Percutaneous Cryoablation of Recurrent or Oligometastatic Tumors in Thoracoabdominal Soft Tissues: Safety, Effectiveness, and Technical Aspects

PURPOSE

To assess the effectiveness and safety of cryoablation (CRA) for the treatment of recurrent or oligometastatic solid tumors located in the thoracoabdominal soft tissues.

MATERIALS AND METHODS

Twenty-two percutaneous CRA procedures performed in 19 patients to treat recurrent or oligometastatic tumors in thoracoabdominal soft tissue were retrospectively examined. All procedures were performed between January 2015 and June 2021 under ultrasound and computed tomography (CT) guidance, and the most complex procedures were performed with CT-based navigation systems. The histology of the primary tumors included colorectal adenocarcinoma, squamous cell lung carcinoma, pancreatic adenocarcinoma, renal cell carcinoma, and hepatocellular carcinoma. Adverse events, technical success, and local tumor control were analyzed.

RESULTS

The mean age of the patients was 66.5 years, with a mean tumor size of 24.8 mm. The mean time of the procedures was 68 minutes, with a mean number of 2.5 cryoprobes used. Hydrodissection was performed in 63% of the procedures to protect the surrounding anatomical structures. The mean size of the ice ball, measured on axial CT scans at the end of the procedures, was 43.5 mm. No severe adverse events were observed. Technical success was achieved in all cases. Three patients experienced local tumor progression (2 residual disease and 1 recurrence), which were successfully treated with a second CRA procedure.

CONCLUSIONS

Percutaneous CRA is a safe and effective therapy in selected cases of recurrent or oligometastatic tumors in the thoracoabdominal soft tissues.

Microwave ablation using two simultaneous antennas for the treatment of liver malignant lesions: a 3 year single-Centre experience

BACKGROUND

sequential or simultaneous applications of multiple antennas have been proposed to create larger ablation zone; however, there is a lack of data in patients affected by liver tumors, with potentially different results from animal liver models. The purpose of this study was to evaluate efficacy and safety of liver percutaneous microwave ablation using simultaneous activation of two antennas to treat lesions bigger than 2,5 cm; particularly the focus was assessing whether the ratio of ablation zone volume in millimeters to applied energy in kilojoules [R(AZ:E)] differs between hepatocellular carcinoma in a cirrhotic liver and liver metastasis and if it is correlated to complications incidence or recurrence of disease.

METHODS

Fifty-five liver microwave ablation performed with two simultaneous antennas from March 2017 to June 2021 were retrospectively reviewed; 9 procedures were excluded due to the association with Chemoembolization. Size, shape, volume of lesions and ablation zones were recorded. Technical success was defined as complete devascularization of the treated area at the post-procedural CT. R(AZ:E) was determined dividing the ablation zone volume in mm3 by the amount of energy in kilojoules applied in each procedure and complications were reported.

RESULTS

Technical success was achieved in all the procedures. Mean R(AZ:E) was 0,75 ± 0,58. T-student test for patients with HCC and patients with metastasis about R(AZ:E) was significant (p = 0.03). The incidence of bilomas was lower for HCC (p = 0.022). One-month follow-up showed Complete Response (CR) in 44/46 (95,6%) patients; Three-six months follow-up demonstrated: CR in 43/46 (93.5%) cases and 12 months follow-up highlighted CR in 40/45 (88,9%) cases.

CONCLUSIONS

These results provide preliminary evidence of efficacy and safety of simultaneous liver MWA using two antennas, highlighting the importance of procedural indications.

CT, MR, and CEUS imaging features of recurrent GIST of the pre-sacral space: A case report

We present the case of a 50-year-old woman affected by a rectal gastrointestinal stromal tumor (GIST), with a recurrence in pre-sacral and pre-coccygeal space after surgery and Imatinib therapy. GISTs are the most common mesenchymal tumors of the gastrointestinal tract and rectal GISTs are rare (only 2% of cases); magnetic resonance and computed tomography are the main imaging techniques for diagnosis and follow-up, while ultrasound and contrast-enhanced ultrasound may be useful to perform a percutaneous biopsy, as in the case presented: the imaging features of the lesion in all these imaging methods are displayed.

