Hepatic metastases: interstitial laser photocoagulation with real-time US monitoring and dynamic CT evaluation of treatment

Monodisperse Sub-100 nm Au Nanoshells for Low-Fluence Deep-Tissue Photoacoustic Imaging

Nanoparticles with high absorption cross sections will advance therapeutic and bioimaging nanomedicine technologies. While Au nanoshells have shown great promise in nanomedicine, state-of-the-art synthesis methods result in scattering-dominant particles, mitigating their efficacy in absorption-based techniques that leverage the photothermal effect, such as photoacoustic (PA) imaging. We introduce a highly reproducible synthesis route to monodisperse sub-100 nm Au nanoshells with an absorption-dominant optical response. Au nanoshells with 48 nm SiO2 cores and 7 nm Au shells show a 14-fold increase in their volumetric absorption coefficient compared to commercial Au nanoshells with dimensions commonly used in nanomedicine. PA imaging with Au nanoshell contrast agents showed a 50% improvement in imaging depth for sub-100 nm Au nanoshells compared with the smallest commercially available nanoshells in a turbid phantom. Furthermore, the high PA signal at low fluences, enabled by sub-100 nm nanoshells, will aid the deployment of low-cost, low-fluence light-emitting diodes for PA imaging.

Interventional oncology of liver tumors: how it all started and where are we now

Liver was the very first organ for which interventional procedures were applied for the local treatment of primary and secondary malignancies. In this paper, the history of Interventional Oncology of liver, from the very beginning to the current situation, is summarized, including both percutaneous and intravascular procedures, and together with the evolution of the techniques for image guidance. The main ongoing developments, such as new techniques, combined interventional treatments and association of local interventions with new drugs are briefly described, too.

Update on Percutaneous Local Ablative Procedures for the Treatment of Hepatocellular Carcinoma

BACKGROUND

 Hepatocellular carcinoma (HCC) is the fifth most common tumor worldwide. Because many hepatocellular carcinomas are already unresectable at the time of initial diagnosis, percutaneous tumor ablation has become established in recent decades as a curative therapeutic approach for very early (BCLC 0) and early (BCLC A) HCC. The aim of this paper is to provide a concise overview of the percutaneous local ablative procedures currently in use, based on their technical characteristics as well as clinical relevance, taking into account the current body of studies.

MATERIALS AND METHODS

 The literature search included all original papers, reviews, and meta-analyses available via MEDLINE and Pubmed on the respective percutaneous ablation procedures; the primary focus was on randomized controlled trials and publications from the last 10 years.

RESULTS AND CONCLUSIONS

 Radiofrequency ablation (RFA) and microwave ablation (MWA) are well-established procedures that are considered equal to surgical resection in the treatment of stage BCLC 0 and A HCC with a diameter up to 3 cm due to their strong evidence in international and national guidelines. For tumors with a diameter between 3 and 5 cm, the current S3 guidelines recommend a combination of transarterial chemoembolization (TACE) and thermal ablation using RFA or MWA as combination therapy is superior to thermal ablation alone in tumors of this size and shows comparable results to surgical resection in terms of overall survival. Alternative, less frequently employed thermal procedures include cryotherapy (CT) and laser ablation (LA). Non-thermal procedures include irreversible electroporation (IRE), interstitial brachytherapy (IBT), and most recently, electrochemotherapy (ECT). Due to insufficient evidence, these have only been used in individual cases and within the framework of studies. However, the nonthermal methods are a reasonable alternative for ablation of tumors adjacent to large blood vessels and bile ducts because they cause significantly less damage to these structures than thermal ablation methods. With advances in the technology of the respective procedures, increasingly good evidence, and advancements in supportive techniques such as navigation devices and fusion imaging, percutaneous ablation procedures may expand their indications for the treatment of larger and more advanced tumors in the coming years.

KEY POINTS

· RFA and MWA are considered equal to surgical resection as a first-line therapy for the curative treatment of stage BCLC 0 and A HCCs with a diameter of up to 3 cm.. · For HCCs with a diameter between 3 and 5 cm, a combination of TACE and RFA or MWA is recommended. This combination therapy yields results comparable to those of surgical resection in terms of overall survival.. · Due to insufficient evidence, alternative ablation methods have only been used in individual cases and within the framework of studies. However, nonthermal methods, such as IRE, IBT, and, most recently, ECT, are a reasonable alternative for ablation of HCCs adjacent to large blood vessels and bile ducts because they cause significantly less damage to these structures than thermal ablation methods..

CITATION FORMAT

· Luerken L, Haimerl M, Doppler M et al. Update on Percutaneous Local Ablative Procedures for the Treatment of Hepatocellular Carcinoma. Fortschr Röntgenstr 2022; DOI: 10.1055/a-1768-0954.

Nanoparticle-Mediated Photothermal Therapy Limitation in Clinical Applications Regarding Pain Management

The development of new effective cancer treatment methods has attracted much attention, mainly due to the limited efficacy and considerable side effects of currently used cancer treatment methods such as radiation therapy and chemotherapy. Photothermal therapy based on the use of plasmonically resonant metallic nanoparticles has emerged as a promising technique to eradicate cancer cells selectively. In this method, plasmonic nanoparticles are first preferentially uptaken by a tumor and then selectively heated by exposure to laser radiation with a specific plasmonic resonant wavelength, to destroy the tumor whilst minimizing damage to adjacent normal tissue. However, several parameters can limit the effectiveness of photothermal therapy, resulting in insufficient heating and potentially leading to cancer recurrence. One of these parameters is the patient’s pain sensation during the treatment, if this is performed without use of anesthetic. Pain can restrict the level of applicable laser radiation, cause an interruption to the treatment course and, as such, affect its efficacy, as well as leading to a negative patient experience and consequential general population hesitancy to this type of therapy. Since having a comfortable and painless procedure is one of the important treatment goals in the clinic, along with its high effectiveness, and due to the relatively low number of studies devoted to this specific topic, we have compiled this review. Moreover, non-invasive and painless methods for temperature measurement during photothermal therapy (PTT), such as Raman spectroscopy and nanothermometry, will be discussed in the following. Here, we firstly outline the physical phenomena underlying the photothermal therapy, and then discuss studies devoted to photothermal cancer treatment concerning pain management and pathways for improved efficiency of photothermal therapy whilst minimizing pain experienced by the patient.

