Rajesh Shah

All Publications

• Determining the Optimal Number of Core Needle Biopsy Passes for Molecular Diagnostics CARDIOVASCULAR AND INTERVENTIONAL RADIOLOGY Hoang, N. S., Ge, B. H., Pan, L. Y., Ozawa, M. G., Kong, C. S., Louie, J. D., Shah, R. P. 2018; 41 (3): 489–95

  Abstract

  The number of core biopsy passes required for adequate next-generation sequencing is impacted by needle cut, needle gauge, and the type of tissue involved. This study evaluates diagnostic adequacy of core needle lung biopsies based on number of passes and provides guidelines for other tissues based on simulated biopsies in ex vivo porcine organ tissues.The rate of diagnostic adequacy for pathology and molecular testing from lung biopsy procedures was measured for eight operators pre-implementation (September 2012-October 2013) and post-implementation (December 2013-April 2014) of a standard protocol using 20-gauge side-cut needles for ten core biopsy passes at a single academic hospital. Biopsy pass volume was then estimated in ex vivo porcine muscle, liver, and kidney using side-cut devices at 16, 18, and 20 gauge and end-cut devices at 16 and 18 gauge to estimate minimum number of passes required for adequate molecular testing.Molecular diagnostic adequacy increased from 69% (pre-implementation period) to 92% (post-implementation period) (p < 0.001) for lung biopsies. In porcine models, both 16-gauge end-cut and side-cut devices require one pass to reach the validated volume threshold to ensure 99% adequacy for molecular characterization, while 18- and 20-gauge devices require 2-5 passes depending on needle cut and tissue type.Use of 20-gauge side-cut core biopsy needles requires a significant number of passes to ensure diagnostic adequacy for molecular testing across all tissue types. To ensure diagnostic adequacy for molecular testing, 16- and 18-gauge needles require markedly fewer passes.

  View details for DOI 10.1007/s00270-017-1861-4

  View details for Web of Science ID 000424336900016

  View details for PubMedID 29279975

• The Role of Cone-Beam CT in Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma: A Systematic Review and Meta-analysis. Journal of vascular and interventional radiology Pung, L., Ahmad, M., Mueller, K., Rosenberg, J., Stave, C., Hwang, G. L., Shah, R., Kothary, N. 2017; 28 (3): 334-341

  Abstract

  To review available evidence for use of cone-beam CT during transcatheter arterial chemoembolization in hepatocellular carcinoma (HCC) for detection of tumor and feeding arteries.Literature searches were conducted from inception to May 15, 2016, in PubMed (MEDLINE), Scopus, and Cochrane Central Register of Controlled Trials. Searches included "cone beam," "CBCT," "C-arm," "CACT," "cone-beam CT," "volumetric CT," "volume computed tomography," "volume CT," AND "liver," "hepatic*," "hepatoc*." Studies that involved adults with HCC specifically and treated with transcatheter arterial chemoembolization that used cone-beam CT were included.Inclusion criteria were met by 18 studies. Pooled sensitivity of cone-beam CT for detecting tumor was 90% (95% confidence interval [CI], 82%-95%), whereas pooled sensitivity of digital subtraction angiography (DSA) for tumor detection was 67% (95% CI, 51%-80%). Pooled sensitivity of cone-beam CT for detecting tumor feeding arteries was 93% (95% CI, 91%-95%), whereas pooled sensitivity of DSA was 55% (95% CI, 36%-74%).Cone-beam CT can significantly increase detection of tumors and tumor feeding arteries during transcatheter arterial chemoembolization. Cone-beam CT should be considered as an adjunct tool to DSA during transcatheter arterial chemoembolization treatments of HCC.