Analysis of Risk Factors of Soft Tissue Bleeding in COVID-19 Patients: A Point of View After Two Years of Pandemic

Background

The aim of the study was to analyze the relationship between patient characteristics, including anagraphic and laboratoristic data and amount of adipose tissue measured in computed tomography (CT) scans in coronavirus disease 2019 (COVID-19) patients, and incidence of soft tissue bleeding requiring medical and/or interventional radiology management.

Methods

A total of 132 patients hospitalized for COVID-19 pathology from October 2020 to May 2021 were included in the study and divided into two groups: a bleeding group of 70 cases with soft tissue bleeding occurring during hospitalization, and a control group of 62 hospitalized COVID-19 patients without bleeding events. In the bleeding group, two subgroups were considered: an embolization group including soft tissue bleeding cases requiring interventional radiology with transarterial embolization (TAE) (16/70; 22.9%) and a non-embolization group, clinically managed without TAE (54/70; 77.1%). Demographics and clinical data, visceral adipose tissue (VAT) area and subcutaneous adipose tissue (SAT) area measured on CT images and VAT/SAT ratio were compared between bleeding and control groups and between embolization and non-embolization subgroups.

Results

Bleeding and control groups did not significantly differ for sex distribution, COVID-19, platelet (PLT) count, international normalized ratio (INR), SAT area, VAT area, and VAT/SAT ratio. Embolization and non-embolization groups did not significantly differ for age, COVID-19, PLT count, INR, SAT area, and VAT/SAT ratio. Bleeding group had lower body mass index (BMI) than control group as well as embolization group compared to non-embolization group. A statistically significant difference was observed between embolization and non-embolization groups for VAT area, with smaller values in embolization group (mean difference: 64.2 cm², 95% confidence interval: 8.3 - 120.1; P < 0.05).

Conclusion

Soft tissue bleeding in COVID-19 is more frequent and severe in patients with low amount of VAT, demonstrating that fat mass may have a containing function on bleeding, limiting its progression in surrounding structures. There are some other factors that influence the risk of bleeding, such as age, thromboprophylaxis therapy and BMI.

Lung Thermal Ablation: Comparison between an Augmented Reality Computed Tomography (CT) 3D Navigation System (SIRIO) and Standard CT-Guided Technique

Simple Summary

Lung cancer is the leading cause of cancer mortality worldwide. In recent years, numerous technologies have been used to perform image-guided percutaneous thermal ablation, mainly including radiofrequency ablation, microwave ablation, and cryoablation. These image-guided ablation techniques have emerged as a safe, cost-effective, minimally invasive treatment alternative for patients who do not require surgery. Procedural planning, monitoring, and lesion targeting are generally performed with the help of computed tomography; navigation systems are emerging as valid tool to reduce procedural time and radiation dose administration. In the present paper, we investigate the efficacy of an optical-based navigation system (SIRIO) to perform lung thermal ablation. SIRIO proved to be a reliable and effective tool when performing CT-guided LTA, displaying a significant decrease in the number of required CT scans, procedure time, and radiation doses administered to patients.

Abstract

(1) Background: The aim of this retrospective study is to assess safety and efficacy of lung radiofrequency (RFA) and microwave ablation (MWA) using an augmented reality computed tomography (CT) navigation system (SIRIO) and to compare it with the standard CT-guided technique. (2) Methods: Lung RFA and MWA were performed with an augmented reality CT 3D navigation system (SIRIO) in 52 patients. A comparison was then performed with a group of 49 patients undergoing the standard CT-guided technique. All the procedures were divided into four groups based on the lesion diameter (>2 cm or ≤2 cm), and procedural time, the number of CT scans, radiation dose administered, and complications rate were evaluated. Technical success was defined as the presence of a “ground glass” area completely covering the target lesion at the immediate post-procedural CT. (3) Results: Full technical success was achieved in all treated malignant lesions for all the considered groups. SIRIO-guided lung thermo-ablations (LTA) displayed a significant decrease in the number of CT scans, procedure time, and patients’ radiation exposure (p < 0.001). This also resulted in a dosage reduction in hypnotics and opioids administrated for sedation during LTA. No significant differences were observed between the SIRIO and non-SIRIO group in terms of complications incidence. (4) Conclusions: SIRIO is an efficient tool to perform CT-guided LTA, displaying a significant reduction (p < 0.001) in the number of required CT scans, procedure time, and patients’ radiation exposure.