AngleNav: MEMS Tracker to Facilitate CT-Guided Puncture

As a low-cost needle navigation system, AngleNav may be used to improve the accuracy, speed, and ease of CT-guided needle punctures. The AngleNav hardware includes a wireless device with a microelectromechanical (MEMS) tracker that can be attached to any standard needle. The physician defines the target, desired needle path and skin entry point on a CT slice image. The accuracy of AngleNav was first tested in a 3D-printed calibration platform in a benchtop setting. An abdominal phantom study was then performed in a CT scanner to validate the accuracy of the device's angular measurement. Finally, an in vivo swine study was performed to guide the needle towards liver targets (n = 8). CT scans of the targets were used to quantify the angular errors and needle tip-to-targeting distance errors between the planned needle path and the final needle position. The MEMS tracker showed a mean angular error of 0.01° with a standard deviation (SD) of 0.62° in the benchtop setting. The abdominal phantom test showed a mean angular error of 0.87° with an SD of 1.19° and a mean tip-to-target distance error of 4.89 mm with an SD of 1.57 mm. The animal experiment resulted in a mean angular error of 6.6° with an SD of 1.9° and a mean tip-to-target distance error of 8.7 mm with an SD of 3.1 mm. These results demonstrated the feasibility of AngleNav for CT-guided interventional workflow. The angular and distance errors were reduced by 64.4 and 54.8% respectively if using AngleNav instead of freehand insertion, with a limited number of operators. AngleNav assisted the physicians to deliver accurate needle insertion during CT-guided intervention. The device could potentially reduce the learning curve for physicians to perform CT-guided needle targeting.

Advantages of cooled fiber for monitoring laser tissue ablation through temporal and spectral analysis of RF ultrasound signal: A case study

The promising minimally invasive laser thermal therapy technique may be improved if thermal lesions induced into the tissue can be carefully monitored in extension and morphology during the treatment. According to results obtained in several recent experimentations, solutions that avoid tissue carbonization during the treatment have been proposed, in order to allow deeper and longer lasting light penetration in treated tissue and to reduce failures of the applicator tip and fiber optic, dangerous for patients. In the work the advantages in using a cooled fiber are shown, in order not only to induce efficient lesions but also in performing an accurate monitoring by ultrasound. Indeed, one important limit of the ultrasound control is caused by the gas bubbles generation, which represent an acoustic barrier that invalidate the ultrasonic image representation of the treated tissue. Ultrasonic radiofrequency signals were acquired from the same bovine liver ex vivo sample by using both bare and cooled fiber and processed to produce B-mode and spectral parametric images by implementing TUV (Thermotherapy Ultrasonic View) algorithm. Radiofrequency signals, B-mode and TUV images were analysed and compared in order to evaluate the different tissue heating processes during ablation and the different lesion extensions induced into the tissue after the treatment. Cooled fiber avoided carbonization and strongly reduced gas bubbles generation inducing a larger lesion and allowing a more effective ultrasound monitoring. Moreover by correlating optical images of the lesions and the corresponding Integral TUV images, by using Dice and Jaccard coefficients, it was proven that TUV algorithm is able to characterize the tissue portions differently modified by ablation exhibiting better performances in the case of cooled fiber and revealing to be a potential tool capable to improve the laser delivery settings control.

Light in diagnosis, therapy and surgery

Light and optical techniques have made profound impacts on modern medicine, with numerous lasers and optical devices being currently used in clinical practice to assess health and treat disease. Recent advances in biomedical optics have enabled increasingly sophisticated technologies — in particular those that integrate photonics with nanotechnology, biomaterials and genetic engineering. In this Review, we revisit the fundamentals of light–matter interactions, describe the applications of light in imaging, diagnosis, therapy and surgery, overview their clinical use, and discuss the promise of emerging light-based technologies.

Single-session radiofrequency ablation on benign thyroid nodules: a prospective single center study : Radiofrequency ablation on thyroid

PURPOSE

The activity of the application of single-session ultrasonography (US)-guided percutaneous radio frequency ablation (RFA) in benign thyroid nodules was investigated in this prospective clinical study.

METHODS

RFA treatment was applied to 100 nodules in 100 patients (78 women, 22 men; average age 44.5 years old; age range 18-71) who had euthyroid condition, nodule size larger than 1 cm in the ultrasonography, proven to be benign by fine needle aspiration cytology. The nodules were separated into three groups according to the content: solid, cystic and mixed. In first 73 cases, the process performed under local anesthesia and the other 27 cases were performed under general anesthesia. RFA process was standardized to 70 W in all of the patients, and a moving shot technique was used. The results acquired in the third and sixth months of the controls were evaluated, and the volume of the nodules was screened.

RESULTS

No differences between the thyroid function tests performed before and after RFA were detected (p > 0.05). The mean volume of the nodules before the process, in the third month after the process, and in the sixth month were 16.8, 4.8, and 2.6 ml, respectively (p < 0.001). The decrease in cystic nodules was greater than solid and mixed structures. Temporary hoarseness occurred in one case and skin edema was detected in a patient at the isthmus.

CONCLUSIONS

RFA is an option for treatment, with minimal invasiveness and a low complication rate, and it is effective primarily in cases with benign nodules and nodular goiter. In cases with good compliance, the likelihood of success is greater. General anesthesia can be a good option for anxious cases to gather better results.

CT Appearance of Hepatocellular Carcinoma after Locoregional Treatments: A Comprehensive Review

Hepatocellular carcinoma (HCC) is a major health problem worldwide, affecting more than 600,000 new patients per year. Curative treatments are available in a small percentage of patients, while most of them present in stages requiring locoregional treatments such as thermoablation, transarterial chemoembolization, and/or radioembolization. These therapies result in specific imaging features that the general radiologist has to be aware of in order to assess the response to treatment and to correctly manage the follow-up of treated patients. Multiphasic helical computed tomography has become a popular imaging modality for detecting hypervascular tumors and characterizing liver lesions. On this basis, many staging and diagnostic systems have been proposed for evaluating response to all different existing strategies. Radiofrequencies and microwaves generate thermoablation of tumors, and transarterial chemoembolization exploits the double effect of the locoregional administration of drugs and embolizing particles. Eventually radioembolization uses a beta-emitting isotope to induce necrosis. Therefore, the aim of this comprehensive review is to analyze and compare CT imaging appearance of HCC after various locoregional treatments, with regard to specific indications for all possible procedures.