  View details for DOI 10.1016/j.jvir.2016.11.037

  View details for PubMedID 28109724

• Noninvasive radiomics signature based on quantitative analysis of computed tomography images as a surrogate for microvascular invasion in hepatocellular carcinoma: a pilot study. Journal of medical imaging (Bellingham, Wash.) Bakr, S., Echegaray, S., Shah, R., Kamaya, A., Louie, J., Napel, S., Kothary, N., Gevaert, O. 2017; 4 (4): 041303

  Abstract

  We explore noninvasive biomarkers of microvascular invasion (mVI) in patients with hepatocellular carcinoma (HCC) using quantitative and semantic image features extracted from contrast-enhanced, triphasic computed tomography (CT). Under institutional review board approval, we selected 28 treatment-naive HCC patients who underwent surgical resection. Four radiologists independently selected and delineated tumor margins on three axial CT images and extracted computational features capturing tumor shape, image intensities, and texture. We also computed two types of "delta features," defined as the absolute difference and the ratio computed from all pairs of imaging phases for each feature. 717 arterial, portal-venous, delayed single-phase, and delta-phase features were robust against interreader variability ([Formula: see text]). An enhanced cross-validation analysis showed that combining robust single-phase and delta features in the arterial and venous phases identified mVI (AUC [Formula: see text]). Compared to a previously reported semantic feature signature (AUC 0.47 to 0.58), these features in our cohort showed only slight to moderate agreement (Cohen's kappa range: 0.03 to 0.59). Though preliminary, quantitative analysis of image features in arterial and venous phases may be potential surrogate biomarkers for mVI in HCC. Further study in a larger cohort is warranted.

  View details for DOI 10.1117/1.JMI.4.4.041303

  View details for PubMedID 28840174

  View details for PubMedCentralID PMC5565686

• Standardized Reporting in IR: A Prospective Multi-Institutional Pilot Study JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY McWilliams, J. P., Shah, R. P., Quirk, M., White, S. B., Dybul, S. L., Ahrar, J., Steele, J. R., Kwan, S. W., Handel, J., Winokur, R. S., Gilliland, C. A., Durack, J. C. 2016; 27 (12): 1779-1785

  Abstract

  To assess adoption and survey-based satisfaction rates following deployment of standardized interventional radiology (IR) procedure reports across multiple institutions.Standardized reporting templates for 5 common interventional procedures (central venous access, inferior vena cava [IVC] filter insertion, IVC filter removal, uterine artery embolization, and vertebral augmentation) were distributed to 20 IR practices in a prospective quality-improvement study. Participating sites edited the reports according to institutional preferences and deployed them for a 1-year pilot study concluding in July 2015. Study compliance was measured by sampling 20 reports of each procedure type at each institution, and surveys of interventionalists and referring physicians were performed. Modifications to the standardized reporting templates at each site were analyzed.Ten institutions deployed the standardized reports, with 8 achieving deployment of 3-12 months. The mean report usage rate was 57%. Each site modified the original reports, with 26% mean reduction in length, 18% mean reduction in wordiness, and 60% mean reduction in the number of forced fill-in fields requiring user input. Linear-regression analysis revealed that reduced number of forced fill-in fields correlated significantly with increased usage rate (R(2) = 0.444; P = .05). Surveys revealed high satisfaction rates among referring physicians but lower satisfaction rates among interventional radiologists.Standardized report adoption rates increased when reports were simplified by reducing the number of forced fill-in fields. Referring physicians preferred the standardized reports, whereas interventional radiologists preferred standard narrative reports.

  View details for DOI 10.1016/j.jvir.2016.07.016

  View details for Web of Science ID 000389788900001

  View details for PubMedID 27670943

• Complications During Transjugular Intrahepatic Portosystemic Shunt Creation. Techniques in vascular and interventional radiology Shah, R. P., Sze, D. Y. 2016; 19 (1): 61-73

  Abstract

  Transjugular intrahepatic portosystemic shunt (TIPS) creation is a widely adopted treatment for complications of portal hypertension, including variceal hemorrhage and refractory ascites. The creation of a TIPS requires establishing a pathway from the portal vein to a hepatic vein or inferior vena cava through hepatic parenchyma, using a stent or stent graft to sustain patency of this pathway. Because it is a technically challenging procedure and patients may be critically ill with severe comorbidities, the risk of procedural complications and mortality is substantial. This article discusses known complications of the TIPS procedure and ways to minimize their occurrence.