Combined trans-arterial embolisation and microwave ablation for the treatment of large unresectable hepatic metastases (>3 cm in maximal diameter)

PURPOSE

To assess the safety and efficacy of a two-step single-session procedure, combining transarterial embolization (TAE) and percutaneous microwave ablation (MWA), in the treatment of > 3 cm unresectable liver metastases. We also compared the final volume obtained by the two techniques (V_E-T) and the expected ablation volume of the stand-alone MWA (V_T).

METHODS

From January 2015 to December 2017, 22 consecutive patients, with a total of 24 unresectable hepatic metastases >3 cm in diameter underwent a two-step single-session combined treatment of TAE and MWA. Follow-up computed tomography scans were performed at 1-, 3-, 6-, 12, and 24 months post-procedure. V_E-T as final ablation volume induced by the combined treatment (TAE-MWA), V_N as initial nodule volume, V_T as expected ablation volume of MWA treatment alone were evaluated and compared.

RESULTS

Tumor dimensions ranged from 32 to 73 mm. Technical success was achieved in all treated tumors with no local tumor recurrence. Final ablation volumes ranged from 50 to 450 cm³ and the short-axis diameter of the ablation zone ranged from 12 to 48 mm. The mean ΔV increment in the final ablation volume with respect to the stand-alone MWA was 196% (ranging from 25 cm³ - 210 cm³) (p < 0.05). The V_E-T mean was four times the V_N mean, while the V_T mean was about twice the V_N mean. No recurrence and only one case of post-embolization bleeding were observed.

CONCLUSIONS

This study demonstrated the safety and efficacy of a combined two-step single-session TAE-MWA treatment of unresectable hepatic metastases > 3 cm in diameter.

Augmented reality 3D navigation system for percutaneous CT-guided pulmonary ground-glass opacity biopsies: a comparison with the standard CT-guided technique

Background

Augmented reality navigation system for percutaneous computed tomography (CT)-guided pulmonary biopsies has recently been introduced. There are no studies in literature about its use for ground glass lesions biopsies. The aim of this study is to evaluate the effectiveness of an augmented reality infrared navigation system performance on CT-guided percutaneous lung ground glass opacity (GGO) biopsy compared to a standard CT-guided technique.

Methods

A total of 80 patients with lung GGO who underwent to a percutaneous CT-guided lung biopsy with an augmented reality infrared navigation system were retrospectively enrolled in the study. Comparison was performed with a group of 80 patients who underwent to lung biopsy with the standard CT-guided technique. Evaluation of maximum lesion diameter (MLD), distance between lesion and pleural surface (DPS), distance travelled by the needle (DTP), procedural time, validity of histological sample, procedural complications and the radiation dose to the patient’s chest were recorded for each patient of both groups. In addition, each group was divided into two subgroups based on lesion size, according to a cut-off of 1.5 cm (<1.5 cm; ≥1.5 cm).

Results

Augmented reality navigation system showed a significant reduction in procedural time, radiation dose administrated to patients and complications rate compared to a standard CT-guided technique. Technical success was achieved in the 100% of cases in both groups, but the diagnostical success was higher in the group where patients underwent to lung biopsies with the use of navigation system. We also found that using an augmented reality navigation system increases the diagnostical success rate for lesion <1.5 cm. MLD, DPS and DTP did not differ significantly between the two groups of patients.