Comparative effect of gold nanorods and nanocages for prostate tumor hyperthermia

Gold nanoparticles have been investigated as photothermal agents, drug delivery carriers, diagnostics, and theranostics. As long-term accumulation of nanoparticles in nontarget tissues is a growing concern, it is vital to establish biodistribution profiles, tumor uptake, and tissue residence times for each nano-based system. This study aimed to investigate the prostate tumor uptake, photothermal therapy mediated macromolecular delivery, acute and chronic biodistribution profiles, and organ residence time differences between two nanoparticles, i.e., gold nanocages and gold nanorods. These particles have tunable surface plasmon resonances in the near infrared, but dissimilar shapes. Gold nanocages and nanorods had very different light to heat transduction efficiencies, with gold nanocages requiring 18.4 times fewer particles and approximately half the gold mass of gold nanorods to achieve the same heating profile given a constant laser intensity. It was also observed that while the photothermal macromolecular delivery enhancements were similar for the two systems when dosed by optical density, the tumoral uptake and biodistribution profiles for each of these shapes differed, with the nanocages residing in the liver, kidneys and spleen for less time than the nanorods. Additionally, it was observed that the nanocages were excreted from the body at a higher percentage of injected dose than the nanorods at both the 7 and 28 day time points. These findings have implications for the use of these constructs in diagnostic and therapeutic applications.

Tunable SERS-tags-hidden gold nanorattles for theranosis of cancer cells with single laser beam

With the use of gold nanostructures, photothermal therapy (PTT) of cancer has great advantages compared to conventional methods, such as noninvasive targeted destruction and easily operation. Generally speaking, respective diagnosis and therapy of tumor require at least two instruments, leading to incongruence of tumor borders between diagnosis and therapy. To tackle this problem, tunable SERS-tags-hidden gold nanorattles (STHGNRs) have been designed and developed here for theranosis of cancer with single laser beam. The surface plasma resonance peak of STHGNRs can be tuned from visible region to near-infrared region by controlling the cavity size and shell thickness. The outer shells not only improve the stability of the SERS reporters but also enhance the brightness by more than two order magnitude compared to gold nanoparticles. In vitro study, immuno STHGNRs can serve as theranosis agents simultaneously for sensitive and efficient theranosis of cancer cells.

MR-guided laser-induced thermotherapy in ex vivo porcine kidney: comparison of four different imaging sequences

PURPOSE

To evaluate the clinical value of different magnetic resonance imaging (MRI) sequences for a real-time thermo-monitoring during laser-induced thermotherapy (LITT) in kidneys.

METHODS

Twenty-eight ex vivo pig kidneys were treated with laser ablation under MR guidance in a high-field MR scanner (Magnetom Espree or Avanto Fit, Siemens, Germany). For the thermal ablation of the kidney, a neodymium yttrium-aluminum-garnet (Nd:YAG) laser was used in combination with a special protective catheter (length 43 cm, 4 French) which is sealed at the distal end. First, ablation was performed for 7, 10, and 13 minutes using FLASH sequences for investigation of time-dependent growth of lesion size. In the second step, we evaluated the optimal imaging sequence during a 7 minutes ablation of the kidney and after cooling using four different MR sequences (Haste, FLASH, radial VIBE, and Caipirinha DIXON).

RESULTS

Macroscopic lesion volume increased from 3,784 ± 1,525 mm(3) to 7,683 ± 5,756 mm(3) after the ablation from 7 to 13 minutes and MR volume ranged from 2,107 ± 1,674 mm(3) to 2,934 ± 1,549 mm(3) after the ablation from 7 to 13 minutes. During ablation, FLASH (132 ± 34%) and radial VIBE (120 ± 43%) sequences displayed lesion volumes most efficiently with a trend to overestimation. The Caipirinha DIXON (323 ± 24%) sequence overestimated the volumes significantly during real-time monitoring. The volumes measured by MRI with FLASH (61 ± 30%), Haste (67 ± 28%), or radial VIBE (48 ± 14%) sequences after cooling of the kidney after ablation were always underestimated. The Caipirinha DIXON (142 ± 2%) sequence still overestimated the lesion volume after cooling of the kidney.

CONCLUSION

LITT is a feasible ablation modality in kidney tissue. Moreover, macroscopic and MR lesion volume increases time-dependently. For online monitoring, radial VIBE and FLASH sequences seem to be most efficient.

US-guided application of Nd:YAG laser in porcine pancreatic tissue: an ex vivo study and numerical simulation

BACKGROUND

Laser ablation (LA) with a neodymium-doped yttrium aluminum garnet (Nd:YAG) laser is a minimally invasive approach able to achieve a high rate of complete tissue necrosis. In a previous study we described the feasibility of EUS-guided Nd:YAG pancreas LA performed in vivo in a porcine model.

OBJECTIVE

To establish the best laser setting of Nd:YAG lasers for pancreatic tissue ablation. A secondary aim was to investigate the prediction capability of a mathematical model on ablation volume.

DESIGN

Ex vivo animal study.

SETTING

Hospital animal laboratory.

SUBJECTS

Explanted pancreatic glands from 60 healthy farm pigs.

INTERVENTION

Laser output powers (OP) of 1.5, 3, 6, 10, 15, and 20 W were supplied. Ten trials for each OP were performed under US guidance on ex vivo healthy porcine pancreatic tissue.

MAIN OUTCOME MEASUREMENTS

Ablation volume (Va) and central carbonization volume (Vc) were measured on histologic specimens as the sum of the lesion areas multiplied by the thickness of each slide. The theoretical model of the laser-tissue interaction was based on the Pennes equation.