  View details for DOI 10.1053/j.tvir.2016.01.007

  View details for PubMedID 26997090

• Endovascular Stent Placement for May-Thurner Syndrome in the Absence of Acute Deep Vein Thrombosis. Journal of vascular and interventional radiology Ahmed, O., Ng, J., Patel, M., Ward, T. J., Wang, D. S., Shah, R., Hofmann, L. V. 2016; 27 (2): 167-173

  Abstract

  To assess the clinical utility of iliac vein stent placement for patients with chronic limb edema or pelvic congestion presenting with nonocclusive May-Thurner physiology.All patients (N = 45) undergoing stent placement for May-Thurner syndrome (MTS) without an associated acute thrombotic event between 2007 and 2014 were retrospectively reviewed; 11 were excluded for poor follow-up. A total of 34 patients (28 female) were studied (mean age, 44 y; range, 19-80 y). Average follow-up time was 649 days (median, 488 d; range, 8-2,499 d).The technical success rate was 100% (34 of 34). No major and two minor (5%) complications occurred, and 68% of patients (23 of 34) had clinical success with relief of presenting symptoms on follow-up visits. Technical parameters including stent size and number, stent type, concurrent angioplasty, access site, and resolution of collateral iliolumbar vessels were not found to be statistically related to clinical success (P > .05). Similarly, no significant relation to clinical success was seen for clinical factors such as the type of symptoms, presence of chronic deep vein thrombosis (DVT), or concurrent coagulopathy (P > .05). Female sex was found to correlate with clinical success (82% vs 18%; P = .04).Iliac stent placement in patients presenting with chronic limb or pelvic symptoms from MTS without acute DVT is associated with clinical success in the majority of patients.

  View details for DOI 10.1016/j.jvir.2015.10.028

  View details for PubMedID 26703783

• Severe Chest Wall Toxicity From Cryoablation in the Setting of Prior Stereotactic Ablative Radiotherapy. Cure¯us Chaudhuri, A. A., Binkley, M. S., Aggarwal, S., Qian, Y., Carter, J. N., Shah, R., Loo, B. W. 2016; 8 (2)

  Abstract

  We present the case of a 42-year-old woman with metastatic synovial sarcoma of parotid origin, treated definitively with chemoradiation, who subsequently developed oligometastatic disease limited to the lungs. She underwent multiple left and right lung wedge resections and left lower lobectomy, followed by right lower lobe stereotactic ablative radiotherapy (SABR), 54 Gy in three fractions to a right lower lobe lesion abutting the chest wall. Two years later, she was treated with cryoablation for a separate right upper lobe nodule abutting the chest wall. Two months later, she presented with acute shortness of breath, pleuritic chest pain, decreased peripheral blood O2 saturation, and productive cough. A computed tomography (CT) scan demonstrated severe chest wall necrosis in the area of recent cryoablation that, in retrospect, also received a significant radiation dose from her prior SABR. This case demonstrates that clinicians should exercise caution in using cryoablation when treating lung tumors abutting a previously irradiated chest wall. Note: Drs. Loo and Shah contributed equally as co-senior authors.