Conclusions

The use of an augmented reality navigation system for percutaneous CT-guided pulmonary GGO biopsies has demonstrated a lower incidence of post-procedural complications, a significantly reduction of the radiation dose administered to patients and a higher diagnostical success rate.

Fundal pressure in second stage of labor (Kristeller maneuver) is associated with increased risk of levator ani muscle avulsion

OBJECTIVE

To investigate the association between application of fundal pressure during the second stage of labor (Kristeller maneuver) and the risk of levator ani muscle (LAM) injury.

METHODS

This was a prospective case-control study of women recruited immediately after their first vaginal delivery in our university hospital between March 2014 and September 2016. Women who underwent the Kristeller maneuver were recruited as cases. For each case, a control (no Kristeller) was recruited matched for body mass index, use of epidural analgesia, duration of second stage of labor and birth weight. All women were invited to undergo four-dimensional (4D) transperineal ultrasound (TPU) 3-6 months postpartum. The main outcome measure was the presence of LAM avulsion on 4D-TPU. TPU results were compared between cases and controls. Multivariate logistic regression analysis was performed to identify independent risk factors for LAM avulsion.

RESULTS

During the study period, 134 women in the Kristeller maneuver group and 128 women in the control group underwent TPU assessment. Women who underwent the Kristeller maneuver had a higher prevalence of LAM avulsion than did controls (38/134 (28.4%) vs 18/128 (14.1%); P = 0.005). In addition, women in the Kristeller-maneuver group had a larger hiatal area on maximum Valsalva maneuver and a greater increase in hiatal area from rest to maximum Valsalva. On multivariate logistic regression analysis, use of the Kristeller maneuver was the only independent factor associated with LAM avulsion (odds ratio, 2.5 (95% CI, 1.29-4.51)).

CONCLUSION

The Kristeller maneuver is associated with an increased risk of LAM avulsion when applied in women during their first vaginal delivery. This should be taken into account when deciding to use fundal pressure to accelerate the second stage of labor and when counseling women following childbirth. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Is curved three-dimensional ultrasound reconstruction needed to assess the warped pelvic floor plane?

OBJECTIVES

Caudal distension of the female pelvic floor is common and results in perineal descent and a caudally curved levator hiatus (warping). Image reconstruction of the pelvic floor using currently available ultrasound techniques involves a linear approach (flat-plane reconstruction). We aimed to evaluate the feasibility, reproducibility and potential usefulness of a new three-dimensional (3D) technique capable of reconstructing a curved plane of the levator hiatus.

METHODS

Primiparous women were recruited to undergo a 3D/four-dimensional transperineal ultrasound examination 3-6 months after delivery. Levator ani muscle warping was evaluated on Valsalva maneuver by measuring the distance between the plane extending from the pubic rami to the anorectal angle and the plane of minimal hiatal dimensions on the coronal plane. Warping distance was used to reconstruct a curved plane of the levator hiatus using the curved OmniView volume contrast imaging (VCI) technique (C-OV). Intra- and interobserver reproducibility of the C-OV technique were assessed, as was intermethod agreement between the C-OV technique and the linear OmniView-VCI (L-OV) technique, for the measurement of levator hiatal area on Valsalva maneuver.

RESULTS

Measurement of the levator hiatal area using C-OV was feasible in all 84 women recruited. The warping distance ranged from -3.5 to 9.7 mm, confirming that the 1-2-cm slice thickness traditionally used for linear reconstruction was adequate for proper assessment of levator hiatal area in our population. C-OV showed excellent intra- and interobserver reproducibility, as well as excellent agreement with the L-OV technique for measuring levator hiatal area. No systematic difference was demonstrated in any of the reproducibility studies performed.