RESULTS

A circumscribed ablation zone was observed in all histologic specimens. Va values grow with the increase of the OP up to 10 W and reach a plateau between 10 and 20 W. The trend of Vc values rises constantly until 20 W. The theoretical model shows a good agreement with experimental Va and Vc for OP between 1.5 and 10 W.

LIMITATIONS

Ex vivo study.

CONCLUSION

Volumes recorded suggest that the best laser OP could be the lowest one to obtain similar Va with smaller Vc in order to avoid the risk of thermal injury to the surrounding tissue. The good agreement between the two models demonstrates the prediction capability of the theoretical model on laser-induced ablation volume in an ex vivo animal model and supports its potential use for estimating the ablation size at different laser OPs.

Heating efficiency of multi-walled carbon nanotubes in the first and second biological windows

Quantum dot based-thermometry, in combination with double beam confocal microscopy and infrared thermal imaging, has been used to investigate the heating efficiency of multi-walled carbon nanotubes (MWCNTs) under optical excitation within the first (808 nm) and second (1090 nm) biological windows as well as in the spectral region separating them (980 nm). It has been found that for the three excitation wavelengths the heating efficiency of MWCNTs (10 nm in diameter and 1.5 μm in length) is close to 50%. Despite this "flat" heating efficiency, we have found that the excitation wavelength is, indeed, critical during in vivo experiments due to the spectral dependence of both tissue absorption and scattering coefficients. It has been concluded that efficiency and selectivity of in vivo photothermal treatments based on MWCNTs are simultaneously optimized when laser irradiation lies within the first or second biological window.

Accelerated killing of cancer cells using a multifunctional single-walled carbon nanotube-based system for targeted drug delivery in combination with photothermal therapy

The photothermal effect of single-walled carbon nanotubes (SWCNTs) in combination with the anticancer drug doxorubicin (DOX) for targeting and accelerated destruction of breast cancer cells is demonstrated in this paper. A targeted drug-delivery system was developed for selective killing of breast cancer cells with polyethylene glycol biofunctionalized and DOX-loaded SWCNTs conjugated with folic acid. In our work, in vitro drug-release studies showed that the drug (DOX) binds at physiological pH (pH 7.4) and is released only at a lower pH, ie, lysosomal pH (pH 4.0), which is the characteristic pH of the tumor environment. A sustained release of DOX from the SWCNTs was observed for a period of 3 days. SWCNTs have strong optical absorbance in the near-infrared (NIR) region. In this special spectral window, biological systems are highly transparent. Our study reports that under laser irradiation at 800 nm, SWCNTs exhibited strong light-heat transfer characteristics. These optical properties of SWCNTs open the way for selective photothermal ablation in cancer therapy. It was also observed that internalization and uptake of folate-conjugated NTs into cancer cells was achieved by a receptor-mediated endocytosis mechanism. Results of the in vitro experiments show that laser was effective in destroying the cancer cells, while sparing the normal cells. When the above laser effect was combined with DOX-conjugated SWCNTs, we found enhanced and accelerated killing of breast cancer cells. Thus, this nanodrug-delivery system, consisting of laser, drug, and SWCNTs, looks to be a promising selective modality with high treatment efficacy and low side effects for cancer therapy.

The influence on liver function after transcatheter arterial chemoembolization combined with percutaneous radiofrequency ablation in patients with hepatocellular carcinoma

OBJECTIVES

Our aim was to investigate how transcatheter arterial chemoembolization (TACE) combined with percutaneous radiofrequency ablation (RFA) affected liver parenchymal function in patients with hepatocellular carcinoma (HCC), and to evaluate the significant risk factors for post-procedural deterioration of liver function.

METHODS

Changes in liver laboratory tests and development of complications were monitored in 53 patients with unresectable hepatocellular carcinoma from January 2007 to January 2009. Cox proportional hazard regression model was performed to evaluate risk factors for deterioration of liver function after the procedure.

RESULTS

Plasma total bilirubin (TB) increased from pre-procedural 22.1 ± 12.4 μmol/L to 34.1 ± 21.8 μmol/L on post-procedural day three (P = 0.017). Alanine aminotransferase (ALT) also increased greatly from 65 ± 58 IU/L to 285 ± 182 IU/L post-procedurally (P = 0.006). Albumin (ALB) dropped from 42.5 ± 4.5 g/L to 34.6 ± 5.4 g/L (P = 0.019) and the Child-Pugh score increased from 5.2 ± 1.3 to 7.1 ± 1.5 three days after treatment (P = 0.021). Most of these parameters returned to normal range within 3-4 weeks. Thirty-three out of 53 patients developed complications in our study. Cox proportional hazards regression univariate analysis demonstrated that a Child-Pugh score ≥ 9 points and age ≥ 60 years were risk factors for deterioration of liver function after the procedure. Furthermore, a Child-Pugh score ≥ 9 points was found to be the only risk factor for post-procedural deterioration of liver function identified by stepwise multivariate analysis.

CONCLUSION

Liver function parameters such as plasma total bilirubin, ALT, serum ALB and Child-Pugh score could be transiently deteriorated by TACE combined with RFA in patients with Child-Pugh grades B or C. Therefore, patients with a Child-Pugh score ≥ 9 points were not appropriate candidates for TACE combined with RFA.

Enhanced tumor treatment using biofunctional indocyanine green-containing nanostructure by intratumoral or intravenous injection

Indocyanine green (ICG) is a conventional dye that can be used in clinical near-infrared (NIR) imaging, and it is also an effective light absorber for laser-mediated photothermal therapy. However, applications of ICG were limited due to its fast degradation in aqueous media and quick clearance from the body. Herein, an ICG-containing nanostructure, ICG-PL-PEG, was developed for photothermal therapy, which was self-assembled by ICG and phospholipid-polyethylene glycol (PL-PEG). Our in vitro and in vivo experiments demonstrated that ICG-PL-PEG suspension was more efficient in producing a NIR-dependent temperature increase than ICG alone, due to the increase of ICG monomers from the addition of PL-PEG to match the central wavelength of the 808 nm laser. When conjugated with integrin α(v)β(3) monoclonal antibody (mAb), ICG-PL-PEG could be selectively internalized and retained in target tumor cells. Irradiation of an 808 nm laser after intravenous administration of ICG-PL-PEG-mAb resulted in tumor suppression in mice, while ICG alone had only limited effect. This is the first time an ICG-containing nanostructure has been used through systemic administration to achieve an efficient in vivo photothermal effect for cancer treatment. Therefore, ICG-PL-PEG could be used as a fluorescent marker as well as a light-absorber for imaging-guided photothermal therapy. All the components of ICG-PL-PEG have been approved for human use. Therefore, this unique ICG-containing nanostructure has great potential in clinical applications.

