Update on Percutaneous Ablation for Sarcoma

PURPOSE OF REVIEW

To provide an update on the current state of percutaneous thermal ablation in the treatment of sarcoma.

RECENT FINDINGS

Data continue to accrue in support of ablation for local control and palliation of specific sarcoma subtypes such as extra-abdominal desmoid fibromatosis and for broader indications such as the treatment of oligometastatic disease. The synergistic possibilities of various combination therapies such as cryoablation and immunotherapy represent intriguing areas of active investigation. Histotripsy is an emerging non-invasive, non-thermal ablative modality that may further expand the therapeutic arsenal for sarcoma treatment. Percutaneous thermal ablation is a valuable tool in the multidisciplinary management of sarcoma, offering a minimally invasive adjunct to surgery and radiation therapy. Although there remains a paucity of high-level evidence specific to sarcomas, ablation techniques are demonstrably safe and effective for achieving local tumor control and providing pain relief in select patients and are of particular benefit in those with metastatic disease or requiring palliative care.

Ethanol ablation of papillary thyroid carcinoma nodal metastases: Long-term outcomes

BACKGROUND

Percutaneous ethanol ablation has emerged as a treatment for recurrent papillary thyroid carcinoma in the lateral neck after compartment-oriented therapeutic lymphadenectomy. However, the safety and utility of percutaneous ethanol ablation as a primary treatment modality for lateral neck metastases remains undefined. We aimed to investigate long-term outcomes of percutaneous ethanol ablation of lateral neck papillary thyroid carcinoma recurrence both with and without prior lymphadenectomy.

METHODS

We conducted a retrospective study of patients with lateral neck papillary thyroid carcinoma treated with percutaneous ethanol ablation from 2013 to 2018. Patient characteristics, disease volume, morbidity, and recurrence (development of new lymphadenopathy within a percutaneous ethanol ablation-treated nodal compartment) were assessed.

RESULTS

We identified 117 patients who underwent percutaneous ethanol ablation for papillary thyroid carcinoma lateral neck metastases-67 (57%) had a prior lateral neck dissection. Median follow-up after percutaneous ethanol ablation was 5.5 years (interquartile range 3.1-7.5). On average, 1.4 lymph nodes (range: 1-6) were treated. Three patients (3%) developed transient nerve-related complications after percutaneous ethanol ablation. Of 15 patients who underwent lateral neck dissection after percutaneous ethanol ablation (including patients undergoing repeat lateral neck dissection), dissection was "difficult" in 8 (53%) (7 of whom had previously undergone lateral neck dissection), and 4 (27%) developed complications (transient nerve dysfunction = 3, lymphatic leak = 1). Thirty-three patients (28%) developed recurrent papillary thyroid carcinoma. No difference in recurrence was seen between patients who did or did not undergo pre-percutaneous ethanol ablation lateral neck dissection (no pre-percutaneous ethanol ablation lateral neck dissection: 24%, pre-percutaneous ethanol ablation lateral neck dissection, 31%; hazard ratio = 1.27, 95% confidence interval 0.62-2.58; P = .514).

CONCLUSION

Percutaneous ethanol ablation may be a safe primary treatment modality for papillary thyroid carcinoma lateral neck nodal recurrence in selected patients with low-volume nodal disease.

Patient Access of Their Radiology Reports Before and After Implementation of 21st Century Cures Act Information-Blocking Provisions at a Large Multicampus Health System

Background: To implement provisions of the 21st Century Cures Act addressing information blocking, federal regulations mandated that health systems provide patients with immediate access to elements of their electronic health information, including imaging results. Objective: To compare patient access of radiology reports before and after implementation of the information-blocking provisions of the 21st Century Cures Act. Method: This retrospective study included patients who underwent outpatient imaging examinations from January 1, 2021, to December 31, 2022 at three campuses within a large health system. The system implemented policies to comply with Cures Act information-blocking provisions on January 1, 2022. Imaging results were released in patient portals after a 36-hour embargo period before implementation, versus immediately upon report finalization after implementation. Data regarding patient report access in the portal and ordering provider report acknowledgment in the EMR were extracted and compared between periods. Results: The study included reports for 1,188,692 examinations in 388,921 patients (mean age, 58.5±16.6 years; 209,589 women, 179,290 men, 8 nonbinary, 34 missing sex information). A total of 77.5% of reports were accessed by the patient before implementation, versus 80.4% after implementation. Median time from report finalization to report release in the patient portal was 36.0 hours before implementation versus 0.4 hours after implementation. Median time from report release to first patient access in the portal was 8.7 hours before implementation versus 3.0 hours after implementation. Median time from report finalization to first patient access was 45.0 hours before implementation versus 5.5 hours after implementation. A total of 18.5% of reports were first accessed by the patient before the ordering provider before implementation, versus 44.0% after implementation. After implementation, median time from report release to first patient access was 1.8 hours for patients with age <60 years versus 4.3 hours for patients with age ≥60 years. Conclusion: After implementing institutional policies to comply with Cures Act information-blocking provisions, the time for patients to access imaging results decreased, and the proportion of patients who accessed their reports before the ordering provider increased. Clinical Impact: Radiologists should consider mechanisms to ensure timely and appropriate communication of important findings to ordering providers.

