix (osteoid), which then must be…

Soft Tissue and Bone Tumors

Soft Tissue Tumors Overview In general, clinical presentation and findings guide diagnostic imaging in the assessment of soft tissue neoplasms. In children with subtle masses, the primary objective of imaging is to confirm or exclude the presence of a mass. In children with obvious masses, imaging is performed to assess the local extent of the tumor, to provide a differential diagnosis, and to guide potential biopsy.…

Musculoskeletal Infections

Overview of Musculoskeletal Infections Musculoskeletal infections remain a diagnostic and therapeutic challenge. Historically, the workup and treatment of such infections has been based on clinical grounds supplemented by diagnostic aspiration and subsequent surgical incision and drainage. Today, imaging plays a critical role in the diagnosis and management of musculoskeletal infections. This chapter will review the clinical presentation, pathophysiology, imaging, and treatment spectrum of osteomyelitis, septic arthritis,…

Arthritis and Differential Inflammatory Joint Disorders

Rheumatologic conditions in children are myriad in presentation, with overlapping imaging features that may sometimes superficially mimic infection. Rheumatologic conditions in children do not follow the typical course and presentation compared with their counterparts in adults. As a consequence, the International League of Associations for Rheumatology (ILAR) formulated a revised nomenclature to describe the various pediatric rheumatologic conditions ( Box 136.1 ). In this chapter, we…