  View details for DOI 10.7759/cureus.477

  View details for PubMedID 27004154

  View details for PubMedCentralID PMC4780688

• Management of High Hepatopulmonary Shunting in Patients Undergoing Hepatic Radioembolization. Journal of vascular and interventional radiology Ward, T. J., Tamrazi, A., Lam, M. G., Louie, J. D., Kao, P. N., Shah, R. P., Kadoch, M. A., Sze, D. Y. 2015; 26 (12): 1751-1760

  Abstract

  To review the safety of hepatic radioembolization (RE) in patients with high (≥ 10%) hepatopulmonary shunt fraction (HPSF) using various prophylactic techniques.A review was conducted of 409 patients who underwent technetium 99m-labeled macroaggregated albumin scintigraphy before planned RE. Estimated pulmonary absorbed radiation doses based on scintigraphy and hepatic administered activity were calculated. Outcomes from dose reductions and adjunctive catheter-based prophylactic techniques used to reduce lung exposure were assessed.There were 80 patients with HPSF ≥ 10% who received RE treatment (41 resin microspheres for metastases, 39 glass microspheres for hepatocellular carcinoma). Resin microspheres were used in 17 patients according to consensus guideline-recommended dose reduction; 38 patients received no dose reduction because the expected lung dose was < 30 Gy. Prophylactic techniques were used in 25 patients (with expected lung dose ≤ 74 Gy), including hepatic vein balloon occlusion, variceal embolization, or bland arterial embolization before, during, or after RE delivery. Repeated scintigraphy after prophylactic techniques to reduce HPSF in seven patients demonstrated a median change of -40% (range, +32 to -69%). Delayed pneumonitis developed in two patients, possibly related to radiation recall after chemoembolization. Response was lower in patients treated with resin spheres with dose reduction, with an objective response rate of 13% and disease control rate of 47% compared with 56% and 94%, respectively, without dose reduction (P = .023, P = .006).Dose reduction recommendations for HPSF may compromise efficacy. Excessive shunting can be reduced by prophylactic catheter-based techniques, which may improve the safety of performing RE in patients with high HPSF.

  View details for DOI 10.1016/j.jvir.2015.08.027

  View details for PubMedID 26525118

• Core samples for radiomics features that are insensitive to tumor segmentation: method and pilot study using CT images of hepatocellular carcinoma. Journal of medical imaging (Bellingham, Wash.) Echegaray, S., Gevaert, O., Shah, R., Kamaya, A., Louie, J., Kothary, N., Napel, S. 2015; 2 (4): 041011-?

  Abstract

  The purpose of this study is to investigate the utility of obtaining "core samples" of regions in CT volume scans for extraction of radiomic features. We asked four readers to outline tumors in three representative slices from each phase of multiphasic liver CT images taken from 29 patients (1128 segmentations) with hepatocellular carcinoma. Core samples were obtained by automatically tracing the maximal circle inscribed in the outlines. Image features describing the intensity, texture, shape, and margin were used to describe the segmented lesion. We calculated the intraclass correlation between the features extracted from the readers' segmentations and their core samples to characterize robustness to segmentation between readers, and between human-based segmentation and core sampling. We conclude that despite the high interreader variability in manually delineating the tumor (average overlap of 43% across all readers), certain features such as intensity and texture features are robust to segmentation. More importantly, this same subset of features can be obtained from the core samples, providing as much information as detailed segmentation while being simpler and faster to obtain.

  View details for DOI 10.1117/1.JMI.2.4.041011

  View details for PubMedID 26587549

  View details for PubMedCentralID PMC4650964

• Quantitative Emphysema Score as a Predictor of Morbidity in Transthoracic Needle Aspiration Biopsy Gonzales, N., Wang, D., Holty, J., Kuschner, W., Raffy, P., Laeseke, P., Shah, R., Sung, A., Van Wert, R. AMER COLL CHEST PHYSICIANS. 2015

  View details for DOI 10.1378/chest.2280739

  View details for Web of Science ID 000367163100042

• Prophylactic Topically Applied Ice to Prevent Cutaneous Complications of Nontarget Chemoembolization and Radioembolization JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Wang, D. S., Louie, J. D., Kothary, N., Shah, R. P., Sze, D. Y. 2013; 24 (4): 596-600