Airway compromise following contrast extravasation from an external jugular intravenous line

Extravasation of iodinated contrast material (ICM) is an uncommon complication (0.1%-1.2%) following intravenous injection for computed tomography exams and other procedures. Most cases of contrast extravasation are mild and resolve without treatment. Alternative injections sites are occasionally necessary among patients with difficult vascular access and are at increased risk of contrast extravasation and subsequent complications compared to the antecubital fossa. We describe a rare case of airway compromise necessitating intubation following iodinated contrast extravasation from an external jugular IV line. Additional care and monitoring must be performed during and after injection of contrast into these higher-risk vascular access sites.

Acute Adverse Events After Iodinated Contrast Agent Administration of 359,977 Injections: A Single-Center Retrospective Study

OBJECTIVE

To assess the effects of patient variables, examination variables, and seasonality on allergic-like and physiologic reactions to iodinated contrast material (ICM).

PATIENTS AND METHODS

All ICM-enhanced computed tomography (CT) examinations performed from June 1, 2009, to May 9, 2017, at our institution were included. Reactions were identified and categorized as allergic-like or physiologic and mild, moderate, or severe. The effect of patient and examination variables on reactions was evaluated by logistic regression models.

RESULTS

A total of 359,977 CT examinations performed on 176,886 unique patients were included. A total of 1150 allergic-like reactions (0.32%; 19 severe [0.005%]) and 679 physiologic reactions (0.19%; 3 severe [0.0008%]) occurred. On multivariable analysis, iopromide had higher rates of reactions compared with iohexol (allergic-like reactions: odds ratio [OR], 3.07 [95% CI, 2.37 to 3.98], P<.0001; physiologic reactions: OR, 2.60 [1.92 to 3.52], P<.0001). Non-White patients had higher rates of reactions compared with White patients (allergic-like reactions: OR, 1.77 [1.36-2.30], P<.0001; physiologic reactions: OR, 1.76 [1.27-2.42], P=.0006). Patient age, sex, prior ICM reaction, ICM dose, CT location, and CT type were also significantly associated with reactions. No significant seasonality trend was observed (P=.07 and .80).

CONCLUSION

Non-White patients and patients administered iopromide had higher rates of acute reactions compared with White patients and patients administered iohexol. Younger patients (<50 years vs 51 to 60 years), female sex, history of ICM allergy or other allergies, ICM dose, and contrast-enhanced CT location and type also correlated with higher acute reaction rates.

Percutaneous Cryoablation of Plasmacytomas: Oncologic Effectiveness and Adverse Events

PURPOSE

To evaluate the oncologic outcomes and adverse events associated with cryoablation of plasmacytomas.

MATERIALS AND METHODS

Retrospective review of an institutional percutaneous ablation database showed 43 patients underwent 46 percutaneous cryoablation procedures for treatment of 44 plasmacytomas between May 2004 and March 2021. Treatment of 25 (25/44, 56.8%) tumors was augmented with bone consolidation/cementoplasty. Median patient age was 64 years [interquartile range (IQR): 54-69], and 30 (30/43, 69.8%) patients were male. Median maximal plasmacytoma diameter was 5.0 cm [IQR: 3.1-7.0]. Thirty (30/44, 68.2%) tumors were periacetabular, vertebral, or located in the iliac wing. Twenty-nine (29/44, 65.9%) cryoablated plasmacytomas were recurrent tumors following prior external beam radiation therapy (EBRT). Survival analyses were performed using the Kaplan-Meier method. Adverse events were graded using Society of Interventional Radiology (SIR) criteria.

RESULTS

Five-year estimated local tumor recurrence-free survival was 85.3% [95% confidence interval (CI): 74.1-98.1%], five-year estimated new plasmacytoma-free survival was 49.9% {95% CI: 33.9-73.4%], and five-year estimated overall survival was 70.4% [95% CI: 56.9-87.1%]. Nine (9/46, 19.6%) major adverse events occurred in 8 patients, including 3 (3/46, 6.5%) new or progressive pathologic fractures at the ablation site requiring surgical intervention, 3 (3/46, 6.5%) nerve injuries, 1 (1/46, 2.2%) avascular necrosis and femoral head collapse, 1 (1/46, 2.2%) septic arthritis, and 1 (1/46, 2.2%) acute renal failure caused by rhabdomyolysis.

CONCLUSIONS

Percutaneous cryoablation is a viable treatment option for patients with plasmacytomas, including those with recurrent plasmacytomas after EBRT. Post-cryoablation adverse events are relatively common.

Safety and accuracy of aortic and periaortic CT-guided percutaneous core needle biopsy

PURPOSE

The purpose of this study was to determine the safety and accuracy of aortic and periaortic computed tomography (CT)-guided percutaneous core needle biopsy performed at a single center over 12 years.

MATERIALS AND METHODS

A retrospective review was conducted of cases performed between February 2010 and August 2022 in which the biopsied region was in direct contact with the aorta or great vessels including the pericardium and common iliac arteries. Clinical notes were reviewed for any early or delayed complications following the procedure, which if present were graded using the National Institute of Health's Common Terminology Criteria for Adverse Events, version 5.0. Pathology results were compared to subsequent outside biopsy results or follow-up surgical pathology, if available, as well as subsequent clinical decision making and/or clinical course, to determine concordance. Sensitivity, specificity, predictive value, and accuracy (indicative of diagnostic yield) were calculated.