Temperature elevation inside neural tissue illuminated by NIR laser

Near infrared (NIR) light energy has been used in medical applications both for diagnostic and treatment purposes. Temperature elevation is the main concern in the neural tissue when illuminated with NIR light. In this report, an NIR light beam was pulsed into a rat brain cortex. The spatial maps of temperature elevation inside the neural tissue were measured directly using a micro probe. The results indicate that the temperature inside the neural tissue saturates with increasing levels of laser power.

Feasibility of percutaneous excision followed by ablation for local control in breast cancer

PURPOSE

Percutaneous ablation of breast cancer has shown promise as a treatment alternative to open lumpectomy. We hypothesized that percutaneous removal of breast cancer followed by percutaneous ablation to sterilize and widen the margins would not only provide fresh naive tissue for tumor marker and research investigation, but also better achieve negative margins after ablation.

METHODS

Patients diagnosed by percutaneous biopsy (ultrasound or stereotactic-guided) with breast cancer ≤1.5 cm, >1 cm from the skin, and ≤1 cm residual disease and no multicentric disease by magnetic resonance imaging were accrued to this institutional review board-approved study. Patients were randomized to laser versus radiofrequency ablation. The ultrasound-guided ablation was performed in the operating room and followed by immediate excision, whole-mount pathology with proliferating cell nuclear antigen staining, and reconstruction.

RESULTS

Twenty-one patients were enrolled onto the study. Fifteen patients received radiofrequency ablation, and all showed 100% ablation and negative margins. Magnetic resonance imaging was helpful in excluding multicentric disease but less so in predicting presence or absence of residual disease. Seven of these patients showed no residual tumor and eight showed residual dead tumor (0.5 ± 0.7 cm, range 0.1-2.5 cm) at the biopsy site with clear margins. The laser arm (3 patients) pathology demonstrated unpredictability of the ablation zone and residual live tumor.

CONCLUSIONS

This pilot study demonstrates the feasibility of a novel approach to minimally invasive therapy: percutaneous excision and effective cytoreduction, followed by radiofrequency ablation of margins for the treatment of breast cancer. Laser treatment requires further improvement.

A chelator-free multifunctional [64Cu]CuS nanoparticle platform for simultaneous micro-PET/CT imaging and photothermal ablation therapy

We synthesized and evaluated a novel class of chelator-free [(64)Cu]CuS nanoparticles (NPs) suitable both for PET imaging and as photothermal coupling agents for photothermal ablation. These [(64)Cu]CuS NPs are simple to make, possess excellent stability, and allow robust noninvasive micro-PET imaging. Furthermore, the CuS NPs display strong absorption in the near-infrared (NIR) region (peak at 930 nm); passive targeting prefers the tumor site, and mediated ablation of U87 tumor cells occurs upon exposure to NIR light both in vitro and in vivo after either intratumoral or intravenous injection. The combination of small diameter (∼11 nm), strong NIR absorption, and integration of (64)Cu as a structural component makes these [(64)Cu]CuS NPs ideally suited for multifunctional molecular imaging and therapy.

Transcatheter chemoembolization for unresectable hepatocellular carcinoma and comparison of five staging systems

AIM

We compared the ability of five staging system to predict survival in patients with hepatocellular carcinoma (HCC) treated with chemoembolization.

METHODS

The study subjects were 214 patients with HCC treated with repeated chemoembolization alone using cisplatin and lipiodol. Predictors of survival were assessed by multivariate analysis. Before chemoembolization was carried out, the modified Japan Integrated Staging (m-JIS), Japan Integrated Staging (JIS score), Barcelona (BCLC) stage, Liver Cancer Study Group of Japan/Tumor-Node-Metastasis (LCSGJ/TNM) and Italian score (CLIP score) were checked. To validate the prognostic value of these staging systems, the survival curve was obtained and analyzed by the Kaplan-Meier method. Discriminatory ability and predictive power were compared using Akaike's information criterion (AIC) score and the likelihood ratio (LR) χ(2) .

RESULTS

 Overall survival was 1 year in 82.9%, 3 years in 39.9% and 5 years in 15.1%. Multivariate analysis identified more than 90% lipiodol accumulation (grade I) after the first chemoembolization (P = 0.001), absence of portal vein tumor thrombosis (PVTT) (P < 0.001) and liver damage A (P = 0.012) as independent determinants of survival. AIC score and the LR χ(2) showed superior predictive power of the m-JIS system in 95 patients with grade I accumulation of lipiodol after first chemoembolization.

CONCLUSION

The discriminate ability of the m-JIS score is substantially better than those of other staging systems and has better prognostic predictive power in patients with grade I accumulation of lipiodol after first chemoembolization.

Hepatic tumor ablation

Ablation of liver tumors is part of a multimodality liver-directed strategy in the treatment of various tumors. The goal of ablation is complete tumor destruction, and ultimately improvement of quality and quantity of life for the patient. Technology is evolving rapidly, with important improvements in efficacy. The current state of ablation technology and indications for ablation are described in this review.