  Abstract

  Cutaneous complications can result from nontarget deposition during transcatheter arterial chemoembolization or radioembolization. Liver tumors may receive blood supply from parasitized extrahepatic arteries (EHAs) that also perfuse skin or from hepatic arteries located near the origin of the falciform artery (FA), which perfuses the anterior abdominal wall. To vasoconstrict cutaneous vasculature and prevent nontarget deposition, ice packs were topically applied to at-risk skin in nine chemoembolization treatments performed via 14 parasitized EHAs, seven chemoembolization treatments near the FA origin, and five radioembolization treatments in cases in which the FA could not be prophylactically coil-embolized. No postprocedural cutaneous complications were encountered.

  View details for DOI 10.1016/j.jvir.2012.12.020

  View details for Web of Science ID 000316828000022

  View details for PubMedID 23522163

• Superselective Internal Radiation With Yttrium-90 Microspheres in the Management of a Chemorefractory Testicular Liver Metastasis CARDIOVASCULAR AND INTERVENTIONAL RADIOLOGY Sideras, P. A., Sofocleous, C. T., Brody, L. A., Siegelbaum, R. H., Shah, R. P., Taskar, N. 2012; 35 (2): 426-429

  Abstract

  We treated a patient with biopsy-proven, chemotherapy-resistant testicular cancer liver metastasis using Y-90 selective internal radiation treatment. We chose yttrium-90 rather than surgery and ablation due to tumor location and size as well as the patient's clinical history. The result was marked tumor response by positron emission tomography and computed tomography as well as significant improvement of the patient's quality of life accompanied by a substantial decrease of his tumor markers.

  View details for DOI 10.1007/s00270-011-0226-7

  View details for Web of Science ID 000304162400029

  View details for PubMedID 21773859

• Asymptomatic Liver Abscesses Mimicking Metastases in Patients after Whipple Surgery: Infectious Complications following Percutaneous Biopsy-A Report of Two Cases. Case reports in hepatology Zhang, K. K., Maybody, M., Shah, R. P., Vakiani, E., Getrajdman, G. I., Brody, L. A., Solomon, S. B. 2012; 2012: 817314-?

  Abstract

  We present two cases of hepatic abscesses that mimicked metastases in patients having undergone Whipple surgery. Both patients had similar imaging features on computed tomographic (CT) scan and ultrasound, and at the time of referral for biopsy neither patient was clinically suspected to have liver abscess. Both patients underwent biopsy of liver lesions and developed postprocedural infectious complications.

  View details for DOI 10.1155/2012/817314

  View details for PubMedID 25374711

• Cystic Artery Localization with a Three-dimensional Angiography Vessel Tracking System Compared with Conventional Two-dimensional Angiography JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Wang, X., Shah, R. P., Maybody, M., Brown, K. T., Getrajdman, G. I., Stevenson, C., Petre, E. N., Solomon, S. B. 2011; 22 (10): 1414-1419

  Abstract

  During transcatheter hepatic therapy, the cystic artery feeding the gallbladder may inadvertently be exposed to tumor therapy. Localization of the cystic artery may help prevent exposure. The objective of this study was to compare the application of a vessel tracking system software based on three-dimensional (3D) angiography versus standard two-dimensional (2D) angiography for identifying the cystic artery and its origin.A software system that can rapidly localize the cystic artery from a 3D common hepatic angiogram was applied in 25 patients and was compared with manual localization of the cystic artery with conventional 2D digital subtraction common hepatic angiograms.With the vessel tracking software prototype, 28 cystic arteries were retrogradely tracked in 25 of 25 cases. The origin sites were correctly located by the software in 27 of 28 cystic arteries, with one mistracked as a result of streak artifact. By contrast, on standard 2D hepatic angiography, the cystic artery was deemed visible with certainty in 12 of 25 cases (P < .001). The vessel tracking system revealed a 56% prevalence of extraanatomic distribution by the cystic artery, with the most common supply going to segment 5 liver parenchyma.The 3D vessel rapid tracking system has advantages over conventional 2D hepatic angiography in revealing the cystic artery and its origin site. It is also an important tool to identify the complete distribution of the cystic artery without superselective angiography. Supply to adjacent hepatic parenchyma or tumor by the cystic artery is not insignificant and should be considered during hepatic therapies.