RESULTS

32 core needle biopsies were reviewed from 30 patients (average lesion longest diameter 3.1 cm, range 0.5-10.9 cm; average needle proximity to the vessel endothelium or deep side of the pericardium 1.0 cm, range 0.3-1.8 cm). Complications occurred in 46.9% of cases (15/32), 93.3% (14/15) of which were minor and included small amounts of bleeding or pain. One patient developed a small nonemergent pneumothorax. Of biopsies obtained, 96.9% provided adequate tissue for diagnosis (31/32). When evaluating concordance between pathological and final diagnosis, sensitivity was 94.7% and specificity was 83.3%; positive and negative predictive value were 90.0% and 90.9%, respectively. Accuracy (diagnostic yield) of biopsy was 90.3%.

CONCLUSION

CT-guided percutaneous aortic and periaortic core needle biopsies are safe and efficacious procedures with high diagnostic yield.

Clinical follow-up in patients with moderate or severe allergic-like reactions to iodinated contrast material

OBJECTIVE

To examine follow-up care in patients with a history of acute allergic-like reaction to iodinated contrast material (ICM), including subsequent imaging management, allergy consultation, and repeat ICM exposure and reactions.

METHODS

All patients who had a moderate or severe acute allergic-like reaction to ICM following contrast-enhanced (CE)CT exam from June 1, 2009 -January 1, 2022 at our institution were included. Chart review was performed to determine 1) whether subsequent imaging was not performed or altered in these patients, 2) whether the patient underwent a subsequent CECT exam, and 3) whether the patient had an allergist consultation.

RESULTS

A total of 251 patients were identified. One-third of patients (90/251, 36%) had at least one change to their subsequent imaging management due to their reaction, including performing an unenhanced CT (62/251, 25%) or MRI (22/251, 8.8%) instead of a CECT, or not performing a CECT when otherwise clinically indicated (20/251, 8.0%). Patients with a prior severe reaction were more likely to have a change in management than patients with a prior moderate reaction (Severe: 22/32 (69%) vs. Moderate: 68/219 (31%), p<.0001). Only 17 patients (6.8%) had an allergy consult for their ICM reaction. A total of 90 patients underwent 274 subsequent CECT exams. Repeat allergic-like reactions were observed in one quarter of patients (24/90, 27%) and a tenth of CECT exams (29/274, 11%).

DISCUSSION

One-third of patients with a history of a moderate or severe allergic-like reaction to ICM had their subsequent imaging care modified due to their reaction.

Safety and technical success of diphenhydramine as an alternative local anaesthetic agent for radiology procedures

AIM

To evaluate retrospectively the safety and technical success of subcutaneous diphenhydramine as an alternative local anaesthetic for radiology procedures.

MATERIALS AND METHODS

Between January 2000 and April 2021, 84 image-guided procedures were performed in 81 adult patients (mean age 61 years, 86% female) using 1% injectable diphenhydramine as a local anaesthetic. Indications were history of severe allergy to "-caine" local anaesthetics in 76 (90%) patients and recent administration of bupivacaine liposomal injectable suspension in eight (10%) patients. Twelve of the 84 (14%) procedures were performed with concomitant moderate sedation. Patient characteristics, procedural techniques, and clinical outcomes were reviewed. Early and delayed (30-day) complications were classified as either related to local diphenhydramine injection or to the procedure itself. Procedure-related complications were gradated using the Clavien-Dindo system.

RESULTS

Percutaneous biopsy was the most frequently performed procedure (57/84, 67%). Fifty-nine (70%) of the 84 procedures were ultrasound guided. The most common procedural site was the breast (34/84, 40%). All procedures were technically successful. There were two minor injection-related complications related to post-procedural pain. A single minor procedure-related complication involved a patient requiring hospital admission for post-renal biopsy related haematuria.

CONCLUSION

Injectable diphenhydramine appears to be a safe and effective local anaesthetic alternative in patients with "-caine" class contraindications undergoing radiology procedures. A future prospective trial would be useful to assess the safety profile in an large cohort of patients.

Feasibility and safety of percutaneous image-guided cryoablation of abdominal wall endometriosis

PURPOSE

To evaluate the feasibility and safety of percutaneous image-guided cryoablation of abdominal wall endometriosis (AWE).

MATERIALS AND METHODS

A retrospective review of percutaneous cryoablation (CT or MR) of AWE was performed from January 2018 to December 2020. Eighteen patients were identified from an internal percutaneous ablation database. Technical success, complications, and outcomes were analyzed according to standard nomenclature.