CONCLUSIONS

3D reconstruction of the warped levator hiatal plane is feasible and highly reproducible. In our population, reconstruction of a curved plane to correct for levator hiatal warping did not offer any benefit over the traditionally performed linear reconstruction. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

A New Method to Measure the Subpubic Arch Angle Using 3-D Ultrasound

Objectives: The aim of this study was to assess the reproducibility of both a new contrast-enhancing technique (Oblique View eXtended Imaging, OVIX; Samsung) and the recently reported 3-D multiplanar technique (MPT) in the measurement of the subpubic angle (SPA) among a group of women at term gestation. In addition, we aimed to study the intermethod agreement between the OVIX technique and MPT. Methods: We acquired a transperineal 3-D ultrasound volume from 155 women with a singleton uncomplicated term pregnancy before the onset of labor. Each 3-D dataset was analyzed by the MPT and OVIX algorithm. The angle formed by the lower edges of the pubic rami (SPA) was measured twice by an operator and once by another operator for each technique in order to assess intra- and interobserver reproducibility. Reproducibility and intermethod agreement were studied by means of the intraclass correlation coefficient (ICC) and Bland-Altman method. Results: SPA measurements performed with OVIX showed high intraobserver [ICC 0.912, 95% confidence interval (CI) 0.882-0.935] and good interobserver (ICC 0.791, 95% CI 0.724-0.844) agreement, while those measured with MPT showed moderate intraobserver (ICC 0.573, 95% CI 0.457-0.670) and good interobserver (ICC 0.640, 95% CI 0.537-0.724) agreement. Whereas the intermethod analysis showed good agreement between the MPT and the OVIX techniques (ICC 0.614, 95% CI 0.414-0.757), the SPA measured by MPT were significantly wider than those measured by OVIX (125 ± 12 vs. 120 ± 11°, p = 0.006). Conclusions: OVIX is a reliable technique for SPA measurement. MPT overestimates the SPA in comparison with OVIX. Further studies are needed to assess its clinical utility.

Prenatal diagnosis of open spina bifida in Emilia-Romagna

OBJECTIVE

To report recent data on the epidemiology of pregnancies affected by open spina bifida in the Emilia-Romagna region of Italy.

METHODS

All cases of open spina bifida diagnosed in the Emilia-Romagna region between 2001 and 2011 and reported to the IMER regional registry were included in the study group. The pregnancy outcome was retrospectively assessed.

RESULTS

In the study period out of 390,978 babies born in Emilia-Romagna 126 cases of open spina bifida were reported to the IMER registry, resulting in a global prevalence of 3.2 per 10,000 births. Prenatal diagnosis was achieved in the vast majority of these cases (105/126; 83.3%) and in a great proportion of those women (85/105; 80.9%) who opted for termination of pregnancy.

CONCLUSIONS

In a wide region of northern Italy where ultrasound anomaly scan is routinely offered to the general population, the vast majority of cases of open spina bifida are diagnosed antenatally and terminated electively.

A new simple technique for 3-dimensional sonographic assessment of the pelvic floor muscles

OBJECTIVES

The purpose of this study was to assess the reproducibility of a new technique for 3-dimensional (3D) pelvic floor sonography: OmniView combined with Volume Contrast Imaging (VCI; GE Healthcare, Kretz Ultrasound, Zipf, Austria) for pelvic hiatal area measurement. In addition, we aimed to study the intermethod agreement between the new technique and the standard 3D rendering method.

METHODS

We acquired a static 3D sonographic transperineal volume from 124 nulliparous asymptomatic women and 118 women with symptoms of pelvic floor dysfunction. Each 3D data set was analyzed by the OmniView-VCI technique to measure the pelvic hiatal area twice by one operator and once by another to assess intraobserver and interobserver reproducibility. The first operator later measured the hiatal area using the 3D rendering method to evaluate intermethod agreement. Reproducibility and intermethod agreement were studied by the intraclass correlation coefficient and Bland-Altman method.

RESULTS

Hiatal area measurements by the OmniView-VCI technique showed high intraobserver and interobserver reproducibility in both asymptomatic and symptomatic women. In addition, high agreement was shown between the new technique and 3D rendering in both groups. No systematic differences were noted in any of the reliability studies performed. The new technique took slightly less time to calculate the hiatal area than the standard rendering method in both asymptomatic and symptomatic women.