New insights of transmembranal mechanism and subcellular localization of noncovalently modified single-walled carbon nanotubes

Translocation and localization of single-walled carbon nanotubes (SWNTs) in normal and cancerous cells have significant biomedical implications. In this study, SWNTs functionalized with different biomolecules in cells were observed with confocal laser scanning microscopy. Functionalized with PL-PEG, SWNTs were found to localize exclusively in mitochondria of both tumor and normal cells due to mitochondrial transmembrane potential, but they were found mainly in lysosomes of macrophages due to phagocytosis. However, when conjugated with different molecules, the subcellular localization of the surface-modified SWNT-PL-PEG depended on how SWNTs enter the cells: inside mitochondria if crossing cell membrane or inside lysosomes if being endocytosized. We also show that mitochondrial SWNT-PL-PEG, when irradiated with a near-infrared light, can induce cell apoptosis due to mitochondrial damages. These findings provide a better mechanistic understanding of cellular localization of SWNTs, which could lead to advanced biomedical applications such as the design of molecular transporters and development of SWNT-assisted cancer therapies.

Early effect of hepatic artery TNF-alpha infusion on systemic hemodynamics and inflammation: a dose-response study in pigs

PURPOSE

Therapy of unresectable hepatic metastases may include tumor necrosis factor (TNF)-alpha treatment. Because of its serious systemic side effects, TNF-alpha is only used in isolated hepatic perfusion. This, however, is a technically demanding procedure with a substantial mortality rate. The infusion of TNF-alpha via the hepatic artery without hepatic isolation would be less invasive. Systemic side effects, however, have not been studied yet. Therefore, we evaluated in pigs the effects of TNF-alpha hepatic artery infusion (HAI) on systemic hemodynamics, inflammation, and organ injury.

METHODS

Animals were randomized in three groups. In group 1, HAI was performed with 0.9% NaCl (n = 6). In group 2, 20 microg/kg TNF-alpha (n = 6), and in group 3, 40 microg/kg TNF-alpha (n = 6) were added. HAI was performed over 15 min, followed by 120 min of observation. Finally, 250 ml hydroxyethylstarch (HAES; 6%) was administered for resuscitation and hemodynamics were analyzed for another 30 min.

RESULTS

Hepatic artery TNF-alpha infusion did not cause complications such as bleeding, cardiac depression, pulmonary dysfunction, or SIRS. TNF-alpha induced a 30% decrease of MAP and systemic vascular resistance, as well as a rise in heart rate and endexspiratory pCO(2). TNF-alpha also moderately (10-20%) lowered the cardiac preload and induced a metabolic acidosis, which, however, could easily be controlled. TNF-alpha HAI did not induce liver toxicity, and all hemodynamic changes normalized either spontaneously within the 120-min observation period, or, at least, after HAES resuscitation.

CONCLUSIONS

TNF-alpha-based HAI, which may represent a minimally invasive alternative to isolated hepatic perfusion, can be performed without early systemic hemodynamic complications.

Modeling of plasmonic heating from individual gold nanoshells for near-infrared laser-induced thermal therapy

Gold nanoparticles can be engineered to target cancerous cells and at the same time designed to absorb specific wavelengths of light. Consequently, with the presence of optically tunable gold nanoparticles such as gold nanoshells, light can be effectively converted to heat via photothermal effect well enough to raise the temperature of medium surrounding gold nanoshells for thermal ablation or hyperthermia treatments of cancers. In this study, the authors proposed a new computational method to estimate thermal response of gold nanoshells embedded in a tissue-like medium when illuminated by a near-infrared (NIR) laser. Specifically, the light transport theory with diffusion approximation was initially applied to model the temperature rise within a medium without gold nanoshells as a result of the dissipation of the NIR laser power throughout the medium. After then, the heat generated by individual gold nanoshells due to photothermal effect was calculated and combined with the results for the medium without gold nanoshells to estimate the global elevation of temperature within the gold nanoshell-laden medium. The current computational model was tested for its validity using two different phantom examples, one of which was similar to a previously reported phantom experiment. The test demonstrated the capability of the current model in terms of producing qualitatively reasonable results, while it also revealed a number of potential differences in the assumptions for the current model and previous experiment. After an adjustment in the model parameters to properly take into account such differences, the computational results and the experimental data matched reasonably well within the average percentage difference of 10%.

Transarterial infusion chemotherapy using cisplatin-lipiodol suspension with or without embolization for unresectable hepatocellular carcinoma

We evaluate the long-term prognosis and prognostic factors in patients treated with transarterial infusion chemotherapy using cisplatin-lipiodol (CDDP/LPD) suspension with or without embolization for unresectable hepatocellular carcinoma (HCC). Study subjects were 107 patients with HCC treated with repeated transarterial infusion chemotherapy alone using CDDP/LPD (adjusted as CDDP 10 mg/LPD 1 ml). The median number of transarterial infusion procedures was two (range, one to nine), the mean dose of CDDP per transarterial infusion chemotherapy session was 30 mg (range, 5.0-67.5 mg), and the median total dose of transarterial infusion chemotherapy per patient was 60 mg (range, 10-390 mg). Survival rates were 86% at 1 year, 40% at 3 years, 20% at 5 years, and 16% at 7 years. For patients with >90% LPD accumulation after the first transarterial infusion chemotherapy, rates were 98% at 1 year, 60% at 3 years, and 22% at 5 years. Multivariate analysis identified >90% LPD accumulation after the first transarterial infusion chemotherapy (p = 0.001), absence of portal vein tumor thrombosis (PVTT; p < 0.001), and Child-Pugh class A (p = 0.012) as independent determinants of survival. Anaphylactic shock was observed in two patients, at the fifth transarterial infusion chemotherapy session in one and the ninth in the other. In conclusion, transarterial infusion chemotherapy with CDDP/LPD appears to be a useful treatment option for patients with unresectable HCC without PVTT and in Child-Pugh class A. LPD accumulation after the first transarterial infusion chemotherapy is an important prognostic factor. Careful consideration should be given to the possibility of anaphylactic shock upon repeat infusion with CDDP/LPD.