RESULTS

Patients comprised 18 females (mean age 36.9 years) who underwent 18 cryoablation procedures to treat 23 AWE deposits. Three of the 18 cases were performed under MR guidance, while the remaining 15 employed CT guidance. Technical success was achieved in all 18 cases (100%). Fifteen of 18 patients (83%) had biopsy proven AWE deposits prior to treatment. Hydrodisplacement was used to displace adjacent bowel, bladder, or neurovascular structures in 13/18 cases (72%). The mean number of probes used per case was 3. Sixteen of 23 (70%) of AWE deposits had imaging follow-up (median 85 days). Of the 16 lesions with imaging follow-up, 15 (94%) demonstrated no residual enhancement or T1 hyperintensity at the treatment site and 1 lesion (6%) demonstrated residual/progressive disease. At clinical follow-up, 13 of 14 (93%) patients reported improvement in AWE-related symptoms. Eleven patients had clinically documented pain scores before and after ablation and all demonstrated substantial symptomatic improvement. No society of interventional radiology (SIR) major complications were observed.

CONCLUSIONS

Percutaneous cryoablation of AWE is feasible with a favorable safety profile. Further longitudinal studies are needed to document durable response over time.

Nonsurgical Management of Thyroid Nodules: The Role of Ablative Therapies

CONTEXT

After a thorough evaluation most thyroid nodules are deemed of no clinical consequence and can be observed. However, when they are compressive, toxic, or involved by papillary thyroid carcinoma surgery or radioactive iodine (RAI) (if toxic) are the treatments of choice. Both interventions can lead to hypothyroidism and other adverse outcomes (eg, scar, dysphonia, logistical limitation with RAI). Active surveillance might be used for papillary thyroid microcarcinoma (PTMC) initially, but anxiety leads many cases to surgery later. Several ablative therapies have thus evolved over the last few years aimed at treating these nodules while avoiding described risks.

CASES

We present 4 cases of thyroid lesions causing concern (compressive symptoms, thyrotoxicosis, anxiety with active surveillance of PTMC). The common denominator is patients' attempt to preserve thyroid function, bringing into focus percutaneous ethanol injection (PEI) and thermal ablation techniques (radiofrequency ablation [RFA] being the most common). We discuss the evidence supporting these approaches and compare them with standard therapy, where evidence exists. We discuss additional considerations for the utilization of these therapies, their side-effects, and conclude with a simplified description of how these procedures are performed.

CONCLUSION

Thermal ablation, particularly RFA, is becoming an attractive option for managing a subgroup of solid thyroid nodules, while PEI has a role in managing thyroid cysts and a select group of PTMC. Their role in the algorithm of thyroid nodule management is still being refined and technical expertise will be essential to reproduce the reported results into everyday practice.

Safety and Efficacy of Percutaneous Image-Guided Mediastinal Mass Core-Needle Biopsy

Objective

To retrospectively evaluate the safety and efficacy of percutaneous image-guided mediastinal mass core-needle biopsy.

Patients and Methods

Retrospective review of an institutionally maintained biopsy registry identified 337 computed tomography- or ultrasound-guided percutaneous mediastinal mass core needle biopsies between October 2002 and August 2017 in a single quaternary referral center. Mean patient age was 51 (range, 18 to 93) years. Procedural techniques, anticoagulation/antiplatelet therapy, and tumor anatomical characteristics were reviewed. Classification and gradation of complications was based on the Clavien-Dindo system. Diagnostic yield was defined as the ratio of diagnostic biopsy to all biopsies performed.

Results

Mean tumor size was 59.2 (range, 10 to 180) mm with 89.9% (n=303) of lesions located in the prevascular (anterior) mediastinum. There was a single major complication (0.3%) of a symptomatic pneumothorax requiring intervention. There were seven (2.1%) minor complications, including three bleeding complications. A transpleural approach was the only variable associated with an increased complication rate (P<.01). Forty-one (12.2%) patients had a biopsy performed while taking an antiplatelet/anticoagulant agent within the therapeutic window, with a single case (0.3%) associated with a minor bleeding complication. Of 18 (5.3%) procedures performed without cessation of anticoagulant/antiplatelet therapy, there were no bleeding complications. Of all 337 biopsies, 322 (95.5%) were diagnostic. None of the analyzed variables were significantly associated with a nondiagnostic biopsy.

Conclusion

Image-guided percutaneous core-needle biopsy of mediastinal masses is a safe procedure with high diagnostic yield. Further prospective studies are required to assess the complication profile in higher risk patients.

Prevention of Allergic-like Reactions at Repeat CT: Steroid Pretreatment versus Contrast Material Substitution