  View details for DOI 10.1016/j.jvir.2011.02.022

  View details for Web of Science ID 000295708400011

  View details for PubMedID 21546264

• Arterially Directed Therapies for Hepatocellular Carcinoma AMERICAN JOURNAL OF ROENTGENOLOGY Shah, R. P., Brown, K. T., Sofocleous, C. T. 2011; 197 (4): W590-W602

  Abstract

  Arterially directed therapies for hepatocellular carcinoma are used for patients who are not candidates for surgery or ablation and for those who need a bridge or down-staging to liver transplantation. These therapies seem to prolong the overall survival when compared with supportive care.Chemoembolization, particle embolization, drug-eluting beads, and radioembolization have been used for locoregional control. This review discusses patient selection, techniques, safety, clinical outcomes, and imaging findings related to these therapies.

  View details for DOI 10.2214/AJR.11.7554

  View details for Web of Science ID 000295081000008

  View details for PubMedID 21940531

• Hepatic arterial embolization complicated by acute cholecystitis. Seminars in interventional radiology Shah, R. P., Brown, K. T. 2011; 28 (2): 252-257

  Abstract

  Hepatic arterial embolization (HAE) is a treatment used in the management of primary and some metastatic hepatic tumors. Complications of HAE are similar to those seen in other treatments, particularly transcatheter arterial chemoembolization (TACE), but without the possibility for chemotherapy related side effects. Particle reflux into the cystic artery is generally clinically occult but gallbladder ischemia severe enough to require cholecystostomy tube placement can occur. The authors discuss the case of a patient who underwent HAE and subsequently required a cholecystostomy tube due to development of acute cholecystitis.

  View details for DOI 10.1055/s-0031-1280675

  View details for PubMedID 22654273

• Synchronous moyamoya syndrome and ruptured cerebral aneurysm in Alagille syndrome JOURNAL OF CLINICAL NEUROSCIENCE Gaba, R. C., Shah, R. P., Muskovitz, A. A., Guzman, G., Michals, E. A. 2008; 15 (12): 1395-1398

  Abstract

  Moyamoya syndrome and cerebral aneurysm formation are rare cerebrovascular manifestations of Alagille syndrome. Although previously reported in isolation, occurrence of these complications in a single patient has not been described. We report clinical and imaging features of synchronous moyamoya syndrome and ruptured cerebral aneurysm in a patient with Alagille syndrome.

  View details for DOI 10.1016/j.jocn.2007.05.033

  View details for Web of Science ID 000264181800018

  View details for PubMedID 18842413

• A case of pancreatic islet cell transplantation in a patient with situs ambiguous: anatomical and radiological considerations. Seminars in interventional radiology Shah, R. P., Bui, J. T., West, D. L., Oberholzer, J., Hatipoglu, B. A., Martellotto, J. N., Owens, C. A. 2007; 24 (1): 43-46

  Abstract

  Pancreatic islet cell transplantation is an evolving treatment of severe, refractory type 1 diabetes that has been gaining more use, particularly after one year rates of insulin independence post-transplantation were found to approach 80% under the Edmonton protocol. Islet cell transplantation involves percutaneous delivery of harvested allogeneic β cells into the portal venous circulation for implantation into the liver. We present the case of a 35-year-old woman with type 1 diabetes and situs ambiguous with left isomerism and resultant variant anatomy of her portal venous anatomy who underwent islet cell transplantation, which, to our knowledge, has not been previously reported.

  View details for DOI 10.1055/s-2007-971190

  View details for PubMedID 21326735