Cancer photothermal therapy in the near-infrared region by using single-walled carbon nanotubes

Single-walled carbon nanotubes (SWNTs) have a high optical absorbance in the near-infrared (NIR) region. In this special optical window, biological systems are known to be highly transparent. The optical properties of SWNTs provide an opportunity for selective photothermal therapy for cancer treatment. Specifically, CoMoCAT nanotubes with a uniform size (about 0.81 nm) and a narrow absorption peak at 980 nm are ideal candidates for such a novel approach. Here, CoMoCAT SWNTs are conjugated to folate, which can bind specifically to the surface of the folate receptor tumor markers. Folate-SWNT (FA-SWNT) targeted tumor cells were irradiated by a 980-nm laser. In our in vitro and in vivo experiments, FA-SWNT effectively enhanced the photothermal destruction on tumor cells and noticeably spared the photothermal destruction for nontargeted normal cells. Thus, SWNTs, combined with suitable tumor markers, can be used as novel nanomaterials for selective photothermal therapy for cancer treatment.

Gold nanorod assisted near-infrared plasmonic photothermal therapy (PPTT) of squamous cell carcinoma in mice

Plasmonic photothermal therapy (PPTT) is a minimally-invasive oncological treatment strategy in which photon energy is selectively administered and converted into heat sufficient to induce cellular hyperthermia. The present work demonstrates the feasibility of in vivo PPTT treatment of deep-tissue malignancies using easily-prepared plasmonic gold nanorods and a small, portable, inexpensive near-infrared (NIR) laser. Dramatic size decreases in squamous cell carcinoma xenografts were observed for direct (P<0.0001) and intravenous (P<0.0008) administration of pegylated gold nanorods in nu/nu mice. Inhibition of average tumor growth for both delivery methods was observed over a 13-day period, with resorption of >57% of the directly-injected tumors and 25% of the intravenously-treated tumors.

Inoperable colorectal liver metastases: a declining entity?

BACKGROUND

Untreated colorectal liver metastases (CLMs) have a dismal prognosis. Surgery remains the gold standard of treatment, but many patients will have inoperable disease at presentation. Until recently, the outlook for such patients was bleak. The purpose of this review was to report on available options in the treatment CLMs, which would be considered unresectable by conventional evaluation.

METHODS

Inclusion criteria were articles published in English-language journals reporting on either retrospective or prospective cohorts of patients undergoing treatment for conventionally inoperable CLM. Main outcome measures were survival, resectability rates, morbidity and mortality following treatment of the patients' disease.

RESULTS

Improved chemotherapy regimes and other innovative treatments have opened up new options for such patients and may even render conventionally inoperable disease resectable. The aim of treatment should be down-staging of metastases to achieve resectability, however, other treatments such as ablation may be also be used (either alone or in conjunction with resection).

CONCLUSION

A nihilistic attitude to the patient with seemingly inoperable liver metastases should be discouraged. Discussion of such patients at multi-disciplinary meetings is essential in order to plan and monitor treatments.

US-guided percutaneous radiofrequency thermal ablation for the treatment of solid benign hyperfunctioning or compressive thyroid nodules

The aim of the study was to define the effectiveness and safety of ultrasound-guided percutaneous radiofrequency (RF) thermal ablation in the treatment of compressive solid benign thyroid nodules. Thirty-one patients not eligible for surgery or radioiodine (131I) treatment underwent RF ablation for benign nodules; a total of 33 nodules were treated (2 patients had 2 nodules treated in the same session): 10 cold nodules and 23 hyperfunctioning. Fourteen patients complained of compressive symptoms. Nodule volume, thyroid function and compressive symptoms were evaluated before treatment and at 1, 3 and 6 mo. Ultrasound-guided RF ablation was performed using a Starbust RITA needle, with nine expandable prongs; total exposure time was 6 to 10 min at 95 degrees C in one area or more of the nodule. Baseline volume (measured at the time of RF ablation) was 27.7 +/- 21.5 mL (mean +/- SD), but significantly decreased during follow-up: 19.2 +/- 16.2 at 1 mo (-32.7%; p < 0.001), 15.9 +/- 14.1 mL at 3 mo (-46.4 %; p < 0.001) and 14.6 +/- 12.6 mL at 6 mo (-50.7%; p < 0.001). After treatment, all patients with cold nodules remained euthyroid: five patients with hot nodules normalized thyroid function, and the remaining sixteen showed a partial remission of hyperthyroidism. Besides a sensation of heat and mild swelling of the neck, no major complications were observed. Improvement in compressive symptoms was reported by 13 patients, with a reduction on severity scale from 6.1 +/- 1.4 to 2.2 +/- 1.9 (p < 0.0001). Radiofrequency was effective and safe in reducing volume by about 50% and compressive symptoms in large benign nodules. Hyperfunction was fully controlled in 24% of patients and partially reduced in the others.

NIR light penetration depth in the rat peripheral nerve and brain cortex

Near infrared (NIR) light energy has been used in medical applications both for diagnostic and treatment purposes. A priory knowledge of optical tissue properties is necessary in these applications; not only of human but also in animals for testing of devices. However, published data on the optical properties of neural tissue in rodents are rare. The aim of this study was to measure the penetration depth of light into the rat peripheral nerve and brain cortex at NIR wavelengths. Penetration depth was calculated from measurements of transmitted light for various thicknesses of the neural tissue. We found the penetration depth in the rat sciatic nerve to be 0.35 +/- 0.023 mm and in the white matter 0.35 +/- 0.026 mm. The penetration depth of the gray matter was 0.41+/-0.029 mm. Compared to the data reported in literature for the human brain, the rat peripheral and the brain cortex attenuate the NIR light much more strongly.

Percutaneous cryoablation of small hepatocellular carcinoma with US guidance and CT monitoring: initial experience

The purpose of this study was to retrospectively determine the safety and effectiveness of percutaneous cryoablation, monitored with computed tomography (CT) and ultrasonographic (US) guidance, for the treatment of hepatocellular carcinoma (HCC). Four patients with small HCCs underwent one percutaneous cryoablation treatment session monitored with CT and US guidance. All patients underwent pretreatment blood chemistry testing and imaging evaluation. We treated lesions with simultaneous insertion of multiple 17-G cryoprobes (two or three) and defined technical success when the extension of a visible iceball was beyond 5 mm from the tumor margin. Intralesional enhancement or tumoral size increase was defined as local progression compared with that on images obtained immediately after ablation. We evaluated complications and follow-up (at 1, 3, and 6 months). All patients survived without short- or long-term complications. Cryoablation was technically successful in all patients at the end of the procedure. During follow-up two patients developed disease recurrence. One patient developed local tumor progression on the margin of the lesion; the other, a new HCC. In the case of local tumor progression a new elevation of alpha-fetoprotein (alphaFP) levels occurred at first follow-up control. In the other case levels of alphaFP remained stable during the first 3 months after the procedure, then demonstrated a progressive increase in alphaFP levels beginning at the fourth month, without tumor evidence during CT control at 3 months. We conclude that percutaneous cryotherapy with US guidance and CT monitoring is a feasible, safe, and effective for treatment of HCC. If local ablative procedures of hepatic lesions are to be performed, percutaneous cryoablation, not laparotomic, should be discussed as an alternative therapeutic measure. Longer follow-up should provide proof of the effectiveness of this technique.