Background It is unclear whether steroid premedication is an effective means of preventing repeat allergic-like reactions in high-risk patients with a previous allergic-like reaction to iodinated contrast material (ICM). Purpose To compare the effectiveness of ICM substitution (ie, using iohexol in a patient with a previous iopromide reaction) with 12- and 2-hour steroid premedication for preventing repeat acute allergic-like reactions in high-risk patients. Materials and Methods This retrospective study identified all high-risk (ie, having a previous allergic-like reaction) adult and pediatric patients who underwent a contrast-enhanced CT examination at the institution from June 1, 2009, to May 9, 2017. Prophylactic treatments and repeat reactions were identified using chart review. The effectiveness of prophylactic treatments on repeat reaction rates was examined with multivariable regression models that used generalized estimating equations. Results A total of 1973 high-risk patients who underwent 4360 subsequent ICM-enhanced CT examinations were included. Of the 4360 examinations, a total of 280 allergic-like reactions occurred (6%) in 224 of the 1973 patients (11% of patients), with only 19 of 280 reactions (7%) that were more severe than the previous reaction being demonstrated. After adjustment, patients who received a different ICM with and without steroid premedication had a significantly lower rate of repeat reactions than did patients who received steroid premedication and the same ICM (same ICM and steroid premedication: 80 of 423 examinations [19%]; different ICM and no steroid premedication: 10 of 322 examinations [3%]; odds ratio [OR], 0.14 [95% CI: 0.06, 0.33]; P < .001; different ICM and steroid premedication: five of 166 patients [3%]; OR, 0.12 [95% CI: 0.04, 0.36]; P < .001). When examining the first scan only, patients who received the same ICM had a similar risk of repeat reactions regardless of whether they received steroid premedication (steroid premedication: 44 of 172 patients [26%] vs no premedication: 73 of 298 patients [25%]; OR, 1.00 [95% CI: 0.64, 1.57]; P = .99). Conclusion In this cohort, using an iodinated contrast material (ICM) substitution was more effective for preventing repeat allergic-like reactions than using steroid premedication and the same ICM that caused the previous reaction. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Davenport and Weinstein in this issue.

Percutaneous Image-Guided Core Needle Biopsy of Neuroendocrine Tumors: How Common Is Intraprocedural Carcinoid Crisis?

PURPOSE

To retrospectively evaluate the incidence of carcinoid crisis, other complications, and physiologic disturbances during percutaneous image-guided core needle biopsy of neuroendocrine tumors (NETs) in the lung and the liver.

MATERIALS AND METHODS

Between January 2010 and January 2020, 106 computed tomography (CT) or ultrasound (US)-guided core needle biopsies of lung and liver NETs were performed in 95 consecutive adult patients. The mean age was 64 ± 13 years, and 48% were female. The small bowel was the most common primary site (33%, 31/95), and 32 (34%) patients had pre-existing symptoms of carcinoid syndrome. The mean tumor size was 3.2 ± 2.6 cm, and mean number of passes was 3.4 ± 1.6. A 17/18-gauge needle was used in 91% (96/106) of the biopsies. Thirteen (12%) patients received either outpatient or prophylactic octreotide.

RESULTS

No patients experienced carcinoid crisis or needed octreotide, inotropes, vasopressors, or resuscitation. A single biopsy procedure (0.9%, 1/106) was complicated by bleeding that required angiographic hepatic artery embolization. Changes in pre-biopsy- versus post-biopsy systolic blood pressure and heart rate were -1.6 mm Hg (P = .390) and 0.6 beat/min (P = .431), respectively. Tumor functional status, overall tumor burden, and the elevation of neuroendocrine markers were not associated with intraprocedural physiologic disturbances. There were 4 minor complications (0.4%, 4/106) associated with the biopsy procedure that were not attributed to hormone excretion from tumor manipulation.

CONCLUSIONS

Percutaneous image-guided core biopsy of NETs is safe, with low complication rate and no definite carcinoid crisis in the current cohort.

Image-guided tumor ablation in gynecologic oncology: Review of interventional oncology techniques and case examples highlighting a collaborative, multidisciplinary program

As interventional oncology services within radiology mature, image-guided ablation techniques are increasingly applied to recurrent gynecologic malignancies. Ablation may be performed using thermal techniques like cryoablation, microwave ablation, or radiofrequency ablation, as well as non-thermal ones, such as focused ultrasound or irreversible electroporation. Feasibility and approach depend on tumor type, size, number, anatomic location, proximity of critical structures, and goals of therapy. Current indications include local control of limited metastatic disease or palliation of painful bone metastases refractory or unsuitable to conventional therapies. Technical aspects of these procedures, including methods to protect nearby critical structures are presented through illustrative examples. Cases amenable to image-guided ablation include, but are not limited to, hepatic or pulmonary metastases, musculoskeletal metastases, retroperitoneal nodal metastases, pelvic side wall disease, abdominal wall disease, and vaginal or vulvar tumors. Protective maneuvers, such as hydro-displacement of bowel, neuromonitoring, and retrograde pyeloperfusion through ureteral stents, permit safe ablation despite close proximity to vulnerable nerves or organs. Image-guided ablation offers an alternative modality to achieve local tumor control without the risks associated with surgery or systemic treatment in appropriately selected patients. A multidisciplinary approach to use of image-guided ablation includes collaboration between gynecologic oncology, interventional radiology, anesthesia, urology and radiation oncology teams allowing for appropriate patient-centered case selection. Long-term follow up and additional studies are needed to determine the oncologic benefits of such techniques.