CONCLUSIONS

OmniView-VCI is a reliable method for pelvic hiatal area measurement. Further studies are needed to assess its reliability under contraction and the Valsalva maneuver and to evaluate its usefulness and reproducibility for diagnosis of levator ani lesions.

Demonstration of the Pericallosal Artery at 11-13 Weeks of Gestation Using 3D Ultrasound

Objective: To assess the sonographic visualization of the pericallosal arteries in normal fetuses at 11-13 weeks of gestation using 3D ultrasound. Methods: We prospectively enrolled women with a singleton pregnancy undergoing ultrasound at 11-13 weeks of gestation. A 3D volume with high-definition power Doppler was acquired starting from the sagittal view of the fetal head and stored in the spatiotemporal image correlation mode. The images of the pericallosal arteries were assigned a score of 0 (no visualization), 1 (visualization of the origin) or 2 (visualization of the whole course). A follow-up scan was performed in all cases at 20 weeks of gestation to assess the presence of the corpus callosum. Results: 70 patients were included and the pericallosal arteries were sonographically detectable in all cases. Image scores of 1 and 2 were obtained in 8 and 62 cases, respectively. The whole length of the vessel was between 3.5 and 4.5 mm. The vast majority of those with a score of 2 were beyond 12 completed weeks of gestation. All fetuses showed a normal corpus callosum at midtrimester and no abnormal brain findings after birth. Conclusions: The pericallosal arteries are sonographically visible since the first trimester in 3D ultrasound scans of fetuses found to have a normal corpus callosum at follow-up.

Caregiver's satisfaction with a video tutorial for shoulder dystocia management algorithm

In our questionnaire, a video tutorial illustrating the management of shoulder dystocia was considered by health personnel as a useful complementary training tool. We prepared a 5-min video tutorial on the management of shoulder dystocia, using a simulator that includes maternal pelvic and baby models. We performed a survey among obstetric personnel in order to assess their opinion on the tutorial by inviting them to watch the video tutorial and answer an online questionnaire. Five multiple-choice questions were set, focusing on the video's main objectives: clarity, simplicity and usefulness. Following the collection of answers, global and category-weighted analyses were conducted for each question. Out of 956 invitations sent, 482 (50.4%) answered the survey. More than 90% of all categories found the video tutorial to be clinically relevant and clear. For revising the management of shoulder dystocia most obstetric personnel would use the video tutorial together with traditional textbooks. In conclusion, our video tutorial was considered by health personnel as a useful complementary training tool.

Prenatal diagnosis versus first-trimester screening of trisomy 21 among pregnant women aged 35 or more

OBJECTIVE

To compare the policy of prenatal diagnosis versus first trimester screening of trisomy 21 among pregnant women of advanced age.

METHODS

A retrospective study was conducted on patients aged ≥35 divided in two groups: patients who requested first trimester combined test and only in case of screen-positive result underwent invasive testing (group A); patients undergoing chorionic villous sampling or amniocentesis as first investigation (group B). The following outcome variables were compared: antenatal detection of trisomy 21, occurrence of trisomy 21 at birth, miscarriage rate, hospitals' costs.

RESULTS

4527 women were included. Of these, 534 (11.80%) underwent T21 screening whereas 3993 (88.20%) requested primary invasive testing. In group A, 64 combined test were positive (11.99%) and 8 trisomy 21 cases were diagnosed (1.50%); the loss of euploid fetuses after invasive procedure was 4.55% (2/44). No false-negative case was observed. In group B 57 cases of trisomy 21 were diagnosed (1.43%), and pregnancy loss rate of chromosomally normal fetuses was 0.45% (17/3806). The estimated cost was, respectively, 67.720€ for the primary screening versus 1.996.500€ for direct prenatal diagnosis.

CONCLUSION

First trimester screening of trisomy 21 is highly accurate and cost saving among women ≥35.