Post-radiofrequency ablation syndrome after percutaneous radiofrequency of abdominal tumours: one centre experience and review of published works

The aim of this study was to evaluate prospectively post-radiofrequency ablation (RFA) syndrome and to determine its effect on the quality of life in the 15 days after percutaneous RFA treatment. We carried out an internal review board-approved prospective study of the delayed symptoms that occurred after 71 consecutive RFA sessions in 53 patients (12 women and 41 men; age range 45-83 years; mean age 71.6 years) with 45 primary liver tumours, 34 liver metastases, 3 renal cell carcinoma (RCC), 2 residual lesions from RCC after nephrectomy and 1 pancreatic metastases from RCC. Postablation symptoms occurred in 17 of 53 (32%) patients. Six of 17 patients developed low-grade fever (from 37.5 to 38.5 degrees C). Other symptoms included delayed pain (9/17), nausea (7/17), vomiting (3/17), malaise (3/17) and myalgia (1). Postablation syndrome is a common phenomenon after RFA of solid abdominal tumours. Not only in our study but also in the previous ones the occurrence is observed in approximately one-third patients. Patients should be informed that these symptoms are self-limiting after RFA and most patients should be able to resume near-complete preprocedural levels of activity within 10 days after the procedure.

Protein-passivated Fe(3)O(4) nanoparticles: low toxicity and rapid heating for thermal therapy

Thermotherapy is a promising technique for the minimally invasive elimination of solid tumors. Here we report the fabrication of protein-coated iron oxide NPs (12 nm core) for use as thermal therapeutic agents. These albumin-passivated NPs are stable under physiological conditions, with rapid heating and cell killing capacity upon alternating magnetic field (AMF) exposure. The mode of action is specific: no measurable cytotoxicity was observed for the particle without AMF or for AMF exposure without the particle.

Efficacy of direct electrical current therapy and laser-induced interstitial thermotherapy in local treatment of hepatic colorectal metastases: an experimental model in the rat

BACKGROUND

Local antitumoral therapy of metastases is an important tool in the palliative treatment of advanced colorectal cancer. Several authors have recently reported on successful local treatment of different malignant diseases with low-level direct current therapy. The aim of the present study was to compare the effectiveness of direct current therapy with the established laser-induced thermotherapy (LITT) on experimental colorectal liver metastases.

MATERIALS AND METHODS

Colorectal metastases were induced in 49 BD IX rats by injection of colon cancer cells beneath the liver capsule. Three weeks after induction, tumor volumes and sizes were estimated with magnetic resonance imaging and by manual measurement of the largest tumor diameter, and two treatment groups and two control groups were established. Direct current (80 C/cm(3)) versus LITT (2 W; 5 to 10 min) was locally applied via laparotomy. Control groups were sham treated. Tumor growth was analyzed 5 wk after therapy by manual measurement of the maximal diameter and histopathological examination was performed.

RESULTS

Measurement of tumor sizes 5 wk after therapy confirmed a significant antitumoral effect of direct current (1.6-fold tumor enlargement) and of LITT (1.3-fold tumor enlargement), compared with controls (2.8-fold and 2.9-fold tumor enlargement). However, after 5 wk, LITT was significantly more effective in limiting tumor growth than direct current treatment (P </= 0,001). Histopathological analysis revealed a complete response rate of 21% and a partial response rate of 77% in the electric current group. In comparison, LITT treated livers showed a complete response rate of 22% and a partial response rate of 78% (n.s.).

CONCLUSIONS

The data confirm that direct current therapy and LITT are effective treatment strategies in the palliative control of colorectal hepatic metastases, with both therapies being equally effective in inducing a complete or partial tumor necrosis.

Assessment of pixel shift in ultrasound images due to local temperature changes during the laser interstitial thermotherapy of liver: in vitro study

Laser interstitial thermotherapy (LITT) is an internal ablation therapy consisting of percutaneous or intraoperative insertion of laser fibers directly into the liver tumor with maximum diameter of 5 cm. It is very important to control the temperature increase, because tissue carbonization occurs with high temperatures, which can damage normal tissues. In this research, pixel shift changes on ultrasound B-mode images with temperature changes were measured. LITT in vitro was performed on 12 freshly excised sheep liver tissues using a Nd:YAG laser with a bare-tip optical fiber. The 1 W power setting was used for 700 s exposure time (2477 J/mm2). Invasive temperature monitoring was performed during the heating and cooling by attaching microthermocouples to the tissue. At the same time, ultrasound B-mode images were saved on the computer for each 5 degrees C temperature increase from 25 degrees C to 100 degrees C, for noninvasive temperature monitoring. These pixel shifts were measured by an echo-tracking algorithm. Linear and nonlinear regression analyses between the independent variable (temperature change) and the dependent variable (pixel shift on images) were performed. Regression functions and correlation coefficients were determined. It was shown that with a correlation coefficient of 0.998, the cubic function was suitable. Pixel shift increased for each 5 degrees C temperature increase and the maximum shift was observed during 60 to 70 degrees C. Beyond these temperatures, the pixel shift decreased. In this method, because of evaporation of tissue water and bubble formation and tissue carbonization, monitoring greater than 100 degrees C was difficult. It is possible to monitor temperature changes on the ultrasound B-mode images in interstitial laser thermotherapy of liver. Also, with the improvement of image processing, this method could be used for noninvasive temperature monitoring for a large number of patients during LITT.