Analysis and impact of a multidisciplinary lymphoma virtual tumor board

The aim is to prospectively evaluate the impact of a multidisciplinary lymphoma virtual tumor board. The utility of multi-site interactive lymphoma-specific tumor boards has not been reported. The Mayo Clinic Lymphoma Tumor Board is a component of the International Mayo Clinic Care Network (MCCN). The format includes the clinical case presentation, presentation of radiology and hematopathology findings by the appropriate subspecialist, proposed treatment options, review of the literature pertinent to the case, pharmacy contributions, and discussion followed by recommendations. Three hundred and nine consecutive highly selected real-time cases with a diagnosis of lymphoma were presented at the Mayo Clinic Lymphoma Tumor Board from January 2014 to June 2018 and decisions were prospectively tracked to assess its impact on the treatment decisions. A total of 309 cases were prospectively evaluated. One hundred and forty (45.3%) cases had some changes made or recommended. The total changes suggested were 179, as some cases had more than one recommendation. There were 93 (30%) clinical management recommendations, 45 (14.6%) additional testing recommendations, 29 (9.4%) pathology changes, and 6 (1.9%) radiology changes. In an electronic evaluation process, 93% of the responders reported an improvement in knowledge and competence, and 100% recommended no change in format of the board. A multidisciplinary lymphoma tumor board approach was found to have a meaningful impact on lymphoma patients while enhancing interdisciplinary interactions and education for multiple levels of the clinical care team.

Safety and Efficacy of Retrograde Pyeloperfusion for Ureteral Protection during Renal Tumor Cryoablation

PURPOSE

To determine safety and efficacy of retrograde pyeloperfusion for ureteral protection during cryoablation of adjacent renal tumors.

MATERIALS AND METHODS

Retrospective review of 155 patients treated with renal cryoablation, including adjunctive retrograde pyeloperfusion, from 2005 to 2019 was performed. Ice contacted the ureter in 67 of the 155 patients who represented the study cohort. Median patient age was 68 years old (interquartile range [61, 74]), 52 patients (78%) were male, and 37 tumors (55%) were clear cell histology. Mean tumor size was 3.4 ± 1.3 cm, and 42 tumors (63%) were located at the lower pole. Treatment-related complication and oncologic outcomes were recorded based on a review of post-procedural images and chart review.

RESULTS

Technical success of cryoablation was attained in 67 cases (100%), and technical success of pyeloperfusion was attained in 66 cases (99%). A total of 13 patients (19.4%) experienced SIR major C or D complications related to the procedure, including hemorrhage (n = 4), urine leak (n = 3), transient urinary obstruction (n = 2), pulmonary embolism (n = 1), hypertensive urgency (n = 1), acute respiratory failure (n = 1), and ureteropelvic junction (UPJ) stricture (n = 1). No complications were attributable to pyeloperfusion. Three of 45 patients with biopsy-proven renal cell carcinoma experienced local recurrence resulting in local recurrence-free survival of 92% (95% confidence interval, 81.5%-100%) 3 years after ablation.

CONCLUSIONS

Retrograde pyeloperfusion of the renal collecting system is a relatively safe and efficacious option for ureteral protection during renal tumor cryoablation. This adjunctive procedure should be considered for patients in whom cryoablation of a renal mass could potentially involve the ureter.

Thermal ablation of intrahepatic cholangiocarcinoma: Safety, efficacy, and factors affecting local tumor progression

PURPOSE

To evaluate the safety and oncologic efficacy of percutaneous thermal ablation of intrahepatic cholangiocarcinoma (ICC) and identify risk factors for local tumor progression (LTP).

MATERIALS AND METHODS

Retrospective review of an institutional tumor ablation registry demonstrated that 20 patients (9 males, 11 females; mean age 62.5 ± 15.8 years) with 50 ICCs (mean size 1.8 ± 1.3 cm) were treated with percutaneous radiofrequency ablation (RFA) or microwave ablation (MWA) between 2006 and 2015. Thirty-eight of the treated ICCs (76%) were metastases that developed after surgical resection of the primary tumor. Patient demographics, procedure technical parameters, and clinical outcomes were reviewed. A Cox proportional hazards model was used to examine the risk of LTP by ablation modality. Survival analyses were performed using the Kaplan-Meier method.

RESULTS

Mean imaging follow-up time was 41.5 ± 42.7 months. Forty-four (88%) ICCs were treated with RFA, and 6 (12%) with MWA. Eleven (22%) cases of LTP developed in 5 (25%) patients. The median time to LTP among these 11 tumors was 7.1 months (range, 2.3-22.9 months). Risk of LTP was not significantly different for ICCs treated with MWA compared to RFA (HR 2.72; 95% CI 0.58-12.84; p = 03.21). Median disease-free survival was 8.2 months (1.1-70.4 months), and median overall survival was 23.6 months (7.4-122.5 months). No major complication occurred.

CONCLUSIONS

Percutaneous thermal ablation is a safe and effective treatment for patients with ICCs and may be particularly valuable in unresectable patients, or those who have already undergone hepatic surgery. Tumor size and ablation modality were not associated with LTP, whereas primary tumors and superficially located tumors were more likely to subsequently recur.

Outcomes of Ultrasound-Guided Thrombin Injection of Nongroin Arterial Pseudoaneurysms

PURPOSE

To evaluate success and complication rates of percutaneous ultrasound-guided thrombin injection of nongroin pseudoaneurysms (PSAs).

MATERIALS AND METHODS

Retrospective review of a prospectively maintained institutional database yielded 39 cases of arterial PSAs occurring at nongroin sites that were treated with percutaneous ultrasound-guided thrombin injection between 2000 and 2016 (average patient age 69.2 y ± 14.0). Of PSAs, 74.4% (29/39) arose in the upper extremities, and 92.3% (36/39) were iatrogenic. The brachial artery was the most commonly affected vessel (51.3% [20/39]), and arterial access was the most common cause (56.4% [22/39]). Average overall PSA size was 2.4 cm (range, 0.5-7.2 cm); average amount of thrombin injected was 320 IU (range, 50-2,000 IU). Technical success was defined as absence of flow within the PSA immediately after thrombin injection. Treatment success was defined as sustained thrombosis on follow-up imaging obtained at 1-3 days after treatment.

RESULTS

Technical and treatment success rates of thrombin injections were 100% (39/39) and 84.8% (28/33), respectively. Longer term follow-up imaging (average 71 d; range, 12-201 d) was available for 7 of the treatment successes with 100% (7/7) showing sustained thrombosis. Comparing treatment successes and failures, there was no significant difference in average PSA size (2.3 cm vs 2.0 cm, P = .51) or average amount of thrombin injected (360 IU vs 180 IU, P = .14). There were no complications.

CONCLUSIONS

Ultrasound-guided thrombin injection is a safe, efficacious treatment option for PSAs arising in nongroin locations.

Evaluation of infectious complications following percutaneous liver ablation in patients with bilioenteric anastomoses

PURPOSE

Prior bilioenteric anastomosis (BEA) has been associated with elevated risk of abscess formation after thermal ablation of hepatic tumors. We assessed the incidence of hepatic abscess after thermal ablation in a BEA cohort treated with extended antibiotic regimens following ablation.

MATERIALS AND METHODS

Retrospective review was performed to identify patients with BEA who underwent percutaneous hepatic thermal ablation between January 1, 2003-September 1, 2016. Fifteen patients with BEA underwent 18 percutaneous thermal ablation procedures. Patient and procedural characteristics were reviewed, as well as the antibiotic regiment utilized post ablation. Complications were characterized via standardized nomenclature [Common Terminology for Clinically Adverse Events (CTCAE) v4.03].

RESULTS

Fifteen patients with BEA underwent treatment of 49 liver lesions during 18 ablation sessions. Mean follow-up in these patients was 39 months (range 3-138 months). Two patients (11%) developed hepatic abscesses, both of which occurred within 45 days of the ablation procedure while the patients were still on extended prophylactic antibiotic therapy. No additional CTCAE clinically significant complications were observed.

CONCLUSION

Thermal ablation of hepatic tumors can be accomplished safely in patients with BEA. Long-term post-procedural antibiotics may mitigate the risk of hepatic abscess formation. Due to the high number of patients who are deemed surgically unresectable, patients with BEA may have limited alternate treatment modalities and percutaneous hepatic thermal ablative treatments warrant consideration.

Effects of Aspirin Therapy on Ultrasound-Guided Renal Allograft Biopsy Bleeding Complications

PURPOSE

To determine if patient aspirin exposure and timing affect bleeding risk after renal allograft biopsy.

MATERIALS AND METHODS

Review of 6,700 renal allograft biopsies (in 2,362 unique patients) was performed. Median patient age was 53.0 years [interquartile range 43.0, 62.0]; 56.2% of patients were male. Of biopsies, 4,706 (70.2%) were performed in patients with no aspirin exposure within 10 days of biopsy; 664 (9.9%), were performed within 8-10 days of aspirin exposure; 855 (12.8%), within 4-7 days; and 475 (7.1%), within 0-3 days. Follow-up to 3 months after the procedure was completed in all patients. Biopsies were categorized as protocol or indication; 19.7% were indication biopsies. Bleeding complications were graded based on SIR criteria. Logistic regression models examined the association between aspirin use and bleeding events.

RESULTS

Rate [95% confidence interval] of major bleeding complications was 0.24% [0.14, 0.39], and rate of any bleeding complication was 0.66% [0.46, 0.90]. Bleeding events were significantly associated with patients undergoing indication biopsies compared with protocol biopsies (odds ratio [OR] 2.27, P = .012). Patient factors associated with major bleeding complications in multivariate models included estimated glomerular filtration rate (OR 0.61, P = .016) and platelet count (OR 0.64, P = .033). Aspirin use was not significantly associated with increased risk of bleeding complication except for use of 325 mg of aspirin within 3 days of biopsy (any complication OR 3.87 [1.12, 13.4], P = .032; major complication OR 6.30 [1.27, 31.3], P = .024).

CONCLUSIONS

Renal allograft biopsy bleeding complications are very rare, particularly for protocol biopsies. Use of 325 mg of aspirin within 3 days of renal allograft biopsy was associated with increased bleeding complications.

Clinical and radiographic predictors of the need for inferior vena cava resection during nephrectomy for patients with renal cell carcinoma and caval tumour thrombus

OBJECTIVE

To evaluate the clinical and radiographic predictors of the need for partial or circumferential resection of the inferior vena cava (IVC) requiring complex vascular reconstruction during venous tumour thrombectomy for renal cell carcinoma (RCC).

PATIENTS AND METHODS

Data were collected on 172 patients with RCC and IVC (levels I-IV) venous tumour thrombus who underwent radical nephrectomy with tumour thrombectomy at the Mayo Clinic between 2000 and 2010. Preoperative imaging was re-reviewed by one of two radiologists blinded to details of the patient's surgical procedure. Univariable and multivariable associations of clinical and radiographic features with IVC resection were evaluated by logistic regression. A secondary analysis was used to assess the ability of the model to predict histological invasion of the IVC by the tumour thrombus.

RESULTS

Of the 172 patients, 38 (22%) underwent IVC resection procedures during nephrectomy. Optimum radiographic thresholds were determined to predict the need for IVC resection based on preoperative imaging included a renal vein diameter at the renal vein ostium (RVo) of 15.5 mm, maximum anterior-posterior (AP) diameter of the IVC of 34.0 mm and AP and coronal diameters of the IVC at the RVo of 24 and 19 mm, respectively. On multivariable analysis, the presence of a right-sided tumour (odds ratio 3.3; P = 0.017), an AP diameter of the IVC at the RVo of ≥24.0 mm (odds ratio 4.4; P = 0.017), and radiographic identification of complete occlusion of the IVC at the RVo (odds ratio 4.9; P < 0.001) were associated with a significantly increased risk of IVC resection. The c-index for the model was 0.81.

CONCLUSIONS

We present a multivariable model of the radiographic features associated with the need for IVC resection during tumour thrombectomy. Pending external validation, this model may be used for preoperative planning, patient counselling and planned involvement of vascular surgical colleagues in anticipation of the need for complex vascular repair.

A randomised controlled trial of joint consultations with general practitioners and cardiologists in primary care

BACKGROUND

Joint consultation sessions of a small group of general practitioners (GPs) and a specialist in orthopaedics proved to be an effective way of decreasing the referral rate of orthopaedic patients. Cardiac complaints comprise an important category of health problems with high referral rates.

AIMS

To study the effects of joint consultation on the quality of care and referrals for patients with cardiac complaints.

DESIGN OF STUDY

Randomised controlled trial.

SETTING

Forty-nine GPs participated in 16 consultation groups, each with one of 13 cardiologists, in monthly joint consultations over a period of about 18 months.

METHOD

The GPs selected patients about whom they were uncertain, and those needing urgent referral were excluded. Patients were randomly assigned to joint consultation or to usual care. After a follow-up period all patients had a joint consultation for outcome assessment. Referral data were provided by two regional health insurance companies and questionnaires were given to the patients, GPs, and cardiologists to gauge their opinion of the trial.

RESULTS

One hundred and forty-eight patients in the intervention group and 158 patients in the control group fulfilled the whole protocol. The quality of care was similar in both groups. In the intervention group, 34% of the patients were referred, compared with 55% in the control group (P = 0.001), and fewer patients underwent further diagnostic procedures (7% compared with 16%, P = 0.013). Referrals to cardiology as a proportion of all referrals decreased in the practices of the participating GPs, compared with their reference districts (P = 0.024).

CONCLUSION

Joint consultation is an effective method that provides a quality of care that at least equals usual care and that contributes to a better selection of patients who need specialist care.

Cardiac dimensions in athletes in relation to variations in their training program

The cardiac dimensions of male long-distance runners (LDR) and cycle racers (CR) were determined echocardiographically during four different training seasons, i.e., a preparation, a competitive, a slowing-down and a resting season, and were compared with those of control subjects (CS). Left ventricular hypertrophy (LVH) was also assessed from the electrocardiogram. The maximal aerobic performance was determined on a bicycle ergometer. In the athletes, left ventricular mass was significantly greater in all seasons than the values in the CS. This difference resulted from a thicker interventricular septum and left ventricular posterior wall as well as a larger left ventricular internal diameter. The existence of LVH was confirmed by the electrocardiographic findings. No differences were observed between the four different training seasons, despite considerable changes in the training program for weeks to months. The maximal aerobic performance test in LDR showed a significantly higher workload during the competitive than during the preparation season. The CR reached significantly lower values during the resting season than during the other seasons. The results indicate that the possible adaptation of the cardiac dimensions to variations in the heaviness of the training program is relatively slow.

Echocardiographic dimensions in athletes in relation to their training programs

The cardiac dimensions of long-distance runners (LDR), cycle racers (CR), and weight lifters (WL) were determined echocardiographically and were compared with those of control subjects (CS). Left ventricular hypertrophy (LVH) was also assessed from the electrocardiogram. Training information was obtained through a questionnaire. The maximal aerobic performance was assessed on a cycle ergometer. Comparison of the cardiac dimensions revealed that left ventricular mass (LVmass) was significantly increased in LDR and CR as compared to CS. This resulted from thickening of the interventricular septum and left ventricular posterior wall as well as from enlargement of the left ventricular internal diameter. The existence of LVH was confirmed by electrocardiographic investigation. Although the left ventricular wall was enlarged in WL, their LVmass was not significantly increased as compared with CS. These results are in agreement with the training program followed. Weight lifters almost exclusively performed strength training, while LDR and CR were mainly involved in endurance training. The LDR and CR reached significantly higher maximal aerobic performance levels than WL. The present results suggest a close relationship between the type of cardiac enlargement and the training program followed by the athletes.